Letter by Miceli et al Regarding Article, “Risk of Assessing Mortality Risk in Elective Cardiac Operations: Age, Creatinine, Ejection Fraction, and the Law of Parsimony”

Abstract

HomeCirculationVol. 121, No. 8Letter by Miceli et al Regarding Article, “Risk of Assessing Mortality Risk in Elective Cardiac Operations: Age, Creatinine, Ejection Fraction, and the Law of Parsimony” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Miceli et al Regarding Article, “Risk of Assessing Mortality Risk in Elective Cardiac Operations: Age, Creatinine, Ejection Fraction, and the Law of Parsimony” Antonio Miceli, MD, Gianni Davide Angelini, MD and Massimo Caputo, MD Antonio MiceliAntonio Miceli Bristol Heart Institute, University of Bristol, Bristol, UK Search for more papers by this author , Gianni Davide AngeliniGianni Davide Angelini Bristol Heart Institute, University of Bristol, Bristol, UK Search for more papers by this author and Massimo CaputoMassimo Caputo Bristol Heart Institute, University of Bristol, Bristol, UK Search for more papers by this author Originally published2 Mar 2010https://doi.org/10.1161/CIR.0b013e3181d43812Circulation. 2010;121:e226To the Editor:We read with interest the article by Ranucci et al that suggests a simple mortality risk score in patients undergoing elective cardiac surgery based on age, left ventricular ejection fraction, and serum creatinine.1Operative mortality is a good indicator of the quality of cardiac surgical care, and preoperative risk assessment needs to be the most accurate possible. Risk factors such as gender, chronic pulmonary disease, previous cardiac operations, and major cardiac procedures other than or in addition to coronary artery bypass graftare well-established independent predictors for adverse events in cardiac surgery and, in our opinion, must be accounted for in a mortality risk model.2–4Among 33 variables tested in the developmental subset, Ranucci and colleagues identified age, body surface area, left ventricular ejection fraction, congestive heart failure, serum creatinine, chronic obstructive pulmonary disease, hematocrit, recent myocardial infarction, long-term dialysis, cardiac procedures other than isolated coronary artery bypass graft, and combined operations to be predictors of mortality in the univariate analysis. However, only 3 variables with the best area under curve value were used and tested in a subsequent multivariate analysis for prediction of mortality. Although the other risk factors had lower accuracy, these could contribute to the magnitude of the risk if statistically significant in the multivariate analysis. Furthermore, serum creatinine value was dichotomized according to a cutoff value of 2 mg/dL and was associated with a relative risk of mortality of 5.3. This cutoff identifies patients with advanced renal disease. Recent data demonstrate that mild preoperative renal dysfunction (serum creatinine 1.47 mg/dL to 2.25 mg/dL) is associated with an increased risk of in-hospital mortality and should be weighted in the risk stratification algorithms for mortality.5 We think it would be of interest to show how the model may be more calibrated and accurate by including these factors in a multivariate analysis.DisclosuresNone. References 1 Ranucci M, Castelvecchio S, Menicanti L, Frigiola A, Pelissero G. Risk of assessing mortality risk in elective cardiac operations: age, creatinine, ejection fraction, and the law of parsimony. Circulation. 2009; 119: 3053–3061.LinkGoogle Scholar2 Roques F, Nashef SAM, Micheal P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E, Harjula A, Jones NT, Pinna Pintor P, Salamon R, Thulin L. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients. Eur J Cardiothorac Surg. 1999; 15: 816–823.CrossrefMedlineGoogle Scholar3 Albert MA, Halevy N, Antman EM. Preoperative evaluation for cardiac surgery. In: Cohn LM, ed. Cardiac Surgery in the Adult. 3rd ed. New York: McGraw-Hill; 2007: 261–280.Google Scholar4 Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation. 1989; 79: I3–I12.MedlineGoogle Scholar5 Zakeri R, Freemantle N, Barnett V, Lipkin GW, Bonser RS, Graham TR, Rooney SJ, Wilson IC, Cramb R, Keogh BE, Pagano D. Relation between mild renal dysfunction and outcomes after coronary artery bypass grafting. Circulation. 2005; 112: I-270–I-275.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2, 2010Vol 121, Issue 8 Advertisement Article InformationMetrics https://doi.org/10.1161/CIR.0b013e3181d43812PMID: 20194871 Originally publishedMarch 2, 2010 PDF download Advertisement SubjectsDevelopmental BiologyEpidemiology