Frequently Asked Questions: Adult Cardiac Database

Version 2.41

The Society of Thoracic Surgeons

National Database Program

March 2004

| Section 1 (10-1400) | Section 2 (1420-2350) | Section 3 (2360-4680) | Section 4 (4760-5690) |

Click on “Seq #” in this area to go directly to that field in the FAQ.

Seq#:  1670,  Meds-ACE Inhibitors - CORRECTION TO PREVIOUSLY ANSWERED QUESTION

Seq#:  5332,  Ace-Inhibitors - Discharge

Click Here to see letter from Paul Meehan at DCRI, “Accepting Zero Values”.  For fields pertaining to this letter look for red asterisk in “NEW” column.

NEW

Date

SeqNo

FieldName

Definition

1420

Cardiogenic Shock

Is the patient, at the time of procedure, in a clinical state of hypoperfusion according to either of the following criteria:

1. Systolic BP < 80 and/or Cardiac Index < 1.8 despite maximal treatment;

2.  IV inotropes and/or IABP necessary to maintain Systolic BP > 80 and/or CI > 1.8.

Choose Yes or No.

1430

Cardiogenic Shock Type

Which of the following types of cardiogenic shock is present? Select one:

Refractory Shock:  Systolic BP < 80 and/or Cardiac Index < 1.8 despite maximal treatment

Hemodynamic Instability:  IV inotropes and/or IABP necessary to maintain Systolic BP > 80 and CI > 1.8.

1440

Resuscitation

The patient required cardiopulmonary resuscitation within one hour before the start of the operative procedure.

1450

Arrhythmia

Is there a preoperative arrhythmia present within two weeks of the procedure, by clinical documentation of any one of the following:

Atrial fibrillation/flutter requiring Rx; Heart block; Sustained Ventricular Tachycardia or Ventricular Fibrillation requiring cardioversion and/or IV amiodarone.

Choose one of the following:

Yes

No

5/03

In this definition, please define “heart block”.

Heart block refers to third degree heart block only.

9/03

Regarding pre-op arrhythmia within 2 weeks of the procedure: Atrial Fibrillation requiring treatment. Does this include a chronic A Fib in which admission EKG strip shows the A Fib pattern and the patient is on Coumadin and Cordarone at home or is this only meant to identify (in the case of a chronic condition) a patient that has an uncontrolled A Fib in which a change in medication was necessary in the two weeks before surgery?

The intent is to capture a pre-op arrhythmia that is present within two weeks of the procedure, whether chronic, new onset, stable, unstable.  In both of your examples, A Fib is present within two weeks of procedure, thus would be coded as "yes".

11/04

Pt has a history of A-fib and is being treated with Amniodarone.  If, within two weeks of surgery, the patient does not have break through A-fib would we still code “yes” to seq# 1450?

Yes.  If the patient is being treated for an arrhythmia but the patient does not experience the treated arrhythmia within two weeks of surgery you would still code “yes”.  Think of arrhythmias as you would diabetes.  Just because the patient is being treated with insulin and thus has more “normal” blood sugars does not mean that the patient no longer has the disease of diabetes.  Rather the patient is successfully being treated for diabetes.  Similarly, if a patient is being treated for an arrhythmia and does not have a breakthrough arrhythmia within two weeks of surgery; you would still consider the patient to have a history of the arrhythmia and thus would code “yes”.

To define “treated for an arrhythmia”:  a patient is considered being treated for an arrhythmia if they are on medication specifically to treat an arrhythmia.  Today, most arrhythmias are treated with antiarrhythmics.  Coumadin would not be considered a treatment for A-fib.  Rather, patients may be on Coumadin to treat potential complications of the arrhythmia but not to treat the arrhythmia.  Patients may or may not be on Digoxin to treat arrhythmias.  In the past Digoxin was used to treat A-fib, but patients can also be on Digoxin to decrease the O2 demands on the heart, increase contractility etc.  Therefore, do not assume that all patients that are on Digoxin are being treated for A-fib.  Amniodarone and other antiarrhythmic medications are used to treat for A-fib and other arrhythmias.  These antiarrhythmics should be recognized as such as compared to Digoxin and anticoagulants.

As an addendum:

Patient with history of A-fib being treated with Amniodarone, no A-fib two weeks prior to surgery -- in the post-op period converts to A-fib.  For this patient do not capture seq# 5320, Complication A-fib, since the A-fib would not be a new onset of A-fib.

1460

Arrhythmia Type

Which arrhythmia is present within two weeks of the procedure; choose one:

Sustained Ventricular Tachycardia or Ventricular Fibrillation requiring cardioversion and/or IV amiodarone.

Heart block.

Atrial fibrillation/flutter requiring Rx.

1530

Classification-CCS

Canadian Cardiovascular Society Classification. This classification represents level of functional status related to frequency and intensity of angina.  The CCS may not be the same as the NYHA classification for same evaluation time period.  Code the highest class leading to episode of hospitalization and/or intervention:

0 = No angina.

I  = Ordinary physical activity, such as walking or climbing the stairs does not cause angina.  Angina may occur with strenuous, rapid or prolonged exertion at work or recreation.

II  = There is slight limitation of ordinary activity.  Angina may occur with moderate activity such as walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals or in the cold, in the wind, or under emotional stress, or walking more than two blocks on the level, and climbing more than one flight of stairs at normal pace under normal conditions.

III  = There is marked limitation of ordinary physical activity.  Angina may occur after walking one or two blocks on the level or climbing one flight of stairs under normal conditions at a normal pace.

IV = There is inability to carry on physical activity without discomfort; angina may be present at rest.

Has the STS considered a Parent/Child relationship between Angina and CCS?  If Angina=No, then CCS=0.

This is a good suggestion for future versions.  In the meantime, you may be able to customize your own software by autoplating fields such as this? (4-19-02)

1540

Classification-NYHA

NYHA: New York Heart Association Class.  NYHA classification represents the overall functional status of the patient in relationship to both congestive heart failure and angina.  The NYHA may not be the same as the CCS classification for the same evaluation period.  Code the highest level leading to episode of hospitalization and/or procedure.

I  = Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

II  = Patients with cardiac disease resulting in slight limitation of physical activity.  They are comfortable at rest.  Ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain.

III  = Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest.  Less than ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain.

IV  = Patients with cardiac disease resulting in inability to carry on physical activity without discomfort.

When no history of heart disease, how is NYHA class coded (example:  car accident).

NYHA class represents limitations in function due to cardiac associated symptoms only.  In the case of a MVA, this scenario would be classed as IV only if there was associated cardiac trauma and the pain were cardiac in origin (3-25-02).

1640

Meds-Digitalis

Has the Patient received Digitalis within 24 hours preceding surgery?

1650

Meds-Beta Blockers

Has the Patient received Beta Blockers within 24 hours preceding surgery?

1670

Meds-ACE Inhibitors

Has the patient received ACE-inhibitors within 24 hours preceding surgery?

Do we only include ACE-I, or should we also include ACE-II, which are really ARB’s?  They are both ACE type meds, but do we include both of them for the ACE question?

Include ACE-I and ACE II’s (3-25-02).

SEE CORRECTION BELOW

CORRECTION

The STS answer to the above question is incorrect.  When coding ACE (Angiotensin Converting Enzyme) Inhibitors, do not include ARB’s (Angiotensin II Receptor Blockers).

1690

Meds-Nitrates-I.V.

Has the Patient received Nitrates within 24 hours preceding surgery?

1710

Meds-Antiplatelets

Has the Patient received any other Anti-platelets (incl. IIIA, IIB inhibitors) within 24 hours preceding surgery?

4/03

Do not include ASA or Ecotrin in this section.

1720

Meds-Anticoagulants

Has the Patient received Anticoagulants within 48 hours preceding surgery?

1730

Meds-Diuretics

Has the Patient received Diuretics within 24 hours preceding surgery?

1740

Meds-Inotropes

Has the Patient received Inotropic Agents within 48 hours preceding surgery?

The time frame for Inotropes was previously 24 hours.  It has now been changed to 48 hours.  Is  this a change, or a typographical error?

This is a change, not a typographical error (3-25-02).

1750

Meds-Steroids

Patient taking within 24 hours of surgery and does not include a one time dose related to prophylaxis therapy (i.e. IV dye exposure for cath procedure or surgery pre-induction period) Non-systemic medications are not included in this category (i.e. nasal sprays, topical creams)

1760

Meds-Aspirin

Has the Patient received Aspirin within 5 days preceding surgery?

4/03

Include Ecotrin in this section.

5/03

Section “H”

Pre Operative Hemodynamics and Cath

In the past, the STS has stated that using intra-op TEE results to code fields in Section “H”, Pre Operative Hemodynamics and Cath, was appropriate.   After reviewing this statement the STS has decided that intra-op TEE results should not be used to code this section.  Only procedure results obtained pre-op should be used to code this section.

Please note that it is not necessary to go back and change data that has been affected by this definition clarification.  However, moving forward please obtain data based on the clarification information given above.

1820

Num Dis Vessels

The number of major coronary vessel systems (LAD system, Circumflex system, and/or Right system) with > 50% narrowing in any angiographic view.  NOTE: Left main disease (>50%) is counted as TWO vessels (LAD and Circumflex). For example, left main and RCA would count as three total. Select from the following:

None (no significant coronary obstructive disease)

One

Two

Three

How do we classify the # of vessels if a patient has disease but not in the three systems defined in the definition (LAD, Circ and./or Right).  For example, do we consider the ramus, PDA, obtuse marginal each as 1 vessel disease?

Consider the vessels as belonging to systems.  The obtuse marginal would belong to the circumflex system.  The PDA would belong to either the right or the circumflex depending on the coronary dominance.  The dictated cath report should let you know where this vessel came from.  The ramus can be considered as part of the circumflex or the LAD system.  If a patient had the 3 vessels you mentioned as diseased >50% with the left system dominant, then the patient has only disease in 1 coronary system (3-25-02).

11/03

A patient went to the cath lab for severe restenosis of a large OM branch of the Circumflex and the vessel had 10-20 % stenosis after a cutting balloon was utilized to reopen the vessel.  The patient's LAD and RCA had less than 50% areas of stenosis at the time of the procedure.  A dissection of the proximal portion of the LAD possibly related to the withdrawal of the cutting balloon was noted.  The patient went for Urgent CABG.  For Seq# 1820, how many diseased vessels would there be since she may not have gone to the OR if the dissection hadn't occurred and the OM lesion was <50% after the cutting balloon procedure?

Patient’s diseased number of vessels is based on what the % stenosis was within the system, not based on what trauma occurred to a vessel.  So this patient will have vessel disease reflective of the OM branch of the Circumflex but not of the trauma to the LAD.   

1830

Left Main Dis > 50%

Left Main Coronary Disease is present when there is > 50% compromise of vessel diameter in any angiographic view.

1858

Hemo Data-EF Done

Was the Ejection Fraction measured pre-operatively?

1860

Hemo Data-EF

The percentage of the blood emptied from the ventricle at the end of the contraction. Use the most recent determination prior to intervention. Enter a percentage in the range of 5 - 90.

1870

Hemo Data-EF Method

How was the Ejection Fraction measurement information obtained?

LV Gram:  Left Ventriculogram

Radionuclide:  MUGA Scan

Estimate:  From other calculations, based upon available clinical data.

ECHO:  Echocardiogram

1915

Hemo Data - HDPA Mean Done

Was the mean pulmonary artery pressure measured?

In some cases HDPA mean is not determined and the field is left blank.  Will the STS be making a change in the definition so that sites can record when HDPA mean is not done?   In our case it was not done and we exceeded the 5% threshold.  For our site this will probably not change too much.

The 2.41 definition for PA mean changed to include this new parent field so that if no PA mean were calculated, you can answer no to this field.  The PA mean child field will only apply if Yes is answered to the PA mean collected.  (4-19-02)

1940

Hemo Data-PA Mean

Mean pulmonary artery pressure in mm Hg, recorded from catheterization data or Swan-Ganz catheter BEFORE the induction of anesthesia.

Therefore, if there was a surgery done without a catheterization, is the Hemo Data-PA Mean or PAMean value still required for STS reporting?

When PA pressure is NOT available from the catheterization report and we look further into the operative record, we have found that our institution places Swan-Ganz catheters after induction.  Therefore, is it correct to interpret that  we would NOT be gathering PAP pressures from the operative record?

The PA field should be marked not done unless specifically a right heart cath was done, or the patient had a preop PA catheter.  Please do not use the recorded PA catheter # in the OR after anesthesia induction.  Also, please do not use the LVEDP as a surrogate (3-25-02).

2010

VD-Stenosis-Aortic

Is Aortic Stenosis present?

2015

VDGradA

Indicate the mean gradient across the aortic valve obtained from an electrocardiogram or angiogram.

7/03

What should we enter if the patient had aortic stenosis but the aortic valve gradient was not documented in the patient's record?

You can only provide information that you have available.  If the information is not available leave the field blank.  However, seek out the department that is responsible for generating the report and/or the CT surgeon to get the answer.

2020

VD-Stenosis-Mitral

Is Mitral Stenosis present?

2030

VD-Stenosis-Tricuspid

Is Tricuspid Stenosis present?

2040

VD-Stenosis-Pulmonic

Is Pulmonic Stenosis present?

2050

VD-Insuff-Aortic

Is there evidence of Aortic valve regurgitation:

0 = None

1 = Trivial

2 = Mild

3 = Moderate

4 = Severe

2060

VD-Insuff-Mitral

Is there evidence of Mitral valve regurgitation:

0 = None

1 = Trivial

2 = Mild

3 = Moderate

4 = Severe

2070

VD-Insuff-Tricuspid

Is there evidence of Tricuspid valve regurgitation:

0 = None

1 = Trivial

2 = Mild

3 = Moderate

4 = Severe

2080

VD-Insuff-Pulmonic

Is there evidence of Pulmonic valve regurgitation:

0 = None

1 = Trivial

2 = Mild

3 = Moderate

4 = Severe

2230

Surgeon

Surgeon's Name

2235

Surgeon Group

The name of the Surgeon's practice group. If the surgeon is not a member of a group (solo practice) and has no group name, then use the surgeon's name.

2300

Status

Select one of the status that best describes the clinical status of the patient at the time of surgery

Emergent Salvage:

Definition: The patient is undergoing CPR en route to the OR or prior to anesthesia induction.

Emergent:

Definition: The patient’s clinical status includes any of the following:

a. Ischemic dysfunction (any of the following): (1) Ongoing ischemia including rest angina despite maximal medical therapy (medical and/or IABP)); (2) Acute Evolving Myocardial Infarction within 24 hours before surgery; or (3) pulmonary edema requiring intubation.

b.. Mechanical dysfunction (either of the following): (1) shock with circulatory support; or (2) shock without circulatory support.

Urgent:

Definition: ALL of the following conditions are met:

a. Not elective status.

b. Not emergent status.

c. Procedure required during same hospitalization in order to minimize chance of further clinical deterioration.

d. Worsening, sudden chest pain, CHF, acute myocardial infarction (AMI), anatomy, IABP, unstable angina (USA) with intravenous (IV) nitroglycerin (NTG) or rest angina may be included.

2310

Urgent Reason

Delay in the operation is necessitated only by attempts to improve the patient's condition, availability of a spouse or parent for informed consent, availability of blood products, or the availability of results of essential laboratory procedures or tests.

Which one of the following applies as the reason why the patient had Urgent Status? (Select one)

Acute myocardial infarction (AMI).

IntraAortic Balloon Pump (IABP).

Worsening, sudden chest pain.

Congestive Heart Failure (CHF).

Coronary Anatomy.

Unstable angina (USA) with intravenous (IV) nitroglycerin (NTG).

Rest angina.

Valve Dysfunction

Aortic Dissection

There used to be an Angiographic Accident/Hemodynamic Instability choice for this field and for “Emergent Reason”.”  What should the alternative be?

The new data fields are linked to associate PTCA < 6 hrs with Urgent and Emergent, and therefore it was possible to eliminate this field. (4-19-02)

We have cases that could fit into either Urgent or Emergent.  What should we do to determine which is the appropriate category?

The definition for the Emergent category is specific, as is the Elective category.  Urgent is everything else. (4-19-02)

5/03

Please define “valve disfunction” in regards to urgent status.

Valve dysfunction is typically associated with mechanical valves and is defined as a structural failure with that mechanical valve – fractured leaflet, thrombus formation, panus development which impedes flow through the valve orifice.  If any of these situations occur a patient’s clinical status is often compromised and the degree of compromise will determine the status – urgent, emergent, or emergent salvage.

2320

Emergent Reason

Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery.  An emergency operation is one in which there should be no delay in providing operative intervention.

Which one of the following applies as the reason why the patient had Emergent Status? (Select one):

Shock with circulatory support.

Shock without circulatory support.

Pulmonary edema requiring intubation.

Acute Evolving Myocardial Infarction within 24 hours before surgery.

Ongoing ischemia including rest angina despite maximal medical therapy (medical and/or IABP).

Valve Dysfunction

Aortic Dissection

Choices include “Shock with circulatory support” and “Shock without circulatory support.”  Please define “Circulatory support.”

Circulatory support was defined by ACC, STS and Dr. Robert Jones'’ short-term outcomes recording paper as:  Shock—please see definition of shock in patient history circulatory support: IABP and/or IV inotrope to maintain DPB or CO.  (3-25-02)

5/03

Please define “valve dysfunction” in regards to emergent status.

Valve dysfunction is typically associated with mechanical valves and is defined as a structural failure with that mechanical valve – fractured leaflet, thrombus formation, panus development which impedes flow through the valve orifice.  If any of these situations occur a patient’s clinical status is often compromised and the degree of compromise will determine the status – urgent, emergent, or emergent salvage.

2340

CAB

Was coronary artery bypass grafting done?

2350

VS-Aortic Proc-Procedure

Was a surgical procedure done on the Aortic Valve, and if so what? Select one of the following:

No;

Replacement;

Repair/Reconstruction;

Root Reconstruction with Valve Conduit;

Root Reconstruction with Valve Sparing;

Resuspension Aortic Valve;

Resection Sub-Aortic Stenosis.