Additive European System For Cardiac Operative Risk Evaluation Research Articles

EuroSCORE Performance in Minimally Invasive Cardiac Surgery: Discrimination Ability and External Calibration.

Prediction of operative risk in adults undergoing cardiac surgery remains a challenge. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most commonly used in clinical settings. Recently, the new EuroSCORE II was published attempting to improve the accuracy of risk prediction. We sought to assess the predictive value of EuroSCORE or EuroSCORE II in selected field of minimally invasive cardiac surgery. Patients who underwent cardiac surgery operation with minimally invasive approach from 2007 to 2013 identified from prospective cardiac surgical database. Additional variables included in EuroSCORE II, but not in original EuroSCORE, were retrospectively collected via electronic health records reviewing. The C-statistic was calculated for the EuroSCORE (additive and logistic) and EuroSCORE II. The Hosmer-Lemeshow test was used to assess model calibration by comparing observed and expected morality in number of risk strata. There were 39 hospitals deaths (1.6%). A total of 2472 patients were identified from the main database. The mean ± SD logistic EuroSCORE was 7.6 ± 8.3, mean ± SD additive EuroSCORE was 6.1 ± 2.7, and mean ± SD EuroSCORE II was 2.9 ± 4.2. EuroSCORE logistic model performed with substantial accuracy of 0.78, EuroSCORE additive performed with accuracy of 0.78, and EuroSCORE II performed as almost perfect 0.82. Model calibration was poor in EuroSCORE II (χ = 17.57, P = 0.02), calibration for logistic EuroSCORE was also poor (χ = 140.58, P < 0.01), and additive model also (χ = 94.95, P < 0.01). The area under the curve was high in all algorithms; logistic EuroSCORE was 0.78 (95% confidence interval = 0.71-0.85), additive EuroSCORE was 0.79 (95% confidence interval = 0.71-0.86), and EuroSCORE II was 0.82 (95% confidence interval = 0.75-0.89). In overall settings, original EuroSCORE and EuroSCORE II perform poorly in minimally invasive operation conditions. Data suggest that EuroSCORE could not be used for estimating operative risks correctly. New risk score should be explored, developed, and implemented for selective minimally invasive cohorts.

EuroSCORE underestimate the mortality risk in cardiac valve surgery of Mexican population

The EuroSCORE (European System for cardiac operative risk evaluation) stratifies cardiac risk surgery in easy and accessible manner; it was validated in North America with good results but in many countries of Latin America is used routinely without prior validation. Our objective was to validate the EuroSCORE in patients with cardiac valve surgery at the Instituto Nacional de Cardiología Ignacio Chávez (INCICh) in México. EuroSCORE additive and logistic models were used to predict mortality in adults undergoing cardiac valve surgery from march 2004 to march 2008. The goodness of fit test of Hosmer-Lemeshow was used to evaluate the calibration. The area under the ROC curve was calculated to determinate discrimination. We included 1188 patients with ages of 51.3±14.5 years, 52% women. There were significant differences in the prevalence of risk factors among the INCICh and the EuroSCORE populations. Total mortality was 9.68% versus 5% and 5.6% predicted by additive and logistic EuroSCORE. According to additive EuroSCORE the risk was low in 11.3%, intermediate in 52.9% and high in 35.9%; for these groups the mortality was .7%, 6.34% and 17.4% against those predicted of 2%, 3.9% and 7.64%. Hosmer-Lemeshow test had a P<.001 for both models and the area under the ROC curve was .707 and .694 for additive and logistic EuroSCORE. In the INCICh 88.7% of patients with cardiac valve surgery had intermediate to high risk and EuroSCORE underestimated the risk of mortality.

Severe aortic valve stenosis in the elderly: high prevalence of sleep-related breathing disorders.

BackgroundAortic valve stenosis is common in the elderly, with a prevalence of nearly 3% in patients aged 75 years or older. Despite the fact that sleep-related breathing disorders (SRBD) are thought to be associated with cardiac disease, little is known about their prevalence in this patient cohort. The purpose of this study was to evaluate the prevalence of SRBD in older patients with aortic valve stenosis admitted for transcatheter aortic valve implantation.MethodsForty-eight consecutive patients (mean age 81±6 years; 37.5% male) with symptomatic aortic valve stenosis and considered for transcatheter aortic valve replacement were screened for SRBD. Sleep studies were performed by in-hospital unattended cardiorespiratory polygraphy measuring nasal air flow, chest and abdominal efforts, as well as oxygen saturation and body position. The patients were divided in subgroups dependent on the documented apnea–hypopnea index (AHI; no SRBD was defined as an AHI of <5 events/hour; mild SRBD as AHI 5–15 events/hour, and moderate to severe SRBD as AHI ≥15 events/hour).ResultsThirty-seven patients (77%) had SRBD defined as an AHI of ≥5 events/hour. Eleven patients had an unremarkable investigation, with AHI <5 events/hour (mean 3.0±1.3 events/hour). Among patients with sleep apnea, 19 patients had mild SRBD, with an AHI of 5–15 events/hour (mean 9.9±3.4 events/hour) and 18 patients had moderate to severe SRBD (mean 26.6±11.3 events/hour). Mainly, obstructive apneas were found. Subgroups were not different regarding EuroSCORE (European System for Cardiac Operative Risk Evaluation) or aortic valve area. Also, no correlations were found between AHI and the additive or logistic EuroSCORE or aortic valve area. Significant correlations were found for AHI and N-terminal of the prohormone brain natriuretic peptide (r=0.53; P=0.003) and for AHI and glomerular filtration rate (r=−0.39; P=0.007).ConclusionSRBD is common in elderly patients with symptomatic aortic valve stenosis admitted for transcatheter aortic valve replacement. Interestingly, this finding is not reflected by the currently used risk scores. Further randomized studies are needed to evaluate the clinical significance of concomitant SRBD in the management of severe aortic stenosis.

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

BackgroundWe hypothesized that the combination of a preoperative and a postoperative scoring system would improve the accuracy of mortality prediction and therefore combined the preoperative ‘additive EuroSCORE‘ (European system for cardiac operative risk evaluation) with the postoperative ‘additive CASUS’ (Cardiac Surgery Score) to form the ‘modified CASUS’.Material/MethodsWe included all consecutive adult patients after cardiac surgery during January 2007 and December 2010 in our prospective study. Our single-centre study was conducted in a German general referral university hospital. The original additive and the ‘modified CASUS’ were tested using calibration and discrimination statistics. We compared the area under the curve (AUC) of the receiver characteristic curves (ROC) by DeLong’s method and calculated overall correct classification (OCC) values.ResultsThe mean age among the total of 5207 patients was 67.2±10.9 years. Whilst the ICU mortality was 5.9% we observed a mean length of ICU stay of 4.6±7.0 days. Both models demonstrated excellent discriminatory power (mean AUC of ‘modified CASUS’: ≥0.929; ‘additive CASUS’: ≥0.920), with no significant differences according to DeLong. Neither model showed a significant p-value (<0.05) in calibration. We detected the best OCC during the 2nd day (modified: 96.5%; original: 96.6%).ConclusionsOur ‘additive’ and ‘modified’ CASUS are reasonable overall predictors. We could not detect any improvement in the accuracy of mortality prediction in cardiac surgery by combining a preoperative and a postoperative scoring system. A separate calculation of the two individual elements is therefore recommended.

Does EuroSCORE Predict intensity of Postoperative Care and Rehabilitation Parameters? A Prospective Evaluation

Objective: An increasing number of elderly and multi-morbid patients undergo cardiac surgery which results in increased postoperative morbidity, prolonged Intensive Care Unit (ICU) length of stay (LOS) and higher hospital costs. We aimed to evaluate the model of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) for the prediction of ICU LOS, hospital LOS, required daily nursing effort, and the type of cardiac rehabilitation. Methods: Prospective observational evaluation of 505 consecutive adult patients (mean age 65.1 ± 12.1 years, 25.7% female) who underwent cardiac and/or thoracic aortic thoracic surgery with Cardiopulmonary Bypass (CPB). Results: Median additive and logistic EuroSCORE was 5 (Interquartile Range (IQR) 3-7) and 5.8 (IQR 2.6-14.1), respectively. In univariate analysis both additive and logistic EuroSCORE were significantly associated with prolonged ICU LOS, prolonged hospital LOS, higher daily nursing effort, and the type of cardiac rehabilitation (inpatient versus outpatient), p<0.001 for all correlations. Multivariate analysis including other clinically relevant variables (CPB duration, type of operation, age, Body Mass Index (BMI), urgency of surgery, Left Ventricular Ejection Fraction (LVEF)) showed higher additive EuroSCORE and higher logistic EuroSCORE, independently associated with prolonged ICU LOS, prolonged hospital LOS, and higher daily nursing effort. However, EuroSCORE did not independently predict the type of rehabilitation. Conclusion: The EuroSCORE model can be used to identify patients with elevated risk for prolonged ICU LOS, prolonged hospital LOS and higher intensity of postoperative workload, and it is predictive for the type of rehabilitation. This conclusion may contribute to optimize the management of hospital bed capacity as well as a systematic planning of ICU resources, postoperative nursing care and cardiac rehabilitation.

Heart valve surgery: EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons score.

This is a validation study comparing the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with the previous additive (AES) and logistic EuroSCORE (LES) and the Society of Thoracic Surgeons' (STS) risk prediction algorithm, for patients undergoing valve replacement with or without bypass in Pakistan. Clinical data of 576 patients undergoing valve replacement surgery between 2006 and 2013 were retrospectively collected and individual expected risks of death were calculated by all four risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration. There were 28 deaths (4.8%) among 576 patients, which was lower than the predicted mortality of 5.16%, 6.96% and 4.94% by AES, LES and EuroSCORE II but was higher than 2.13% predicted by STS scoring system. For single and double valve replacement procedures, EuroSCORE II was the best predictor of mortality with highest Hosmer and Lemmeshow test (H-L) p value (0.346 to 0.689) and area under the receiver operating characteristic (ROC) curve (0.637 to 0.898). For valve plus concomitant coronary artery bypass grafting (CABG) patients actual mortality was 1.88%. STS calculator came out to be the best predictor of mortality for this subgroup with H-L p value (0.480 to 0.884) and ROC (0.657 to 0.775). For Pakistani population EuroSCORE II is an accurate predictor for individual operative risk in patients undergoing isolated valve surgery, whereas STS performs better in the valve plus CABG group.

The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was developed to improve the overestimation of surgical risk associated with the original (additive and logistic) EuroSCOREs. The purpose of this study was to evaluate the significance of the EuroSCORE II by comparing its performance with that of the original EuroSCOREs in Japanese patients undergoing surgery on the thoracic aorta. We have calculated the predicted mortalities according to the additive EuroSCORE, logistic EuroSCORE and EuroSCORE II algorithms in 461 patients who underwent surgery on the thoracic aorta during a period of 20 years (1993-2013). The actual in-hospital mortality rates in the low- (additive EuroSCORE of 3-6), moderate- (7-11) and high-risk (≥11) groups (followed by overall mortality) were 1.3, 6.2 and 14.4% (7.2% overall), respectively. Among the three different risk groups, the expected mortality rates were 5.5 ± 0.6, 9.1 ± 0.7 and 13.5 ± 0.2% (9.5 ± 0.1% overall) by the additive EuroSCORE algorithm, 5.3 ± 0.1, 16 ± 0.4 and 42.4 ± 1.3% (19.9 ± 0.7% overall) by the logistic EuroSCORE algorithm and 1.6 ± 0.1, 5.2 ± 0.2 and 18.5 ± 1.3% (7.4 ± 0.4% overall) by the EuroSCORE II algorithm, indicating poor prediction (P < 0.0001) of the mortality in the high-risk group, especially by the logistic EuroSCORE. The areas under the receiver operating characteristic curves of the additive EuroSCORE, logistic EuroSCORE and EuroSCORE II algorithms were 0.6937, 0.7169 and 0.7697, respectively. Thus, the mortality expected by the EuroSCORE II more closely matched the actual mortality in all three risk groups. In contrast, the mortality expected by the logistic EuroSCORE overestimated the risks in the moderate- (P = 0.0002) and high-risk (P < 0.0001) patient groups. Although all of the original EuroSCOREs and EuroSCORE II appreciably predicted the surgical mortality for thoracic aortic surgery in Japanese patients, the EuroSCORE II best predicted the mortalities in all risk groups.

Comparison Between Different Risk Scoring Algorithms on Isolated Conventional or Transcatheter Aortic Valve Replacement

There are a number of scoring systems for risk evaluation in cardiac surgery, the most important of which are the European System for Cardiac Operative Risk Evaluation (EuroSCORE), The Society of Thoracic Surgeons (STS) score, the ACEF score (acronym for age, preoperative creatinine, and ejection fraction), and more recently, the new EuroSCORE-II. The aim of our study was to analyze and compare the predictive value of these scores in patients undergoing aortic valve replacement (AVR) or transcatheter aortic valve replacement (TAVR). A total of 1,512 consecutive patients undergoing either conventional AVR (n = 1,066) or TAVR (transfemoral, n = 291; transapical, n = 155) were enrolled. Logistic and additive EuroSCORE of all patients were 13.3% ± 13.2% and 7.8% ± 3.3%, on average. The mean STS score, ACEF score, and EuroSCORE-II were 5.7% ± 5.0%, 1.5% ± 0.7%, and 4.2% ± 4.9%, respectively. Overall mortality at 30 days was 6.3%. The area under the curve (AUC) was 73.8 for the logistic EuroSCORE and 73.5 for the additive EuroSCORE. The STS score gave an AUC of 70.8. The AUCs for the ACEF and EuroSCORE-II were 63.8 and 71.2, respectively. In the transfemoral TAVR group, AUCs were 59.8 and 59.3 for the logistic and additive EuroSCORE, respectively, 63.2 for the STS score, and 55.9 and 55.4 for the ACEF and EuroSCORE-II, respectively. In the transapical TAVR group, AUCs were 88.0 and 82.8 for the logistic and additive EuroSCORE, respectively, 79.0 for the STS score, and 61.7 and 83.7 for the ACEF and EuroSCORE-II, respectively. Overall, 30-day mortality was best predicted by the STS score. Discrimination threshold predicting mortality was equal between all other risk calculators. Surprisingly, the new EuroSCORE-II was not superior to other models in risk prediction for AVR and TAVR patients.

GW24-e3724 Comparison of the SinoSCORE and the EuroSCORE for predicting in-hospital mortality in patients undergoing coronary artery bypass Grafting

ObjectivesThe European System for Cardiac Operative Risk Evaluation (EuroSCORE) is a commonly used risk model worldwide for the predicting mortality after cardiac surgery and the Sino System for Coronary Operative...

EuroSCORE II Versus Additive and Logistic EuroSCORE in Patients Undergoing Percutaneous Coronary Intervention

The aim of the present study was to externally validate the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII) in patients undergoing percutaneous coronary intervention (PCI) and to compare its performance with that of its previously released versions, named additive (addES) and logistic EuroSCORE (logES). A total of 537 patients undergoing PCI were analyzed by different measurements of discrimination, calibration, and global accuracy. A significant gradient in all-cause mortality was seen with all the models at 30 days, 1 year, and 5 years, with the exception of the ESII at 30 days. The ESII had the lowest area under the receiver operating characteristic curve at all time points compared with its previous version, being 0.83 (vs 0.90 for both addES and logES) at 30 days, 0.75 (vs 0.82 for both addES and logES) at 1 year, and 0.69 (vs 0.77 for addES and 0.76 for logES) at 5 years. However, the ESII displayed a better calibration than the logES at 30 days, whereas both scores were miscalibrated at 1 and 5 years. The Brier score displayed similar global accuracy between the ESII and logES. In conclusion, the ESII is better calibrated than the logES at 30 days but does not represent a step forward in discrimination and global accuracy compared with its previous versions for predicting early- and long-term mortality of patients undergoing PCI.

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

The aim of this study was to compare additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II and the Society of Thoracic Surgeons (STS) models in calculating mortality risk in a Turkish cardiac surgical population. The current patient population consisted of 428 patients who underwent isolated coronary artery bypass grafting (CABG) between 2004 and 2012, extracted from the TurkoSCORE database. Observed and predicted mortalities were compared for the additive/logistic EuroSCORE, EuroSCORE II and STS risk calculator. The area under the receiver operating characteristics curve (AUC) values were calculated for these models to compare predictive power. The mean patient age was 74.5 ± 3.9 years at the time of surgery, and 35.0% were female. For the entire cohort, actual hospital mortality was 7.9% (n = 34; 95% confidence interval [CI] 5.4-10.5). However, the additive EuroSCORE-predicted mortality was 6.4% (P = 0.23 vs observed; 95% CI 6.2-6.6), logistic EuroSCORE-predicted mortality was 7.9% (P = 0.98 vs observed; 95% CI 7.3-8.6), EuroSCORE II- predicted mortality was 1.7% (P = 0.00 vs observed; 95% CI 1.6-1.8) and STS predicted mortality was 5.8% (P = 0.10 vs observed; 95% CI 5.4-6.2). The mean predictive performance of the analysed models for the entire cohort was fair, with 0.7 (95% CI 0.60-0.79). AUC values for additive EuroSCORE, logistic EuroSCORE, EuroSCORE II and STS risk calculator were 0.70 (95% CI 0.60-0.79), 0.70 (95% CI 0.59-0.80), 0.72 (95% CI 0.62-0.81) and 0.62 (95% CI 0.51-0.73), respectively. EuroSCORE II significantly underestimated mortality risk for Turkish cardiac patients, whereas additive and logistic EuroSCORE and STS risk calculators were well calibrated.

Accuracy, calibration and clinical performance of the new EuroSCORE II risk stratification system

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used for many years since its introduction in 1999. Recently, a new EuroSCORE (EuroSCORE II) has been developed to update the previous version. The EuroSCORE II includes some different predictors and/or introduces a new classification of the already existing predictors. This study presents a validation series for the EuroSCORE II compared with the previous additive and the logistic EuroSCORE and with the Age, Creatinine and Ejection Fraction (ACEF) score. A total of 1090 consecutive adult patients operated on at our institution from September 2010 to October 2011 were admitted to this retrospective study. All the patients received a risk stratification based on the EuroSCORE II and the other scores considered. Accuracy, calibration and clinical performance of the various risk models were assessed. The accuracy of the EuroSCORE II was good (c-statistic 0.81) but not significantly higher than the other scores (range 0.78-0.8). Calibration at the Hosmer-Lemeshow statistic was good for all the scores; the difference between observed (3.75%) and predicted mortality in the overall population was not significant for the EuroSCORE II (3.1%) and the ACEF score (3.4%), whereas the additive EuroSCORE (5.8%) and the logistic EuroSCORE (7.3%) significantly overestimated the risk. In patients at low, mild moderate and high mortality risk, the EuroSCORE II provided a risk prediction not significantly different from the observed mortality rate, whereas in very high-risk patients (observed mortality rate 11%), it significantly underestimated (6.5%) the mortality risk. The accuracy of the EuroSCORE II was acceptable in isolated coronary surgery, and good or excellent in the other operations. The EuroSCORE II represents a useful update of the previous EuroSCORE version, with a much better clinical performance and the same good level of accuracy. It is possible that for the risk stratification of very high-risk patients, other factors (rare but associated with a mortality rate >50%) should be included in the future models.

EuroSCORE predicts long-term mortality of unselected patients undergoing percutaneous coronary interventions

BackgroundThe European System for Cardiac Operative Risk Evaluation (EuroSCORE) is a simple risk model able to predict early and late mortality after cardiac surgery. Recent data suggest that this score may also predict early clinical outcome after percutaneous coronary intervention (PCI). Data regarding EuroSCORE usefulness to predict late outcome after PCI in unselected patients are lacking. MethodsEuroSCORE was prospectively assessed in consecutive patients undergoing PCI during 18months. The primary end-point was cardiac mortality during the follow-up after PCI. Total mortality was the secondary end-point. Kaplan–Meyer analyses were performed dividing the study population in three subgroups according to the additive EuroSCORE algorithm (low risk group: EuroSCORE 0–2; medium risk group: EuroSCORE 3–5; high-risk group: EuroSCORE ≥6). Receiver operating characteristics (ROC) curve and landmark analysis on cardiac mortality after 30days were performed. ResultsThe study population comprised 1170 patients undergoing PCI. Mean follow-up duration was 633days (range: 365–1000days). Cardiac mortality was 2%; 2.4%; 13.2% in patients with low, medium and high EuroSCORE respectively.Kaplan–Meyer survival curves for cardiac death differed significantly between EuroSCORE groups (p<0.0001). The area under the ROC curve for the prediction of cardiac death was 0.77. Similar results were obtained for total mortality. At landmark analysis starting 30days after PCI, EuroSCORE groups were significantly associated with different survival in the long term (P=0.014). ConclusionEuroSCORE risk model can be efficiently utilized to predict late mortality in consecutive, unselected, patients undergoing PCI.

Performance of the original EuroSCORE

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

Comparison of the EuroSCORE and Cardiac Anesthesia Risk Evaluation (CARE) score for risk-adjusted mortality analysis in cardiac surgery

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Cardiac Anesthesia Risk Evaluation (CARE) score are risk indices designed in the mid-1990 s to predict mortality after cardiac surgery. This study assesses their ability to provide risk-adjusted mortality in a contemporary cardiac surgical population. The mortality probability was estimated with the additive and logistic EuroSCORE, and CARE score, for 3818 patients undergoing cardiac surgery at one institution between 1 April 2006 and 31 March 2009. Model discrimination was obtained using the area under the receiver operating characteristics (ROC) curve and calibration using the appropriate chi-square goodness-of-fit test. Recalibration of risk models was obtained by logistic calibration, when needed. Calculation of risk-adjusted mortality was performed for the institution and eight surgeons, using each model before and when needed, after recalibration. The area under the ROC curve is 0.72 (95% confidence interval (CI): 0.71-0.74) with the additive EuroSCORE, 0.84 (95% CI: 0.83-0.85) with the logistic EuroSCORE, and 0.79 (95% CI: 0.78-0.81) with the CARE score. The additive and logistic EuroSCORE have poor calibration, predicting a hospital mortality of 6.24% and 7.72%, respectively, versus an observed mortality of 3.25% (P < 0.001). Consequently, the risk-adjusted mortality obtained with those models is significantly underestimated for the institution and all surgeons. The CARE score has good calibration, predicting a mortality of 3.38% (P = 0.50). The hospital risk-adjusted mortality with the recalibrated additive and logistic EuroSCORE and CARE score is 3.24% (95% CI: 3.05-3.43%), 3.25% (95% CI: 3.05-3.44%), and 3.12% (95% CI: 2.94-3.34%), respectively. The individual surgeons' risk-adjusted mortality is similar with the recalibrated EuroSCORE models and CARE score, identifying two surgeons with higher rates than the hospital average mortality. The original additive and logistic EuroSCORE models significantly overestimate the risk of mortality after cardiac surgery. However, after recalibration both models provide reliable risk-adjusted mortality results. Despite its lower discrimination as compared with the logistic EuroSCORE, the CARE score remains calibrated a decade after its development. It is as robust as the recalibrated additive and logistic EuroSCORE to perform risk-adjusted mortality analysis.

Conventional aortic valve replacement for high-risk aortic stenosis patients not suitable for trans-catheter aortic valve implantation: feasibility and outcome☆

High-risk patients with aortic stenosis are increasingly referred to specialist multidisciplinary teams (MDTs) for consideration of trans-catheter aortic valve implantation (TAVI). A subgroup of these cases is unsuitable for TAVI, and high-risk conventional aortic valve replacement (AVR) is undertaken. We have studied our outcomes in this cohort. Data prospectively collected between March 2008 and November 2009 for patients (n = 28, nine male) undergoing high-risk AVR were analysed. The mean age was 78.4 ± 9.2 years. The mean additive EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 10.0 ± 3.6 and mean logistic EuroSCORE was 19.9 ± 18.8. Three patients had undergone previous coronary artery bypass grafting (CABG). The mean ejection fraction was 51 ± 16%, mean valve area 0.56 ± 0.19 cm², and mean peak gradient 91 ± 27 mm Hg. Ascending aortic, right axillary artery and femoral artery cannulation was used in 64%, 29% and 7% of cases, respectively. Median cross-clamp and cardiopulmonary bypass times were 84 (68-143) min and 111 (94-223) min. The median (range) inserted valve size was 21 (19-25) mm. Median intensive care and overall hospital stay were 5 (2-37) and 11 (5-44) days, respectively. In-hospital mortality was 4% (one patient). Postoperative complications included re-operation for bleeding (7%), renal failure (21%), tracheostomy (14%), sternal wound infection (7%), atrial fibrillation (25%) and permanent pacemaker implantation (7%). Kaplan-Meier survival at median follow-up of 359 (148-744) days was 81% (one further death of non-cardiac aetiology). Quality-of-life assessment at follow-up also yielded satisfactory results. MDT assessment of high-risk aortic stenosis in the era of TAVI has increased the number of referrals. Conventional open surgery remains a valid option for these patients, with acceptable in-hospital mortality and early/midterm outcomes but high in-hospital morbidity.

Validation of the EuroSCORE risk models in Turkish adult cardiac surgical population☆☆☆

The aim of this study was to validate additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) models on Turkish adult cardiac surgical population. TurkoSCORE project involves a reliable web-based database to build up Turkish risk stratification models. Current patient population consisted of 9443 adult patients who underwent cardiac surgery between 2005 and 2010. However, the additive and logistic EuroSCORE models were applied to only 8018 patients whose EuroSCORE determinants were complete. Observed and predicted mortalities were compared for low-, medium-, and high-risk groups. The mean patient age was 59.5 years (± 12.1 years) at the time of surgery, and 28.6% were female. There were significant differences (all p<0.001) in the prevalence of recent myocardial infarction (23.5% vs 9.7%), moderate left ventricular function (29.9% vs 25.6%), unstable angina (9.8% vs 8.0%), chronic pulmonary disease (13.4% vs 3.9%), active endocarditis (3.2% vs 1.1%), critical preoperative state (9.0% vs 4.1%), surgery on thoracic aorta (3.7% vs 2.4%), extracardiac arteriopathy (8.6% vs 11.3%), previous cardiac surgery (4.1% vs 7.3%), and other than isolated coronary artery bypass graft (CABG; 23.0% vs 36.4%) between Turkish and European cardiac surgical populations, respectively. For the entire cohort, actual hospital mortality was 1.96% (n=157; 95% confidence interval (CI), 1.70-2.32). However, additive predicted mortality was 2.98% (p<0.001 vs observed; 95%CI, 2.90-3.00), and logistic predicted mortality was 3.17% (p<0.001 vs observed; 95%CI, 3.03-3.21). The predictive performance of EuroSCORE models for the entire cohort was fair with 0.757 (95%CI, 0.717-0.797) AUC value (area under the receiver operating characteristic, AUC) for additive EuroSCORE, and 0.760 (95%CI, 0.721-0.800) AUC value for logistic EuroSCORE. Observed hospital mortality for isolated CABG was 1.23% (n=75; 95%CI, 0.95-1.51) while additive and logistic predicted mortalities were 2.87% (95%CI, 2.82-2.93) and 2.89% (95%CI, 2.80-2.98), respectively. AUC values for the isolated CABG subset were 0.768 (95%CI, 0.707-0.830) and 0.766 (95%CI, 0.705-0.828) for additive and logistic EuroSCORE models. The original EuroSCORE risk models overestimated mortality at all risk subgroups in Turkish population. Remodeling strategies for EuroSCORE or creation of a new model is warranted for future studies in Turkey.

Mortality risk prediction in cardiac surgery: comparing a novel model with the EuroSCORE

Several models for prediction of early mortality after open-heart surgery have been developed. Our objectives were to develop a local mortality risk prediction model, compare it with the European System for Cardiac Operative Risk Evaluation (EuroSCORE), and investigate whether the addition of intra-operative variables could enhance the accuracy of risk prediction. All 5029 patients undergoing open-heart surgery in 2000-2007 were included in the study. Logistic regression with bootstrap methods was used to develop a pre-operative risk prediction model for in-hospital mortality. Next, several intra-operative variables were added to the pre-operative model. Calibration and discrimination were assessed, and the model was internally validated for prediction in future datasets. We thereafter compared the pre-operative model with the additive and logistic EuroSCOREs. Our pre-operative model included eight risk factors that are routinely registered in our department: age, gender, degree of urgency, operation type, previous cardiac surgery, and renal, cardiac, and pulmonary dysfunction. The model estimated mortality accurately throughout the dataset except in the 1% of patients at extremely high risk, in which mortality was somewhat overestimated. The estimated shrinkage factor was 0.930. The areas under the receiver operating characteristic curve for our pre-operative model and the logistic EuroSCORE were 0.857(0.823-0.891) and 0.821(0.785-0.857) (P=0.02). There was no significant difference in performance between the pre-operative and the intra-operative model (P>0.10). Our pre-operative model was simple and easy to use, and showed good predictive ability in our population. Internal validation indicated that it would accurately predict mortality in a future dataset.

Letter by Pocar et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

To the Editor: We congratulate Moller et al for outlining no major differences in short-term outcomes after off-pump versus conventional coronary bypass surgery in patients with European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥5.1 Mean additive EuroSCORE was 6.9, but no patient with ejection fraction <30% was enrolled, suggesting the prevalence of extracardiac risk factors in determining a higher risk profile. Although the …

Study on the efficiency of the European System for Cardiac Operative Risk Evaluation (EuroSCORE)in predicting in-hospital mortality of the patients with percutaneous coronary intervention

To investigate the efficiency of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in predicting in-hospital mortality for the patients after percutaneous coronary intervention (PCI). Retrospective analysis was conducted on the patients who had undergone PCI in our hospital since year 2005 to 2007. We used both cumulative EuroSCORE score and logistic EuroSCORE to predict the in-hospital morality and to analyze the correlation between the predicted mortality and the actual mortality. According to the additive EuroSCORE, we divided the patients into three groups, the additive EuroSCORE 0-2 were divided into low-risk group, 3-5 were divided into mid-risk group and ≥ 6 into high-risk group. The actual in-hospital mortality rates were 0%, 0.47% and 6.09% respectively. The EuroSCORE model demonstrated an overall relation between the EuroSCORE ranking and the incidence of in-hospital mortality (P<0.001). Results from the multivariable logistic regression analysis showed that the EuroSCORE was an independent in-hospital mortality predictor (P<0.01). The EuroSCORE risk model and the in-hospital mortality were significantly correlated, indicating that the model was a promising method for predicting the in-hospital mortality of PCI patients.