2020 AHA/ACC Key Data Elements and Definitions for Coronary Revascularization: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Coronary Revascularization)

April 27, 2020 Editor

Aortic regurgitation The degree of aortic regurgitation (insufficiency) reported closest to incision but not >6 mo before surgery • Aortic regurgitation, severe• Aortic regurgitation, moderate• Aortic regurgitation, mild• Aortic regurgitation, none• Aortic regurgitation not assessed. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰ Aortic regurgitation, severe • Jet width ≥65% of LVOT• Vena contracta >0.6 cm• Holodiastolic flow reversal in the proximal abdominal aorta• RVol ≥60 mL/beat• RF ≥50%• ERO ≥0.3 cm² Aortic regurgitation, moderate • Jet width 25%–64% of LVOT• Vena contracta 0.3–0.6 cm• RVol 30–59 mL/beat• RF 30%–49%• ERO 0.10–0.29 cm² Aortic regurgitation, mild • Jet width <25% of LVOT• Vena contracta <0.3 cm• RVol <30 mL/beat• RF <30%• ERO <0.10 cm² Aortic regurgitation, none Aortic regurgitation, not assessed Aortic valve disease The presence of any stenosis or regurgitation (insufficiency) greater than “trace” • Yes• No STS ACSD v2.9 Training Manual (seq. #1595)⁸ Aortic stenosis The presence of any degree of aortic stenosis • Yes• No STS ACSD v2.9 Training Manual (seq. #1600)⁸ Most recent value closest to surgery but not >6 mo before surgery. Hemodynamic/echocardiography data available Aortic valve hemodynamic measurements are available. • Yes• No STS ACSD v2.9 Training Manual (seq. #1605)⁸ Most recent value closest to induction but not >6 mo before induction, or the value closest to and before incision if no reported values are available. Aortic valve area The documented aortic valve area closest to the time of incision, before induction • Numeric, in cm² STS ACSD v2.9 Training Manual (seq. #1610)⁸ Most recent value closet to induction but not >6 mo before; the value closest to and before incision if no reported values are available. Mean aortic valve gradient The documented mean gradient across the documented aortic valve • Numeric, in mm Hg STS ACSD v2.9 Training Manual (seq. #1615)⁸ Most recent value before induction but not >6 mo before, or the value closest to and before incision if no reported values are available. Mitral regurgitation, primary The degree of mitral regurgitation reported • Mitral regurgitation, severe• Mitral regurgitation, moderate (progressive)• Mitral regurgitation, mild (at risk of MR)• Mitral regurgitation, none• Mitral regurgitation, not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰O’Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70:2421–49.⁷³STS ACSD v2.9 Training Manual (seq. #1680)⁸ Most recent value closest to incision but not >6 mo before. Mitral regurgitation, severe • Central jet mitral regurgitation >40% LA or holosystolic eccentric jet mitral regurgitation• Vena contracta ≥0.7 cm• Regurgitant volume ≥60 mL• Regurgitant fraction ≥50%• ERO ≥0.40 cm² Mitral regurgitation, moderate (progressive) • Central jet mitral regurgitation 20%–40% LA or late systolic eccentric jet mitral regurgitation• Vena contracta <0.7 cm• Regurgitant volume <60 mL• Regurgitant fraction <50%• ERO <0.40 cm² Mitral regurgitation, mild (at risk of MR) • No mitral regurgitation jet or small central jet area <20% LA on Doppler• Small vena contracta <0.3 cm Mitral regurgitation, none Mitral regurgitation, not assessed Mitral regurgitation, secondary The degree of mitral regurgitation reported • Mitral regurgitation, severe• Mitral regurgitation, moderate (progressive)• Mitral regurgitation, mild (at risk of MR)• Mitral regurgitation, none• Mitral regurgitation, not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰O’Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70:2421–49.⁷³ Mitral regurgitation, severe • ERO ≥0.20 cm²• Regurgitant volume ≥30 mL• Regurgitant fraction ≥50% Mitral regurgitation, moderate (progressive) • ERO <0.20 cm²• Regurgitant volume <30 mL• Regurgitant fraction <50% Mitral regurgitation, mild (at risk of MR) • No mitral regurgitation jet or small central jet area <20% LA on Doppler• Small vena contracta <0.30 cm Mitral regurgitation, none Mitral regurgitation, not assessed Mitral stenosis Presence of mitral stenosis • Yes• No STS ACSD v2.9 Training Manual (seq. #1690)⁸ Most recent value closest to incision but not >6 mo before, even if patient is not scheduled for valve repair and/or replacement. Hemodynamic/echocardiography data available Availability of mitral valve hemodynamic measurements • Yes• No STS ACSD v2.9 Training Manual (seq. #1695)⁸ Mitral valve area The documented MV area closest to the time of incision, before induction • Numeric, in cm² STS ACSD v2.9 Training Manual (seq. #1700)⁸ Most recent value before induction but not >6 mo before, or the value closest to and before incision if no reported values are available. Mean gradient The documented mean gradient (in mm Hg) across the MV closest to the time of incision, before induction • Numeric, in mm Hg STS ACSD v2.9 Training Manual (seq. #1705)⁸ Most recent value before induction but not >6 mo before, or the value closest to and before incision if no reported values are available. Carpentier mitral leaflet motion classification Mechanism of leaflet motion • Type I• Type II• Type IIIA• Type IIIB O’Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70:2421–49.⁷³ The next STS ACSD version upgrade will collect Carpentier classification (I, II, IIIA, IIIB, mixed [II and IIIA]) Type I • Normal leaflet motion• Annular dilation, leaflet perforation• Regurgitation jet directed centrally Type II • Excessive leaflet motion• Papillary muscle rupture, chordal rupture, redundant chordae• Eccentric jet, directed away from involved leaflet Type IIIA • Leaflet motion restricted in both systole and diastole• Rheumatic heart disease• Jet may be centrally or eccentrically directed Type IIIB • Leaflet motion restricted in diastole• Papillary muscle dysfunction, left ventricular dilation• Jet may be centrally or eccentrically directed Mitral valve disease etiology Cause of MV disease. • Myxomatous degeneration/prolapse• Rheumatic• Ischemic—acute, post infarction (MI ≤21 d)• Ischemic-chronic (MI >21 d)• Nonischemic cardiomyopathy• Endocarditis• Hypertrophic obstructive cardiomyopathy• Tumor, carcinoid• Tumor, myxoma• Tumor, papillary fibroelastoma• Tumor, other• Carcinoid• Trauma• Congenital• Pure annular dilatation• Reoperation—failure of prior MV repair or replacement• Mixed etiology• Not documented STS ACSD v2.9 Training Manual (seq. #1731)⁸ Note that in the next STS ACSD version upgrade the choices for tumors will be combined, carcinoid will be renamed as carcinoid syndrome, and endocarditis (prosthetic valve), and radiation-induced heart disease will be added as options for etiology. Mitral valve lesion Type of MV lesion • Leaflet prolapse, posterior• Leaflet prolapse, bileaflet• Leaflet prolapse, anterior• Leaflet prolapse, unspecified• Elongated/ruptured chord(s)/flail• Annular dilatation• Leaflet calcification• Leaflet perforation/hole• Mitral annular calcification• Papillary muscle elongation• Papillary muscle rupture• Leaflet thickening• Leaflet retraction• Chordal tethering• Chordal thickening/retraction/fusion• Commissural fusion• Mixed lesion• Not documented STS ACSD v2.9 Training Manual (seq. #1746)⁸ Tricuspid valve regurgitation Evidence of tricuspid valve regurgitation/insufficiency • Tricuspid regurgitation, severe• Tricuspid regurgitation, moderate (progressive)• Tricuspid regurgitation, mild (progressive)• Tricuspid regurgitation, none• Tricuspid regurgitation, not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰ Most recent value closest to incision but not >6 mo before. Tricuspid regurgitation, severe • Central jet area >10.0 cm²• Vena contracta width >0.70 cm• CW jet density and contour: Dense, triangular with early peak• Hepatic vein flow: Systolic reversal Tricuspid regurgitation, moderate (progressive) • Central jet area 5.0–10.0 cm²• Vena contracta width not defined but <0.70 cm• CW jet density and contour: Dense, variable contour• Hepatic vein flow: Systolic blunting Tricuspid regurgitation, mild (progressive) • Central jet area <5.0 cm²• Vena contracta width not defined• CW jet density and contour: Soft and parabolic• Hepatic vein flow: Systolic dominance Tricuspid regurgitation, none Tricuspid regurgitation, not assessed Tricuspid valve disease The presence of any stenosis or regurgitation/insufficiency greater than “trace” • Yes• No STS ACSD v2.9 Training Manual (seq. #1780)⁸ Tricuspid stenosis The presence of any degree of tricuspid valve stenosis • Yes• No STS ACSD v2.9 Training Manual (seq. #1785)⁸ Incidence (of cardiac surgical procedures) Whether this is the patient’s first or subsequent cardiac surgical procedure • First cardiovascular surgery• First reop cardiovascular surgery• Second reop cardiovascular surgery• Third reop cardiovascular surgery• Fourth or more reop cardiovascular surgery• N/A—not a cardiovascular surgery For the purposes of this data element a cardiothoracic surgical procedure is defined as a surgical procedure performed on the heart, great vessels or major pericardial procedures with or without the use of CPB. The procedure must involve surgical (open) entry into the pericardial space to qualify. STS ACSD v2.9 Training Manual (seq. #1970)⁸ First cardiovascular surgery The first cardiovascular surgical procedure involving entry into the pericardium. The exception to this would be a patient with a prior transcatheter valve procedure that requires surgical replacement of the prior transcatheter prosthesis. This situation would qualify as a reoperation. First reop cardiovascular surgery A second intrapericardial procedure. Second reop cardiovascular surgery A third intrapericardial procedure. Third reop cardiovascular surgery A fourth intrapericardial procedure. Fourth or more reop cardiovascular surgery. A fifth or more intrapericardial procedure. N/A—not a cardiovascular surgery A procedure that does not qualify. Status The clinical status of the patient prior to entering the OR. • Elective• Urgent• Emergency• Emergency/salvage STS ACSD v2.9 Training Manual (seq. #1975)⁸ Elective The patient’s cardiac function has been stable in the days or weeks before surgery. The procedure could be deferred without increased risk of compromise cardiac outcome. Urgent Procedure required during same hospitalization to minimize chance of further clinical deterioration.Examples include but are not limited to worsening, sudden chest pain, HF, AMI, anatomy, IABP, UA, with IV nitroglycerin, or rest angina. Emergency Patients requiring emergency surgeries 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 surgery is one in which there should be no delay in providing operative intervention. Emergency/salvage Patients requiring CPR en route to the OR before induction of anesthesia or requiring ECMO to maintain life. Urgent/emergency reason for surgery • AMI• Anatomy• Aortic aneurysm• Aortic dissection• HF• Device failure• Diagnostic/interventional procedure complication• Endocarditis• Failed transcatheter valve therapy• IABP• Infected device• Intracardiac mass or thrombus• Ongoing ischemia• PCI incomplete without clinical deterioration• PCI or attempted PCI with clinical deterioration• Pulmonary edema• Pulmonary embolus• Rest angina• Shock, circulatory support• Shock, no circulatory support• Syncope• Transplant• Trauma• Unstable angina• Valve dysfunction• Worsening CP• Other reasons STS ACSD v2.9 Training Manual (seq. #1990)⁸ These terms are not further defined by the STS. Initial operative approach The initial operative approach • Full conventional sternotomy• Partial sternotomy• Transverse sternotomy (includes clamshell)• Right or left parasternal incision• Subxiphoid• Subcostal• Left thoracotomy• Right thoracotomy• Bilateral thoracotomy• Limited (mini) thoracotomy, right (transapical TAVR)• Limited (mini) thoracotomy, left• Limited (mini) thoracotomy, bilateral• Thoracoabdominal incision• Percutaneous• Port access• Other• None (canceled case) STS ACSD v2.9 Training Manual (seq. #2100)⁸ Note that in the next version of the STS ACSD, transverse sternotomy, right or left parasternal, subcostal, port access, and none will be removed as separate options and coded as “other.” Additionally, all thoracotomy and mini thoracotomy approaches will be combined into 1 “thoracotomy” option. Approach converted during procedure Operative approach converted during the procedure • Yes, planned• Yes, unplanned• No STS ACSD v2.9 Training Manual (seq. #2105)⁸ Note that these options will change to yes or no in the next STS ACSD version upgrade. Robot used Robotic assistance used during cardiac surgery • Yes• No STS ACSD v2.9 Training Manual (seq. #2110)⁸ These terms are not further defined by the STS. Extent of robot use Time frame of robotic use • Entire operation• Part of the operation STS ACSD v2.9 Training Manual (seq. #2115)⁸ Surgical coronary revascularization (ie, CABG); planned or unplanned CABG performed • Yes, planned• Yes, unplanned due to surgical complication• Yes, unplanned due to unsuspected disease or anatomy• No STS ACSD v2.9 Training Manual (seq. #2120)⁸ These distinctions are made so that STS can accurately classify the category of the operation for the purposes of risk stratification and performance assessment. Yes, planned Yes, unplanned due to surgical complication Surgical coronary revascularization is required to address a complication of another cardiac surgical procedure performed during this same operation. Yes, unplanned due to unsuspected disease or anatomy Surgical coronary revascularization is necessitated by disease or anatomy that was not anticipated and/or recognized prior to surgery. No Other cardiac procedure, atrial fibrillation Surgical procedure was performed for atrial fibrillation. • Yes• No STS ACSD v2.9 Training Manual (seq. #2145)⁸ Valve surgery performed Surgical procedure performed on ≥1 cardiac valves. • Yes, planned• Yes, unplanned due to surgical complication• Yes, unplanned due to unsuspected disease or anatomy• No STS ACSD v2.9 Training Manual (seq. #2125)⁸ These distinctions are made so that STS can accurately classify the category of the operation for the purposes of risk stratification and performance assessment. Yes, planned Yes, unplanned due to surgical complication Surgical valve procedure is required to address a complication of another cardiac surgical procedure performed during this same operation. Yes, unplanned due to unsuspected disease or anatomy Surgical coronary revascularization is necessitated by disease or anatomy that was not anticipated and/or recognized before surgery. No Aorta procedure performed Surgical procedure performed on the aorta. • Yes, planned• Yes, unplanned due to surgical complication• Yes, unplanned due to unsuspected disease or anatomy• No STS ACSD v2.9 Training Manual (seq. #2128)⁸ These distinctions are made so that STS can accurately classify the category of the operation for the purposes of risk stratification and performance assessment. Yes, planned Yes, unplanned due to surgical complication A procedure on the aorta is required to address a complication of another cardiac surgical procedure performed during this same operation. Yes, unplanned due to unsuspected disease or anatomy A procedure on the aorta is necessitated by disease or anatomy that was not anticipated and/or recognized before surgery. No Other cardiac procedure performed Another cardiac procedure was performed other than CABG and/or valve procedures. • Yes, planned• Yes, unplanned due to surgical complication• Yes, unplanned due to unsuspected disease or anatomy• No STS ACSD v2.9 Training Manual (seq. #2140)⁸ Yes, planned Yes, unplanned due to surgical complication An “other” cardiac procedure was required to address a complication of another cardiac surgical procedure performed during this same operation. Yes, unplanned due to unsuspected disease or anatomy An “other” cardiac procedure was necessitated by disease or anatomy that was not anticipated and/or recognized before surgery. No Other noncardiac procedure performed Noncardiac procedure performed. • Yes• No STS ACSD v2.9 Training Manual (seq. #2155)⁸ Operating room entry date and time Date and time to the nearest minute (using 24-h clock) that the patient enters the OR. • Date, in mm-dd-yyyy• Time, in hh:mm (24-h clock) STS ACSD v2.9 Training Manual (seq. #2245)⁸ If the procedure was performed in a location other than the OR, record the time when the sterile field, or its equivalent, was set up. Operating room exit date and time Date and time to the nearest minute (using 24-h clock) that the patient exits the OR. • Date, in mm/dd/yyyy• Time, in hh:mm (24-h clock) STS ACSD v2.9 Training Manual (seq. #2250)⁸ If the procedure was performed in a location other than the OR, record the time when the sterile field, or its equivalent, was set up. Appropriate antibiotic selection Documentation of an order for a first- or second-generation cephalosporin prophylactic antibiotic, and documentation that it was given preoperatively or in the event of a documented allergy an alternate antibiotic choice is ordered and administered. • Yes• No• Exclusion STS ACSD v2.9 Training Manual (seq. #2280)⁸Engelman R, Shahian D, Shemin R, et al. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: antibiotic choice. Ann Thorac Surg. 2007;83:1569–76.⁷⁴ Appropriate antibiotic administration timing Prophylactic antibiotics administered within 1 h of surgical incision or start of procedure if no incision required (2 h if receiving vancomycin or fluoroquinolone). • Yes• No• Exclusion STS ACSD v2.9 Training Manual (seq. #2285)⁸Edwards FH, Engelman RM, Houck P, et al. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part I: duration. Ann Thorac Surg. 2006;81:397–404.⁷⁵ Cardiopulmonary bypass utilization Level of CPB or coronary perfusion used during the procedure • None• Combination• Full STS ACSD v2.9 Training Manual (seq. #2325)⁸ None No CPB or coronary perfusion used during the procedure Combination With or without CPB and/or with or without coronary perfusion at any time during the procedure (capture conversions from off-pump to on-pump only) Full CPB or coronary perfusion was used for the entire procedure Cardiopulmonary bypass utilization, combination Use of both off-pump and on-pump technique was planned or unplanned • Planned• Unplanned STS ACSD v2.9 Training Manual (seq. #2330)⁸ Reason for unplanned combination cardiopulmonary bypass utilization Reason there was unplanned use of a combined approach • Exposure/visualization• Inadequate size/diffuse disease of distal vessel• Hemodynamic instability (hypotension/arrhythmias)• Conduit quality and/or trauma• Other STS ACSD v2.9 Training Manual (seq. #2335)⁸ Arterial cannulation insertion site Arterial cannulation site for CPB • Aortic• Femoral• Axillary• Innominate• Other• No STS ACSD v2.9 Training Manual (seq. #2340, 2345, 2350, 2355)⁸ Venous cannulation insertion site Venous cannulation site for CPB • Femoral• Jugular• Right atrial• Left atrial• Pulmonary vein• Caval/bicaval• Other STS ACSD v2.9 Training Manual (seq. #2365, 2370, 2375, 2380, 2385, 2390, 2395)⁸ Cardiopulmonary bypass time Total minutes of CPB • Numeric, in min STS ACSD v2.9 Training Manual (seq. #2400)⁸ Aorta occlusion Technique of ascending aortic occlusion • None, beating heart• None, fibrillating heart• Aortic cross clamp• Balloon occlusion STS ACSD v2.9 Training Manual (seq. #2430)⁸ Cross clamp time Total number of minutes the coronary circulation is mechanically isolated from the systemic circulation either by an aortic cross clamp or systemic circulatory arrest. • Numeric, in min STS ACSD v2.9 Training Manual (seq. #2435)⁸ Cardioplegia delivery Method of cardioplegia delivery • None, if not used• Antegrade• Retrograde• Both STS ACSD v2.9 Training Manual (seq. #2440)⁸ None Cardioplegia not used Antegrade From the aortic root or by coronary artery cannulation Retrograde From the coronary sinus Both From the aortic root and coronary sinus Type of cardioplegia Composition of the cardioplegic solution • Blood• Crystalloid• Blood and crystalloid• Other STS ACSD v2.9 Training Manual (seq. #2445)⁸ Cerebral oximetry used Cerebral oximetry used to monitor the cerebral circulation. • Yes• No STS ACSD v2.9 Training Manual (seq. #2450)⁸ Intraoperative blood products Transfusion of any blood products (packed red blood cells, platelets, fresh frozen plasma or cryoprecipitate) during surgery • Yes• No• Refused STS ACSD v2.9 Training Manual (seq. #2515)⁸ Intraoperative blood products, type Type of blood products infused intraoperatively • Red blood cells• Platelets• Fresh frozen plasma• Cryoprecipitate STS ACSD v2.9 Training Manual (seq. #2520, 2525, 2530, 2535)⁸ Intraoperative blood products, quantity Units of each type of blood product transfused during surgery. • Numeric, in units for:– Red blood cells– Platelets– Fresh frozen plasma– Cryoprecipitate STS ACSD v2.9 Training Manual (seq. #2520, 2525, 2530, 2535)⁸ Intraoperative clotting factors Clotting factors administered intraoperatively. • Yes, Factor VIIa• Yes, FEIBA• Yes, composite• No STS ACSD v2.9 Training Manual (seq. #2545)⁸ Intraoperative antifibrinolytic medications Antifibrinolytic medications administered intraoperatively. • Epsilon aminocaproic acid• Tranexamic acid• No STS ACSD v2.9 Training Manual (seq. #2550, 2555)⁸ Aprotinin will be included as an option in the next STS ACSD version upgrade. Transesophageal echocardiography performed postprocedure TEE performed in the OR, post cardiac procedure, off CPB and before OR exit. • Yes• No STS ACSD v2.9 Training Manual (seq. #2560)⁸ Highest level of aortic regurgitation found Highest level of aortic regurgitation/insufficiency demonstrated by TEE post CPB and before OR exit. • Aortic regurgitation, severe• Aortic regurgitation, moderate• Aortic regurgitation, mild• Aortic regurgitation, none• Aortic regurgitation not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰ Aortic regurgitation, severe • Jet width ≥65% of LVOT• Vena contracta >0.6 cm• Holodiastolic flow reversal in the proximal abdominal aorta• RVol ≥60 mL/beat• RF ≥50%• ERO ≥0.3 cm² Aortic regurgitation, moderate • Jet width 25%–64% of LVOT• Vena contracta 0.3–0.6 cm• RVol 30–59 mL/beat• RF 30%–49%• ERO 0.10–0.29 cm² Aortic regurgitation, mild • Jet width <25% of LVOT• Vena contracta <0.3 cm• RVol <30 mL/beat• RF <30%• ERO <0.10 cm² Aortic regurgitation, none Aortic regurgitation, not assessed Highest level of mitral regurgitation found Highest level of mitral regurgitation/insufficiency demonstrated by TEE post CPB and before OR exit. • Mitral regurgitation, severe• Mitral regurgitation, moderate (progressive)• Mitral regurgitation, mild (at risk of MR)• Mitral regurgitation, none• Mitral regurgitation, not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰ Mitral regurgitation, severe • Central jet mitral regurgitation >40% LA or holosystolic eccentric jet mitral regurgitation• Vena contracta ≥0.7 cm• Regurgitant volume ≥60 mL• Regurgitant fraction ≥50%• ERO ≥0.40 cm² Mitral regurgitation, moderate (progressive) • Central jet mitral regurgitation 20%–40% LA or late systolic eccentric jet mitral regurgitation• Vena contracta <0.7 cm• Regurgitant volume <60 mL• Regurgitant fraction <50%• ERO <0.40 cm² Mitral regurgitation, mild (at risk of MR) • No MR jet or small central jet area <20% LA on Doppler• Small vena contracta <0.3 cm Mitral regurgitation, none Mitral regurgitation, not assessed Highest level of tricuspid regurgitation found Highest level of tricuspid regurgitation/insufficiency demonstrated by TEE and post CPB before OR exit. • Tricuspid regurgitation, severe• Tricuspid regurgitation, moderate (progressive)• Tricuspid regurgitation, mild (progressive)• Tricuspid regurgitation, none• Tricuspid regurgitation, not assessed Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.⁶⁰ Tricuspid regurgitation, severe • Central jet area >10.0 cm²• Vena contracta width >0.70 cm• CW jet density and contour: Dense, triangular with early peak• Hepatic vein flow: Systolic reversal Tricuspid regurgitation, moderate (progressive) • Central jet area 5.0–10.0 cm²• Vena contracta width not defined but <0.70 cm• CW jet density and contour: Dense, variable contour• Hepatic vein flow: Systolic blunting Tricuspid regurgitation, mild (progressive) • Central jet area <5.0 cm²• Vena contracta width not defined• CW jet density and contour: Soft and parabolic• Hepatic vein flow: Systolic dominance Tricuspid regurgitation, none Tricuspid regurgitation, not assessed Ejection fraction, post procedure LVEF obtained intraoperatively post procedure. • Yes• No STS ACSD v2.9 Training Manual (seq. #2581)⁸ Ejection fraction Measured EF • Numeric value STS ACSD v2.9 Training Manual (seq. #2582)⁸ Combined cardiac surgery and PCI performed Combination of a cardiac surgical procedure and PCI performed. • PCI + CABG• PCI + valve• PCI + aortic• PCI + other• No Commonly referred to as a hybrid procedure Combined cardiac surgery, status Timing of combined procedure. • Concurrent, same setting• Staged, PCI followed by surgery• Staged, surgery followed by PCI PCI procedure • Angioplasty• Stent• Angioplasty and stent• Atherectomy• Attempted PCI UDIs could be substituted in the future if available. Angioplasty PCI performed only by the use of a balloon. Stent A metal scaffold intended to expand a stenosis and prevent vessel recoil. Angioplasty and stent Combination of a balloon angioplasty at 1 location and stent placement at a different location. Atherectomy Endovascular procedure in which atheromatous plaque is excised by a cutting or rotating catheter. Attempted PCI A PCI that was attempted but unsuccessful. Stent type • Bare-metal• Drug-eluting• Drug-eluting with bioabsorbable polymer• Bioresorbable• Covered• Multiple• Unknown UDIs could be substituted in the future if available. Bare-metal Metallic coronary stent without a polymer or antiproliferative drug coating Drug-eluting Metallic coronary stent with or without a polymer but with an antiproliferative drug coating Drug-eluting with bioabsorbable polymer Metallic coronary stent with a bioabsorbable polymer with an antiproliferative drug coating Bioresorbable Stent struts composed of bioabsorbable materials also containing an antiproliferative drug Covered Metallic coronary stent scaffold incorporating fabric or graft material, such as polytetrafluoroethylene (PTFE) or polyurethane as a membrane component Multiple Treatment of several arteries using different stent types Unknown A proper value is applicable but not known Planned postprocedure PCI Planned PCI after OR exit and before hospital discharge • Yes• No STS ACSD v2.9 Training Manual (seq. #2606)⁸ Number of distal anastomoses with arterial conduits Total number of distal coronary anastomoses performed with arterial conduits. • Numeric Number of distal anastomoses with venous conduits Total number of distal coronary anastomoses performed with venous conduits. • Numeric STS ACSD v2.9 Training Manual (seq. #2638)⁸ Vein harvest technique Technique used for venous harvesting. • Endoscopic• Direct vision (open)• Endoscopic and direct vision (open)• Cryopreserved STS ACSD v2.9 Training Manual (seq. #2639)⁸ Vein harvest and prep time Total time for saphenous vein harvest and preparation. Numeric, min STS ACSD v2.9 Training Manual (seq. #2640)⁸ Internal mammary artery used for grafts IMA used for grafting. • Left IMA• Right IMA• Both IMAs• No IMA STS ACSD v2.9 Training Manual (seq. #2626)⁸ Primary reason for not using internal mammary artery Reason for not using an IMA graft for coronary revascularization • Subclavian stenosis• Prior cardiac or thoracic surgery• Prior mediastinal radiation• Emergency or salvage procedure• No (bypassable) LAD disease• Other• Other, acceptable STS-provided exclusion STS ACSD v2.9 Training Manual (seq. #2627)⁸ Note that in the next version of the STS ACSD, an option will be provided to account for rare STS-approved exclusions that are not currently listed by the NQF. Total number of distal anastomoses using internal mammary artery grafts Total number of distal anastomoses using IMA grafts • Numeric STS ACSD v2.9 Training Manual (seq. #2628)⁸ Note that in the next version of the STS ACSD, this field will be removed. The total of IMA conduits will be collected if the IMA was used for the entire conduit or if a distal portion of composite graft was IMA. Radial arteries used for grafts Radial artery used for conduit. • Yes• No STS ACSD v2.9 Training Manual (seq. #2633)⁸ Number of radial artery distal anastomoses Total number of distal anastomoses with radial arteries • Numeric STS ACSD v2.9 Training Manual (seq. #2634)⁸ Number of other arterial distal anastomoses used (other than radial or internal mammary artery) Number of arterial distal anastomoses that were used, other than radial or IMA. • Numeric STS ACSD v2.9 Training Manual (seq. #2641)⁸ Proximal technique Technique used for proximal graft anastomosis. • Single cross clamp• Partial occlusion clamp• Anastomotic assist device STS ACSD v2.9 Training Manual (seq. #2710)⁸ Distal graft insertion site • Numerical value(s) and segment name(s) according to the coronary segment classification in Appendix 10 Hicks KA, Tcheng JE, Bozkurt B, et al. 2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Cardiovascular Endpoints Data Standards). Circulation. 2015;132:302–61.¹⁵ Proximal site Proximal site of bypass graft • In situ mammary• Ascending aorta• Descending aorta• Subclavian artery• Innominate artery• T-graft off SVG• T-graft off radial• T-graft off LIMA• T-graft off RIMA• Natural Y vein graft• Other STS ACSD v2.9 Training Manual (seq. #2740)⁸ Note that in the next version of the ACSD the options will be aorta, T-graft off artery, T-graft off vein, in situ IMA, and other. Conduit Conduit type used. • Vein graft• In situ LIMA• In situ RIMA• Free IMA• Radial artery• Other arteries, homograft• Synthetic graft• Composite artery-vein STS ACSD v2.9 Training Manual (#2750)⁸ Note that in the next version of the STS ACSD, the options will be in situ IMA, free IMA, vein, radial artery, and other. If composite, then the distal portion of the composite will be captured. Distal anastomotic technique Anastomotic position of distal site • End-to-side• Sequential (side-to-side) STS ACSD v2.9 Training Manual (seq. #2755)⁸ Coronary endarterectomy Coronary endarterectomy performed. • Yes• No STS ACSD v2.9 Training Manual (seq. #2760)⁸ Postoperative events • Sternal superficial wound infection• Deep sternal infection/mediastinitis• Thoracotomy site infection• Conduit harvest site infection• Cannulation site infection• Reoperation for bleeding/tamponade• Reoperation for valvular dysfunction• Reintervention for MI• Aortic reintervention• Reoperation for other cardiac reasons• Returned to the OR for other noncardiac reasons• Open chest with planned delayed sternal closure• Sternotomy issue• Sepsis• Stroke, ischemic• Stroke, hemorrhagic• Stroke, undetermined cause• TIA• Encephalopathy, anoxic• Encephalopathy, drug-induced• Encephalopathy, metabolic• Encephalopathy, unknown cause• Coma/unresponsive state (not stroke)• Lower extremity paralysis• Paresis, transient• Paresis, permanent• Phrenic nerve injury• Recurrent laryngeal nerve injury• Prolonged ventilation• Pneumonia• Pulmonary thromboembolism• Deep venous thrombosis• Pleural effusion requiring drainage• Pneumothorax requiring intervention• Renal (kidney) failure• Dialysis, newly required• Ultrafiltration required• Iliac/femoral dissection• Acute limb ischemia• Mechanical assist device-related complication• Rhythm disturbance requiring permanent device• Cardiac arrest• Postoperative aortic endoleak• Aortic rupture• Aortic dissection• Aortic side branch malperfusion STS ACSD Data Collection Form v2.9⁷⁶ Note that in the next version of the STS ACSD, the italicized postoperative events will be eliminated. The underlined events will be revised as follows: The 3 subcategories of stroke will be combined into a single field “stroke”; for patients undergoing aortic surgery the field related to paresis/paralysis will be revised to “Paralysis >24 h” and “Paresis >24 h”; the fields related to encephalopathy will be combined into a single field “encephalopathy/delirium”; anticoagulant event will be more specifically defined as “anticoagulant bleeding event”; GI event will be subcategorized to include liver dysfunction/failure, ischemic bowel, GI bleeding, pancreatitis, cholecystitis, and other. New postoperative events will include heparin-induced thrombocytopenia and heparin-induced thrombocytopenia with thrombosis.• Aortic stent graft-induced entry tear• Anticoagulant bleeding event• Pericardiocentesis• GI event• Liver dysfunction/failure• Multisystem failure• Atrial fibrillation• Operative mortality• Other Sternal superficial wound infection A superficial sternal wound infection was diagnosed within 90 d of the procedure or any time during the hospitalization for surgery. STS ACSD v2.9 Training Manual (seq. #6695)⁸Surgical Site Infection (SSI) Event. National Healthcare Safety Network (NHSN) Patient Safety Component Manual.⁷⁷ Additional details of this metric can be found in the STS Training Manual. Deep sternal infection/mediastinitis A deep sternal wound infection or mediastinitis was diagnosed within 90 d of the procedure or any time during the hospitalization for surgery. STS ACSD v2.9 Training Manual (seq. #6700)⁸Surgical Site Infection (SSI) Event. National Healthcare Safety Network (NHSN) Patient Safety Component Manual.⁷⁷ Additional details of this metric can be found in the STS Training Manual. Thoracotomy site infection A surgical site infection involving a thoracotomy or parasternal site was diagnosed within 30 d of the procedure or any time during the hospitalization for surgery. STS ACSD v2.9 Training Manual (seq. #6710)⁸ Conduit harvest site infection A surgical site infection involving a conduit harvest site was diagnosed within 30 d of the procedure or any time during the hospitalization for surgery. STS ACSD v2.9 Training Manual (seq. #6715)⁸ Additional details of this metric can be found in the STS Training Manual. Cannulation site infection A surgical site infection involving a cannulation site was diagnosed within 30 d of the procedure or any time during the hospitalization for surgery. STS ACSD v2.9 Training Manual (seq. #6720)⁸ Additional details of this metric can be found in the STS Training Manual. Reoperation for bleeding/tamponade The patient was re-explored for mediastinal bleeding with or without tamponade either in the ICU or returned to the OR. STS ACSD v2.9 Training Manual (seq. #6755)⁸ Additional details of this metric can be found in the STS Training Manual. Reoperation for valvular dysfunction The patient returned to the OR for prosthetic or native valve dysfunction. Dysfunction may be structural and/or nonstructural failure. Dysfunction may be of prosthesis, a progressive native disease process, or an acute event process that disrupts valve function and creates either clinical compromising insufficiency/regurgitation or valve orifice narrowing. STS ACSD v2.9 Training Manual (seq. #6765)⁸ Additional details of this metric can be found in the STS Training Manual. Reintervention for MI The patient required postoperative reintervention for MI. STS ACSD v2.9 Training Manual (seq. #6771)⁸ Additional details of this metric can be found in the STS Training Manual. Aortic reintervention The patient underwent postoperative aortic reintervention. STS ACSD v2.9 Training Manual (seq. #6774)⁸ Reoperation for other cardiac reasons The patient returned to the OR for other cardiac reasons. STS ACSD v2.9 Training Manual (seq. #6778)⁸ Returned to the OR for other noncardiac reasons The patient returned to the OR for other noncardiac reasons. This includes procedures requiring a return to the OR such as tracheostomy, general surgery procedures. This does not include procedures performed outside the OR such as GI lab for PEG tube, shunts for dialysis. STS ACSD v2.9 Training Manual (seq. #6780)⁸ Additional details of this metric can be found in the STS Training Manual. Open chest with planned delayed sternal closure The chest was left open with planned delayed sternal closure. STS ACSD v2.9 Training Manual (seq. #6785)⁸ Sternotomy issue Presence of a postoperative sternotomy issue STS ACSD v2.9 Training Manual (seq. #6790)⁸ Additional details of this metric can be found in the STS Training Manual. Sepsis Sepsis is defined as evidence of serious infection accompanied by a deleterious systemic response. In the time period of the first 48 h postoperative or post procedural, the diagnosis of sepsis requires the presence of a SIRS resulting from a proven infection (eg, bacteremia, fungemia, or UTI). In the time period after the first 48 h postoperative or post procedural, sepsis may be diagnosed by the presence of a SIRS resulting from suspected or proven infection. During the first 48 h, a SIRS may result from the stress associated with surgery and/or CPB. Thus, the clinical criteria for sepsis during this time period should be more stringent. A SIRS is present when at least 2 of the following criteria are present: hypo- or hyperthermia (>38.5 or <36.0), tachycardia or bradycardia, tachypnea, leukocytosis or leukopenia, or thrombocytopenia. STS ACSD v2.9 Training Manual (seq. #6800)⁸ Additional details of this metric can be found in the STS Training Manual. Stroke, ischemic The patient had a postoperative ischemic stroke (ie, confirmed neurological deficit of abrupt onset caused by blockage of a blood vessel supplying the brain) that did not resolve within 24 h. STS ACSD v2.9 Training Manual (seq. #6810)⁸ Additional details of this metric can be found in the STS Training Manual. Stroke, hemorrhagic The patient had a postoperative hemorrhagic stroke (ie, confirmed neurological deficit of abrupt onset caused by bleeding into or around the brain) that did not resolve within 24 h. STS ACSD v2.9 Training Manual (seq. #6810)⁸ Additional details of this metric can be found in the STS Training Manual. Stroke, undetermined cause The patient had a postoperative stroke (ie, confirmed neurological deficit of abrupt onset) of undetermined cause that did not resolve within 24 h. STS ACSD v2.9 Training Manual (seq. #6810)⁸ Additional details of this metric can be found in the STS Training Manual. TIA The patient had a postoperative TIA: Loss of neurological function that was abrupt in onset but with complete return of function within 24 h. STS ACSD v2.9 Training Manual (seq. #6815)⁸ Additional details of this metric can be found in the STS Training Manual. Encephalopathy, anoxic The patient had encephalopathy caused by lack of oxygen or blood flow to the brain. STS ACSD v2.9 Training Manual (seq. #6821)⁸ Additional details of this metric can be found in the STS Training Manual. Encephalopathy, drug-induced The patient had encephalopathy caused by prolonged exposure to drugs. STS ACSD v2.9 Training Manual (seq. #6821)⁸ Additional details of this metric can be found in the STS Training Manual. Encephalopathy, metabolic The patient had encephalopathy caused by metabolic dysfunction. STS ACSD v2.9 Training Manual (seq. #6821)⁸ Additional details of this metric can be found in the STS Training Manual. Encephalopathy, unknown cause The patient had encephalopathy of unknown cause. STS ACSD v2.9 Training Manual (seq. #6821)⁸ Additional details of this metric can be found in the STS Training Manual. Coma/unresponsive state (not stroke) The patient developed a postoperative coma or unresponsive state (not stroke). STS ACSD v2.9 Training Manual (seq. #6822)⁸ Additional details of this metric can be found in the STS Training Manual. Lower extremity paralysis The patient had a new postoperative paralysis, paraparesis, or paraplegia related to spinal cord ischemia and not related to a stroke. STS ACSD v2.9 Training Manual (seq. #6825)⁸ Additional details of this metric can be found in the STS Training Manual. Paresis, transient Postoperative paresis was present. Transient is nonlasting and of short (<24 h) duration. STS ACSD v2.9 Training Manual (seq. #6829, #6830)⁸ Additional details of this metric can be found in the STS Training Manual. Paresis, permanent Postoperative paresis was present. Permanent is enduring, lasting, or without change for >24 h. STS ACSD v2.9 Training Manual (seq. #6829, #6830)⁸ Additional details of this metric can be found in the STS Training Manual. Phrenic nerve injury The patient has symptoms of phrenic nerve injury, (eg, immobility or elevation of the diaphragm). STS ACSD v2.9 Training Manual (seq. #6832)⁸ Additional details of this metric can be found in the STS Training Manual. Recurrent laryngeal nerve injury The patient has symptoms of recurrent laryngeal nerve injury, (eg, hoarseness, difficulty speaking). STS ACSD v2.9 Training Manual (seq. #6833)⁸ Additional details of this metric can be found in the STS Training Manual. Prolonged ventilation The patient had prolonged postoperative pulmonary ventilation >24 h.The hours of postoperative ventilation time include OR exit until extubation, plus any additional hours following reintubation.Include (but not limited to) causes such as acute respiratory distress syndrome, pulmonary edema, and/or any patient requiring mechanical ventilation >24 h postoperatively. STS ACSD v2.9 Training Manual (seq. #6835)⁸ Additional details of this metric can be found in the STS Training Manual. Pneumonia The patient had pneumonia according to the CDC definition. STS ACSD v2.9 Training Manual (seq. #6840)⁸ STS uses the CDC’s definition of pneumonia.National Healthcare Safety Network Patient Safety Component Manual. Pneumonia (ventilator-associated and non–ventilator-associated pneumonia) event.⁷⁸ Pulmonary thromboembolism The patient had a pulmonary thromboembolism diagnosed by radiologic study such as V/Q scan, angiogram, or spiral CT. STS ACSD v2.9 Training Manual (seq. #6850)⁸ Additional details of this metric can be found in the STS Training Manual. Deep venous thrombosis The patient had thrombosis (clot formation) in a deep vein. STS ACSD v2.9 Training Manual (seq. #6855)⁸ Additional details of this metric can be found in the STS Training Manual. Pleural effusion requiring drainage A postoperative pleural effusion required drainage via thoracentesis or chest tube insertion. STS ACSD v2.9 Training Manual (seq. #6860)⁸ Additional details of this metric can be found in the STS Training Manual. Pneumothorax requiring intervention The patient had a postoperative pneumothorax requiring intervention. STS ACSD v2.9 Training Manual (seq. #6865)⁸ Additional details of this metric can be found in the STS Training Manual. Renal (kidney) failure The patient had acute renal (kidney) failure or worsening renal (kidney) function resulting in ONE OR BOTH of the following:1. Increase in serum creatinine level 3.0× greater than baseline, or serum creatinine level ≥4 mg/dL. Acute rise must be at least 0.5 mg/dL2. A new requirement for dialysis postoperatively. STS ACSD v2.9 Training Manual (seq. #6870)⁸ Additional details of this metric can be found in the STS Training Manual. Dialysis, newly required The patient had a new requirement for dialysis postoperatively, which may include hemodialysis, peritoneal dialysis. STS ACSD v2.9 Training Manual (seq. #6875)⁸ Additional details of this metric can be found in the STS Training Manual. Ultrafiltration required The patient required ultrafiltration. STS ACSD v2.9 Training Manual (seq. #6885)⁸ Additional details of this metric can be found in the STS Training Manual. Iliac/femoral dissection The patient had a dissection occurring in the iliac or femoral arteries. STS ACSD v2.9 Training Manual (seq. #6890)⁸ Additional details of this metric can be found in the STS Training Manual. Acute limb ischemia The patient had any complication producing limb ischemia. This may include upper or lower limb ischemia. STS ACSD v2.9 Training Manual (seq. #6891)⁸ Additional details of this metric can be found in the STS Training Manual. Mechanical assist device-related complication There was a postoperative event related to a mechanical assist device. STS ACSD v2.9 Training Manual (seq. #6892)⁸ Rhythm disturbance requiring permanent device The patient developed a new dysrhythmia requiring insertion of a permanent device. STS ACSD v2.9 Training Manual (seq. #6900)⁸ Additional details of this metric can be found in the STS Training Manual. Cardiac arrest The patient had an acute cardiac arrest documented by 1 of the following:• Ventricular fibrillation• Rapid ventricular tachycardia with hemodynamic instability• Asystole• ICD shocks STS ACSD v2.9 Training Manual (seq. #6905)⁸ Postoperative aortic endoleak A postoperative endoleak occurred. An endoleak is defined as persistent blood flow in the aneurysm sac through and around the endovascular seal and is the most common complication after endovascular aneurysm repair. STS ACSD v2.9 Training Manual (seq. #6906)⁸ Aortic rupture Aortic rupture occurred postoperatively. STS ACSD v2.9 Training Manual (seq. #6908)⁸ Aortic dissection The patient had a dissection occurring in any part of the aorta. This includes ascending, arch, descending, thoracic or abdominal aorta. Aortic dissection is bleeding into or along the wall of the aorta. This does not include an aneurysmal event, unless it goes on to rupture or dissect. STS ACSD v2.9 Training Manual (seq. #6909)⁸ Aortic side branch malperfusion Aortic side branch malperfusion occurred. STS ACSD v2.9 Training Manual (seq. #6911)⁸ Additional details of this metric can be found in the STS Training Manual. Aortic stent graft-induced entry tear An aortic stent graft-induced entry tear occurred. STS ACSD v2.9 Training Manual (seq. #6912)⁸ Additional details of this metric can be found in the STS Training Manual. Anticoagulant bleeding event The patient had bleeding, hemorrhage, and/or embolic events related to anticoagulant therapy postoperatively. This may include patients who experience disseminated intravascular coagulopathy or heparin-induced thrombocytopenia. STS ACSD v2.9 Training Manual (seq. #6914)⁸ Additional details of this metric can be found in the STS Training Manual. Pericardiocentesis The patient had a pericardiocentesis to remove fluid in the pericardial space compromising cardiac filling. STS ACSD v2.9 Training Manual (seq. #6915)⁸ Additional details of this metric can be found in the STS Training Manual. GI event The patient had a postoperative occurrence of any GI event, including but not limited to:• Ischemic bowel• GI bleed• Pancreatitis• Cholecystitis• Liver dysfunction• Ileus• Other STS ACSD v2.9 Training Manual (seq. #6920)⁸ Additional details of this metric can be found in the STS Training Manual. Multisystem failure The patient had ≥2 major organ systems suffer compromised functions. STS ACSD v2.9 Training Manual (seq. #6925)⁸ Additional details of this metric can be found in the STS Training Manual. Atrial fibrillation The patient experienced atrial fibrillation/flutter requiring treatment. Exclude patients who were in atrial fibrillation at the start of surgery. STS ACSD v2.9 Training Manual (seq. #6930)⁸ Additional details of this metric can be found in the STS Training Manual. Operative mortality 1) All deaths, regardless of cause, occurring during the hospitalization in which the operation was performed, even if after 30 d (including patients transferred to other acute care facilities) and 2) all deaths, regardless of cause, occurring after discharge from the hospital but before the end of postoperative day 30. STS ACSD v2.9 Training Manual (seq. #7124)⁸ Other A postoperative event occurred that is not identified in the categories above yet impacts hospital length of stay and/or outcome. STS ACSD v2.9 Training Manual (seq. #6950)⁸ Additional details of this metric can be found in the STS Training Manual.

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