Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm

Prospective validation of a risk score to predict pacemaker implantation after transcatheter aortic valve replacement

INTRODUCTION

The need for pacemaker is a common complication after transcatheter aortic valve replacement (TAVR). We previously described the Emory Risk Score (ERS) to predict the need for new pacemaker implant (PPM) after TAVR. Metrics included in the score are a history of syncope, pre-existing RBBB, QRS duration ≥140 ms, and prosthesis oversizing ≥16%. To prospectively validate the previously described risk score.

METHODS

We prospectively evaluated all patients without pre-existing pacemakers, ICD, or pre-existing indications for pacing undergoing TAVR with the Edwards SAPIEN 3 prosthesis at our institution from March 2019 to December 2020 (n = 661). Patients were scored prospectively; however, results were blinded from clinical decision-making. The primary endpoint was PPM at 30 days after TAVR. Performance of the ERS was evaluated using logistic regression, a calibration curve to prior performance, and receiver operating characteristic (ROC) analysis.

RESULTS

A total of 48 patients (7.3%) had PPM after TAVR. A higher ERS predicted an increased likelihood of PPM (OR 2.61, 95% CI: 2.05-3.25 per point, p < 0.001). There was good correlation between observed and expected values on the calibration curve (slope = 1.04, calibration at large = 0.001). The area under the ROC curve was 0.81 (95% CI [0.74-0.88], p < 0.001).

CONCLUSIONS

The ERS prospectively predicted the need for PPM in a serial, real-world cohort of patients undergoing TAVR with a balloon-expandable prosthesis, confirming findings previously described in retrospective cohorts. Notably, the prospective performance of the score was comparable with that of the initial cohorts. The risk score could serve as a framework for preprocedural risk stratification for PPM after TAVR.

Redefining "low risk": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era

OBJECTIVES

Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.

METHODS

From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.

RESULTS

With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population.

CONCLUSIONS

STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.

Systematic review and meta-analysis of mortality risk prediction models in adult cardiac surgery

OBJECTIVES

The most used mortality risk prediction models in cardiac surgery are the European System for Cardiac Operative Risk Evaluation (ES) and Society of Thoracic Surgeons (STS) score. There is no agreement on which score should be considered more accurate nor which score should be utilized in each population subgroup. We sought to provide a thorough quantitative assessment of these 2 models.

METHODS

We performed a systematic literature review and captured information on discrimination, as quantified by the area under the receiver operator curve (AUC), and calibration, as quantified by the ratio of observed-to-expected mortality (O:E). We performed random effects meta-analysis of the performance of the individual models as well as pairwise comparisons and subgroup analysis by procedure type, time and continent.

RESULTS

The ES2 {AUC 0.783 [95% confidence interval (CI) 0.765-0.800]; O:E 1.102 (95% CI 0.943-1.289)} and STS [AUC 0.757 (95% CI 0.727-0.785); O:E 1.111 (95% CI 0.853-1.447)] showed good overall discrimination and calibration. There was no significant difference in the discrimination of the 2 models (difference in AUC -0.016; 95% CI -0.034 to -0.002; P = 0.09). However, the calibration of ES2 showed significant geographical variations (P < 0.001) and a trend towards miscalibration with time (P=0.057). This was not seen with STS.

CONCLUSIONS

ES2 and STS are reliable predictors of short-term mortality following adult cardiac surgery in the populations from which they were derived. STS may have broader applications when comparing outcomes across continents as compared to ES2.

REGISTRATION

Prospero (https://www.crd.york.ac.uk/PROSPERO/) CRD42020220983.

Development and Validation of a Novel Nomogram for Preoperative Prediction of In-Hospital Mortality After Coronary Artery Bypass Grafting Surgery in Heart Failure With Reduced Ejection Fraction

Background and Aims: Patients with heart failure with reduced ejection fraction (HFrEF) are among the most challenging patients undergoing coronary artery bypass grafting surgery (CABG). Several surgical risk scores are commonly used to predict the risk in patients undergoing CABG. However, these risk scores do not specifically target HFrEF patients. We aim to develop and validate a new nomogram score to predict the risk of in-hospital mortality among HFrEF patients after CABG.

Methods: The study retrospectively enrolled 489 patients who had HFrEF and underwent CABG. The outcome was postoperative in-hospital death. About 70% (n = 342) of the patients were randomly constituted a training cohort and the rest (n = 147) made a validation cohort. A multivariable logistic regression model was derived from the training cohort and presented as a nomogram to predict postoperative mortality in patients with HFrEF. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the model with EuroSCORE-2 in terms of discrimination and calibration.

Results: Postoperative death occurred in 26 (7.6%) out of 342 patients in the training cohort, and in 10 (6.8%) out of 147 patients in the validation cohort. Eight preoperative factors were associated with postoperative death, including age, critical state, recent myocardial infarction, stroke, left ventricular ejection fraction (LVEF) ≤35%, LV dilatation, increased serum creatinine, and combined surgery. The nomogram achieved good discrimination with C-indexes of 0.889 (95%CI, 0.839–0.938) and 0.899 (95%CI, 0.835–0.963) in predicting the risk of mortality after CABG in the training and validation cohorts, respectively, and showed well-fitted calibration curves in the patients whose predicted mortality probabilities were below 40%. Compared with EuroSCORE-2, the nomogram had significantly higher C-indexes in the training cohort (0.889 vs. 0.762, p = 0.005) as well as the validation cohort (0.899 vs. 0.816, p = 0.039). Besides, the nomogram had better calibration and reclassification than EuroSCORE-2 both in the training and validation cohort. The EuroSCORE-2 underestimated postoperative mortality risk, especially in high-risk patients.

Conclusions: The nomogram provides an optimal preoperative estimation of mortality risk after CABG in patients with HFrEF and has the potential to facilitate identifying HFrEF patients at high risk of in-hospital mortality.

Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease

IMPORTANCE

Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown.

OBJECTIVE

To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020.

MAIN OUTCOMES AND MEASURES

The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist.

RESULTS

Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002).

CONCLUSIONS AND RELEVANCE

The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.

Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery

Purpose of review

Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence.

Recent findings

While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available.

Summary

We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.

Comparison between three different equations for the estimation of glomerular filtration rate in predicting mortality after coronary artery bypass

Background

This study was undertaken to compare the accuracy of chronic kidney disease-epidemiology collaboration (eGFR_CKD-EPI) to modification of diet in renal disease (eGFR_MDRD) and the Cockcroft-Gault formulas of Creatinine clearance (C_CG) equations in predicting post coronary artery bypass grafting (CABG) mortality.

Methods

Data from 4408 patients who underwent isolated CABG over a 11-year period were retrieved from one institutional database. Discriminatory power was assessed using the c-index and comparison between the scores’ performance was performed with DeLong, bootstrap, and Venkatraman methods. Calibration was evaluated with calibration curves and associated statistics.

Results

The discriminatory power was higher in eGFR_CKD-EPI than eGFR_MDRD and C_CG (Area under Curve [AUC]:0.77, 0.55 and 0.52, respectively). Furthermore, eGFR_CKD-EPI performed worse in patients with an eGFR ≤29 ml/min/1.73m² (AUC: 0.53) while it was not influenced by higher eGFRs, age, and body size. In contrast, the MDRD equation was accurate only in women (calibration statistics p = 0.72), elderly patients (p = 0.53) and subjects with severe impairment of renal function (p = 0.06) whereas C_CG was not significantly biased only in patients between 40 and 59 years (p = 0.6) and with eGFR 45–59 ml/min/1.73m² (p = 0.32) or ≥ 60 ml/min/1.73m² (p = 0.48).

Conclusions

In general, CKD-EPI gives the best prediction of death after CABG with unsatisfactory accuracy and calibration only in patients with severe kidney disease. In contrast, the CG and MDRD equations were inaccurate in a clinically significant proportion of patients.

Society of Thoracic Surgeons Risk Score and EuroSCORE-2 Appropriately Assess 30-Day Postoperative Mortality in the STICH Trial and a Contemporary Cohort of Patients With Left Ventricular Dysfunction Undergoing Surgical Revascularization

BACKGROUND

The STICH trial (Surgical Treatment for Ischemic Heart Failure) demonstrated a survival benefit of coronary artery bypass grafting in patients with ischemic cardiomyopathy and left ventricular dysfunction. The Society of Thoracic Surgeons (STS) risk score and the EuroSCORE-2 (ES2) are used for risk assessment in cardiac surgery, with little information available about their accuracy in patients with left ventricular dysfunction. We assessed the ability of the STS score and ES2 to evaluate 30-day postoperative mortality risk in STICH and a contemporary cohort (CC) of patients with a left ventricle ejection fraction ≤35% undergoing coronary artery bypass grafting outside of a trial setting.

METHODS AND RESULTS

The STS and ES2 scores were calculated for 814 STICH patients and 1246 consecutive patients in a CC. There were marked variations in 30-day postoperative mortality risk from 1 patient to another. The STS scores consistently calculated lower risk scores than ES2 (1.5 versus 2.9 for the CC and 0.9 versus 2.4 for the STICH cohort), and underestimated postoperative mortality risk. The STS and ES2 scores had moderately good C statistics: CC (0.727, 95% CI: 0.650-0.803 for STS, and 0.707, 95% CI: 0.620-0.795 for ES2); STICH (0.744, 95% CI: 0.677-0.812, for STS and 0.736, 95% CI: 0.665-0.808 for ES2). Despite the CC patients having higher STS and ES2 scores than STICH patients, mortality (3.5%) was lower than that of STICH (4.8%), suggesting a possible decrease in postoperative mortality over the past decade.

CONCLUSIONS

The 30-day postoperative mortality risk of coronary artery bypass grafting in patients with left ventricular dysfunction varies markedly. Both the STS and ES2 score are effective in evaluating risk, although the STS score tend to underestimate risk.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Performance of EuroSCORE II and logistic EuroSCORE in Bangladeshi population undergoing off-pump coronary artery bypass surgery: A prospective cohort study

Introduction

European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to identify patients who may have a greater postoperative risk for adverse effects following adult cardiac surgery. This study evaluated the discriminatory potential of using the EuroSCORE system in predicting the early, as well as late, postoperative outcomes following coronary artery bypass graft surgery in Bangladesh.

Methods

A total of 865 patients who underwent isolated coronary artery bypass graft surgery were evaluated with the EuroSCORE risk scoring system. Moreover, we also compared the discriminatory potentials between the EuroSCORE II and the original logistic EuroSCORE.

Results

Operative mortality was best predicted by EuroSCORE II (area under the curve (AUC) 0.863, Brier score 0.030) compared to the original logistic EuroSCORE (AUC 0.849, Brier score 0.033). However, the overall expected-to-observed mortality ratio for EuroSCORE II was 1.1, whereas the observed ratio for the original logistic EuroSCORE was 1.7. EuroSCORE II was predictive of an intensive care unit stay of five days or more (AUC 0.786), prolonged inotropes use (AUC 0.746), stroke (AUC 0.646), de novo dialysis (AUC 0.810), and low output syndrome (AUC 0.715). Moreover, a high EuroSCORE II quintile significantly predicted the risk for late mortality (p < 0.0001).

Conclusions

EuroSCORE has an important role in predicting the early, as well as late, postoperative outcomes following coronary artery bypass surgery. However, the performance of EuroSCORE II is significantly better than the original logistic EuroSCORE in predicting postoperative morbidity and mortality after isolated coronary artery bypass graft surgery among Bangladeshi patients.

Complexity of preoperative blood pressure dynamics: possible utility in cardiac surgical risk assessment

Complexity measures are intended to assess the cardiovascular system's capacity to respond to stressors. We sought to determine if decreased BP complexity is associated with increased estimated risk as obtained from two standard instruments: the Society of Thoracic Surgeons' (STS) Risk of Mortality and Morbidity Index and the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE II). In this observational cohort study, preoperative systolic, diastolic, mean (MAP) and pulse pressure (PP) time series were derived in 147 patients undergoing cardiac surgery. The complexity of the fluctuations of these four variables was quantified using multiscale entropy (MSE) analysis. In addition, the traditional time series measures, mean and standard deviation (SD) were also computed. The relationships between time series measures and the risk indices (after logarithmic transformation) were then assessed using nonparametric (Spearman correlation, r_s) and linear regression methods. A one standard deviation change in the complexity of systolic, diastolic and MAP time series was negatively associated (p < 0.05) with the STS and EuroSCORE indices in both unadjusted (21-34%) and models adjusted for age, gender and SD of the BP time series (15-31%). The mean and SD of BP time series were not significantly associated with the risk index except for a positive association with the SD of the diastolic BP. Lower preoperative BP complexity was associated with a higher estimated risk of adverse cardiovascular outcomes and may provide a novel approach to assessing cardiovascular risk. Future studies are needed to determine whether dynamical risk indices can improve current risk prediction tools.

Practice Variation Among Hospitals in Revascularization Therapy and Its Association With Procedure-related Mortality

BACKGROUND

While substantial practice variation in coronary revascularization has been described and deviation from clinical practice guidelines has been associated with worse outcomes, the degree to which this is driven by flawed decision making and/or appropriate deviation associated with comorbid conditions is unknown. We evaluated heterogeneity in procedure use, and the extent to which hospital-level practice variation is related to surgical mortality.

METHODS

We analyzed data on 554,563 inpatients undergoing either percutaneous coronary intervention or coronary artery bypass grafting at 391 centers in 6 states. Procedure-specific risk models were developed based on demographics and comorbidities, allowing for differential effects of comorbidities for each sex. For each patient, the revascularization procedure that minimized predicted probability of inhospital mortality was designated as the model-preferred procedure.Hospital-level discordance rates-the proportion of cases in each hospital for which the opposite from the model-preferred procedure was performed-were calculated. Hierarchical linear models were used to analyze the relationship between HDRs and hospital-level risk-standardized mortality ratios (RSMRs).

RESULTS

Comorbidities and demographics alone explained between 68% and 86% of overall variation in inhospital mortality (corresponding C-statistics of 0.84-0.93). The mean (SD) HDR was 26.3% (9.6%). There was a positive independent association between HDRs and inhospital mortality, with a 10% increase in HDR associated with an 11% increase in RSMR (P<0.001).

CONCLUSIONS

Variance in procedure use according to model preference was strongly associated with worse outcomes. A systematic approach to incorporating comorbidity as part of the decision-making process for coronary revascularization is needed.

Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity-Matched Studies

BACKGROUND

Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed.

METHODS

A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals.

RESULTS

Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04).

CONCLUSIONS

The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.

Simplified prediction of postoperative cardiac surgery outcomes with a novel score: R2CHADS2

OBJECTIVE

To compare the accuracy of R2CHADS2, CHADS2, and CHA2DS2-VASc scores vs the Society of Thoracic Surgeons (STS) score as predictors of morbidity and mortality after cardiovascular surgery.

METHODS

All patients who underwent cardiothoracic surgery at our institution from January 2008 to July 2013 were analyzed. Only those patients who fulfilled the criteria for STS score calculation were included. The R2CHADS2 score was computed as follows: 2 points for GFR < 60 mL/min/1.73 m(2) (R2), prior stroke or TIA (S2); 1 point for history of congestive heart failure (C), hypertension (H), age ≥75 years (A), or diabetes (D). Area under the curve (AUC) analysis was used to estimate the accuracy of the different scores. The end point variables included operative mortality, permanent stroke, and renal failure as defined by the STS database system.

RESULTS

Of the 3,492 patients screened, 2,263 met the inclusion criteria. These included 1,160 (51%) isolated valve surgery, 859 (38%) coronary artery bypass graft surgery, and 245 (11%) combined procedures. There were 147 postoperative events: 75 (3%) patients had postoperative renal failure, 48 (2%) had operative mortality, and 24 (1%) had permanent stroke. AUC analysis revealed that STS, R2CHADS2, CHADS2, and CHA2DS2-VASc reliably estimated all postoperative outcomes. STS and R2CHADS2 scores had the best accuracy overall, with no significant difference in AUC values between them.

CONCLUSION

The R2CHADS2 score estimates postoperative events with acceptable accuracy and if further validated may be used as a simple preoperative risk tool calculator.

Right internal thoracic artery versus radial artery as the second best arterial conduit: Insights from a meta-analysis of propensity-matched data on long-term survival

OBJECTIVE(S)

We conducted a meta-analysis of propensity score-matching (PSM) studies comparing long-term survival of patients receiving right internal thoracic artery (RITA) versus radial artery (RA) as a second arterial conduit for coronary artery bypass grafting.

METHODS

A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Primary endpoint was long-term mortality. Secondary endpoints were operative mortality, incidence of sternal wound infection, and repeat revascularization. Binary events were pooled using the DerSimonian and Laird method. For time-to-event outcomes, estimates of log hazard ratio (HR) and standard errors obtained were combined using the generic inverse-variance method.

RESULTS

A total of 8 PSM studies were finally selected including 15,374 patients (RITA, 6739; RA, 8635) with 2992 matched pairs for final comparison. Mean follow-up time ranged from 45 to 168 months. When compared with RA, RITA was associated with a lower risk reduction of late death (HR, 0.75; 95% confidence interval [CI], 0.58-0.97; P = .028) and repeat revascularization (HR, 0.37; 95% CI, 0.16-0.85; P = .03). On the other hand, RITA did not increase operative mortality (odds ratio [OR], 1.53; 95% CI, 0.97-2.39; P = .07). RITA was associated with an increased risk of sternal wound complication when pedicled harvesting was used (OR, 3.18; 95% CI, 1.34-7.57), but not with skeletonized harvesting (OR, 1.07; 95% CI, 0.67-1.71).

CONCLUSIONS

The present PSM data meta-analysis suggests that the use of RITA compared with RA was associated with superior long-term survival and freedom from repeat revascularization, with similar operative mortality and incidence of sternal wound complication when the skeletonized harvesting technique was used.

Comparison of Plasma and Urine Biomarker Performance in Acute Kidney Injury

Background

New renal biomarkers measured in urine promise to increase specificity for risk stratification and early diagnosis of acute kidney injury (AKI) but concomitantly may be altered by urine concentration effects and chronic renal insufficiency. This study therefore directly compared the performance of AKI biomarkers in urine and plasma.

Methods

This single-center, prospective cohort study included 110 unselected adults undergoing cardiac surgery with cardiopulmonary bypass between 2009 and 2010. Plasma and/or urine concentrations of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), liver fatty acid-binding protein (L-FABP), kidney injury molecule 1 (KIM1), and albumin as well as 15 additional biomarkers in plasma and urine were measured during the perioperative period. The primary outcome was AKI defined by AKIN serum creatinine criteria within 72 hours after surgery.

Results

Biomarkers in plasma showed markedly better discriminative performance for preoperative risk stratification and early postoperative (within 24h after surgery) detection of AKI than urine biomarkers. Discriminative power of urine biomarkers improved when concentrations were normalized to urinary creatinine, but urine biomarkers had still lower AUC values than plasma biomarkers. Best diagnostic performance 4h after surgery had plasma NGAL (AUC 0.83), cystatin C (0.76), MIG (0.74), and L-FAPB (0.73). Combinations of multiple biomarkers did not improve their diagnostic power. Preoperative clinical scoring systems (EuroSCORE and Cleveland Clinic Foundation Score) predicted the risk for AKI (AUC 0.76 and 0.71) and were not inferior to biomarkers. Preexisting chronic kidney disease limited the diagnostic performance of both plasma and urine biomarkers.

Conclusions

In our cohort plasma biomarkers had higher discriminative power for risk stratification and early diagnosis of AKI than urine biomarkers. For preoperative risk stratification of AKI clinical models showed similar discriminative performance to biomarkers. The discriminative performance of both plasma and urine biomarkers was reduced by preexisting chronic kidney disease.

Combination of European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Cardiac Surgery Score (CASUS) to Improve Outcome Prediction in Cardiac Surgery

Background

We hypothesized that the combination of a preoperative and a postoperative scoring system would improve the accuracy of mortality prediction and therefore combined the preoperative ‘additive EuroSCORE‘ (European system for cardiac operative risk evaluation) with the postoperative ‘additive CASUS’ (Cardiac Surgery Score) to form the ‘modified CASUS’.

Material/Methods

We included all consecutive adult patients after cardiac surgery during January 2007 and December 2010 in our prospective study. Our single-centre study was conducted in a German general referral university hospital. The original additive and the ‘modified CASUS’ were tested using calibration and discrimination statistics. We compared the area under the curve (AUC) of the receiver characteristic curves (ROC) by DeLong’s method and calculated overall correct classification (OCC) values.

Results

The mean age among the total of 5207 patients was 67.2±10.9 years. Whilst the ICU mortality was 5.9% we observed a mean length of ICU stay of 4.6±7.0 days. Both models demonstrated excellent discriminatory power (mean AUC of ‘modified CASUS’: ≥0.929; ‘additive CASUS’: ≥0.920), with no significant differences according to DeLong. Neither model showed a significant p-value (<0.05) in calibration. We detected the best OCC during the 2^nd day (modified: 96.5%; original: 96.6%).

Conclusions

Our ‘additive’ and ‘modified’ CASUS are reasonable overall predictors. We could not detect any improvement in the accuracy of mortality prediction in cardiac surgery by combining a preoperative and a postoperative scoring system. A separate calculation of the two individual elements is therefore recommended.

Effects of acute kidney injury and chronic kidney disease on long-term mortality after coronary artery bypass grafting

BACKGROUND

Both acute kidney injury (AKI) and chronic kidney disease (CKD) are important issues in patients undergoing coronary artery bypass grafting (CABG), particularly with regard to mortality. However, their synergistic or discrete effects on long-term mortality remain unresolved.

METHODS

A total of 1,899 patients undergoing CABG were retrospectively analyzed. The adjusted hazard ratios for all-cause mortality were calculated after stratifying the timeframes. To evaluate the synergistic effects between AKI and CKD, the relative excess risk due to interaction was applied.

RESULTS

The presence of AKI, CKD, or both increased the hazard ratios for mortality, compared with the absence of both: AKI alone, 1.84 (1.464-2.319); CKD alone, 2.46 (1.735-3.478); and AKI and CKD together, 3.21 (2.301-4.488). However, the relationships with mortality were different between AKI and CKD, according to the timeframes: AKI primarily affected early mortality, particularly within 3 years, whereas CKD had a relatively constant effect on both the early and late periods. When the parameters from the relative excess risk due to interaction were obtained, there was a synergistic additive effect on early mortality between AKI and CKD.

CONCLUSIONS

The relationships with mortality after CABG were different between AKI and CKD. However, their effects were not exclusive but synergistic.

EuroSCORE models in a cohort of patients with valvular heart disease and a high prevalence of rheumatic fever submitted to surgical procedures

Objectives

Epidemiological differences can be found between Brazilian and European valvular heart disease patients. The prevalence of heart valve diseases due to rheumatic disease is significantly higher in the Brazilian compared with the European population. Therefore, they could have different risks during and after cardiac surgery. The aim of this study was to evaluate the applicability of the additive and logistic EuroSCORE and EuroSCORE II in a cohort of high-risk patients with valvular heart disease of predominantly rheumatic aetiology submitted to surgery.

Methods

Between 1 February and 30 December 2009, 540 consecutive patients scheduled for valvular heart surgery were included in this study. In this set of patients, we examined the performance of the additive, logistic, and EuroSCORE II models for predicting in-hospital mortality. Calibration of each model was assessed by comparing predicted and observed in-hospital mortality and by the goodness of fit of the Hosmer-Lemeshow chi-square test. Discrimination performance of the model was evaluated with the receiver operating characteristic (ROC) curve analysis.

Results

The mean age was 56 ± 16 years, 50.6% were female, and the mortality rate was 16.0% (6.0% in elective surgery and 34.0% in emergency/urgency surgery). Mortality rates were estimated according to the additive and logistic EuroSCORE and EuroSCORE II at 6.1%, 8.7%, and 4.3%, respectively. The AUC was 0.76 (95% confidence interval [95% CI] 0.70–0.81) for the additive EuroSCORE, 0.76 (95% CI 0.70–0.81) for the logistic EuroSCORE and 0.81 (95% CI 0.76–0.86) for EuroSCORE II. Hosmer-Lemeshow goodness-of-fit statistics were P = 0.52, P = 0.07, and P = 0.12 for additive, logistic EuroSCORE, and EuroSCORE II.

Conclusions

In this cohort of Brazilian patients with valvular heart disease submitted to surgical procedure, the EuroSCORE models had a good discriminatory capacity; however, the calibration was compromised because of an underestimation of the mortality rate.

Frontal planar QRS/T angle can be a prognostic factor in the early postoperative period of patients undergoing coronary bypass surgery

BACKGROUND

Wide QRS/T angle reflects the ventricular repolarization heterogeneity and has been found in association with cardiac morbidity and mortality in various study populations. However, literature data about the availability of QRS/T angle in patients undergoing cardiac surgery has not yet been available.

METHODS

A total of 157 patients who underwent isolated coronary artery bypass surgery were included in this study. A preoperative 12-lead ECG was obtained one day before surgical procedure. The absolute difference between the frontal QRS wave axes and T-wave axes was defined as frontal planar QRS/T angle. Afterwards, patients were divided into two groups according to their frontal planar QRS/T angle (the cut-off value as 90°).

RESULTS

Group 1 consisted of 109 patients with frontal planar QRS/T angle of <90, and the remaining 48 patients with frontal planar QRS/T angle 90 were placed into group 2. Mean EuroSCORE was much higher in group 2. There were significant differences for positive inotropic agent usage (27.5% for group 1 versus 58.3% for group 2, P < .001) and the prevalence of postoperative atrial fibrillation (11.9% for group 1 versus 31.2% for group 2, P = .004) between the two groups. In multivariate logistic regression analysis, used to determine the independent predictors of positive inotropic usage in the early postoperative period, only frontal planar QRS/T angle (OR: 0.989, 95% CI: 0.981-0.997, P = .008) and EuroSCORE (OR: 0.792, 95% CI: 0.646-0.971, P = .025) were found to be statistically significant.

CONCLUSION

We found that frontal planar QRS/T angle might be an important preoperative parameter in predicting the need for inotropic drugs in the early postoperative period following coronary artery bypass surgery.

Applicability of two international risk scores in cardiac surgery in a reference center in Brazil

Background

The applicability of international risk scores in heart surgery (HS) is not well defined in centers outside of North America and Europe.

Objective

To evaluate the capacity of the Parsonnet Bernstein 2000 (BP) and EuroSCORE (ES) in predicting in-hospital mortality (IHM) in patients undergoing HS at a reference hospital in Brazil and to identify risk predictors (RP).

Methods

Retrospective cohort study of 1,065 patients, with 60.3% patients underwent coronary artery bypass grafting (CABG), 32.7%, valve surgery and 7.0%, CABG combined with valve surgery. Additive and logistic scores models, the area under the ROC (Receiver Operating Characteristic) curve (AUC) and the standardized mortality ratio (SMR) were calculated. Multivariate logistic regression was performed to identify the RP.

Results

Overall mortality was 7.8%. The baseline characteristics of the patients were significantly different in relation to BP and ES. AUCs of the logistic and additive BP were 0.72 (95% CI, from 0.66 to 0.78 p = 0.74), and of ES they were 0.73 (95% CI; 0.67 to 0.79 p = 0.80). The calculation of the SMR in BP was 1.59 (95% CI; 1.27 to 1.99) and in ES, 1.43 (95% CI; 1.14 to 1.79). Seven RP of IHM were identified: age, serum creatinine > 2.26 mg/dL, active endocarditis, systolic pulmonary arterial pressure > 60 mmHg, one or more previous HS, CABG combined with valve surgery and diabetes mellitus.

Conclusion

Local scores, based on the real situation of local populations, must be developed for better assessment of risk in cardiac surgery.

EuroSCORE II with SYNTAX score to assess risks of coronary artery bypass grafting outcomes

OBJECTIVES

We evaluated the usefulness of the combination of European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) and SYNergy between percutaneous intervention with TAXus drug-eluting stents and cardiac surgery (SYNTAX) score in predicting risks associated with early and late outcomes after coronary artery bypass grafting (CABG).

METHODS

Between January 2010 and April 2012, 412 patients underwent isolated CABG at our institution. EuroSCORE II and SYNTAX score were calculated retrospectively, and their ability to predict early and long-term outcomes was evaluated. Patients were divided into four groups according to median EuroSCORE II and SYNTAX score: Group 1, low EuroSCORE II, low SYNTAX (n=103); Group 2, low EuroSCORE II, high SYNTAX (n=103); Group 3, high EuroSCORE II, low SYNTAX (n=99); and Group 4, high EuroSCORE II, high SYNTAX (n=107).

RESULTS

Operative death was not different among the groups; however, Group 4 had the highest major complication rate of the four groups (0 in Group 1, 2.9% in Group 2, 3.0% in Group 3 and 8.4% in Group 4; P=0.011). Multivariate analyses revealed that both high EuroSCORE II (odds ratio [OR]: 4.154; P=0.030) and high SYNTAX score (OR: 3.988; P=0.035) were independent predictors of postoperative major complications and that high EuroSCORE II was an independent predictor of late mortality (OR: 4.673; P=0.016) but high SYNTAX score was not (OR: 0.808; P=0.662). Actuarial survival rate at 3 years was the lowest in Group 4 (99.0±1.0% in Group 1, 97.7±1.6% in Group 2, 91.9±2.7% in Group 3 and 90.5±4.7% in Group 4; P=0.045).

CONCLUSIONS

The combination of EuroSCORE II and SYNTAX score was useful in predicting early major complications after CABG. In the long term, EuroSCORE II continued to be associated with late mortality, but SYNTAX score did not.

Two new mathematical models for prediction of early mortality risk in coronary artery bypass graft surgery

OBJECTIVES

The aim of this study was to develop new models for prediction of short-term mortality risk in on-pump coronary artery bypass grafting (CABG) surgery using decision tree (DT) methods.

METHODS

Between September 2005 and April 2006, 948 consecutive patients underwent CABG surgery at Rajaie Heart Center. Potential risk factors were reviewed and univariate and multivariate analysis for short-term mortality were performed. The whole dataset was divided into mutually exclusive subsets. An entropy error fuzzy decision tree (EEFDT) and an entropy error crisp decision tree (EECDT) were implemented using 650 (68.6%) patient data and tested with 298 (31.4%) patient data. Ten times hold-out cross validation was done and the area under the receiver operative characteristic curve (AUC) was reported as model performance. The results were compared with the logistic regression (LR) model and EuroSCORE.

RESULTS

The overall short-term mortality rate was 3.8%, and was statistically higher in women than men (P<.001). The final EEFDT selected 19 variables and resulted in a tree with 39 nodes, 20 conditional rules, and AUC of 0.90±0.008. The final EECDT selected 15 variables and resulted in a tree with 35 nodes, 18 conditional rules, and AUC of 0.86±0.008. The LR model selected 10 variables and resulted in an AUC of 0.78±0.008; the AUC for EuroSCORE was 0.77±0.003. There were no differences in the discriminatory power of EEFDT and EECDT (P=.066) and their performance was superior to LR and EuroSCORE.

CONCLUSIONS

EEFDT, EECDT, LR, and EuroSCORE had clinical acceptance but the performance and accuracy of the DTs were superior to the other models.

Indocyanine green clearance as an outcome prediction tool in cardiac surgery: a prospective study

PURPOSE

To evaluate the role of plasma disappearance rate of indocyanine green (PDR-ICG) as an outcome prediction tool in cardiac surgery.

PATIENTS AND METHODS

One hundred ninety patients undergoing coronary artery bypass grafting, valve surgery or combined procedures were enrolled. PDR-ICG measurements along with standard lab values were performed preoperative and on postoperative days 1, 2, and on discharge from the intensive care unit. Adverse outcomes were defined as prolonged length of stay in the intensive care unit and/or mortality. Two groups were defined according to length of stay in the intensive care unit (≤ 3 days vs >3 days).

RESULTS

PDR-ICG values differed significantly for all time points between the groups. In a multivariate model, in patients over 65 years with a EuroSCORE below 8.5, a preoperative PDR-ICG value below 12.85%/min was the strongest independent predictor for prolonged intensive care unit stay (>3 days). A preoperative PDR-ICG value below 8.2%/min was the strongest independent predictor for mortality in a multivariate analysis including age, cardiac function, and EuroSCORE.

CONCLUSIONS

In addition to the established scores, PDR-ICG may provide valuable information for the assessment of perioperative morbidity and mortality in cardiac surgery. Pre- and early postoperative measurements may help to identify patients at risk for developing perioperative complications.

A systematic review of risk prediction in adult cardiac surgery: considerations for future model development

OBJECTIVES

Risk prediction in adult patients undergoing cardiac surgery remains inaccurate and should be further improved. Therefore, we aimed to identify risk factors that are predictive of mortality, stroke, renal failure and/or length of stay after adult cardiac surgery in contemporary practice.

METHODS

We searched the Medline database for English-language original contributions from January 2000 to December 2011 to identify preoperative independent risk factors of one of the following outcomes after adult cardiac surgery: death, stroke, renal failure and/or length of stay. Two investigators independently screened the studies. Inclusion criteria were (i) the study described an adult cardiac patient population; (ii) the study was an original contribution; (iii) multivariable analyses were performed to identify independent predictors; (iv) ≥ 1 of the predefined outcomes was analysed; (v) at least one variable was an independent predictor, or a variable was included in a risk model that was developed.

RESULTS

The search yielded 5768 studies. After the initial title screening, a second screening of the full texts of 1234 studies was performed. Ultimately, 844 studies were included in the systematic review. In these studies, we identified a large number of independent predictors of mortality, stroke, renal failure and length of stay, which could be categorized into variables related to: disease pathology, planned surgical procedure, patient demographics, patient history, patient comorbidities, patient status, blood values, urine values, medication use and gene mutations. Many of these variables are frequently not considered as predictive of outcomes.

CONCLUSIONS

Risk estimates of mortality, stroke, renal failure and length of stay may be improved by the inclusion of additional (non-traditional) innovative risk factors. Current and future databases should consider collecting these variables.

Comparison of original EuroSCORE, EuroSCORE II and STS risk models in a Turkish cardiac surgical cohort

OBJECTIVES

The aim of this study was to compare additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II and the Society of Thoracic Surgeons (STS) models in calculating mortality risk in a Turkish cardiac surgical population.

METHODS

The current patient population consisted of 428 patients who underwent isolated coronary artery bypass grafting (CABG) between 2004 and 2012, extracted from the TurkoSCORE database. Observed and predicted mortalities were compared for the additive/logistic EuroSCORE, EuroSCORE II and STS risk calculator. The area under the receiver operating characteristics curve (AUC) values were calculated for these models to compare predictive power.

RESULTS

The mean patient age was 74.5 ± 3.9 years at the time of surgery, and 35.0% were female. For the entire cohort, actual hospital mortality was 7.9% (n = 34; 95% confidence interval [CI] 5.4-10.5). However, the additive EuroSCORE-predicted mortality was 6.4% (P = 0.23 vs observed; 95% CI 6.2-6.6), logistic EuroSCORE-predicted mortality was 7.9% (P = 0.98 vs observed; 95% CI 7.3-8.6), EuroSCORE II- predicted mortality was 1.7% (P = 0.00 vs observed; 95% CI 1.6-1.8) and STS predicted mortality was 5.8% (P = 0.10 vs observed; 95% CI 5.4-6.2). The mean predictive performance of the analysed models for the entire cohort was fair, with 0.7 (95% CI 0.60-0.79). AUC values for additive EuroSCORE, logistic EuroSCORE, EuroSCORE II and STS risk calculator were 0.70 (95% CI 0.60-0.79), 0.70 (95% CI 0.59-0.80), 0.72 (95% CI 0.62-0.81) and 0.62 (95% CI 0.51-0.73), respectively.

CONCLUSIONS

EuroSCORE II significantly underestimated mortality risk for Turkish cardiac patients, whereas additive and logistic EuroSCORE and STS risk calculators were well calibrated.

Performance of the original EuroSCORE

The European system for cardiac operative risk evaluation (EuroSCORE) is a commonly used risk score for operative mortality following cardiac surgery. We aimed to conduct a systematic review of the performance of the additive and logistic EuroSCORE. A literature search resulted in 67 articles. Studies applying the EuroSCORE on patients undergoing cardiac surgery and which reported early mortality were included. Weighted meta-regression showed that the EuroSCORE overestimated mortality. However, this performance depended on the risk profile of patients: in high-risk patients, the additive model actually underestimated mortality. Discriminative performance was good. Given the poor predictive performance, the EuroSCORE may not be suitable as a tool for patient selection nor for benchmarking.

Mortality from isolated coronary bypass surgery: a comparison of the Society of Thoracic Surgeons and the EuroSCORE risk prediction algorithms

We compared the performances of the additive European System for Cardiac Operative Risk Evaluation, EuroSCORE (AES) and logistic EuroSCORE (LES) with the Society of Thoracic Surgeons' risk prediction algorithm in terms of discrimination and calibration in predicting mortality in patients undergoing isolated coronary artery bypass grafting (CABG) at a single institution in Pakistan. Both models were applied to 380 patients, operated upon at the Aga Khan University Hospital from August 2009 to July 2010. The actual mortality was 2.89%. The mean AES of all patients was 4.36 ± 3.58%, the mean LES was 5.96 ± 9.18% and the mean Society of Thoracic Surgeons' (STS) score was 2.30 ± 4.16%. The Hosmer-Lemeshow goodness-of-fit test gave a P-value of 0.801 for AES, 0.699 for LES and 0.981 for STS. The area under the receiver operating characteristic curve was 0.866 for AES, 0.842 for LES and 0.899 for STS. STS outperformed AES and LES both in terms of calibration and discrimination. STS, however, underestimated mortality in the top 20% of patients having an STS score >2.88, thus overall STS estimates were lower than actual mortality. We conclude that STS is a more accurate model for risk assessment as compared to additive and logistic EuroSCORE models in the Pakistani population.

[Trends of risk factors in coronary surgery]

INTRODUCTION

In current era of widespread use of percutaneous coronary interventions (PCI), it is debatable whether coronary artery by-pass graft (CABG) patients are at higher risk.

OBJECTIVE

The aim of the study was to evaluate trends in risk profile of isolated CABG patients.

METHODS

By analysing the EuroSCORE and its risk factors, we reviewed a consecutive group of 4675 isolated CABG patients, operated on during the last 8 years (2001-2008) at our Clinic. The number of PCI patients was compared to the number of CABG patients. For statistical analyses, Pearson's chi-square and ANOVA tests were used.

RESULTS

The number of PCI increased from 159 to 1595 (p < 0.001), and the number of CABG from 557 to 656 (p < 0.001). The mean EuroSCORE increased from 2.74 to 2.92 (p = 0.06). The frequency of the following risk factors did not change over years: female gender, previous cardiac surgery, serum creatinine > 200 micromol/l, left ventricular dysfunction and postinfarct ventricular septal rupture. Chronic pulmonary disease, neurological dysfunction, and unstable pectoral angina declined significantly (p < 0.001). Critical preoperative care declined from 3.1% in 2001 to 0.5% in 2005, than increased and during the last 3 years did not change (2.3%). The mean age increased from 56.8 to 60.7 (p < 0.001) and extracardiac arteriopathy increased from 9.2% to 22.9% (p < 0.001). Recent preoperative myocardial infarction increased from 11% to 15.1% (p = 0.021), while emergency operations increased from 0.9% to 4.0% (p = 0.001).

CONCLUSION

The number of CABG increases despite the enlargement of PCI. The risk for isolated CABG given by EuroSCORE increases over years. The risk factors, significantly contributing to higher EuroSCORE are: older age, extracardiac arteriopathy, recent myocardial infarction and emergency operation.

Evaluation of the EuroSCORE risk scoring model for patients undergoing coronary artery bypass graft surgery: a word of caution

Background. Risk-adjusted mortality rates are used to compare quality of care of different hospitals. We evaluated the EuroSCORE (European System for Cardiac Operative Risk Evaluation) in patients undergoing isolated coronary artery bypass grafting (CABG).Patients and method. Data of all CABG patients from January 2004 until December 2008 were analysed. Receiver-operating characteristics (ROC) curves for the additive and logistic EuroSCOREs and the areas under the ROC curve were calculated. Predicted probability of hospital mortality was calculated using logistic regression analyses and compared with the EuroSCORE. Cumulative sum (CUSUM) analyses were performed for the EuroSCORE and the actual hospital mortality.Results. 5249 patients underwent CABG of which 89 (1.7%) died. The mean additive EuroSCORE was 3.5+/-2.5 (0-17) (median 3.0) and the mean logistic EuroSCORE was 4.0+/-5.5 (0-73) (median 2.4). The area under the ROC curve was 0.80+/-0.02 (95% confidence interval (CI) 0.76 to 0.84) for the additive and 0.81+/-0.02 (0.77 to 0.85) for the logistic EuroSCORE. The predicted probability (hazard ratio) was different from the additive and logistic EuroSCOREs. The hospital mortality was half of the EuroSCOREs, resulting in positive variable life-adjusted display curves. Conclusions. Both the additive and logistic EuroSCOREs are overestimating the in-hospital mortality risk in low-risk CABG patients. The logistic EuroSCORE is more accurate in high-risk patients compared with the additive EuroSCORE. Until a more accurate risk scoring system is available, we suggest being careful when comparing the quality of care of different centres based on risk-adjusted mortality rates. (Neth Heart J 2010;18:355-9.).

Transcatheter aortic valve implantation for high risk patients with severe aortic stenosis using the Edwards Sapien balloon-expandable bioprosthesis: a single centre study with immediate and medium-term outcomes

BACKGROUND

Transcatheter aortic valve implantation (TCAVI) is an emerging alternative therapy to open-heart surgery in high-risk patients with symptomatic aortic stenosis.

METHODS

Between January 2007 and May 2009, 46 patients underwent TCAVI with the 23 mm or 26 mm Edwards Sapien bioprosthesis via either the transapical (TA-AVI) or transfemoral (TF-AVI) approach. All patients had an estimated operative mortality risk of >15%.

RESULTS

A total of 46 patients (30 TA-AVI, 16 TF-AVI) with a mean aortic valve area (AVA) of 0.63 +/- 0.2 cm(2) and mean gradient of 54 +/- 16 mm Hg were treated. Predicted operative mortality was 25.3% by logistic Euroscore and 8.7% by Society of Thoracic Surgeons risk score. Procedural success was 93% in the TA-AVI group and 88% in the TF-AVI group. There was one intraprocedural death in the TA-AVI group. Overall 30-day mortality was 6.5% (2-TA-AVI, 1-TF-AVI). Four patients (9.5%) died from noncardiac causes after 30 days. Successful TCAVI was associated with a significant increase in AVA from 0.6 +/- 0.1 cm(2) to 1.6 +/- 0.6 cm(2) in the TA-AVI group and 0.6 +/- 0.1 cm(2) to 1.4 +/- 0.2 cm(2) in the TF-AVI group at a mean follow up of 7.4 +/- 4.4 and 8.3 +/- 5.0 months, respectively. At discharge, there was significant improvement in AVA (P < 0.0001), transaortic mean gradient (P < 0.0001), and mitral regurgitation (P = 0.01). At medium term follow up, the valve area was maintained and there was significant improvement in NYHA class in both groups (P < 0.0001).

CONCLUSION

At medium term follow-up, both transcatheter approaches demonstrated good valve durability with no cardiac-related mortality post hospital discharge.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]

OBJECTIVE

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007.

METHODS

Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit.

RESULTS

The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%.

CONCLUSIONS

The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

A new hydrocolloid dressing prevents surgical site infection of median sternotomy wounds

PURPOSE

This prospective and semi-randomized study was conducted to clarify the effectiveness of a new hydrocolloid dressing placed over median sternotomy wounds using an occlusive dressing technique.

METHODS

The subjects were 253 patients undergoing coronary artery bypass grafting (CABG), who were randomized to receive either the new hydrocolloid dressing (Karayahesive, n = 117) or a polyurethane foam dressing (Tegaderm plus Pad, n = 136) immediately after sternal wound closure. Karayahesive was left in place for 7 days, whereas the Tegaderm plus Pad was removed on postoperative day (POD) 2 and replaced with an adhesive wound dressing until POD 7.

RESULTS

In the Karayahesive group, complete integrity of the wound was achieved in 91% of the patients, with an infection developing in 3.4%: as a superficial surgical site infection (SSI) in three and as a deep SSI in one. On the other hand, in the Tegaderm plus Pad group, an infection developed in 10.3% (14 patients) of the patients: as a superficial SSI in nine and as a deep SSI in five (P < 0.05). The total treatment costs from the application of the dressing until completion of treatment was 699 yen for the Karayahesive and 910 yen for the Tegaderm plus Pad (P < 0.001).

CONCLUSIONS

The new hydrocolloid dressing, applied with an occlusive dressing technique to median sternotomy wounds, prevented SSI and was cost effective.

Validation, updating and impact of clinical prediction rules: a review

OBJECTIVE

To provide an overview of the research steps that need to follow the development of diagnostic or prognostic prediction rules. These steps include validity assessment, updating (if necessary), and impact assessment of clinical prediction rules.

STUDY DESIGN AND SETTING

Narrative review covering methodological and empirical prediction studies from primary and secondary care.

RESULTS

In general, three types of validation of previously developed prediction rules can be distinguished: temporal, geographical, and domain validations. In case of poor validation, the validation data can be used to update or adjust the previously developed prediction rule to the new circumstances. These update methods differ in extensiveness, with the easiest method a change in model intercept to the outcome occurrence at hand. Prediction rules -- with or without updating -- showing good performance in (various) validation studies may subsequently be subjected to an impact study, to demonstrate whether they change physicians' decisions, improve clinically relevant process parameters, patient outcome, or reduce costs. Finally, whether a prediction rule is implemented successfully in clinical practice depends on several potential barriers to the use of the rule.

CONCLUSION

The development of a diagnostic or prognostic prediction rule is just a first step. We reviewed important aspects of the subsequent steps in prediction research.

Are coronary angiograms of value in the risk stratification of patients undergoing coronary artery bypass surgery?

INTRODUCTION

There are currently more than 20 risk-scoring systems that attempt to predict peri-operative mortality following coronary artery bypass surgery (CABG). All these scoring systems use objective criteria to assess operative risk. Angiographic data are currently not included in any of these systems. This pilot study assessed the value of coronary angiography in predicting peri-operative mortality following CABG.

PATIENTS AND METHODS

Fourteen patients who died following first-time isolated CABG surgery were identified. These were matched with 14 patients of similar age, sex, left ventricle function and European System for Cardiac Operative Risk Evaluation (EuroSCORE). A panel of 25 clinicians were given details of the patients' age, sex, diabetic status, family history, smoking history, hypertensive status, lipid status, pre-operative symptoms, left ventricle ejection fraction and weight and shown the coronary angiograms of the patient. They were asked to predict the outcome following CABG for each patient.

RESULTS

Receiver operator characteristic curves were constructed and the area under the curves calculated and analysed using a commercially available statistical package (PRISM). The area under the curve for the group was 0.6820 for the group. Consultant clinicians achieved an area of 0.6789 versus their trainees 0.6844 (P = NS). The cardiologists achieved an area of 0.7063 versus the cardiothoracic surgeons 0.6491 (P = NS).

CONCLUSIONS

Despite the EuroSCORE predicting equal risk for the two groups of patients, it would appear that clinicians are able to identify individual higher risk patients by assessing pre-operatively the quality of the patient's coronary vasculature. Although the clinicians were able to predict individual patient mortality better than the EuroSCORE, the area under the curve indicates that it is not a robust method and clinicians, with all the clinical information to hand, are only moderately good at predicting the outcome following coronary artery bypass surgery.

Percutaneous transcatheter aortic valve implantation: Evolution of the technology

Aortic stenosis (AS) is currently the most common valvular abnormality in developed countries. The gold standard treatment of severe symptomatic AS is surgical aortic valve replacement. Mechanical valves were initially the prostheses of choice; with improvement of surgical technique and results, and increased durability of bioprosthetic valves, there has been a trend toward increasing use of bioprostheses. Concurrently, percutaneous technology has advanced exponentially, and the first human percutaneous aortic valve replacement (PAVR) became a reality in 2002. Various groups have now reported their early experiences with PAVR using different technologies. This new treatment modality is evolving very rapidly. There are currently 2 devices being used in clinical trials; several more devices have first-in-man results and others in preclinical development. It appears that PAVR will most likely become a viable option for selected patients in the near future. For these technologies to continue to improve and benefit patients, cross-specialty teamwork is vital. Treatment of severe AS will greatly evolve as these new and emerging technologies improve. Enhancement in device designs and increasing operator experience will make this technology safer and allow its application to a wider patient population.