European System For Cardiac Operative Risk Evaluation Research Articles

Early outcomes of transapical mitral valve implantation versus surgical replacement in matched elderly patients at intermediate surgical risk.

Data comparing transcatheter mitral valve implantation (TMVI) with surgical mitral valve replacement (SMVR) are lacking. This study sought to compare the 30-day Valve Academic Research Consortium (VARC)-3 device success of TMVI with that of SMVR. Matching protocol combined exact matching (sex, atrial fibrillation, previous surgical aortic valve replacement [SAVR] or coronary artery bypass grafting [CABG]), coarsened exact matching (age) and propensity score matching (body mass index, mitral valve pathology and concomitant tricuspid regurgitation). A total of 40 Tendyne TMVI and 80 SMVR patients with similar baseline characteristics were analysed (TMVI vs SMVR): age (78 years [interquartile range [{IQR} 75; 80] vs 78 years [IQR 73; 80]; p=0.8), female (60% vs 60%; p=1.0), atrial fibrillation (67.5% vs 63.7%; p=0.8), previous SAVR (12.5% vs 10.0%; p=0.8), previous CABG (20.0% vs 16.2%; p=0.8), body mass index (25.54 kg/m² vs 25.24 kg/m²; p=0.7) and valve pathology (mitral regurgitation: 70.0% vs 73.8%, mitral stenosis: 7.5% vs 3.8%, and mixed disease: 22.5% vs 22.5%; p=0.6). Most baseline characteristics not included in the matching model were balanced among the TMVI/SMVR cohorts: European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (5.8% [IQR 2.9; 7.5] vs 4.2% [IQR 2.4; 6.8]; p=0.3) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score (5.2% [IQR 3.2; 8.6] vs 4.1% [IQR 3.3; 6.1]; p=0.076). Coronary artery disease (67.5% vs 32.5%; p<0.001) and previous percutaneous coronary intervention (47.5% vs 25.0%; p=0.023) differed among groups. Mitral VARC (MVARC) device success at 30 days was achieved in 82.5% of patients after TMVI and 57.5% of patients after SMVR (p=0.04). MVARC procedural success at 30 days was 75.0% after TMVI versus 52.5% after SMVR (p=0.07). Thirty-day mortality (2.5% vs 3.8%; p=0.47), technical success (97.5% vs 97.5%; p=1.0), major bleeding (17.5% vs 18.7%; p=0.087), stroke (5.0% vs 4.9%; p=1.0) and postoperative haemodialysis (7.5% vs 5.2%; p=0.4) were similar in both groups. Patients with intermediate surgical risk, according to STS-PROM and EuroSCORE II, demonstrated higher rates of MVARC device at 30 days after TMVI compared to 30 days after SMVR. Rates of survival and procedural success, neurological, renal and bleeding complications were similar. Transfusion count and length of stay were lower after TMVI. For elderly patients at intermediate risk, a TMVI eligibility assessment may be considered.

Poor olfaction prior to cardiac surgery: Association with cognition, plasma neurofilament light, and post-operative delirium.

Post-operative delirium (POD) affects up to 50% of cardiac surgery patients, with higher incidence in older adults. There is increasing need for screening tools that identify individuals most vulnerable to POD. Here, we examined the relationship between pre-operative olfaction and both incident POD and POD severity in patients undergoing cardiac surgery. We also examined cross-sectional relationships between baseline olfaction, cognition, and plasma neurofilament light (NfL). Individuals undergoing cardiac surgery (n=189; mean age=70years; 75% men) were enrolled in a clinical trial of cerebral autoregulation monitoring. At baseline, odor identification performance (Brief Smell Identification Test), cognitive performance, and plasma concentrations of NfL levels (Simoa™ NF-Light Assay) were measured. Delirium was assessed with the Confusion Assessment Method (CAM) or CAM-ICU, and delirium severity was assessed using the Delirium Rating Scale-Revised-98. The association of baseline olfaction, delirium incidence, and delirium severity was examined in regression models adjusting for age, duration of cardiopulmonary bypass, logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), and baseline cognition. Olfactory dysfunction was present in 30% of patients, and POD incidence was 44%. Pre-operative olfactory dysfunction was associated with both incident POD (OR=3.17, p=0.001) and greater severity of POD after cardiac surgery (OR=3.94 p<0.001) in models adjusted for age, duration of bypass, and a surgical risk score. The addition of baseline cognition attenuated the strength of the association, but it remained significant for incident POD (OR=2.25, p=0.04) and POD severity (OR 2.10, p=0.04). Poor baseline olfaction was associated with greater baseline cognitive dysfunction (p<0.001) and increased baseline plasma NfL concentrations (p=0.04). Neither age, cognition, nor baseline NFL concentration modified the association of impaired olfaction and delirium outcomes. Olfactory assessment may be a useful pre-surgical screening tool for the identification of patients undergoing cardiac surgery at increased risk of POD. Identifying those at highest risk for severe delirium and poor cognitive outcomes following surgery would allow for earlier intervention and pre-operative rehabilitation strategies, which could ultimately impact the functional disability and morbidity associated with POD.

Open-heart surgery in patients with cirrhosis: Variables associated with survival outcomes

BackgroundUnderstanding the risks of performing open-heart surgery in patients with cirrhosis is of critical importance given increased risks of morbidity and mortality. We analyzed the variables and risk scoring systems associated with survival and postoperative outcomes among patients with cirrhosis after open-heart surgery. MethodsThis is a single-center retrospective study of 32 patients with cirrhosis who underwent open-heart surgery at our institution between August 2020 – September 2022. Patients were stratified by mortality status to compare demographic and clinical variables. Survival was assessed using Kaplan-Meier curves and log-rank tests for the following variables: Model for End-Stage Liver Disease (MELD) score (<11 vs ≥11), Child-Turcotte-Pugh (CTP) class (A vs B vs C), Society of Thoracic Surgeons (STS) score (predicted mortality <4 vs 4 to 8 vs ≥8), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (<3.3 vs ≥3.3), and cardiopulmonary bypass (off pump vs on pump). ResultsOverall survival for our patient cohort was 93.8% at 30 days, 81.3% at 1 year, and 78.1% at 2 years postoperatively. Increased preoperative creatinine (p = 0.049), preoperative total bilirubin (p = 0.017), intraoperative blood products (p = 0.016), and intensive care unit length of stay (p = 0.001) were significantly associated with decreased survival. Among the risk scoring systems, only CTP class was significantly associated with survival (p < 0.0001). ConclusionsWe demonstrated high short-term and long-term survival among patients with cirrhosis after open-heart surgery, suggesting that select patients may be operative candidates. Among risk-scoring systems, only CTP was significantly associated with survival, which may guide future risk stratification strategies.

External validation of the EuroSCORE I and II prediction models for postoperative 30-day mortality in patients with infective endocarditis: results from a nationwide prospective registry

Abstract Background The European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II are widely used risk models for predicting 30-day mortality after cardiac surgery [1,2]. It is suggested that both models overpredict 30-day mortality in specific groups of patients [3,4]. However, their performance in patients with infective endocarditis (IE) is unclear, since few IE patients were included in the development cohort (&amp;lt;500 patients for EuroSCORE II). Moreover, all previous studies that have evaluated the performance of EuroSCORE models in IE had small sample sizes [5-7]. Purpose To externally validate the EuroSCORE I and II prediction models in patients with IE in a nationwide prospective registry. Methods The Netherlands Heart Registration (NHR) is a national prospective registry of all patients undergoing cardiac surgeries and interventions in The Netherlands. It collects clinically relevant data, such as medical history and postoperative complications, and follows patients up to many years after surgery. In addition, the EuroSCORE I and II are recorded for each individual. For this study, we included all patients with IE who underwent cardiac surgery in the Netherlands between 2013 and 2021. The predictive performance of EuroSCORE I and II was assessed by discrimination and calibration. Discrimination was assessed by the area under the curve (AUC), and reflects how well the model discriminates between patients with and without the outcome of interest. Calibration describes the agreement between observed and predicted risks and was assessed by calibration in the large (average observed risk versus average predicted risk) and calibration plots. Results We included 2577 IE patients (median age 64 years (IQR 53 – 71), 76.2% male, 33.6% with previous cardiac surgery of which 94.3% previous valve surgery). Overall 30-day mortality was 10.2%. The mean EuroSCORE I and II were 27.9% (SD 22.1) and 14.9% (SD 16.3) respectively. The AUCs for EuroSCORE I and II were 0.73 (95% CI 0.70 – 0.76) and 0.72 (95% CI 0.69 – 0.75) (Figure 1). Calibration in the large showed that both models overpredict risks, with an observed to expected ratio of 0.37 for EuroSCORE I and 0.68 for EuroSCORE II. The calibration plot showed that EuroSCORE I overpredicts risks across the full range (Figure 2A). Calibration of the EuroSCORE II was reasonable in patients with low predicted probability, but overpredicts risks when the predicted probability was &amp;gt;20% (Figure 2B). Conclusion Both EuroSCORE I and II substantially overestimate 30-day mortality risk after cardiac surgery in IE patients. Use of EuroSCORE I and II may therefore lead to disadvantageous decision making if patients with a high predicted 30-day mortality risk are subsequently withheld from indicated surgical treatment (class I or IIa) [8]. Further research will recalibrate the EuroSCORE II for IE patients and assess the influence of its individual parameters on 30-day mortality in this population.Receiver operating characteristic curvesCalibration plots of EuroSCORE I and II

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

BackgroundThe 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. MethodsThis 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. ResultsA 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). ConclusionsAlthough 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.

On-table Extubation After Minimally Invasive Cardiac Surgery: A Retrospective Observational Pilot Study

To assess the safety of "on-table" extubation after minimally-invasive heart valve surgery. A single-center retrospective observational study. At a tertiary referral academic hospital. Patients who underwent nonemergent isolated heart valve surgery through a minithoracotomy approach between January 2016 and August 2021. All patients were treated by 1 of the 6 cardiac anesthesiologists of the hospital. Only some of them practiced "on-table" extubation, and the outcome of patients extubated "on-table" was compared to those extubated in the intensive care unit (ICU). The primary outcome was the occurrence of any postoperative respiratory complication during the entire hospital stay. Secondary outcomes included the use of inotropes and vasopressors, de novo atrial fibrillation, and lengths of stay in the ICU and the hospital. A total of 294 patients met inclusion criteria, of whom 186 (63%) were extubated "on-table." Cardiopulmonary bypass duration was significantly longer, and moderate intraoperative hypothermia was significantly more frequent in patients extubated in the ICU. After adjustment for these confounders and for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II using a multivariate logistic model, no association was found between the extubation strategy and postoperative pulmonary complications (adjusted odds ratio=0.84; 95% CI=0.40-1.77; p=0.64). "On-table" extubation was associated with a lower risk of postoperative pneumonia and fewer vasopressors requirements. "On-table" extubation was not associated with an increased incidence of respiratory complications. A randomized controlled trial is warranted to confirm these results and determine whether "on-table" extubation offers additional benefits.

Atrial Fibrillation and Perioperative Inflammation (FIBRILLAMMED Study): A Retrospective Analysis of the Predictive Role of Preoperative Albumin-Adjusted Platelet-Leukocytic Indices in OPCABG.

New-onset atrial fibrillation (NOAF), an important postoperative complication, has pertinent inflammatory links. Motivated by the encouraging literature on the prognostic role of hypoalbuminemia, leukocytic indices [LIs: neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR)], systemic inflammation response index (SIRI=NLR×monocyte) and platelet-leukocytic indices [PLIs: platelet-to-lymphocyte ratio (PLR)], systemic immune inflammation index (SII=NLR×platelet), aggregate index of systemic inflammation (AISI=NLR×platelet×monocyte), we sought to investigate the NOAF-predictive value of preoperative albumin-adjusted indices (aa-LIs and aa-PLIs) in an off-pump coronary artery bypass grafting (OPCABG) setting. Of 899 patients, 151 patients (16.79%) developed the primary outcome i.e. NOAF that was analyzed further retrospectively for its predictors instead of the highlighted text perioperative data of 899 patients undergoing elective OPCABG, were retrospectively analyzed. The study participants were categorized into non-NOAF and NOAF groups (defined as new-onset atrial arrhythmia with irregular RR interval with indistinct P wave in the first week postoperatively). One hundred and fifty-one patients (16.79%) developed NOAF. On univariate analysis: age, smoker status, The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, systemic hypertension, diabetes mellitus, prior congestive heart failure (CHF), and a higher preoperative NLR, PLR, SII, and albumin were significant predictors of NOAF. While age, CHF, and EuroSCORE II retained predictive significance in multivariate analysis, LI-PLIs and albumin did not emerge as independent NOAF predictors. Notably, aa-NLR, aa-PLR, and aa-SII independently predicted NOAF on the computation of model-estimates in the regression analysis (Odds ratio; 95% confidence interval: 31.05;15.75-70.61, 1.04;1.02-1.05, 1.12;1.10-1.14, respectively, P < 0.001). aa-NLR ≥1.32, aa-PLR ≥52.64, and aa-SII ≥344.38 predicted NOAF with the respective AUC;sensitivity;specificity of 0.66;63.6%;73.3%, 0.63;66.2%;59.0%, and 0.65;58.3%;78.2%. Preoperative aa-NLR, aa-PLR and aa-SII also positively correlated with CHA2DS2-VASc score (R=0.40, 0.45 and 0.42; P < 0.001). The independent NOAF predictive value of aa-NLR, aa-PLR, and aa-SII reiterates the inflammatory relationship of the arrhythmic complication following OPCABG.

Predictive Value of EuroSCORE II in a Nepalese Tertiary University Hospital – Prospective Observational Study

Background and Aims: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is an important tool for risk stratification in cardiac surgery. Updated EuroSCORE II (ESC II) is widely regarded as essential for risk stratification and several studies validate its efficacy, but these are fewer in Southern Asia and none in Nepal.  Aim of this study was to compare the predicted versus observed early mortality in adults undergoing major cardiac surgeries in Nepalese population. Methods:  A prospective observational study was  conducted from September 2019 to May 2021 at Manmohan Cardiothoracic Vascular and Transplant Center. Calibration and discrimination  of scoring system were main parameters analyzed in total sample and subgroups. Discrimination were observed by plotting receiver operating characteristic (ROC) curves and calculating area under curve (AUC). Two sample t test, McNemar’s test, Fisher’s exact t test and Chi square test were used to derive P value. Results: In this study, 249 patients were evaluated. Poor mortality prediction was shown by statistically significant p value &lt;0.05 across all surgical groups. AUC for total cases, CABG and valve surgeries were 0.835, 0.766, 0.82 respectively. Conclusion The present study underpredicted mortality but displayed good discrimination for overall cardiac surgeries, with excellent discrimination in valve surgeries. As current sample is not entirely comparable to parent study, weak calibration could be attributed to it as etiology was mostly rheumatic with poorer cardiopulmonary reserve in this study versus degenerative etiology in original study.

Perioperative Levels of Troponin and BNP and the Outcome after Coronary Artery Bypass Grafting.

The independent predictive values of troponin I (cTnI) and B-type natriuretic peptide (BNP) after coronary artery bypass grafting (CABG) have been reported in several studies. However, adjustment only has been limited to preoperative risk factors. This study was conducted to assess the independent values of postoperative cTnI and BNP to predict the outcome after CABG with adjustment for preoperative risk estimates and postoperative complications and to report risk stratification gains, when considering the European System for Cardiac Operative Risk Evaluation (EuroSCORE) combined with postoperative biomarkers. This retrospective cohort study included 282 consecutive patients undergoing CABG between January 2018 and December 2021. We evaluated the preoperative and postoperative cTnI and BNP, EuroSCORE, and postoperative complications. The composite endpoint was death or cardiac-related adverse events. The AUROC for postoperative cTnI was significantly higher than that of BNP (0.777 vs. 0.625, p = 0.041). The optimal cut-off values to predict the composite outcome were >4830 (pg/mL) and >6.95 (ng/mL) for BNP and cTnI, respectively. Adjustment for relevant and significant perioperative factors showed that postoperative BNP and cTnI had a high discriminatory power (C-index = 0.773 and 0.895, respectively) for predicting major adverse events. Postoperative BNP and cTnI are independent predictors of death or major adverse events, following CABG, and can add to the predictive power of EuroSCORE II.

Validation of the German Registry for Acute Aortic Dissection Type A Score in predicting 30-day mortality after type A aortic dissection surgery.

No reliable scores are available to predict mortality following surgery for type A acute aortic dissection (TAAAD). Recently, the German Registry of Acute Aortic Dissection Type A (GERAADA) score has been developed. We aim to compare how the GERAADA score performs in predicting operative mortality for TAAAD to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. We calculated the GERAADA score and EuroSCORE II in patients who underwent TAAAD repair at the Bristol Heart Institute. As there are no precise criteria to calculate the GERAADA score, we used 2 methods: a Clinical-GERAADA score, which evaluated malperfusion with clinical and radiological evidence, and a Radiological-GERAADA score, where malperfusion was assessed by computed tomography scan alone. 207 consecutive patients had surgery for TAAAD, and the observed 30-day mortality was 15%. The Clinical-GERAADA score showed the strongest discriminative power with an area under the curve (AUC) of 0.80 [95% confidence interval (CI) 0.71-0.89], while the Radiological-GERAADA score had an AUC of 0.77 (95% CI 0.67-0.87). EuroSCORE II showed acceptable discriminative power with an AUC of 0.77 (95% CI 0.67-0.87). Clinical GERAADA score performed better than the other scores and it is specific and easy to use in the context of a TAAAD. Further validation of the new criteria for malperfusion is needed.

Outcomes of transapical mitral valve repair with neochordae implantation.

Transapical off-pump beating-heart neochord implantation (NC) has shown encouraging early results in patients with degenerative mitral regurgitation. The aim of this study was to evaluate clinical and echocardiographic 5-year outcomes of patients who underwent NC. All patients who underwent NC at our institution from November 2013 to March 2016 were included. Indications were severe symptomatic degenerative mitral regurgitation due to leaflet prolapse/flail. Patients were classified as having favorable anatomy (FA) and unfavorable anatomy (UA) on the basis of the extent and severity of mitral valve disease. All patients underwent clinical and echocardiographic follow-up at 1, 3, 6, and 12months, and annually thereafter. Data were prospectively collected and retrospectively analyzed. Outcomes were on the basis of the Mitral Valve Academic Research Consortium guidelines. One hundred consecutive patients were included in the analysis (FA: 81%; UA: 19%). Median age was 66years (interquartile range, 58-76) and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 1.4% (interquartile range, 0.7-2.3). Technical and procedural success were 98% and 94%, respectively. Thirty-day mortality was 2%. Device success was 94%, 92%, and 78%, at 30days, 1-year, and 5years, respectively. Patient success at 1year was 92%. Median follow-up was 5.1years. At 5years, overall survival was 83% with no difference between FA and UA patients. Cumulative incidence of severe mitral regurgitation recurrence at 5years was 14% (95% CI, 6.5%-22.8%) in FA patients and 63% (95% CI, 39.7%-86.2%) in UA patients, respectively (P<.001). Patients with FA compared with UAhad a lower incidence of reintervention (14.7% vs 43.4%; P<.001). Transapical off-pump beating heart NC might represent an acceptable option in patients with degenerative mitral valve disease and FA.

Clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making

ObjectivesThe aim of this study using decision curve analysis (DCA) was to evaluate the clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making compared with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and to 2 machine-learning models. MethodsUsing data from a French prospective database, this retrospective study evaluated all patients who underwent cardiac surgery in 43 hospital centers between January 2012 and December 2020. A receiver operating characteristic analysis was performed to compare the accuracy of the EuroSCORE II, machine-learning models, and an adapted Tabular Bidirectional Encoder Representations from Transformers deep-learning model in predicting postoperative in-hospital mortality. The clinical utility of these models for cardiac surgery decision making was compared using DCA. ResultsOver the study period, 165,640 patients underwent cardiac surgery, with a mean EuroSCORE II of 3.99 ± 6.67%. In the receiver operating characteristic analysis, the area under the curve was significantly greater for the deep-learning model (0.834; 95% confidence interval, 0.831-0.838) than the EuroSCORE II (P < .001), the random forest model (P = .03), and the Extreme Gradient Boosting model (P = .03). In the DCA, the clinical utility of the 3 artificial intelligence models was superior to that of the EuroSCORE II, especially when the threshold probability of death was high (>45%). The deep-learning model showed the greatest advantage over the EuroSCORE II. ConclusionsThe deep-learning model had better predictive accuracy and greater clinical utility than the EuroSCORE II and the 2 machine-learning models. These findings suggest that deep learning with Tabular Bidirectional Encoder Representations from Transformers prediction model could be used in the future as the gold standard for cardiac surgery decision making.

Outcomes of Medical Therapy Plus PCI for Multivessel or Left Main CAD Ineligible for Surgery

BackgroundPercutaneous coronary intervention (PCI) is increasingly used to revascularize patients ineligible for CABG, but few studies describe these patients and their outcomes. ObjectivesThis study sought to describe characteristics, utility of risk prediction, and outcomes of patients with left main or multivessel coronary artery disease ineligible for coronary bypass grafting (CABG). MethodsPatients with complex coronary artery disease ineligible for CABG were enrolled in a prospective registry of medical therapy + PCI. Angiograms were evaluated by an independent core laboratory. Observed-to-expected 30-day mortality ratios were calculated using The Society for Thoracic Surgeons (STS) and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II scores, surgeon-estimated 30-day mortality, and the National Cardiovascular Data Registry (NCDR) CathPCI model. Health status was assessed at baseline, 1 month, and 6 months. ResultsA total of 726 patients were enrolled from 22 programs. The mean SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score was 32.4 ± 12.2 before and 15.0 ± 11.7 after PCI. All-cause mortality was 5.6% at 30 days and 12.3% at 6 months. Observed-to-expected mortality ratios were 1.06 (95% CI: 0.71-1.36) with The Society for Thoracic Surgeons score, 0.99 (95% CI: 0.71-1.27) with the EuroSCORE II, 0.59 (95% CI: 0.42-0.77) using cardiac surgeons’ estimates, and 4.46 (95% CI: 2.35-7.99) using the NCDR CathPCI score. Health status improved significantly from baseline to 6 months: SAQ summary score (65.9 ± 22.5 vs 86.5 ± 15.1; P < 0.0001), Kansas City Cardiomyopathy Questionnaire summary score (54.1 ± 27.2 vs 82.6 ± 19.7; P < 0.0001). ConclusionsPatients ineligible for CABG who undergo PCI have complex clinical profiles and high disease burden. Following PCI, short-term mortality is considerably lower than surgeons’ estimates, similar to surgical risk model predictions but is over 4-fold higher than estimated by the NCDR CathPCI model. Patients’ health status improved significantly through 6 months.

Simultaneous Hybrid Coronary Revascularization vs Conventional Strategies for Multivessel Coronary Artery Disease: A 10-Year Follow-Up

BackgroundAlthough evidence is sufficient to confirm that hybrid coronary revascularization (HCR) is safe and effective in the short term, its value in the long run is debatable. ObjectivesThis study sought to compare the long-term outcomes of HCR with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease. MethodsThree groups of patients, 540 each, receiving HCR, CABG, or PCI between June 2007 to September 2018, were matched using propensity score matching. Patients were stratified by EuroSCORE (European System for Cardiac Operative Risk Evaluation) II (low ≤0.9; 0.9 < medium <1.5; high ≥1.5) and SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (low ≤22; 22 < medium <33; high ≥33). Major adverse cardiac and cerebrovascular events (MACCE) and Seattle Angina Questionnaire (SAQ) scores were compared among the 3 groups. ResultsIn terms of MACCE and SAQ, HCR performed similarly to off-pump CABG but significantly outperformed PCI (P < 0.001). In the low-to-medium EuroSCORE II and medium-to-high SYNTAX score tertiles, MACCE rates in the HCR group were significantly lower than those in the PCI (EuroSCORE II: low, 30.7% vs 41.2%; P = 0.006; medium, 31.3% vs 41.7%; P = 0.013; SYNTAX score: medium, 27.6% vs 41.2%; P = 0.018; high, 32.4% vs 52.7%; P = 0.011) but were similar to those in the CABG group. In the high EuroSCORE II stratum, HCR had a lower MACCE rate than CABG (31.9% vs 47.0%; P = 0.041) and PCI (31.9% vs 53.7%; P = 0.015). ConclusionsCompared with conventional strategies, HCR provided satisfactory long-term outcomes in MACCE and functional status for multivessel disease.

Contemporary risk models for infective endocarditis surgery: a narrative review.

Infective endocarditis is a complex heterogeneous condition involving the infection of the endocardium and heart valves, leading to severe complications, including death. Surgery is often indicated in patients with infective endocarditis but is associated with elevated risk compared with other forms of cardiac surgery. Risk models play an important role in many cardiac surgeries as they can help inform clinicians and patients regarding procedural risk, decision-making to proceed or not, and influence perioperative management; however, they remain under-utilized in the infective endocarditis settings. Another crucial role of such risk models is to assess predicted versus found mortality, thereby allowing an assessment of institutional performance in infective endocarditis surgery. Traditionally, general cardiac surgery risk models such as European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, and Society of Thoracic Surgeon's score have been applied to endocarditis surgery. However, there has been the development of many endocarditis surgery-specific scores over the last decade. This review aims to discuss clinical characteristics and applications of all contemporary risk scores in the setting of surgical treatment of infective endocarditis.

Clinical performance of a novel bioprosthetic surgical aortic valve in a German high-volume center.

Bioprosthetic surgical aortic valve replacement (SAVR) is increasingly adopted in younger patients. We aimed to analyze mid-term follow-up data after SAVR to assess the performance of the prosthesis. Data were collected from a single-center series of 154 patients, who underwent SAVR with a bioprosthetic heart valve with the RESILIA tissue at our Heart Centre in Siegburg. All procedural and midterm patient outcomes were documented. Patients had a mean age of 56.8 ± 9.9 years, 35.7% were female, and the mean logistic European system for cardiac operative risk evaluation (EuroSCORE) was 3.4 ± 3.6%. Diabetes (12.3%), atrial fibrillation (10.4%), and chronic obstructive pulmonary disease (COPD) (5.8%) were common comorbidities. The mean surgery duration was 163.8 ± 73.4 min, with the 23 mm (34.4%) and 25 mm (33.8%) heart valves being most frequently implanted. At 3-year follow-up, mean pressure gradient was 13.9 ± 5.9 mmHg, peak gradient was 23.6 ± 7.7 mmHg, and effective orifice area (EOA) was 1.9 ± 0.4 cm². No patient died during the operation, 3 (2.1%) patients within 30 days, and 4 (2.7%) thereafter with an overall mortality of n = 7. Of the surviving patients, 97.8% were in New York Heart Association (NYHA) class I/II and none had structural valve deterioration (SVD). Results of our single-center study indicate favorable procedural outcomes. The safety outcomes confirm preliminary earlier results of this novel bioprosthesis but include more patients and a longer midterm follow-up.

The ability of the logistic EuroSCORE to predict long-term outcomes after coronary artery bypass graft surgery.

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) predicts in-hospital mortality for patients undergoing cardiac surgery. Many variables associated with increased surgical mortality persist postoperatively. The aim of this study was to investigate the predictive value of the logistic EuroSCORE to long-term survival after coronary artery bypass surgery. Data were collected retrospectively for all patients undergoing coronary artery bypass graft(CABG) at a single center between January 1, 2009and December 31, 2009. Data submitted to NICOR were used for EuroSCORE and in-hospital outcomes; longer-term, all-cause mortality from NHS digital Personal Demographic Service. Low (<3), intermediate (3-6), and high-risk (>6) logistic EuroSCORE groups were identified and analyzed using the appropriate statistical methodology, with p valuesless than .05 being taken as significant. Six hundred and sixty-three patients underwent isolated CABG procedures during the study. The 1-, 3-, 5-,and 10-year survival rates were 97.6%, 94.3%, 89.3%, and 73.5%, respectively. Comparing survival outcomes between low-, intermediate-, and high-risk groups showed that the logistic EuroSCORE was able to predict long-term outcomes (p < .05). In addition, poor left ventricular ejection fraction, serum creatinine above 200 ml, chronic pulmonary disease, extracardiac arteriopathy, and pulmonary hypertension were identified as independent predictors of long-term mortality. Our study demonstrates the logistic EuroSCORE predicted long-term outcomes following CABG surgery. This finding can inform patients of the long-term risks of CABG surgery and guide MDT decision-making.

Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry

ObjectivesDegeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration. MethodsData provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed. ResultsBetween 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P < .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P < .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group. ConclusionsIn both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

External Aortic Wrapping for Type A Dissection: SEWing but Not as We Know It

In their fascinating article in this issue of The Annals of Thoracic Surgery, Suematsu and colleagues1 present their experience of performing stepwise external wrapping (SEW) of the aorta for patients with type A aortic dissection deemed at excessive risk for conventional surgical repair. In this cohort of 43 patients with a mean age of 79 years, a median EuroSCORE (European System for Cardiac Operative Risk Evaluation) II of 63.9 the operative mortality was only 2.3%. Cerebral malperfusion was present in 65% of patients preoperatively; however, only 2 patients had persistent postoperative neurological disorders.

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

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