Validation of the European system for cardiac operative risk evaluation II in a large Taiwan cardiac surgical centre

BACKGROUND

The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established scoring system for predicting mortality in cardiac surgery. This system was derived predominantly from a European patient cohort; however, no validation of this system has been conducted in Taiwan. We sought to assess the performance of EuroSCORE II at a tertiary centre.

METHODS

The 2161 adult patients receiving cardiac surgery between 2017 and 2020 in our institution were included.

RESULTS

Overall, the in-hospital mortality rate was 7.89%. The performance of EuroSCORE II was assessed using the area under the receiver operator curve (AUC) for discrimination and the Hosmer-Lemeshow (H-L) test for calibration. Data were analysed for type of surgery, risk stratification, and status of the operation. EuroSCORE II had good discriminative power (AUC=0.854, 95% Confidence Interval (CI): 0.822-0.885) and good calibration (χ2=5.19, p=0.82) for all types of surgery except ventricular assist devices (AUC=0.618, 95% CI: 0.497-0.738). EuroSCORE II also showed good calibration for most types of surgery except coronary artery bypass surgery (CABG) combined procedure (P=0.033), heart transplantation (HT) (P=0.017), and urgent operation (P=0.041). EuroSCORE II significantly underestimated the risk for CABG combined procedure and urgent operations, and overestimated the risk for HT.

CONCLUSION

EuroSCORE II had satisfactory discrimination and calibration power to predict surgical mortality in Taiwan. However, the model is poorly calibrated for CABG combined procedure, HT, urgent operation, and, likely, lower- and higher-risk patients.

Combination of the triglyceride-glucose index and EuroSCORE II improves the prediction of long-term adverse outcomes in patients undergoing coronary artery bypass grafting

AIMS

We aimed to investigate the independent and combined association of the triglyceride-glucose (TyG) index and EuroSCORE II with major adverse cardiovascular event (MACE) after coronary artery bypass grafting (CABG), and examine whether the addition of the TyG index improves the predictive performance of the EuroSCORE II.

MATERIALS AND METHODS

This study included 1013 patients who underwent CABG. The primary endpoint was MACE, which was defined as the composite of all-cause death, repeat coronary artery revascularisation, non-fatal myocardial infarction and non-fatal stroke. The patients were grouped by the TyG index and EuroSCORE II tertiles and the combination of these risk indicators.

RESULTS

During the follow-up, 211 individuals developed MACE. Elevated levels of the TyG index and EuroSCORE II were associated with an increased risk of MACE. The hazard ratio [95% confidence interval (CI)] was 3.66 (2.34-5.73) in patients with the highest tertile of the TyG index and EuroSCORE II. Compared with the EuroSCORE II alone, combining the TyG index with EuroSCORE II achieved a better predictive performance [C-statistic increased 0.032, p < 0.001; continuous net reclassification improvement (NRI) (95% CI): 0.364 (0.215-0.514), p < 0.001; integrated discrimination improvement (IDI) (95% CI): 0.015 (0.007-0.023), p < 0.001, Akaike's information criteria (AIC) and Bayesian information criterion (BIC) decreased, and the likelihood ratio test, p < 0.001].

CONCLUSIONS

The TyG index and EuroSCORE II are independently associated with poor prognosis. Furthermore, the TyG index is an important adjunct to the EuroSCORE II for improving risk stratification and guiding early intervention among post-CABG patients.

Validation of EuroSCORE II Scoring System on Isolated CABG Patient in Indonesia

BACKGROUND

Coronary Artery Bypass Graft (CABG) is one solution to overcome cardiovascular problems. EuroSCORE II is a scoring system to predict mortality risk in patients undergoing cardiac surgery including CABG. Unfortunately, there's still much debate about the benefits of EuroSCORE II in Asia, including Indonesia. This study aims to validates EuroSCORE II in predicting the outcomes in patients underwent CABG without any other procedure.

RESULTS

A total of 2628 patients were included. The mean age was 59 years, mostly male (84.97%; n = 2233). Most patients underwent elective surgery (93.07%; n = 2446) and only 1.67% (n = 44) of the patients has high EuroSCORE category. Death was found in 4.22% (n-111) patients. EuroSCORE II had fair discriminant power (AUC 0.72), but a lower mortality predicted value for each group.

CONCLUSION

The parameters in EuroSCORE II are related with mortality in isolated CABG patients, but they cannot be used as mortality predictors in Indonesia.

Validation study of EuroSCORE II for dialysis patients: A single-center study in Japan

BACKGROUND

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II is a predictive model for in-hospital mortality after cardiac surgery. Although it has good performance among the general population undergoing cardiac surgery, it has not been validated among dialysis patients, who have a higher rate of mortality after cardiac surgery. This study aimed to evaluate the performance of the model in predicting in-hospital mortality in maintenance dialysis patients undergoing cardiac surgery.

METHODS

This retrospective, single-center study included adult patients on maintenance dialysis who underwent open cardiac surgery at our institution. Calibration performance of EuroSCORE II for in-hospital death was determined based on the comparison between expected and observed mortalities for low- (EuroSCORE II <4 %), intermediate- (4-8 %), and high-risk (>8 %) groups. The area under receiver operating characteristic curve (AUROC) was investigated to determine the model's discrimination performance.

RESULTS

A total of 163 patients (male, 73.6 %; median age, 70 years; median dialysis vintage, 9 years; median EuroSCORE II, 3.3 %) were included. The mortality rate was 9.2 %. The observed mortality rates (vs. mean expected mortality) rates were 2.1 % (vs. 2.4 %), 7.5 % (vs. 5.5 %), and 34.5 % (vs. 21.1 %) in the low-, intermediate-, and high-risk groups, respectively. Its AUROC was 0.825 (95 % confidence interval, 0.711-0.940).

CONCLUSIONS

Although EuroSCORE II model adequately estimated in-hospital mortality in the low-and intermediate-risk groups (EuroSCORE II <8 %), it underestimated in-hospital mortality in the high-risk group (EuroSCORE II >8 %) among maintenance dialysis patients. The discrimination performance of the model for in-hospital death was good among maintenance dialysis patients.

TRI-SCORE is superior to EuroSCORE II and STS-Score in mortality prediction following transcatheter edge-to-edge tricuspid valve repair

BACKGROUND

The development of transcatheter tricuspid edge-to-edge repair for tricuspid regurgitation is a therapeutic milestone but a specific periprocedural risk assessment tool is lacking. TRI-SCORE has recently been introduced as a dedicated risk score for tricuspid valve surgery.

AIMS

This study analyzes the predictive performance of TRI-SCORE following transcatheter edge-to-edge tricuspid valve repair.

METHODS

180 patients who underwent transcatheter tricuspid valve repair at Ulm University Hospital were consecutively included and stratified into three TRI-SCORE risk groups. The predictive performance of TRI-SCORE was assessed throughout a follow-up period of 30 days and up to 1 year.

RESULTS

All patients had severe tricuspid regurgitation. Median EuroSCORE II was 6.4% (IQR 3.8-10.1%), median STS-Score 8.1% (IQR 4.6-13.4%) and median TRI-SCORE 6.0 (IQR 4.0-7.0). 64 patients (35.6%) were in the low TRI-SCORE group, 91 (50.6%) in the intermediate and 25 (13.9%) in the high-risk groups. The procedural success rate was 97.8%. 30-day mortality was 0% in the low-risk group, 1.3% in the intermediate-risk and 17.4% in the high-risk groups (p < 0.001). During a median follow-up of 168 days mortality was 0%, 3.8% and 52.2%, respectively (p < 0.001). The predictive performance of TRI-SCORE was excellent (AUC for 30-day mortality: 90.3%, for one-year mortality: 93.1%) and superior to EuroSCORE II (AUC 56.6% and 64.4%, respectively) and STS-Score (AUC 61.0% and 59.0%, respectively).

CONCLUSION

TRI-SCORE is a valuable tool for prediction of mortality after transcatheter edge-to-edge tricuspid valve repair and its performance is superior to EuroSCORE II and STS-Score. In a monocentric cohort of 180 patients undergoing edge-to-edge tricuspid valve repair TRI-SCORE predicted 30-day and up to one-year mortality more reliably than EuroSCORE II and STS-Score. AUC area under the curve, 95% CI 95% confidence interval.

Evaluation of Two Online Risk Prediction Models for the Mortality Rate of Acute Type A Aortic Dissection Surgery: The German Registry of Acute Aortic Dissection Type A Score and the European System for Cardiac Operative Risk Evaluation II

EuroSCORE II is one of the most widely utilized cardiovascular surgery risk scoring systems. Recently, a new online score calculator, namely the German Registry of Acute Aortic Dissection Type A (GERAADA), was launched to predict 30-day surgical mortality for acute type A aortic dissection (ATAAD) patients. The aim of this study is to evaluate the predictive performance of these two scores. We calculated the two scores for 1346 ATAAD patients from January 2012 to December 2021. The overall performance was evaluated using Brier scores and Hosmer-Lemeshow statistics. Receiver Operating Characteristic (ROC) curves were employed to assess diagnostic ability, and the standardized mortality ratio (SMR) was utilized to evaluate calibration. The GERAADA score and EuroSCORE II predicted 30-day mortality rates of 14.7% and 3.1%, respectively, while the observed rate was 12.5%. The predictive ability of EuroSCORE II (AUC 0.708, 95% CI: 0.664-0.792) was superior to that of the GERAADA score (0.648, 95% CI: 0.605-0.692). The GERAADA score had higher sensitivity but lower specificity than EuroSCORE II. And the GERAADA score may overestimate mortality (0.76, 95% CI: 0.65-0.89), while EuroSCORE II may underestimate the mortality rate (3.17, 95% CI: 2.92-3.44). The EuroSCORE II was superior in predicting surgical mortality among ATAAD patients. But the observed 30-day mortality rate certified a good calibration for the GERAADA score.

One-Year Survival after Cardiac Surgery in Frail Older People-Social Support Matters: A Prospective Cohort Study

There are increasing rates of cardiac surgery in the elderly. Frailty, depression, and social vulnerability are frequently present in older people, and should be considered while assessing risk and providing treatment options. We aimed to analyse the impact of clinically relevant variables on survival at one year, and identify areas of future intervention. We performed a prospective cohort study at a University Hospital, with a sample of 309 elective cardiac surgery patients 65 years old and over. Their socio-demographic and clinical variables were collected. Frailty prevalence was 61.3%, while depression was absent in the majority of patients. Mortality was 1.6% and 7.8% at 30 days and 12 months, respectively. After Kaplan-Meier analysis, severe frailty (p = 0.003), severe depression (p = 0.027), pneumonia until 30 days (p = 0.014), and re-operation until 12 months (p = 0.003) significantly reduced survival, while social support increased survival (p = 0.004). In the adjusted multivariable Cox regression model, EuroSCORE II (HR = 1.27 [95% CI 1.069-1.499] p = 0.006), pneumonia until 30 days (HR = 4.19 [95% CI 1.169-15.034] p = 0.028), re-intervention until 12 months (HR = 3.14 [95% CI 1.091-9.056] p = 0.034), and social support (HR = 0.24 [95% CI 0.079-0.727] p = 0.012) explained time until death. Regular screening for social support, depression, and frailty adds relevant information regarding risk stratification, perioperative interventions, and decision-making in older people considered for cardiac surgery.

Fluorine 18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Cardiac Viability Risk Stratification in Comparison with EuroSCORE II for Revascularization in Patients with Left Ventricular Dysfunction

Background

Diagnostic value of fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (F18-FDG PET/CT) in the assessment of myocardial viable segments is well known; hence, it can identify patients with left ventricular (LV) systolic dysfunction who may benefit from revascularization. The presence of significant myocardial viable segments before revascularization will offer better prognosis with reduced mortality and morbidity. However, the usage of F18-FDG PET/CT myocardial viability study in the presurgical risk stratification is limited.

Objective

The objective of the study is to predict perioperative mortality with hibernating viable myocardial (HVM) segments established by F18-FDG PET/CT in comparison with EuroSCORE II in patients with LV dysfunction undergoing coronary artery bypass grafting surgery.

Materials and Methods

A prospective, observational study included 75 patients of chronic ischemic coronary artery disease with ejection fraction ≤40%. Tc-99m sesta-methoxyisobutylisonitrile myocardial perfusion single photon emission CT/CT and myocardial viability with F18-FDG PET/CT at rest were performed. Mortality risk stratification was done according to the EuroSCORE II. Patients were followed for post-coronary artery bypass graft surgery (CABG) 30-day mortality. Mortality observed by HVM segment groups were compared with EuroSCORE II predicted mortality.

Results

Receiver operating curve for 30-day mortality prediction with HVM segments and EuroSCORE II was constructed. It showed that a cutoff of <4 HVM segments (area under the curve [AUC] = 0.7) had a sensitivity of 85%, whereas EuroSCORE II (AUC = 0.4) had only 28.6% sensitivity. EuroSCORE II underestimated perioperative risk in patients with <4 viable segments, that is 5 times higher risk was observed in patients with <4 viable segments.

Conclusions

HVM segments established by F18-FDG PET/CT had independently predicted mortality postoperatively. Hence, including F18-FDG PET/CT for viability assessment along with EuroSCORE II in preoperative risk assessment for revascularization by CABG in patients with LV dysfunction provided better risk stratification.

Validation in Indonesia of two published scores for mortality prediction after cardiac surgery

Introduction

No mortality risk prediction model has previously been validated for cardiac surgery in Indonesia. This study aimed at validating the EuroSCORE II and Age Creatinine Ejection Fraction (ACEF) score as predictors for in-hospital mortality after cardiac surgery a in tertiary center, and if necessary, to recalibrate the EuroSCORE II model to our population.

Methods

This study was a single-center observational study from prospectively collected data on adult patients undergoing cardiac surgery from January 2006 to December 2011 (n = 1833). EuroSCORE II and ACEF scores were calculated for all patients to predict in-hospital mortality. Discrimination was assessed using the area under the curve (AUC) with a 95% confidence interval. Calibration was assessed with the Hosmer-Lemeshow test (HL test). Multivariable analysis was performed to recalibrate the EuroSCORE II; variables with P < 0.2 entered the final model.

Results

The in-hospital mortality rate was 3.8%, which was underestimated by the EuroSCORE II (2.1%) and the ACEF score (2.4%). EuroSCORE II (AUC 0.774 (0.714-0.834)) showed good discrimination, whereas the ACEF score (AUC 0.638 [0.561-0.718]) showed poor discrimination. The differences in AUC were significant (P = 0.002). Both scores were poorly calibrated (EuroSCORE II: HL test P < 0.001, ACEF score: HL test P < 0.001) and underestimated mortality in all risk groups. After recalibration, EuroSCORE II showed good discrimination (AUC 0.776 [0.714- 0.840]) and calibration (HL test P = 0.79).

Conclusions

EuroSCORE II and the ACEF score were unsuitable for risk prediction of in-hospital mortality after cardiac surgery in our center. Following recalibration, the calibration of the EuroSCORE II was greatly improved.

Performance of the EuroSCORE II Model in Predicting Short-Term Mortality of General Cardiac Surgery: A Single-Center Study in Taiwan

BACKGROUND

The latest European System for Cardiac Operative Risk Evaluation (EuroSCORE) II is a well-accepted risk evaluation system for mortality in cardiac surgery in Europe.

OBJECTIVES

To determine the performance of this new model in Taiwanese patients.

METHODS

Between January 2012 and December 2014, 657 patients underwent cardiac surgery at our institution. The EuroSCORE II scores of all patients were determined preoperatively. The short-term surgical outcomes of 30-day and in-hospital mortality were evaluated to assess the performance of the EuroSCORE II.

RESULTS

Of the 657 patients [192 women (29.22%); age 63.5 ± 12.68 years], the 30-day mortality rate was 5.48%, and the in-hospital mortality rate was 9.28%. The discrimination power of this new model was good in all populations, regardless of 30-day mortality or in-hospital mortality. Good accuracy was also noted in different procedures related to coronary artery bypass grafting, and good calibration was noted for cardiac procedures (p value > 0.05). When predicting surgical death within 30 days, the EuroSCORE II overestimated the risk (observed to expected: 0.79), but in-hospital mortality was underestimated (observed to expected: 1.33). The predictive ability [area under the curve (AUC) of the receiver operating characteristic (ROC) curve] and calibration of the EuroSCORE II for 30-day mortality (0.792) and in-hospital mortality (0.825) suggested that in-hospital mortality is a better endpoint for the EuroSCORE II.

CONCLUSIONS

The new EuroSCORE II model performed well in predicting short-term outcomes among patients undergoing general cardiac surgeries. For short-term outcomes, in-hospital mortality was better than 30-day mortality as an indicator of surgical results, suggesting that it may be a better endpoint for the EuroSCORE II.

Validation for EuroSCORE II in the Indonesian cardiac surgical population: a retrospective, multicenter study

BACKGROUND

In 2011, the European System for Cardiac Operative Risk (EuroSCORE) II was created as an improvement of the additive/logistic EuroSCORE for the prediction of mortality after cardiac surgery.

OBJECTIVE

To validate EuroSCORE II in predicting the mortality of open cardiac surgery patients in Indonesia.

METHODS

We performed a multi-center retrospective study of cardiac surgery patients from three participating centers (Dr. Sardjito Hospital, Kariadi Hospital, and Abdul Wahab Sjahranie Hospital) between January 1st, 2016, and December 31st, 2020. Discrimination and calibration tests were performed.

RESULTS

The observed mortality rate was 9.5% (73 out of 767 patients). The median EuroSCORE II value was 1.13%. The area under the curve for EuroSCORE II was 0.71 (95% CI: 0.65-0.77), suggesting fair discriminatory power. Calibration analysis suggested that EuroSCORE II underestimated postoperative mortality. Gender, age, chronic pulmonary disease, limited mobility, NYHA, and critical pre-operative state were significant predictors of post-cardiac surgery mortality in our population.

CONCLUSION

This study suggested that the EuroSCORE II was a poor predictor for postoperative mortality in Indonesian patients who underwent cardiac surgery procedures. Therefore, EuroSCORE II may not be suitable for mortality risk prediction in Indonesian populations, and surgical planning should be decided on an individual basis.

Is EuroSCORE II still a reliable predictor for cardiac surgery mortality in 2022? A retrospective study study

OBJECTIVES

The European System for Cardiac Operation Risk Evaluation II (EuroSCORE II) is the most common tool used to evaluate the perioperative risk of mortality after cardiac surgery in Europe, and its use is currently recommended by the relevant guidelines. However, recently, its role has been questioned: Several papers have suggested that these algorithms may no longer be adequate for risk prediction due to an overestimation of adult cardiac surgical risk. Our goal was to validate the EuroSCORE II in the prediction of 30-day in-hospital mortality in patients undergoing open cardiac surgery in a high-volume hospital.

METHODS

In this retrospective cohort study, we included all patients who underwent cardiac surgery from January 2016 to May 2022 within the departments of cardiac surgery of the Monzino Cardiology Centre in Milan, Italy. We evaluated the discrimination power of the EuroSCORE II by using the receiver operating characteristic curve and the corresponding area under the curve. We performed calibration plots to assess the concordance between the model's prediction and the observed outcomes.

RESULTS

A total of 4,034 patients were included (mean age = 65.1 years; 68% males), of which 674 (16.7%) underwent isolated coronary artery bypass grafting. The EuroSCORE II showed a good discrimination power in predicting 30-day in-hospital mortality (area under the curve = 0.834). However, for interventions performed in an elective setting, very low values of the EuroSCORE II overestimated the observed mortality, whereas for interventions performed in an emergency setting, EuroSCORE II values above 10 extensively underestimated the observed mortality.

CONCLUSIONS

Our study suggests that the EuroSCORE II seems not to be a reliable score in estimating the true risk of death, especially in high-risk patients.

Predictive Ability of European Heart Surgery Risk Assessment System II (EuroSCORE II) and the Society of Thoracic Surgeons (STS) Score for in-Hospital and Medium-Term Mortality of Patients Undergoing Coronary Artery Bypass Grafting

Objective

To evaluate the powers of European Heart Surgery Risk Assessment System II (EuroSCORE II) and the Society of Thoracic Surgeons (STS) score in predicting in-hospital and medium-term mortality of patients undergoing coronary artery bypass grafting (CABG).

Methods

Totally 1628 Chinese patients were included between January 2000 and January 2018. Their perioperative clinical data were collected and the patients were closely followed up. According to the length of follow-up time, the total cohort was divided into 1-year, 2-year, 3-year, 4-year and 5-year groups. The in-hospital and medium-term risk prediction of EuroSCORE II and STS score were comparatively assessed by calibration, discrimination, decision curve analysis (DCA), net reclassification index (NRI), integrated discrimination improvement (IDI) and Bland-Altman analysis.

Results

About 36 (2.21%) patients died during hospitalization. Both EuroSCORE II and STS score performed extremely well in predicting in-hospital mortality (area under curve = 0.900 and 0.879, respectively). However, calibration and discrimination analyses showed gradual decrease when these two risk evaluation systems were used to predict mortality during the follow-up period. At the same time, the predictive ability of EuroSCORE II was better than STS score. DCA curves showed that the performances of the two evaluation systems were roughly equal between the threshold probability of 0% to 20%. The percentage of correct reclassification of EuroSCORE II was 21.64% higher than that of STS score in predicting 2-year postoperative mortality. The IDI index showed that the predictive capabilities of these two systems were roughly equivalent. Bland-Altman analysis showed no significant difference between the values of the two systems.

Conclusion

EuroSCORE II and STS score have excellent predictive powers in predicting in-hospital mortality of patients undergoing CABG. In particular, EuroSCORE II is superior in calibration and discrimination. The prediction efficiency of the two risk evaluation systems is still acceptable for two-year postoperative mortality, but decreases year by year.

Comparison of European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Society of Thoracic Surgeons(STS) score for risk prediction in Indian patients undergoing coronary artery bypass grafting

BACKGROUND

For risk stratifying patients undergoing coronary artery bypass graft (CABG), the Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) are currently used. However, the superiority of one over the other in the context of Indian patients has not been assessed. The aim of this study was to compare these 2 scoring systems in Indian patients undergoing CABG.

METHODOLOGY

This was a retrospective analysis of prospectively collected data between January 2015 and September 2020 of all patients undergoing CABG. Observed mortality in the cohort was compared with the predicted mortality using the STS and the EuroSCORE II. Sensitivity and specificity were calculated for both the scores. Receiver operating characteristic (ROC) curves were constructed for both the STS and the EuroSCORE II and area under the ROC curve (AUC) was calculated.

RESULTS

A total of 4895 patients were included in the study. The overall observed mortality in the entire cohort was 74 (1.5%). The EuroSCORE II-predicted mortality was 1.9 ± 2.5 whereas the STS score-predicted mortality was 1.2 ± 1.8. The observed to predicted mortality ratio for EuroSCORE was 0.79 and 1.25 for the STS score. The discriminative ability for operative mortality of the STS score was 0.72 (0.71 to 0.74) and 0.713 for the EuroSCORE, suggesting satisfactory discriminatory power. There was no difference between the STS score and the EuroSCORE in terms of discriminatory power (p = 0.58) and a difference in the AUC being 0.01. The discriminatory power of the EuroSCORE and the STS score was best in the high-risk category.

CONCLUSIONS

Both the EuroSCORE and the STS scores had satisfactory and similar discriminatory power. However, in the Indian population, while the EuroSCORE II overestimated mortality, the STS score underestimated it to a similar degree of error.

Evidence-Based Determination of Cut-Off Points for Increased Cardiac-Surgery Mortality Risk With EuroSCORE II and STS: The Best-Performing Risk Scoring Models in a Single-Centre Australian Population

OBJECTIVES

Risk scoring models (RSMs) are commonly used for estimation of postoperative-mortality risk in patients undergoing cardiac surgery, but their prediction accuracy may vary in different populations and clinical situations. The prognostic accuracies of some RSMs have not yet been fully evaluated in the Australian population. In this retrospective observational study, our aims were to assess the performance of four contemporary RSMs, to identify the best RSMs for prediction of postoperative-mortality in the single-centre cohort, and to determine a statistical threshold for classification of patients with increased or "higher" mortality risk.

METHODS

The study population included patients who underwent cardiac surgery at Liverpool Hospital between January 2013 and December 2014. Demographic information was collected, and mortality risks were estimated with the ES2 (EuroSCORE II), STS (Society of Thoracic Surgeons Score), AS (AusSCORE total) and ASMR (AusSCORE multi-risk) RSMs. (Additive EuroSCORE) (AES) and LES (logistic EuroSCORE) were included for historical interest. Discrimination, the ability to stratify patients between mortality and no mortality outcomes, and calibration, the comparison of risk score estimated and observed outcome in the population, were evaluated for each RSM, to determine their predictive accuracy in the study population. Discrimination was assessed by the AUC (area under the receiver operating characteristic curve), and acceptable calibration by the p-value greater than 0.05 for the Hosmer-Lemeshow (H-L) test. The best AUCs in contempory models were compared using the DeLong test. For ES2 and STS risk scores, cut-off points, or thresholds, for patients at increased risk of mortality were derived using Youden's J-statistics, calculated from sensitivity and specificity of models in predicting mortality.

RESULTS

From a total study population of 898 patients, 738 had scores for all six RSMs. The three EuroSCORE risk models and Youden's J-statistics analysis included the total population. Of the models in contemporary use, ES2 had higher discrimination (AUC=0.850) in this population than ASMR (AUC=0.767, p=0.024) and AS (AUC=0.739) and non-significantly higher discrimination than STS (AUC=0.806, p=0.19). All contemporary models had acceptable calibration but the older LES (H-L p=0.024) did not. Estimated mortality was closest to observed mortality with the ES2 model. Both AES and LES over predicted mortality. The RSM with the highest discrimination in isolated coronary artery bypass graft surgery (CAGs) (AUC=0.847), isolated valves (AUC=0.830), and females (AUC=0.784) was the ES2 model. STS discrimination was highest in CAGs plus valve procedures (AUC 0.891), and males (STS AUC=0.891). Cut-off points for risk scores to define increased risk populations were 3.0% for ES2 and 1.7% for STS. Similar proportions of patients in each RSM (ES2-26% to STS-32%) were defined as higher risk by the model threshold score depending on type of procedure.

CONCLUSION

Among RSMs in contemporary use, ES2 and STS showed the best discrimination and acceptable calibration. Caution is recommended in specific subgroups. Increased mortality risk score cut-off points could be identified for these two RSMs in this single-centre cohort.

Risk Factors of Midterm Mortality After Aortic Valve Replacement for Severe Calcified Tricuspid Aortic Valve Stenosis: A retrospective analysis of Perioperative Events Assessment in Adult Cardiac surgery (PESSAC) Registry

OBJECTIVE

The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) initially developed for predicting early postoperative mortality of all types of cardiac surgery, is less able to predict, more specifically, long-term outcomes after aortic valve replacement (AVR). The study authors here evaluated the risk factors for three-year mortality after isolated aortic valve replacement (AVR) for severe calcified tricuspid aortic valve stenosis and compared them with EuroSCORE II to predict long-term outcomes.

DESIGN

A retrospective study.

SETTING

A university teaching hospital.

PARTICIPANTS

This study included 1,101 adults who underwent isolated AVR for severe calcified tricuspid aortic valve stenosis between September 2010 to June 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was that of three-year all-cause mortality after AVR. By three years, 168 patients (15.3%) had died. Risk factors for all-cause mortality were: male gender (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.21-2.62; p < 0.01), peripheral arterial disease (OR = 1.77; 95% CI = 1.08-2.92; p = 0.03), age (OR = 1.06 per year increase; 95% CI =1.04-1.09; p < 0.01), pulmonary artery systolic pressure (OR = 1.02 per mmHg increase; 95% CI = 1.01-1.03; p < 0.01), platelet count (OR = 1.003 per G/L increase; 95% CI = 1.000-1.005; p = 0.04), and valve area (OR = 0.97 per cm²/m² increase; 95% CI= 0.95-0.99; p < 0.01). The area under the receiver operating characteristic curves were 0.67 (95% CI = 0.60-0.75) and 0.60 (95% CI = 0.56-0.65) for the authors' logistic regression model and EuroSCORE II, respectively (p = 0.11).

CONCLUSIONS

The study authors identified six independent risk factors for three-year mortality after isolated AVR. The logistic regression model had relatively modest predictive performance for three-year mortality.

Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm² and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

Is the EuroSCORE II reliable in surgical mitral valve repair? A single-centre validation study

OBJECTIVES

The EuroSCORE II is widely used to predict 30-day mortality in patients undergoing open and transcatheter cardiac surgery. The aim of this study is to evaluate the discriminatory ability of the EuroSCORE II in predicting 30-day mortality in a large cohort of patients undergoing surgical mitral valve repair in a high-volume centre.

METHODS

A retrospective review of our institutional database was carried on to find all patients who underwent mitral valve repair in our department from January 2012 to December 2019. Discrimination of the EuroSCORE II was assessed using receiver operating characteristic curves. The maximum Youden's Index was employed to define the optimal cut-point. Calibration was assessed by generating calibration plot that visually compares the predicted mortality with the observed mortality. Calibration was also tested with the Hosmer-Lemeshow goodness-of-fit test. Finally, the accuracy of the models was tested calculating the Brier score.

RESULTS

A total of 2645 patients were identified, and the median EuroSCORE II was 1.3% (0.6-2.0%). In patients with degenerative mitral regurgitation (MR), the EuroSCORE II showed low discrimination (area under the curve 0.68), low accuracy (Brier score 0.27) and low calibration with overestimation of the 30-day mortality. In patients with secondary MR, the EuroSCORE II showed a good overall performance estimating the 30-day mortality with good discrimination (area under the curve 0.88), good accuracy (Brier score 0.003) and good calibration.

CONCLUSIONS

In patients with degenerative MR operated on in a high-volume centre with a high level of expertise in mitral valve repair, the EuroSCORE II significantly overestimates the 30-day mortality.

Prediction value of EuroSCORE II in total arterial revascularization and its usage in the evaluation of postoperative complications: Single-center experience

BACKGROUND

Total arterial revascularization is the most durable and technically the most demanding type of coronary artery bypass grafting procedure. It has proven long-term supremacy in comparison to conventional coronary artery bypass grafting. In our study, we investigated the reliability of EuroSCORE II as a predictor of intrahospital death. We showed its impact on adverse perioperative events.

METHODS

In this nonrandomized prospective study, we analyzed 116 consecutive patients who underwent the total arterial revascularization procedure at our Institute from January 2011 until the present. For myocardial revascularization, the most suitable combinations with left internal mammary artery, right internal mammary artery, and radial artery grafts were used. Main fact in this research was intrahospital mortality value in comparison with the value predicted.

RESULTS

There were 104 (89.7%) males and 12 (10.3%) females. Mean preoperative EuroSCORE II prediction value was 1.98% and postoperative we obtained 1.72%. Postoperative redo for bleeding was 6%. Positive correlation was proven between the EuoroSCORE II value and intensive care unit stay (0.452; p < 0.001). Among patients who received two internal mammary arteries, the highest EuroSCORE II was among those with presternal wound infection (p = 0.005). Patients with bilateral internal mammary arteries and diabetes showed that they have the highest values of EuroSCORE II and, at the same time, that they are extremely prone to wound problems.

CONCLUSIONS

We achieved a lower intrahospital mortality level than it was predicted with preoperative EuroSCORE II value. This tool is a reliable method for preoperative death risk calculation in this group of patients.

Performance of EuroSCORE II and Society of Thoracic Surgeons risk scores in elderly patients undergoing aortic valve replacement surgery

BACKGROUND

In cardiac surgery, risk is estimated with models such as EuroSCORE II and the Society of Thoracic Surgeons (STS) score. Performance of these scores may vary across various patient age ranges.

AIM

To assess the effect of patient age on performance of the EuroSCORE II and STS scores, regarding postoperative mortality after surgical aortic valve replacement.

METHODS

In a prospective cohort of patients, we assessed risk stratification of EuroSCORE II and STS scores for discrimination of in-hospital mortality with the area under the receiver operating characteristic curve (AUROC) and calibration with the Hosmer-Lemeshow test. Two groups of patients were compared: elderly (aged>75years) and younger patients.

RESULTS

Of 1229 patients included, 635 (51.7%) were elderly. Mean EuroSCORE II score was 3.7±4.4% and mean STS score was 2.1±1.5%. Overall in-hospital mortality was 4.8% and was higher in the elderly compared with younger patients (6.6% vs. 2.8%; log-rank P=0.014). AUROC for the EuroSCORE II score was lower in elderly than in younger patients (0.731 vs. 0.784; P=0.025). Similarly, AUROC for the STS score was lower in elderly versus younger patients (0.738 vs. 0.768; P=0.017). In elderly patients, EuroSCORE II and STS scores were not adequately calibrated and significantly underestimated mortality. Age was independently associated with mortality, regardless of EuroSCORE II or STS score.

CONCLUSIONS

In this cohort, EuroSCORE II and STS scores did not perform as well in elderly patients as in younger patients. Elderly patients may be at increased postoperative risk, regardless of risk score.

Rapid-deployment aortic valve replacement in high-risk patients: A case-control study

Introduction: Aortic valve stenosis is the most frequent cardiac valve pathology in the western world. In high-risk patients, conventional aortic valve replacement (C-AVR) carries high rates of morbidity and mortality. In the last few years, rapid-deployment valves (RDV) have been developed to reduce the surgical risks. In this work, we aimed to compare the mid-term outcomes of rapid-deployment AVR (RD-AVR) with those of the C-AVR in high-risk patients.

Methods: This retrospective case-control study identified 23 high-risk patients who underwent RD-AVR between 12/2015 to 01/2018. The study group was compared with a control group of 46 patients who were retrospectively selected from a database of 687 C-AVR patients from 2016 to 2017 which matched with the study group for age and Euro SCORE II.

Results: RD-AVR group presented more cardiovascular risk factors. Euro SCORE II was higher in the RD-AVR group (P =0.06). In the RD-AVR group, we observed significantly higher mean prosthetic size (P <0.001). In-hospital mortality was zero in RD-AVR group versus 2 deaths in C-AVR group. Hospital stay was longer in the RD-AVR group with statistical significance (P =0.03). In the group AVR with associated cardiac procedures, while comparing subgroups RD-AVR versus C-AVR, early mean gradient was lower in the first cited (P =0.02). The overall mean follow-up was 10.9 ± 4.3 months.

Conclusion: The RD-AVR technique is reliable and lead to positive outcomes. This procedure provides a much larger size with certainly better flow through the aortic root. It is an alternative to C-AVR in patients recognized to be surgically fragile.

Prognostic implications of left ventricular geometry in coronary artery bypass grafting patients

Background

The prognostic implications of left ventricular (LV) mass and geometry have been confirmed in populations with different cardiac diseases. However, the prognostic value of LV geometry in coronary artery bypass grafting (CABG) patients is unclear.

Methods

A total of 2,517 patients undergoing CABG between January 2012 and September 2016 in our cardiac surgery unit were included. Patients were divided into the following 4 groups according to left ventricular mass index (LVMi) and relative wall thickness (RWT): normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy.

Results

The median follow-up period was 47.0 months (interquartile range was 32.5-61.3 months). Compared to the normal geometry group, the concentric remodeling group [hazard ratio (HR): 3.023; 95% confidence interval (CI): 1.134-8.060], the eccentric hypertrophy group (HR: 3.422; 95% CI: 1.395-8.398), and the concentric hypertrophy group (HR: 5.399; 95% CI: 2.289-12.735) have higher main adverse cardiovascular and cerebrovascular event (MACCE) risk. Moreover, increased MACCE risk was associated with higher LVMi (HR: 1.015 per 1 g/m² increase in LVMi; 95% CI: 1.005-1.026) and RWT (HR: 1.991 per 0.1-U increase in RWT; 95% CI: 1.343-2.952). We observed similar results concerning mortality. Adding LV geometry to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II significantly improved the area under the curve (AUC) for MACCE (from 0.621 to 0.703; P=0.042). The addition of LV geometry showed significant integrated discrimination improvement (IDI) and net reclassification improvement (NRI) for MACCE (IDI: 0.043, P<0.001; NRI: 0.200, P<0.001) and death (IDI: 0.018, P=0.020; NRI: 0.308, P=0.002), as was the addition of LVMi and RWT.

Conclusions

LV geometry is an independent and incremental prognostic factor for MACCE and death in CABG patients.

MAGGIC, STS, and EuroSCORE II Risk Score Comparison After Aortic and Mitral Valve Surgery

OBJECTIVES

To compare the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with the established Society of Thoracic Surgeons (STS) and EuroSCORE II risk prediction models regarding mortality discrimination after aortic and mitral valve surgery.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary academic medical center.

PARTICIPANTS

A total of 259 patients who underwent open aortic valve replacement or open mitral valve repair/replacement from 2009-2014.

INTERVENTIONS

Retrospective chart review.

MEASUREMENTS AND MAIN RESULTS

MAGGIC, STS, and EuroSCORE II risk scores for each patient were studied using binary logistic regression and receiver operating characteristic analysis for the primary endpoint of one-year mortality and secondary endpoint of 30-day mortality. One-year mortality C-statistics were similar across risk scores (STS 0.709, 95% confidence interval [CI] 0.578-0.841; MAGGIC 0.673, 95% CI 0.547-0.799; EuroSCORE II 0.642, 95% CI 0.521-0.762; p = 0.56 between STS and MAGGIC; p = 0.20 between STS and EuroSCORE II; and p = 0.69 between MAGGIC and EuroSCORE II). Thirty-day mortality C-statistics also were similar between STS (0.797, 95% CI 0.655-0.939; p < 0.0001 v null hypothesis), MAGGIC (0.721, 95% CI 0.581-0.860; p = 0.33 v STS), and EuroSCORE II (0.688, 95% CI 0.557-0.818; p = 0.06 v STS; p = 0.68 v MAGGIC).

CONCLUSIONS

The MAGGIC risk score performs similarly to STS and EuroSCORE II risk models in mortality discrimination after aortic and mitral valve surgery, albeit in a small sample size. This finding has important implications in establishing MAGGIC as a viable prognostic model in this population subset, with fewer variables and ease of use representing key advantages over STS and EuroSCORE II.

Predictive ability of EuroSCORE II integrating cardiactroponin T in patients undergoing OPCABG

Background

Preoperative risk evaluation systems are significant and important to the allocation of medical resources and the communication between doctors and patients. The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is widely used in clinical practice. Cardiac troponin T (cTnT) can specifically and accurately reflect myocardial injury. Whether EuroSCORE II can improve the predictive power after integrating with cTnT is still unclear. This study was a retrospective single center study designed to assess the predictive ability of EuroSCORE II integrated with cTnT for patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG).

Methods

This retrospective and observational cohort study included 1887 patients who underwent first isolated OPCABG. cTnT was detected within 48 h before operation in each patient. According to myocardial injury, patients were divided by cTnT into 4 stages. A new risk evaluation system was created through logistic regression with EuroSCORE II and myocardial injury classification as covariates. Then the two risk evaluation systems were comparatively assessed by regression analysis, receiver operator characteristic curves, net reclassification index, Bland–Altman plots and decision curve analysis.

Results

There were 43 in-hospital deaths, with a mortality of 2.30% (43/1887). The logistic regression analysis showed that preoperative myocardial injury classification was a significant risk factor for in-hospital mortality in both total cohort (OR 1.491, 95%CI 1.049–2.119) and subsets (OR 1.761, 95%CI 1.102–2.814). The new risk evaluation system has higher calibration and discrimination power than EuroSCORE II, both for overall cohort and subsets. Especially, the new system has obvious advantages in discrimination power in the subset of acute myocardial infarction (AUC 0.813 vs. 0.772, 0.906 vs. 0.841, and 0.715 vs. 0.646, respectively).

Conclusions

Both myocardial injury classification and EuroSCORE II are independent risk factors of in-hospital mortality in OPCABG patients. The new risk evaluation system has higher predictive ability than EuroSCORE II, especially in patients with a recent history of AMI.

The Asian system for cardiac operative risk evaluation for predicting mortality after isolated coronary artery bypass graft surgery (ASCORE-C)

OBJECTIVE

The mortality of coronary artery bypass graft surgery (CABG) in Asian patients predicted by Western population-based risk models is not ideal. We aimed to develop a risk scoring system based on a multiracial Asian patient population to predict early-stage mortality.

METHODS

A total of 2495 patients who underwent isolated CABG in Singapore from 2009 to 2015 were included to develop a regional scoring system: the regional Asian System for Cardiac Operative Risk Evaluation in CABG (ASCORE-C). Predictors were identified via a stepwise multiple logistic regression to construct models for 30-day, 90-day, and 1-year cumulative mortality prediction. The optimal cut-offs of ASCORE-C risk strata were determined by the multiway χ² and Interaction Detection decision tree. The performance of ASCORE-C was compared with European System for Cardiac Operative Risk Evaluation score (EuroSCORE) II and Society of Thoracic Surgeons (STS) score by observed/estimated mortality ratio.

RESULTS

The observed postoperative 30-day, 90-day, and 1-year cumulative mortality following isolated CABG were 2.6%, 3.3%, and 4.6%, respectively. The ASCORE-C to predict these three events were constructed with age (>65 years), Malay ethnicity, congestive heart failure, abnormal heart rhythm, aortic atherosclerosis, estimated glomerular filtration rate, peripheral vascular disease, critical preoperative status, and emergency surgery. Tested by three different validation datasets, receiver operating characteristic curve of ASCORE-C model prediction performed well with the Hosmer-Lemeshow test. The ASCORE-C was found to have better predictive accuracy than EuroSCORE II and STS score in CABG mortality prediction, especially for the high-risk patients.

CONCLUSION

The ASCORE-C system is reliable for early-stage CABG mortality prediction in a multiracial Asian population.

Usefulness of FRAIL Scale in Heart Valve Diseases

Background

The frailty syndrome is a serious health problem for an aging population. The occurrence of frailty in the group of symptomatic patients undergoing heart valve surgery may have additional clinical implications. The predictive ability of the FRAIL scale in patients undergoing heart valve surgery during a 30-day follow-up has not yet been described.

Patients and Methods

A prospective study was conducted on a group of consecutive patients with hemodynamically significant valve disease (aortic stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) that underwent elective valve surgery in 2014–2019. The primary endpoint was 30-day mortality. Univariate analysis, followed by multivariate regression analysis, was performed.

Results

The study group included 672 consecutive patients (aortic valve stenosis, aortic regurgitation, mitral stenosis and mitral regurgitation) who underwent replacement or repair of the valve. Twenty-five patients died during the 30-day follow-up. At multivariate analysis, FRAIL scale result (OR 2.802; 95% CI 1.275–6.157; p=0.01) and red cell distribution width (RDW) (OR 1.810; 95% CI 1.181–2.775; p=0.006) remained independent predictors of the primary endpoint.

Conclusion

The presented study showed the predictive ability of the FRAIL scale result in patients undergoing heart valve surgery for 30-day mortality.

Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement

BACKGROUND

The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center.

METHODS

A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews.

RESULTS

For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85).

CONCLUSIONS

Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.

Aortic Valve Sclerosis Adds to Prediction of Short-Term Mortality in Patients with Documented Coronary Atherosclerosis

Aims: Aortic valve sclerosis (AVSc), a non-uniform thickening of leaflets with an unrestricted opening, is characterized by inflammation, lipoprotein deposition, and matrix degradation. In the general population, AVSc predicts long-term cardiovascular mortality (+50%) even after adjustment for vascular risk factors and clinical atherosclerosis. We have hypothesized that AVSc is a risk-multiplier able to predict even short-term mortality. To address this issue, we retrospectively analyzed 90-day mortality of all patients who underwent isolated coronary artery bypass grafting (CABG) at Centro Cardiologico Monzino over a ten-year period (2006–2016). Methods: We analyzed 2246 patients and 90-day all-cause mortality was 1.5% (31 deaths). We selected only patients deceased from cardiac causes (n = 29) and compared to alive patients (n = 2215). A cardiologist classified the aortic valve as no-AVSc (n = 1352) or AVSc (n = 892). Cox linear regression and integrated discrimination improvement (IDI) analyses were used to evaluate AVSc in predicting 90-day mortality. Results: AVSc 90-day survival (97.6%) was lower than in no-AVSc (99.4%; p < 0.0001) with a hazard ratio (HR) of 4.0 (95%CI: 1.78, 9.05; p < 0.0001). The HR for AVSc, adjusted for propensity score, was 2.7 (95%CI: 1.17, 6.23; p = 0.02) and IDI statistics confirmed that AVSc significantly adds (p < 0.001) to the identification of high-risk patients than EuroSCORE II alone. Conclusion: Our data supports the hypothesis that a risk stratification strategy based on AVSc, added to ESII, may allow better recognition of patients at high-risk of short-term mortality after isolated surgical myocardial revascularization. Results from this study warrant further confirmation.

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.

Performance of the EuroSCORE II and the Society of Thoracic Surgeons score in patients undergoing aortic valve replacement for aortic stenosis

Background

The aim of the study was to assess the predictive ability of risk calculators of the EuroSCORE II and the Society of Thoracic Surgeons (STS) score in patients undergoing aortic valve replacement (AVR) due to severe aortic valve stenosis (AS) during a 30-day and 1-year follow-up.

Methods

A prospective study was conducted on a group of consecutive patients with hemodynamically significant aortic valve stenosis that underwent elective valve replacement surgery. The risk of surgery using EuroSCORE II and STS was calculated for each patient. The primary and secondary endpoints were 30-day and 1-year mortality.

Results

The study group included 428 consecutive patients who underwent replacement of the aortic valve. Thirteen patients died during the 30-day follow-up and 25 patients died during 1-year follow-up. Actual mortality in 30-day observation was 3.0% compared to the predicted 2.9% using EuroSCORE II and 2.1% for STS. The discriminations of ES II and STS score were above 0.8 for mortality prediction during the 30-day and 1-year observation period.

Conclusions

The EuroSCORE II and STS score showed satisfactory discrimination and calibration for predicting 30-day and 1-year mortality in patients undergoing AVR.

External validation of the European System for Cardiac Operative Risk Evaluation II in a Tunisian population

OBJECTIVE

The main objective of this study is to evaluate the performance of the predictive model (EuroSCORE II) on a Tunisian population to validate its use in our country.

METHODS

This is a retrospective study of data from 418 adult patients undergoing cardiac surgery with cardiopulmonary bypass between 1 January 2015 and 31 December 2016 in the department of cardiovascular and thoracic surgery of the Sahloul University Hospital of Sousse. The EuroSCORE ΙΙ is calculated using the application validated on the site www.euroscore.org. The performance of the score is evaluated by analyzing its discriminative power by constructing the receiver operating characteristic (ROC) curve and analyzing its calibration using the Hosmer-Lemeshow statistics.

RESULTS

The EuroSCORE II shows good discriminative power in our population with an area under the ROC curve more than 0.7 in all study groups (0.864 ± 0.032 for general cardiac surgery, 0.822 ± 0.061 for coronary surgery, 0.864 ± 0.052 for valvular surgery, and 0.900 ± 0.041 for urgent cardiac surgery). The model appears to be calibrated as well by obtaining P values above the statistical significance level of 0.05 (0.638 for general cardiac surgery, 0.543 for coronary surgery, 0.179 for valvular surgery, and 0.082 for urgent cardiac surgery).

CONCLUSION

The EuroSCORE II presents acceptable performance in our population, attested by a good discriminative power and an adequate calibration.

The usefulness of selected biomarkers in patients with valve disease

AIM

The aim of the study was to investigate the prognostic value of selected biomarkers in patients undergoing valve surgery.

MATERIALS & METHODS

A prospective study was conducted on a group of consecutive patients with hemodynamically significant valve defects that underwent elective valve repair or replacement surgery. The primary end point was any major adverse event including death within 30 days.

RESULTS

The study group included 416 patients. The composite end point occurred in 81 patients. At multivariate analysis high-sensitivity C-reactive protein (p = 0.03), red cell distribution width (p = 0.0001) and red blood cell count (p = 0.005) remained independent predictors of the primary end point.

CONCLUSION

Elevated high-sensitivity C-reactive protein, red cell distribution width and red blood cell count were associated with a poorer outcome following valve surgery.

Increased risk profile in the treatment of patients with symptomatic degenerative aortic valve stenosis over the last 10 years

Introduction

Currently, Cardiology Centres are overfilled with patients with degenerative aortic valve stenosis (DAS), usually eldery, with severe concommittant comorbidities, who are referred for further decisions and possible intervention.

Aim

To evaluate changes in the risk profile of patients with severe DAS admitted to the cardiology department a decade ago compared with patients currently being admitted.

Material and methods

We retrospectively evaluated all patients admitted with confirmed severe DAS, hospitalized during 2005-2006 (group I: 140 patients) and in 2016 (group II: 152 patients), admitted for aortic valve intervention. A standard transthoracic echocardiogram, cardiovascular symptom and risk factor distribution, perioperative risk with the logistic EuroSCORE II and STS mortality scores were obtained.

Results

Patients in group II were significantly older (p < 0.001), had more cardiovascular risk factors, and more often presented with atrial fibrillation (27% vs. 11.4%, p = 0.001), renal impairment (34.9% vs. 22.8%; p = 0.024), severe lung disease (17.1% vs. 2.1%, p < 0.001), and extracardiac arteriopathy (40.1% vs. 17.8%, p < 0.001). The aortic valve area (AVA) (p = 0.356), mean-transvalvular pressure gradient (p = 0.215), and left ventricular ejection fraction (p = 0.768) were similar in both groups. However, the prevalence of pulmonary hypertension, severe mitral regurgitation, and low-flow, low-gradient DAS were 3.1-, 8.4- and 1.84-fold more frequent in group II than group I. The percentages of subjects with EuroSCORE II and STS scores ≥ 4% in 2005-2006 were 7.1% and 6.4%, as compared to 27% and 26.3% in 2016 (both p < 0.001). 22% of patients in 2016, as compared to 31% in 2005/2006, were considered ineligible for DAS intervention.

Conclusions

In just a decade, the risk profile of patients admitted with DAS has increased hugely, mainly due to older age, accumulation of comorbidities and more advanced disease at presentation. Although transcatheter aortic valve intervention has expanded the indications for intervention in high-risk patients, the number of patients disqualified from interventional treatment remains high.

The usefulness of selected biomarkers in aortic regurgitation

BACKGROUND

The aim of the study was to investigate the prognostic value of selected biomarkers in patients with aortic regurgitation undergoing valve surgery.

METHODS

A prospective study was conducted on a group of consecutive patients with hemodynamically significant aortic regurgitation that underwent elective aortic valve surgery. The primary endpoint was 30-day mortality and any major adverse event within 30 days.

RESULTS

The study group included 205 consecutive patients who underwent replacement or repair of the aortic valve. The primary endpoint occurred in 72 patients. At multivariate analysis red cell distribution width (RDW; p = 0.03) and high-sensitivity troponin T (hs-TnT; p = 0.02) remained independent predictors of the major complications including death.

CONCLUSIONS

Elevated preoperative RDW and hs-TnT were associated with a poorer outcome following aortic valve surgery.

Validation of EuroSCORE II in patients undergoing coronary artery bypass grafting (CABG) surgery at the National Heart Institute, Kuala Lumpur: a retrospective review

Background: The European System for Cardiac Operative Risk (EuroSCORE) II was developed in 2011 to replace the aging EUROScore for predicting in-house mortality after cardiac surgery. Our aim was to validate EuroSCORE II in Malaysian patients undergoing coronary artery bypass graft (CABG) surgery at our Institute. Methods: A retrospective single-center study was performed. A database was created to include EuroSCORE II values and actual mortality of 1718 patients undergoing CABG surgery in Malaysia from 1st January to 31st December 2016. The goodness-of-fit of EuroSCORE II was determined by the Hosmer-Lemeshow goodness-of-fit test and discriminatory power with the areas under the receiver operating characteristics (ROC) curve (AUC). Results: Observed mortality rate was 4.66% (80 out of 1718 patients). The median EuroSCORE II value was 2.06% (Inter Quartile Range: 1.94%) (1st quartile: 1.45%, 3rd quartile: 3.39%). The AUC for EuroSCORE II was 0.7 (95% CI 0.640 - 0.759) indicating good discriminatory power. The Hosmer-Lemeshow goodness-of-fit test did not show significant difference between expected and observed mortality in accordance to the EuroSCORE II model (Chi-square = 13.758, p = 0.089) suggesting good calibration of the model in this population. Cross-tabulation analysis showed that there is slight overestimation of EuroSCORE II in low-risk groups (0-10%) and slight underestimation in high-risk groups (>20%). Multivariate logistic regression analysis showed that gender, age, total hospital stay, serum creatinine and critical pre-operative state are significant predictors of mortality post-CABG surgery. Conclusion: This study indicated that the EuroSCORE II is a good predictor of post-operative mortality in the context of Malaysian patients undergoing CABG surgery. Our study also showed that certain independent variables might possess higher weightage in predicting mortality among this patient group. Therefore, it is suggested that EuroSCORE II can be safely used for risk assessment while ideally, clinical consideration should be applied on an individual basis.

Validation of EuroSCORE II in patients undergoing coronary artery bypass grafting (CABG) surgery at the National Heart Institute, Kuala Lumpur: a retrospective review

Background: The European System for Cardiac Operative Risk (EuroSCORE) II was developed in 2011 to replace the aging EUROScore for predicting in-house mortality after cardiac surgery. Our aim was to validate EuroSCORE II in Malaysian patients undergoing coronary artery bypass graft (CABG) surgery at our Institute. Methods: A retrospective single-center study was performed. A database was created to include EuroSCORE II values and actual mortality of 1718 patients undergoing CABG surgery in Malaysia from 1st January to 31st December 2016. The goodness-of-fit of EuroSCORE II was determined by the Hosmer-Lemeshow goodness-of-fit test and discriminatory power with the areas under the receiver operating characteristics (ROC) curve (AUC). Results: Observed mortality rate was 4.66% (80 out of 1718 patients). The median EuroSCORE II value was 2.06% (Inter Quartile Range: 1.94%) (1st quartile: 1.45%, 3rd quartile: 3.39%). The AUC for EuroSCORE II was 0.7 (95% CI 0.640 - 0.759) indicating good discriminatory power. The Hosmer-Lemeshow goodness-of-fit test did not show significant difference between expected and observed mortality in accordance to the EuroSCORE II model (Chi-square = 13.758, p = 0.089) suggesting good calibration of the model in this population. Cross-tabulation analysis showed that there is slight overestimation of EuroSCORE II in low-risk groups (0-10%) and slight underestimation in high-risk groups (>20%). Multivariate logistic regression analysis showed that gender, age, total hospital stay, serum creatinine and critical pre-operative state are significant predictors of mortality post-CABG surgery. Conclusion: This study indicated that the EuroSCORE II is a good predictor of post-operative mortality in the context of Malaysian patients undergoing CABG surgery. Our study also showed that certain independent variables might possess higher weightage in predicting mortality among this patient group. Therefore, it is suggested that EuroSCORE II can be safely used for risk assessment while ideally, clinical consideration should be applied on an individual basis.

Assessment of three risk evaluation systems for patients aged ≥70 in East China: performance of SinoSCORE, EuroSCORE II and the STS risk evaluation system

Objectives

To assess and compare the predictive ability of three risk evaluation systems (SinoSCORE, EuroSCORE II and the STS risk evaluation system) in patients aged ≥70, and who underwent coronary artery bypass grafting (CABG) in East China.

Methods

Three risk evaluation systems were applied to 1,946 consecutive patients who underwent isolated CABG from January 2004 to September 2016 in two hospitals. Patients were divided into two subsets according to their age: elderly group (age ≥70) with a younger group (age <70) used for comparison. The outcome of interest in this study was in-hospital mortality. The entire cohort and subsets of patients were analyzed. The calibration and discrimination in total and in subsets were assessed by the Hosmer-Lemeshow and the C statistics respectively.

Results

Institutional overall mortality was 2.52%. The expected mortality rates of SinoSCORE, EuroSCORE II and the STS risk evaluation system were 0.78(0.64)%, 1.43(1.14)% and 0.78(0.77)%, respectively. SinoSCORE achieved the best discrimination (the area under the receiver operating characteristic curve (AUC) = 0.829), followed by the STS risk evaluation system (AUC = 0.790) and EuroSCORE II (AUC = 0.769) in the entire cohort. In the elderly group, the observed mortality rate was 4.82% while it was 1.38% in the younger group. SinoSCORE (AUC = .829) also achieved the best discrimination in the elderly group, followed by the STS risk evaluation system (AUC = .730) and EuroSCORE II (AUC = 0.640) while all three risk evaluation systems all had good performances in the younger group. SinoSCORE, EuroSCORE II and the STS risk evaluation system all achieved positive calibrations in the entire cohort and subsets.

Conclusion

The performance of the three risk evaluation systems was not ideal in the entire cohort. In the elderly group, SinoSCORE appeared to achieve better predictive efficiency than EuroSCORE II and the STS risk evaluation system.

Mortality prediction in Indian cardiac surgery patients: Validation of European System for Cardiac Operative Risk Evaluation II

BACKGROUND AND AIMS

Risk Stratification has an important place in cardiac surgery to identify high-risk cases and optimally allocate resources. Hence various risk scoring systems have been tried to predict mortality. The aim of the present study was to validate the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) in Indian cardiac surgical patients.

METHODS

After obtaining ethics committee clearance, data on EuroSCORE II variables were collected for all patients >18 years undergoing on-pump coronary artery bypass graft (CABG), valve surgery and mixed (CABG + valve) procedures between January 2011 and December 2012. Mortality prediction was done using the online calculator from the site www.euroscore.org. The calibration of the EuroSCORE II model was analysed using the Hosmer-Lemeshow test and discrimination was analysed by plotting receiver operating characteristic curves (ROC) and calculating area under the curve (AUC). The analysis was done in the total sample, CABG, valve surgery and in mixed procedures.

RESULTS

The overall observed mortality was 5.7% in the total sample, 6.6% in CABG, 4.2% in valve surgeries and 10.2% in mixed procedures whereas the predicted mortality was 2.9%, 3.1%, 2.4%, 5.1% in total sample, CABG, valve surgery and mixed procedure, respectively. The significance (P value) of Hosmer-Lemeshow test was 0.292, 0.45, 0.56 and 1 for the total sample, CABG, valve surgery and mixed procedure, respectively, indicating good calibration. The AUC of ROC was 0.76, 0.70, 0.83 and 0.78 for total sample, CABG, valve surgery and mixed procedure, respectively.

CONCLUSION

Mortality of the sample was under-predicted by EuroSCORE II. Calibration of the EuroSCORE II model was good for total sample as well as for all surgical subcategories. Discrimination was good in the total sample and in the mixed procedure population, acceptable in CABG patients and excellent in valve surgeries.

Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Low-Risk Patients

BACKGROUND

The proven efficacy of transcatheter aortic valve implantation (TAVI) in high-risk patients is leading to the expansion of its indications toward lower-risk patients. However, this shift is not supported by meaningful evidence of its benefit over surgical aortic valve replacement (SAVR). This analysis aims to describe outcomes of TAVI versus SAVR in low-risk patients.

METHODS AND RESULTS

We compared the outcome after TAVI and SAVR of low-risk patients (European System for Cardiac Operative Risk Evaluation II [EuroSCORE II] <4%) included in the Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment (OBSERVANT) study. The primary outcome was 3-year survival. Secondary outcomes were early events and major adverse cardiac and cerebrovascular events at 3 years. Propensity score matching resulted in 355 pairs of patients with similar baseline characteristics. Thirty-day survival was 97.1% after SAVR and 97.4% after TAVI (P=0.82). Cardiac tamponade, permanent pacemaker implantation, major vascular damage, and moderate-to-severe paravalvular regurgitation were significantly more frequent after TAVI compared with SAVR. Stroke rates were equal in the study groups. SAVR was associated with higher risk of cardiogenic shock, severe bleeding, and acute kidney injury. At 3 years, survival was 83.4% after SAVR and 72.0% after TAVI (P=0.0015), whereas freedom from major adverse cardiac and cerebrovascular events was 80.9% after SAVR and 67.3% after TAVI (P<0.001).

CONCLUSIONS

In patients with low operative risk, significantly better 3-year survival and freedom from major adverse cardiac and cerebrovascular events were observed after SAVR compared with TAVI. Further studies on new-generation valve prostheses are necessary before expanding indications of TAVI toward lower-risk patients.

Predictive value of high-sensitivity troponin T in addition to EuroSCORE II in cardiac surgery

OBJECTIVES

Plasma troponins, measured by fourth-generation assays, are associated with increased mortality and morbidity after cardiac surgery. They also offer predictive information in addition to EuroSCORE, a widely used risk model after cardiac surgery. However, preoperatively measured troponin has provided no additional information to postoperative values. Whether these facts hold true also for the high-sensitivity fifth-generation troponin assay and the better calibrated risk model, EuroSCORE II, is unknown. We hypothesized that preoperative and/or postoperative high-sensitivity troponin T (hs-TnT) would increase the predictive value of EuroSCORE II.

METHODS

Consecutive coronary artery bypass grafting (CABG) and other cardiac surgical patients were prospectively enrolled in a university hospital. Plasma samples and EuroSCORE II variables were collected. The primary and secondary end-points were 180-day mortality and any major adverse event within 30 days, and 961-day mortality. The data were analysed by Kaplan-Meier survival curves, regression analyses, receiver operator characteristic curves and decision curve analysis.

RESULTS

Mortality rates in 180 days were 3.5% (15/428) in CABG and 6.4% (14/220) in other cardiac surgical patients. Survival curves differed only in patients with not only high postoperative hs-TnT value (>500 ng/l), but also high preoperative hs-TnT value (>14 ng/l), compared with patients with both hs-TnT values low. Adding hs-TnT to EuroSCORE II improved the prediction of 180-day mortality in other cardiac surgical patients (maximum net benefit of 1.5%), but not in CABG patients. Regarding major adverse events, adding hs-TnT to EuroSCORE II improved the prediction in both CABG patients and other cardiac surgical patients (maximum net benefits of 3 and 7%).

CONCLUSIONS

Elevated postoperative hs-TnT was predictive of mortality only when combined with elevated preoperative hs-TnT. Hs-TnT measurements added information to the EuroSCORE II regarding major adverse events in all cardiac surgical patients and regarding 180-day mortality in non-CABG patients.

Cardiac Magnetic Resonance Imaging Predictors of Short-Term Outcomes after High Risk Coronary Surgery

BACKGROUND

The euroSCORE II is a widely used pre-coronary artery bypass graft surgery (CAGS) risk score, but its predictive power lacks the specificity to predict outcomes in high-risk patients (<LVEF 40%) due to changes in cardiac surgery case mix, revascularisation techniques and related outcomes in recent years. We investigated the utility of Cardiac Magnetic Resonance Imaging (CMRI) in predicting immediate and six-week outcomes after CAGS.

METHODS

Fifty-two consecutive patients with high euroSCORE II (>16) and left ventricular (LV) dysfunction (<40%) based on 2D-echocardiography who underwent CAGS and in whom CMRI (1.5T) was performed preoperatively were retrospectively studied. Cardiac magnetic resonance imaging parameters were assessed in patients who either had complications immediately post-surgery (n=35), six weeks post-surgery (n=20) or were uncomplicated.

RESULTS

The average age of patients recruited was 69±5 years with high euroSCORE II (22±4) and low 2D-echocardiography LV ejection fraction (38%±2%). Cardiac magnetic resonance imaging results demonstrated that those with immediate complications had higher LV scar/infarct burden as a proportion of LV mass (17±3% vs 10±3%; p=0.04) with lower circumferential relaxation index (2.5±0.46 vs 2.8±0.56; p=0.05) compared to those with no complications. Early mortality from surgery was 17% (n=9) and was associated with lower RV stroke volume (55±12 vs 68±18; p=0.03) and higher LV infarct scar/burden (18±2% vs 10±2%, p=0.04). Cardiac magnetic resonance imaging showed patients with complications at six weeks post-surgery had higher LV scar/infarct burden (14.5±2% vs 6.8±2%, p=0.03) compared to those without complications.

CONCLUSION

Cardiac magnetic resonance imaging preoperative LV and RV parameters are valuable in assessing the likelihood of successful outcomes from CAGS in high-risk patients with LV dysfunction.

Routine operation theatre extubation after cardiac surgery in the elderly

OBJECTIVES

The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery.

METHODS

A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score.

RESULTS

Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002).

CONCLUSIONS

OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.

Validation of EuroSCORE II risk model for coronary artery bypass surgery in high-risk patients

Introduction

Determining operative mortality risk is mandatory for adult cardiac surgery. Patients should be informed about the operative risk before surgery. There are some risk scoring systems that compare and standardize the results of the operations. These scoring systems needed to be updated recently, which resulted in the development of EuroSCORE II. In this study, we aimed to validate EuroSCORE II by comparing it with the original EuroSCORE risk scoring system in a group of high-risk octogenarian patients who underwent coronary artery bypass grafting (CABG).

Material and methods

The present study included only high-risk octogenarian patients who underwent isolated coronary artery bypass grafting in our center between January 2000 and January 2010. Redo procedures and concomitant procedures were excluded. We compared observed mortality with expected mortality predicted by EuroSCORE (logistic) and EuroSCORE II scoring systems.

Results

We considered 105 CABG operations performed in octogenarian patients between January 2000 and January 2010. The mean age of the patients was 81.43 ± 2.21 years (80-89 years). Thirty-nine (37.1%) of them were female. The two scales showed good discriminative capacity in the global patient sample, with the AUC (area under the curve) being higher for EuroSCORE II (AUC 0.772, 95% CI: 0.673-0.872). The goodness of fit was good for both scales.

Conclusions

We conclude that EuroSCORE II has better AUC (area under the ROC curve) compared to the original EuroSCORE, but both scales showed good discriminative capacity and goodness of fit in octogenarian patients undergoing isolated coronary artery bypass grafting.

Risk Stratification in Off-Pump Coronary Artery Bypass (OPCAB) Surgery—Role of EuroSCORE II

OBJECTIVES

To evaluate the EuroSCORE II for risk stratification in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.

DESIGN

A retrospective observational study.

SETTING

Two tertiary care hospitals.

PARTICIPANTS

Participants were 1,211 patients undergoing OPCAB surgery.

INTERVENTIONS

No interventions were implemented.

MEASUREMENTS AND MAIN RESULTS

The EuroSCORE II estimated the operative risk for each patient. The calibration of the scoring system was assessed using the Hosmer Lemeshow test, and the discriminative capacity was estimated with area under receiver operating characteristic curves. The incidence, patient characteristics, causes of intraoperative conversion to on-pump coronary artery bypass (ONCAB), and outcome were studied. The all-cause in-hospital mortality was 2.39%. Predicted mortality with the EuroSCORE II was 2.03±1.63. Using the Hosmer Lemeshow test, a C statistic of 8.066 (p = 0.472) was obtained, indicating satisfactory model fit. The calculated area under the receiver operating characteristic curve was 0.706 (p = 0.0002), indicating good discriminatory power. Emergency intraoperative conversion to ONCAB occurred in 6.53% of patients. The mortality in the ONCAB group was significantly higher compared with patients who underwent successful OPCAB surgery (15.18% v 1.5%, p<0.0001). On multiple regression analysis with conversion to ONCAB as the endpoint, associated factors were patients with a higher EuroSCORE II (odds ratio = 1.13, confidence interval = 1.03-1.27) and more-than-trivial mitral regurgitation (odds ratio = 1.84, confidence interval = 1.07-3.06). Net reclassification improvement of 0.714 (p<0.0001) was obtained when on-pump conversion was added to the EuroSCORE II.

CONCLUSIONS

The EuroSCORE II has satisfactory calibration and discrimination power to predict mortality after OPCAB surgery. Intraoperative conversion to ONCAB is a major complication of OPCAB surgery. A higher EuroSCORE II also predicts higher probability of conversion to ONCAB.

Risk stratification for in-hospital mortality after cardiac surgery: external validation of EuroSCORE II in a prospective regional registry

OBJECTIVES

To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients.

METHODS

Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed.

RESULTS

Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of re-estimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality.

CONCLUSIONS

This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.

Impact of failed mitral clipping on subsequent mitral valve operations

BACKGROUND

This study analyzed the effect of failed percutaneous mitral intervention with the MitraClip device (Abbott Laboratories, Abbott Park, IL) on subsequent mitral valve (MV) operations.

METHODS

Nineteen patients (74 ± 9 years) with treatment failure after implantation of 37 MitraClips (mean, 1.9 ± 0.8; range, 1 to 4) for functional or degenerative MV disease underwent operations a median of 12 days later (range, 0 to 546 days). All patients were studied before and after the operation by clinical investigation and echocardiographic analysis. Intraoperative findings and the effect on the operation were analyzed and are described in detail. Data before clipping and at the time of operation were compared, and the surgical outcome was recorded.

RESULTS

There was a significant increase in risk between that at the time of clipping and that at subsequent operations, noted as a rise of the European System for Cardiac Operative Risk Evaluation II from a median 12.74% to 26.87%, respectively (p < 0.0001, Wilcoxon signed rank test). Severe clip implantation-induced tissue damage was found in most patients. Surgical MV repair could be performed in 5 of 6 patients (83%) with a 1-clip implant and in only 3 of 13 patients (23%) when 2 or more clips had been inserted (p = 0.0188, Wilcoxon-Mann-Whitney test). All patients required other associated procedures: closure of an artificial atrial septal defect that was caused by the clipping procedure (100%), tricuspid valve repair (37%), atrial fibrillation ablation operations (37%), coronary artery bypass grafting (16%), and aortic valve replacement (11%). Two early cardiac deaths (< 30 days) occurred. Survival at 1 year was 68%.

CONCLUSIONS

There is a remarkable impact of failed clipping procedures on MV operations. We observed a severely aggravated cardiac pathology in parallel with a reduced preoperative clinical state compared with the original condition. Moreover, the likelihood of an optimal surgical solution with valve reconstruction was reduced thereafter. However, operations in the critical situation of an unsuccessful mitral clipping procedure should be discussed immediately, because it still seems to be an option compared with conservative therapy.