Society Of Thoracic Surgeons Risk Score Research Articles

Association of neighborhood socioeconomic status with echocardiographic parameters and re-admission following transcatheter aortic valve replacement.

Data on predictors of poor hemodynamic presentation and rehospitalizations following transcatheter aortic valve replacement (TAVR) are limited. We evaluate the association between neighborhood socioeconomic status (NSES) on echocardiographic presentation and post-TAVR readmission at a high-volume institution. All patients undergoing TAVR at a single institution between 2012 and 2022 were included. Patient addresses, baseline variables including Society of Thoracic Surgeons (STS) preoperative risk of mortality and frailty, and post-procedural outcomes were extracted from electronic health records. Using a validated US Census Bureau Index, the NSES of each patient (1-100) was tabulated, with lower values correlating to increased social deprivation. Patients were separated into four ranked groups based on NSES (rank 1: 1-25, rank 4: 76-100). Multivariable regression was performed to determine variables associated with number of days hospitalized in one-year following index TAVR procedure. A total of 2031 patients were included. The median NSES was 68 (IQR: 53-80). There was a total of 232 (11.4%) readmissions. The median number of days hospitalized in one year following TAVR was 4 (interquartile range [IQR]: 2-7) After adjusting for baseline variables including STS risk score and patient frailty, compared to patients in the lowest ranked socioeconomic group, patients of higher NSES were associated with lower aortic valve gradients at baselines (Exp[β]=0.997, 95% CI: 0.993-0.999, P=0.049). Additionally, compared to patients in the lowest ranked socioeconomic group, patients of NSES were associated with shorter duration of readmission after risk-factor adjustments (Exp[β]=0.996, 95% CI: 0.992-0.999, P=0.032). Patients of lower socioeconomic status are associated with higher aortic valve gradient at baseline and more days hospitalized in the first year after their index TAVR procedure after adjusting for other risk factors. As TAVR volume continues to expand, physicians and health systems must consider this independent factor when determining patient prognosis and readmission policies.

Intraoperative Features Improve Model Risk Predictions After Coronary Artery Bypass Grafting

BackgroundIntraoperative physiologic parameters could offer predictive utility in evaluating risk of adverse postoperative events yet are not included in current standard risk models. This study examined whether the inclusion of continuous intraoperative data improved machine learning model predictions for multiple outcomes after coronary artery bypass grafting, including 30-day mortality, renal failure, reoperation, prolonged ventilation, and combined morbidity and mortality (MM). MethodsThe Society of Thoracic Surgeons (STS) database features and risk scores were combined with retrospectively gathered continuous intraoperative data from patients. Risk models were developed for each outcome by training a logistic regression classifier on intraoperative data using 5-fold cross-validation. STS risk scores were included as offset terms in the models. ResultsCompared with the STS Risk Calculator, models developed using a combination of the intraoperative features and the STS preoperative risk score had improved mean area under the receiver operating characteristic curve for prolonged ventilation (0.750 [95% CI, 0.690-0.809] vs 0.800 [95% CI, 0.750-0.851]) and MM (0.695 [95% CI, 0.644-0.746] vs 0.724 [95% CI, 0.673-0.775]). Additionally, models developed using intraoperative features had improved calibration, measured with Brier score, for prolonged ventilation (0.060 [95% CI, 0.050-0.070] vs 0.055 [95% CI, 0.045-0.065]) and MM (0.092 [95% CI, 0.081-0.103] vs 0.087 [95% CI, 0.075-0.098]). ConclusionsThe inclusion of time series intraoperative data in risk models may improve early postoperative care by identifying patients who require closer monitoring postoperatively.

Long-term outcomes of transcatheter tricuspid valve repair in prohibitive risk patients: futility or benefit?

Abstract Background Transcatheter tricuspid valve repair (TTVR) for tricuspid regurgitation (TR) is an emerging treatment option in inoperable patients. However, patient selection is challenging, and mostly predetermined by comorbidities and non-specific surgical risk scores. Current guidelines (1) distinguish between high-risk (HR) and prohibitive risk (PR) patients, in order to avoid clinical and procedural futility. Therefore, the aim of this study was to understand if PR patients can benefit from TTVR long-term. Methods Forty-one consecutive patients with severe TR were assessed by the heart team, considered inoperable, and underwent edge-to-edge TTVR at our institution between November 2020 and January 2022. They were divided into a PR (n=23) and an HR group (n=18), in accordance with the latest guidelines (1). Subgroup allocation took into account STS (Society of Thoracic Surgeons) risk score, and several comorbidities (Figure 1A). Mean age was 82.2±5.9 (PR) vs 81.1±3.5 years (HR), with mean STS-Score 14.3±6.7% vs 6.2±1.6% (Figure 1B). Results The primary efficacy endpoint of at least one-grade TR reduction by 30 days was recorded in 92.7% of all patients, with no device related complications. By 12 months, 6 patients died, 5 PR and 1 HR, and MACE rate was 18.1%. Secondary endpoints addressed symptoms, quality of life and multiorgan function, which improved in both groups (Figure 2). More precisely, at inclusion, all patients in the PR group were in NYHA class III and IV, while after 12 months only 27.7%. In comparison, there were no more HR patients in NYHA stage III and IV, after one year. Similarly, self-reported quality of life increased, as assessed by the "Kansas City Cardiomyopathy Questionnaire" (KCCQ) score, which increased by 23±18.2 (p<0.001) in PR and 27.5±16.1 (p<0.001) points in HR patients, respectively. Walk distance in the 6-minute test also improved by 79.2±82 (p<0.001) vs 113.6±72.8 (p<0.001) meters. Renal and liver function were also impacted by TR reduction, with statistical significance in the PR group [GFR- Glomerular Filtration Rate improvement from 46.7±13.9ml/min/1,73m2 to 51.9±18.1 (p=0.045) vs 62.1±17.1 to 62.1±18.5 (p=0.990); AST- Aspartate Aminotransferase from 33.7±15.4U/L to 27.3±12.3 (p=0.001) vs 33.2±26.1 to 26.2±6.8 (p=0.188)]. Furthermore, TR reduction led to long-term reverse cardiac remodeling, as right ventricular systolic function increased [TAPSE from 14.2±3.1mm to 17.7±2.2 (p<0.001) vs 16.4±3.5 to 20.7±5.4 (p<0.001)], and right atrial size decreased [indexed volume from 93.5±39.1 ml/m2 to 66.3±42.6 (p=0.005) vs 86.3±57.8 to 63.3±59.5 (p=0.032)]. Conclusions TTVR is feasible in very sick symptomatic patients and is associated with improved quality of life, functional capacity, multiorgan function and reverse cardiac remodeling. Patient selection based on risk assessment with surgical risk scores may deprive many symptomatic inoperable patients of this specific percutaneous treatment.Figure 1Figure 2

Assessment of TVT and STS Risk Score Performances in Patients Undergoing Transcatheter Aortic Valve Replacement.

The Society of Thoracic Surgeons (STS) score has been used to risk stratify patients undergoing transcatheter aortic valve replacement (TAVR). The Transcatheter Valve Therapy (TVT) score was developed to predict in-hospital mortality in high/prohibitive-risk patients. Its performance in low and intermediate-risk patients is unknown. We sought to compare TVT and STS scores' ability to predict clinical outcomes in all-surgical-risk patients undergoing TAVR. Consecutive patients undergoing TAVR from 2012-2020 within a large health care system were retrospectively reviewed and stratified by STS risk score. Predictive abilities of TVT and STS scores were compared using observed-to-expected mortality ratios (O:E) and area under the receiver operating characteristics curves (AUCs) for 30-day and 1-year mortality. We assessed a total of 3270 patients (mean age 79 ± 9 years, 45% female), including 191 (5.8%) low-risk, 1093 (33.4%) intermediate-risk, 1584 (48.4%) high-risk, and 402 (5.8%) inoperable. Mean TVT and STS scores were 3.5% ± 2.0% and 6.1% ± 4.3%, respectively. Observed 30-day and 1-year mortality were 2.8% (92/3270; O:E TVT 0.8 ± 0.16 vs STS 0.46 ± 0.09), and 13.2% (432/3270), respectively. In the all-comers population, both TVT and STS risk scores showed poor prediction of 30-day (AUC: TVT 0.68 [0.62-0.74] vs STS 0.64 [0.58-0.70]), and 1-year (AUC: TVT 0.65 [0.62-0.58] vs STS 0.65 [0.62-0.58]) mortality. After stratifying by surgical risk, discrimination of the TVT and STS scores remained poor in all categories at 30 days and 1 year. An updated TAVR risk score with improved predictive ability across all-surgical-risk categories should be developed based on a larger national registry.

Transcatheter Aortic Valve Replacement Prognostication with Augmented Mean Arterial Pressure.

Post-transcatheter aortic valve replacement (TAVR) patient outcome is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure (AugMAP)) derived from blood pressure and aortic valve gradients. Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between 1 January 2012 and 30 June 2017 were identified to retrieve baseline clinical, echocardiographic and mortality data. AugSBP, AugMAP and valvulo-arterial impedance (Zva) (Zva) were evaluated using Cox regression. Receiver operating characteristic curve analysis and the c-index were used to assess the model performance against the Society of Thoracic Surgeons (STS) risk score. The final cohort contained 974 patients with a mean age of 81.4 ± 8.3 years old, and 56.6% were male. The mean STS risk score was 8.2 ± 5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Both univariate and multivariate Cox regression showed that AugSBP and AugMAP parameters were independent predictors for intermediate-term post-TAVR mortality (all p < 0.0001). AugMAP1 < 102.5 mmHg was associated with a 3-fold-increased risk of all-cause mortality 1-year post-TAVR (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p < 0.0001). A univariate model of AugMAP1 surpassed the STS score model in predicting intermediate-term post-TAVR mortality (area under the curve: 0.700 vs. 0.587, p = 0.005; c-index: 0.681 vs. 0.585, p = 0.001). Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.

Cardiac Computed Tomography Angiography Anatomical Characterization of Patients Screened for a Dedicated Transfemoral Transcatheter Valve System for Primary Aortic Regurgitation

BackgroundCardiac computed tomography angiography was used to identify anatomical characteristics of the aortic root in patients with severe aortic regurgitation (AR) as compared to those with aortic stenosis (AS) to judge feasibility of transcatheter aortic valve replacement (TAVR) with the JenaValve Trilogy system. MethodsCardiac computed tomography angiography was performed prior to planned TAVR for 107 patients with severe AR and 92 patients with severe AS. Measurements related to aortic root and coronary artery anatomy were obtained and compared between groups. Perimeter >90 mm and aortic annulus angle ​>70 degrees were defined as the theoretical exclusion criteria for TAVR. A combination of sinus of Valsalva diameter <30 mm and coronary height <12 mm was defined as high risk for coronary occlusion. ResultsThe mean age of patients in the AR group was 74.9 ± 11.2 years, 46% were women, and the mean Society of Thoracic Surgeons risk score for mortality was 3.6 ± 2.1. Comparatively, the mean age of patients in the AS group was 82.3 ± 5.53 years, 65% were women, and the mean Society of Thoracic Surgeonsrisk score was 5.5 ± 3.3. Annulus area, perimeter, diameter, and angle were larger in patients with severe AR. Sinus of Valsalva diameters and heights were larger in patients with severe AR. More AR patients were excluded based on perimeter (14 vs. 2%) and annulus angle (6 vs. 1%). More AS patients exhibited high-risk anatomy for left main coronary occlusion (21 vs. 7%) and right coronary occlusion (14 vs. 3%). The maximum dimension of the ascending aorta was larger in patients with severe AR (39 vs. 35 mm). The percentage of referred AR patients with significant aortopathy requiring surgical intervention was very low (only 1 AR patient with ascending aorta diameter >5.5 cm). ConclusionsA significantly larger proportion of patients with severe AR are excluded from TAVR as compared to AS due to large aortic annulus size and steep annulus angulation. By far the most prevalent excluding factor is aortic annulus size, with fewer patients excluded due to angulation. AR patients have lower-risk anatomy for coronary occlusion. Larger transcatheter valve sizes and further delivery system modifications are required to treat a larger proportion of AR patients.

Race-Specific Impact of Conventional Surgical Risk Score on 1-Year Mortality After Transcatheter Aortic Valve Replacement

BackgroundInterracial differences in the distribution and prognostic value of conventional Society of Thoracic Surgeons (STS) score on long-term mortality after transcatheter aortic valve replacement (TAVR) are uncertain. ObjectivesThis study aims to compare the impact of STS scores on clinical outcomes at 1-year after TAVR between Asian and non-Asian populations. MethodsWe used the Trans-Pacific TAVR (TP-TAVR) registry, a multinational multicenter, observational registry involving patients undergoing TAVR at 2 major centers in the United States and 1 major center in Korea. Patients were classified into 3 groups (low, intermediate, and high-risk) according to the STS score and compared between STS risk groups and race. The primary outcome was all-cause mortality at 1-year. ResultsAmong 1,412 patients, 581 were Asian and 831 were non-Asian. The distribution of the STS risk score group was different between Asian and non-Asian groups (62.5% low-, 29.8% intermediate-, and 7.7% high-risk in Asian vs 40.6% low-, 39.1% intermediate-, and 20.3% high-risk in non-Asian). In the Asian population, the all-cause mortality at 1-year was substantially higher in the high-risk STS group than in the low- and intermediate-risk groups (3.6% low-risk, 8.7% intermediate-risk, and 24.4% high-risk; log-rank P < 0.001), which was primarily driven by noncardiac mortality. In the non-Asian group, there was a proportional increase in all-cause mortality at 1-year according to the STS risk category (5.3% low-risk, 12.6% intermediate-risk, and 17.8% high-risk; log-rank P < 0.001). ConclusionsIn this multiracial registry of patients with severe aortic stenosis who underwent TAVR, we identified a differential proportion and prognostic impact of STS score on 1-year mortality between Asian and non-Asian patients (TP-TAVR [Transpacific TAVR Registry]; NCT03826264)

Society of thoracic surgeons risk score and left atrial pressure for predicting clinical outcomes among transcatheter mitral edge-to-edge repair patients.

Limited data exist regarding the performance of the Society of Thoracic Surgeons (STS) risk score among transcatheter mitral edge-to-edge repair (TEER) patients. Evaluate STS score accuracy, and the incremental value of post-procedural left atrial pressure (LAP). A retrospective analysis of TEER patients between 2013 and 2020. Patients were allocated into 3 groups: high (≥8% [n = 298, 31%]), intermediate (4%-8% [n = 318, 33%]), and low (<4% [n = 344, 36%]). Primary outcomes included 1-year mortality or cardiovascular hospitalizations. Cox proportional hazards regression modeling was used to determine the hazard ratio of the primary outcome, and STS score accuracy was assessed by receiver operating characteristic. A spline curve was used to display the relationship between LAP and the primary endpoint. Continuous net reclassification improvement (NRI) was used to determine the incremental value of LAP. We included 960 patients, primarily elderly (79 [70-85]), with a median STS risk of 5.6 (3-9). High-risk patients were older (83 [75-89], 81 [74-87], 72 [64-79], p < 0.001), and had more comorbidities compared to intermediate and low-risk groups. Upon Cox regression, STS score (high vs. low: HR 2.5 [1.7-3.8]; Intermediate vs. low: HR 1.8 [1.2-2.7] and LAP HR 1.03 [1.01-1.06], p = 0.007) were associated with the outcome. C statistics analysis revealed low accuracy of the STS score (AUC-0.61 [0.58-0.65, p < 0.001]). Continuous NRI analysis indicated an improvement in risk prediction of 17% (6.9-26.2), p < 0.001. STS risk score has low accuracy in predicting clinical outcomes after TEER. Adding LAP measurements can improve reclassification and identify those prone to adverse outcomes.

Use of a digital application to optimize the clinical trajectory of patients in a TAVI program

Abstract Background/Purpose Application-based technology has been studied for patient engagement and collecting patient-reported outcomes (PROs) in several one-day surgical specialties with limited research in transcathether valve therapies program. The aim of study was to determine the effectiveness of app-based technology for collecting PROs, improving the patient experience, and reducing health services utilization in a transcatheter valve implantation (TAVI) program. Methods Patients accessed an interactive app via smartphones. Patients were guided from their visit to the TAVI clinic via reminders, tasks, PRO surveys, and evidence-based education. They received notifications and health surveys 2 days before the procedure to ensure they were ready for the procedure. In the postoperative period, patients were engaged with daily health surveys to track warning signs and recovery milestones for 7 days. Based on the patient's signs and symptoms, the app escalated lower risk issues to self-care education or higher risk issues to the care team (TAVI program's nurse coordinator). Follow-up surveys and Kansas City Cardiomyopathy Questionnaire (KCCQ12) were sent to patients at 1, 3, 6 and 12 months to evaluate their functional recovery. All data are reported with median and interquartile range. Results 227 patients underwent a TAVI procedure at the MHI from December 2020 to October 2021. 99 patients (44%) accepted to use the application and formed the digital application group. The two groups (digital application group vs. non-digital application group) were comparable in terms of age (76 years old (72, 81) vs 77 years old (71,82)), STS (Society of Thoracic Surgeons' risk model) score (6,1% vs 6,7%), vascular complications (8,1 vs 7.8%) and post procedure pacemakers (10,1% vs 10.9%). In the digital application group, 93% recommended the application, 95% said it helped them feel more confident before the procedure and 84%, after the procedure. KCCQ12 score (PRO) improved from 34/70 (28, 41) at baseline to 54/70 (48,62) at 1 month after the procedure and remained stable over the 12 months. Digital application use helped to reduce emergency visits by 33.5% (7.9 vs 11.9%) and rehospitalizations related to the procedure by 50.1% (7.9% vs 15.9%) in the month following the TAVI procedure. Conclusion App-based technology for patient engagement is an effective modality to enhance the patient experience, better understand the trajectory of recovery, gather PRO and reduce unnecessary health services utilization in aging population of a TAVI program. Funding Acknowledgement Type of funding sources: None.

USE OF A DIGITAL APPLICATION TO OPTIMIZE THE CLINICAL TRAJECTORY OF PATIENTS IN A TAVI PROGRAM

USE OF A DIGITAL APPLICATION TO OPTIMIZE THE CLINICAL TRAJECTORY OF PATIENTS IN A TAVI PROGRAM

Clinical Factors and Outcomes When Real-World Heart Teams Overruled STS Risk Scores in TAVR Cases.

Objectives This study was conducted to determine why heart teams recommended transcatheter aortic valve replacement (TAVR) versus surgical AVR (SAVR) for patients at low predicted risk of mortality (PROM) and describe outcomes of these cases. Background Historically, referral to TAVR was based predominately on the Society of Thoracic Surgeons (STS) risk model's PROM >3%. In selected cases, heart teams had latitude to overrule these scores. The clinical reasons and outcomes for these cases are unclear. Methods Retrospective data were gathered for all TAVR and SAVR cases conducted by 9 hospitals between 2013 and 2017. Results Cases included TAVR patients with STS PROM >3% (n = 2,711) and ≤3% (n = 415) and SAVR with STS PROM ≤3% (n = 1,438). Leading reasons for recommending TAVR in the PROM ≤3% group were frailty (57%), hostile chest (22%), severe lung disease (16%), and morbid obesity (13%), and 44% of cases had multiple reasons. Most postoperative and 30-day outcomes were similar between TAVR groups, but the STS PROM ≤3% group had a one-day shorter length of stay (2.5 ± 3.4 vs. 3.5 ± 4.7 days; p ≤ 0.001) and higher one-year survival (91.6% vs. 86.0%, p=0.002). In patients with STS PROM ≤3%, 30-day mortality was higher for TAVR versus SAVR (2.0% vs. 0.6%; p < 0.001). Conclusions Heart teams recommended TAVR in patients with STS PROM ≤3% primarily due to frailty, hostile chest, severe lung disease, and/or morbid obesity. Similar postoperative outcomes between these patients and those with STS PROM >3% suggest that decisions to overrule STS PROM ≤3% were merited and may have reduced SAVR 30-day mortality rate.

775 Impact of frailty on medium-term follow-up in patients undergoing transcatheter aortic valve implantation in a high flow referral centre with high volumes

Abstract Aims Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients. To assess the impact of frailty status on a composite endpoint comprising all-cause death and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care centre. Methods and results Consecutive patients &amp;gt;80 years referred to TAVI from January to December 2019 at our institution were screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the multidimensional prognostic index (MPI). Physical function was evaluated by the short physical performance battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB &amp;lt;6 is an established strong predictor of mortality and disability. The MPI is a three-level score used to stratify risk of mortality (low, intermediate, or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy, and co-habitation). Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up. Overall, 134 patients were referred for TAVI (mean age: 84 ± 4 years; &amp;gt;90 years: 12%, women 67%). The STS risk score was 4.6 ± 3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3 ± 3.7 (SPPB &amp;lt;6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R = 0.31, P = 0.01, MPI R = 0.29, P = 0.03, Figure 1A and B). At 1 year, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N = 6(4.5%); stroke: N = 4 (3.0%); re-do: N = 1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs. low risk: HR: 2.9, 95% CI: 1.1–6.8, P = 0.031, Figure 1C), while no association with STS (P = 0.332) was found. Conclusions In a prospective cohort of TAVI candidates, frailty stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure. 120 Figure

Impact of frailty status on medium-term follow up in patients undergoing percutaneous transcatheter aortic valve implantation in a high-flow referral center with high procedural volumes

Abstract Background Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Current guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients. Purpose To assess the impact of frailty status on a composite endpoint comprising mortality and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center. Methods Consecutive patients &amp;gt;80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI). Physical function was evaluated by the Short Physical Performance Battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB &amp;lt;6 is an established strong predictor of mortality and disability. The MPI is a three-level score used to stratify risk of mortality (low, intermediate or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy and co-habitation). Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up. Results Overall, 134 patients were referred for TAVI (mean age: 84±4 years; &amp;gt;90 years: 12%, women 67%). The average STS risk score was 4.6±3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB &amp;lt;6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R=0.31, p=0.01, MPI R=0.29, p=0.03, Figure Panel A and B). At 12 months, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N=6 (4.5%); stroke: N=4 (3.0%); re-do: N=1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs low risk: HR 2.9, 95% CI 1.1–6.8, p=0.031, Figure 1 Panel C), while no association with STS (p=0.332) was found. Conclusions In a prospectively enrolled cohort of TAVI candidates, frailty indices stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure. Funding Acknowledgement Type of funding sources: None. Figure 1

Association Between Transcatheter Aortic Valve Replacement for Bicuspid vs Tricuspid Aortic Stenosis and Mortality or Stroke Among Patients at Low Surgical Risk

There are limited data on outcomes of transcatheter aortic valve replacement (TAVR) for bicuspid aortic stenosis in patients at low surgical risk. To compare the outcomes of TAVR with a balloon-expandable valve for bicuspid vs tricuspid aortic stenosis in patients who are at low surgical risk. Registry-based cohort study of patients undergoing TAVR at 684 US centers. Participants were enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapies Registry from June 2015 to October 2020. Among 159 661 patients (7058 bicuspid, 152 603 tricuspid), 37 660 patients (3243 bicuspid and 34 417 tricuspid) who were at low surgical risk (defined as STS risk score <3%) were included in the analysis. TAVR for bicuspid vs tricuspid aortic stenosis. Coprimary outcomes were 30-day and 1-year mortality and stroke. Secondary outcomes included procedural complications and valve hemodynamics. Among 159 661 patients (7058 bicuspid; 152 603 tricuspid), 3168 propensity-matched pairs of patients with bicuspid and tricuspid aortic stenosis at low surgical risk were analyzed (mean age, 69 years; 69.8% men; mean [SD] STS-predicted risk of mortality, 1.7% [0.6%] for bicuspid and 1.7% [0.7%] for tricuspid). There was no significant difference between the bicuspid and tricuspid groups' rates of death at 30 days (0.9% vs 0.8%; hazard ratio [HR], 1.18 [95% CI, 0.68-2.03]; P = .55) and at 1 year (4.6% vs 6.6%; HR, 0.75 [95% CI, 0.55-1.02]; P = .06) or stroke at 30 days (1.4% vs 1.2%; HR, 1.14 [95% CI, 0.73-1.78]; P = .55) and at 1 year (2.0% vs 2.1%; HR 1.03 [95% CI, 0.69-1.53]; P = .89).There were no significant differences between the bicuspid and tricuspid groups in procedural complications, valve hemodynamics (aortic valve gradient: 13.2 mm Hg vs 13.5 mm Hg; absolute risk difference [RD], 0.3 mm Hg [95% CI, -0.9 to 0.3 mm Hg]), and moderate or severe paravalvular leak (3.4% vs 2.1%; absolute RD, 1.3% [95% CI, -0.6% to 3.2%]). In this preliminary, registry-based study of propensity-matched patients at low surgical risk who had undergone TAVR for aortic stenosis, patients treated for bicuspid vs tricuspid aortic stenosis had no significant difference in mortality or stroke at 30 days or 1 year. Because of the potential for selection bias and absence of a control group treated surgically for bicuspid aortic stenosis, randomized trials are needed to adequately assess the efficacy and safety of transcatheter aortic valve replacement for bicuspid aortic stenosis in patients at low surgical risk.

Prediction of operative mortality for patients undergoing cardiac surgical procedures without established risk scores

ObjectiveCurrent cardiac surgery risk models do not address a substantial fraction of procedures. We sought to create models to predict the risk of operative mortality for an expanded set of cases. MethodsFour supervised machine learning models were trained using preoperative variables present in the Society of Thoracic Surgeons (STS) data set of the Massachusetts General Hospital to predict and classify operative mortality in procedures without STS risk scores. A total of 424 (5.5%) mortality events occurred out of 7745 cases. Models included logistic regression with elastic net regularization (LogReg), support vector machine, random forest (RF), and extreme gradient boosted trees (XGBoost). Model discrimination was assessed via area under the receiver operating characteristic curve (AUC), and calibration was assessed via calibration slope and expected-to-observed event ratio. External validation was performed using STS data sets from Brigham and Women's Hospital (BWH) and the Johns Hopkins Hospital (JHH). ResultsModels performed comparably with the highest mean AUC of 0.83 (RF) and expected-to-observed event ratio of 1.00. On external validation, the AUC was 0.81 in BWH (RF) and 0.79 in JHH (LogReg/RF). Models trained and applied on the same institution's data achieved AUCs of 0.81 (BWH: LogReg/RF/XGBoost) and 0.82 (JHH: LogReg/RF/XGBoost). ConclusionsMachine learning models trained on preoperative patient data can predict operative mortality at a high level of accuracy for cardiac surgical procedures without established risk scores. Such procedures comprise 23% of all cardiac surgical procedures nationwide. This work also highlights the value of using local institutional data to train new prediction models that account for institution-specific practices.

Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Aortic Valve Replacement for Aortic Stenosis (SAVR): A Cost-Comparison Study

Comparative costing studies using real-world data stratified by patient case-mix, are valuable to decision makers for making reimbursement decisions of new interventions. This study evaluated real-world hospital admissions and short-term costs of transcatheter aortic valve implantation (TAVI) and isolated surgical aortic valve replacement (SAVR) for patients with aortic stenosis, stratified by the Society of Thoracic Surgeons (STS) risk scores. Retrospective analysis of consecutive patients with a principal diagnosis of aortic stenosis who underwent isolated valve replacement at a single tertiary hospital, January 2012-December 2017. Patients were followed-up for 30 days post-procedure or until hospital discharge if index hospitalisation was greater than 30 days. Intensive care unit (ICU) and hospital length of stay (days), and costs in 2018 Australian dollars for the index procedure and 30-day follow-up were assessed. Multivariable generalised linear and two-part models with gamma distribution and log link function adjusting for Society of Thoracic Surgeons (STS) risk group and key sociodemographic characteristics were used. Of 488 patients, 61% males, median age 78 years (IQR 14 years), 221 (45%) received transcatheter aortic valve replacement (TAVI) and 267 (55%) received surgical aortic valve replacement (SAVR). STS risk scores were low (28%), intermediate (46%) and high (26%) for TAVI patients, and low (85%), intermediate (12%) and high (3%) for SAVR patients. When adjusted, TAVI length of stay was 57% shorter than SAVR (95% CI 31-83%, p<0.001) for intensive care unit (ICU) admission, and 64% shorter (95% CI 47-81%, p<0.001) for hospital admissions. TAVI costs were 13% lower than SAVR (95% CI 4-22%, p=0.005). This data suggests short-term health care costs are lower for patients with aortic stenosis undergoing TAVI than SAVR. A further roll-out of the TAVI program in hospitals across Australia may result in savings to the health system.

Rapid decline in cardiac function in diabetic patients with calcified coronary artery disease undergoing hemodialysis: two case reports

BackgroundClinical symptoms of patients on dialysis do not match the signs of coronary disease progression, making the prediction of the true progression of their medical condition in clinical settings difficult. Emergency and concomitant surgeries are significant risk factors of mortality following open-heart surgery in patients on hemodialysis.Case presentation We report two cases of successful coronary artery bypass grafting (CABG) in patients on dialysis with a history of cardiac surgery. The first case describes a 65-year-old woman who had undergone aortic valve replacement 2 years ago and was hospitalized urgently, because of a sudden decline in heart function and hypotension. She had moderate mitral regurgitation with right ventricular pressure of 66 mmHg and poor left ventricular function [left ventricular ejection fraction (LVEF), 40%]. Cineangiography revealed an increase in the rate of stenosis in the left main trunk, from 25 to 99% at admission, in addition to 100% occlusion in proximal left anterior descending artery (LAD) and 99% stenosis in the proximal left circumflex artery (LCX). We inserted an intra-aortic balloon pump preoperatively and performed emergency surgery (Euro II risk score, 61.7%; Society of Thoracic Surgeons (STS) risk score, 56.3%). The second case described a 78-year-old man who had undergone surgery for left atrial myxoma 4 years ago and was hospitalized urgently due to dyspnea, chest discomfort, and an LVEF of 44% (Euro II risk score, 40.7%; STS risk score, 33.2%). Cineangiography revealed an increase in the rate of stenosis in the proximal LAD, from 25% (4 years ago) to 90% at admission, in addition to 99% stenosis in proximal LCX and 95% stenosis in the posterolateral branch of LCX. Both patients underwent emergency CABG due to unstable hemodynamics and decreased left ventricular function despite regular dialysis. The surgeries were successful, and the patients were discharged without any complications.ConclusionsIn patients with multiple comorbidities and those who undergo dialysis treatment, calcified lesions in coronary arteries can progress severely and rapidly without any symptoms, including chest pain. Close outpatient management involving nephrologists and the cardiovascular team is necessary for patients on dialysis.

Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis

BackgroundTranscatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR).MethodsPatients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR.ResultsDelirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2–15.1, p = .025) and 16.5 (95%CI 2.0–138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [− 3.03–0.80], p = .248).ConclusionsDelirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions.

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

The Performance of the Current Risk Prediction Scoring Systems in Patients Undergoing Anaortic Off-pump Coronary Artery Bypass Grafting.

BackgroundThis study aimed to evaluate the performance of the Society of Thoracic Surgeons (STS) risk model and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II for patients undergoing anaortic off-pump coronary artery bypass grafting (OPCAB).MethodsFrom January 2010 to June 2017, 1,048 patients (isolated anaortic OPCAB: 1,043, on-pump conversion:5) undergoing isolated anaortic OPCAB were enrolled. The STS risk score and EuroSCORE II were calculated with dedicated online software. Calibration of the models were performed by the risk-adjusted event ratio that was defined as observed events divided by expected events (O/E ratio) and Hosmer-Lemeshow test. The discrimination powers were evaluated by the area under the receiver operating characteristic curve (AUC).ResultsOperative mortality occurred in 10 patients (0.95%). The predicted mortality rates by the EuroSCORE II and STS risk model were 2.58 ± 4.15% and 1.72 ± 2.92%, respectively. The O/E ratio of the EuroSCORE II was 0.370 with significant overprediction of operative mortality (confidence interval [CI], 0.157–0.652; P = 0.003). The STS score also overpredicted the operative mortality (O/E ratio, 0.556) with marginal significance (CI, 0.266–1.023; P = 0.052). Permanent stroke occurred in 6 patients (0.53%). The predicted permanent stroke occurrence rate was 1.73 ± 1.48%. The O/E ratio was 0.332 with significant overprediction of permanent stroke (CI, 0.121–0.722; P = 0.011). Regarding discrimination power for the STS risk model, the operative mortality was excellent (AUC, 0.876) and permanent stroke was acceptable (AUC, 0.740). The EuroSCORE II showed good discrimination power (AUC, 0.784). There was a significant difference in discrimination power for mortality between STS and EuroSCORE II risk models (P = 0.007).ConclusionPreexisting risk predicting scoring systems, STS risk model and EuroSCORE II, overpredict the risk of mortality and stroke rate for anaortic OPCAB. These findings suggest the possibility that anaortic OPCAB can lower the operative mortality and occurrence of postoperative stroke than conventional coronary artery bypass grafting.