Society Of Thoracic Surgeons Risk Score Research Articles

Transcatheter and ministernotomy aortic valve replacement after bioprosthetic valve failure.

Transcatheter valve-in-valve implantation (TViV) and minimally invasive reoperative aortic valve replacement (MIrAVR) have rapidly increased as alternatives to conventional reoperative surgical AVR. This study reports a single-center experience of patients undergoing TViV and MIrAVR after bioprosthetic valve failure. In this retrospective review between March 2009 and October 2018, 68 patients without reoperative full sternotomies, concomitant procedures, active endocarditis, and prior homografts or coronary artery bypass grafting underwent isolated AVR for degenerated aortic bioprostheses. Society of Thoracic Surgeons (STS) risk scores and age are reported as median (interquartile range [IQR]) and length of stay is reported as mean (standard deviation [SD]) due to their characteristics of the distribution. Forty-one (60.3%) patients underwent TViV, and 27 (39.7%) patients underwent MIrAVR. Median [IQR] STS risk scores were 5.7 [4.0-7.8] and 2.0 [1.5-3.4] for TViV and MIrAVR, respectively (p ≤ .001). The median [IQR] age for TViV patients was higher (78 [71-84] vs. 66 [53-72] years, p ≤ 0.001). More permanent pacemakers were implanted (22.2% vs. 9.8%) following MIrAVR. The MIrAVR group had a higher rate of atrial fibrillation (18.5% vs. 9.8%, p = .466). Average (SD) length of stay was less in TViV (5.3 days, SD: 3.4 vs. 8.6 days, SD: 7.4, p = .001). Survival at 1 year was not significantly different for TViV and MIrAVR (94.9% [95% confidence interval [CI]: 81.0%, 98.7%] and 86.9% [95% CI: 64.0%, 95.7%], respectively [p = .969]). Despite being at higher-risk, patients undergoing TViV had reduced rates of permanent pacemaker implantations and atrial fibrillation, and a shorter hospital stay as compared to MIrAVR. Survival at 1-year was similar between the two groups.

Pre-operative physical performance as a predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

ObjectiveRisk stratification of cardiac surgery patients is usually based on the Society of Thoracic Surgeons (STS) score, that has limited predictive value in older persons. We aimed assessing whether the Short Physical Performance Battery (SPPB) improves, beyond the STS score, assessment of hospital prognosis in older patients undergoing elective cardiac surgery. MethodsAll patients aged 75+ years referred for elective cardiac surgery to Careggi University Hospital (Florence, Italy) from April 2013 to March 2017 were evaluated pre-operatively. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM): low (<4%), intermediate (4 to 8%), and high risk (>8%). Primary study outcomes were hospital mortality and STS-defined major morbidity. Length of hospital stay was an additional outcome. ResultsOut of 235 participants (females: 46.5%; mean age: 79.6 years), 144 (61.3%) were at low, 67 (28.5%) at intermediate and 24 (10.2%) at high risk, based on the STS-PROM. SPPB (mean±SEM) was 8.8 ± 0.2, 7.0 ± 0.5, and 6.0 ± 0.8 in participants at low, intermediate, and high risk, respectively (p<0.001). The primary outcome occurred in 62 participants (26.4%). In low-risk participants, the SPPB score predicted the primary endpoint (adjusted OR 0.77, 95% CI 0.66–0.89 per each point increase; p<0.001) controlling for STS-Major Morbidity or Operative Mortality (STS-MM) score. This result was not observed in the intermediate-high risk group. ConclusionsSPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, classified as low risk with the STS risk score. The SPPB, applied preoperatively, might improve risk stratification in older patients undergoing elective cardiac surgery.

Prognostic performance of the Society of Thoracic Surgeons risk score in patients with left main coronary artery disease undergoing revascularisation: a post hoc analysis of the EXCEL trial.

Accurate risk prediction in patients undergoing revascularisation is essential. We aimed to assess the predictive performance of Society of Thoracic Surgeons (STS) risk models in patients with left main coronary artery disease (LMCAD) undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention with everolimus-eluting stents (PCI-EES). The predictive performance of STS risk models for perioperative mortality, stroke and renal failure was evaluated for their discriminative ability (C statistic) and calibration (Hosmer-Lemeshow goodness-of-fit-test; χ2 and p-values) among patients with LMCAD undergoing PCI-EES (n=935) and CABG (n=923) from the randomised EXCEL trial. STS risk scores, in CABG patients, showed good discrimination for 30-day mortality and average discrimination for stroke (C statistic 0.730 and 0.629, respectively) with average calibration. For PCI, STS risk scores had no discrimination for mortality (C statistic 0.507), yet good discrimination (C statistic 0.751) and calibration for stroke. The predictive performance for renal failure was good for CABG (C statistic 0.82), yet poor for PCI (C statistic 0.59). In selected patients with LMCAD from the EXCEL trial, STS risk models showed good predictive performance for CABG yet lacked predictive performance for PCI for perioperative mortality and renal failure. The STS stroke risk model was surprisingly more discriminating in PCI compared to CABG. Improved and procedure-specific risk prediction instruments are needed to accurately estimate adverse events after LMCAD revascularisation by CABG and PCI. ClinicalTrials.gov Identifier: NCT01205776.

New risk factors in determining long‑term mortality in patients undergoing TAVI: can the conventional risk scores be used as a long‑term mortality predictor?

Surgical risk in patients after transcatheter aortic valve implantation (TAVI) is determined by conventional scoring systems. However, these risk scores were developed to predict surgical mortality. Due to their insufficient predictive ability in patients after TAVI, novel risk scores are needed to predict long‑term mortality in this population. The study aimed to investigate the value of conventional risk scores in predicting long‑term mortality. Additionally, the impact of laboratory parameters on long‑term mortality was evaluated. Our study included 121 patients who underwent transfemoral TAVI. The mean (SD) logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, and the Society of Thoracic Surgeons (STS) risk score were 27.4 (9.7), 7.9 (4.6), and 4.6 (2.4), respectively. In‑hospital mortality rate was 1.7%. None of the risk scoring systems predicted in‑hospital mortality correctly. The STS score corresponded with the mortality rate of approximately 2 months, EuroSCORE II, with 6 months, and logistic EuroSCORE, with 30 months. Male gender (odds ratio [OR], 5.668; 95% CI, 1.055–30.446; P = 0.04) and low albumin levels before TAVI (OR, 0.109; 95% CI, 0.018–0.654; P = 0.02) were found to be the independent predictors of long‑term mortality. Although all conventional risk scores overestimated in‑hospital mortality, the STS risk score predicted 2‑month, EuroSCORE II, 6‑month, and logistic EuroSCORE, 30‑month mortality. The independent predictors of long‑term mortality were male gender and low blood albumin levels before the TAVI procedure.

P5983Pre-operative physical performance as an independent predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

Abstract Introduction Risk stratification of patients candidate to cardiac surgery is usually based on the Society of Thoracic Surgeons (STS) score or on the Euroscore II. However, these risk scores has limited predictive value in elderly patients. Purpose We conducted a study to determine whether the Short Physical Performance Battery (SPPB), a tool assessing physical performance, predicts hospital death and major morbidity, beyond STS risk score. The outcome was a composite end-point as defined by STS Major Morbidity or Operative Mortality (STS-MM) in STS Risk Model Outcomes: operative mortality, stroke, renal failure, prolonged mechanical ventilation, deep sternal wound infection, and reoperation. Methods In this prospective, single-center, cohort, hospital-based study, conducted at Careggi University Hospital, Florence, Italy, all patients aged 75+ years referred for an elective coronary aortic by-pass grafting, valvular surgery or combined cardiac surgery were evaluated pre-operatively. Assessment included SPPB, cognitive and functional status and evaluation of comorbidity. Patients receiving emergency/urgent cardiac surgery or a procedure not considered in the STS risk score calculator, who reported previous cardiac surgery or were clinically unstable were excluded. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM) as at low (&lt;4%), intermediate (4 to 8%) or high risk (&gt;8%). Results Out of 250 participants (females: 48.4%; mean age: 79.9 years), 148 (59.2%) were at low, 73 (29.2%) at intermediate and 29 (11.6%) at high risk, based on the STS-PROM. Mean±SEM SPPB score was 8.8±0.2, 7.1±0.4 and 6.0±0.7 in participants at low, intermediate, and high risk, respectively (p&lt;0.001). The outcome occurred in 67 subjects (26.8%). SPPB score predicted the outcome in the entire study sample, controlling for STS-MM score, CKD, and anaemia (adjusted OR: 0.89, 95% CI 0.81–0.98 per each point increase; p 0.017). When analyses were repeated separately in participants with STS-PROM indicative of low (&lt;4%) and in those at medium-high risk, the predictive value of SPPB was enhanced in the formers (adjusted OR 0.73, 95% CI 0.62–0.86 per each point increase; p&lt;0.001- controlling for STS score), whereas was lost in the latter. An alternative model was subsequently tested, where STS score was not included and peripheral artery disease and creatinine (variables contributing to the STS score) were individually entered: SPPB was confirmed as a significant predictor also in this model, controlling for anaemia, peripheral artery disease, and creatinine. The corresponding AUC was 0.813 (Figure 1). Figure 1 Conclusions SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, in particular in those classified as low-risk with the STS risk score. Use of SPPB should therefore be recommended to improve preoperative risk stratification of older patients.

Minimally invasive single-vessel left internal mammary to left anterior descending artery bypass grafting improves outcomes over conventional sternotomy: A single-institution retrospective cohort study.

Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited. The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity. A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010). Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting.

Prevalence of and Risk Factors for Permanent Pacemaker Implantation After Aortic Valve Replacement

Damage to the cardiac conduction system requiring permanent pacemaker implantation is a complication of aortic valve replacement (AVR) that may importantly affect quality of life. We investigated the prevalence of and preprocedure risk factors for new permanent pacemakers after surgical (SAVR) and transcatheter AVR (TAVR) at a single institution. Preoperative variables and baseline electrocardiograms were reviewed for 5807 patients undergoing elective SAVR, with or without coronary artery bypass grafting, and 1292 undergoing TAVR, with or without percutaneous coronary intervention, from 2006 to 2017 at Cleveland Clinic. Patients with previous permanent pacemakers were excluded. Risk factors for permanent pacemaker implantation were identified using multivariable logistic regression analysis. New permanent pacemakers were implanted in 151 (2.6%) after SAVR and in 125 (9.7%) after TAVR (whole group SAVR vs TAVR, P <.0001). Risk factors forpacemaker implantation after TAVR included preoperative conduction disturbances and type of prosthesis (SAPIEN, 9.5%; SAPIEN XT, 4.8%; SAPIEN 3, 10% [Edwards Lifesciences, Irvine, CA]; CoreValve, 30% [Medtronic, Minneapolis, MN]; and other TAVR, 10%). There were no reliable risk factors for pacemaker implantationafter SAVR. Bicuspid valves, mechanical vsbioprosthetic valves, higher Society of Thoracic Surgeonsrisk score, and concomitant coronary artery bypass grafting were not associated with elevated risk. At a high-volume institution in the current era, establishing a baseline for pacemaker implantation after AVR is necessary. Preoperative conduction disturbances and transcatheter valve type affect its prevalence. These data provide a benchmark that should be taken into account when considering TAVR in low-risk patients.

Phase of Care Mortality Analysis According to Individual Patient Risk Profile

Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk (<4%), intermediate (4% to 8%), and high risk (>8%). A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

100.67 STS Risk Score Associates With One-year Mortality in Patients Selected for Percutaneous Coronary Intervention by a Multidisciplinary Heart Team

The Society of Thoracic Surgeons (STS) risk scores predict mortality in patients undergoing cardiac surgery; however, it is unknown whether these scores are associated with mortality among complex patients with coronary artery disease (CAD) who are being considered for percutaneous coronary

Comparative survival and role of STS score in aortic paravalvular leak after SAVR or TAVR: a retrospective study from the USA

ObjectiveThe presence of aortic paravalvular leak (PVL) is associated with lower survival, but a direct comparison of its impact after transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement...

East meets West: the influence of racial, ethnic and cultural risk factors on cardiac surgical risk model performance

ObjectiveTo explore the impact of racial and ethnic diversity on the performance of cardiac surgical risk models, the Chinese SinoSCORE was compared with the Society of Thoracic Surgeons (STS) risk...

Clinical Frailty as an Outcome Predictor After Transcatheter Aortic Valve Implantation

Society of Thoracic Surgeons (STS) score and frailty index are calculated routinely as part of transcatheter aortic valve implantation (TAVI) assessment to determine procedure risk. We aim to evaluate the incremental improvement of STS risk score using frailty status in predicting short- and long-term outcome after TAVI. Study population included 544 consecutive TAVI patients who completed full frailty assessment and STS score calculation before the procedure. Frailty is defined by the presence of any 3 of the following 5 criteria: algorithm-defined grip strength and 15-foot walking tests, body mass index < 20 kg/m2, Katz activity of daily living ≤ 4/6, serum albumin < 3.5 g/dl. Multivariable logistic analysis of 30-day and 1-year mortality was performed using a logistic regression model that comprised the STS risk score model as a single variable. Based on frailty definition, 242 patients were frail and 302 patients were not. STS score was higher in the frail group than in the nonfrail group. Compared with STS risk score alone, frailty status was a significant predictor of 1-year mortality after TAVI procedure (odds ratio 1.0, 95% confidence interval [CI] 1.0 to 1.1, p = 0.029 vs 2.75, 95% CI 1.55 to 4.87, p <0.001, respectively). Although the c-statistic of the 1-year STS risk prediction model only changed from 0.62 to 0.66 (p = 0.08), the net reclassification improvement increased significantly to 52.8% after adding frailty to the prediction model (95% CI 0.28 to 0.77, p <0.0001). Frailty status is associated with higher mortality in TAVI cohort and incrementally improves the well-validated STS risk prediction model. Frailty assessment should continue to be part of the preprocedural assessment to further improve patient outcomes after TAVI.

TCT-807 Accuracy of the Society of Thoracic Surgeons (STS) Mortality and Stroke Risk Scores for Predicting Outcomes in Patients With Left Main Coronary Artery Disease Undergoing CABG Versus PCI: Insights From the EXCEL Trial

Whether STS risk scores can accurately predict outcomes in patients with left main (LM) coronary artery disease undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) is unknown. We compared the observed 30-day mortality and stroke rates to those expected

Reoperative Surgical Aortic Valve Replacement Versus Transcatheter Valve-in-Valve Replacement for Degenerated Bioprosthetic Aortic Valves

Bioprosthetic aortic valve use has increased steadily according to The Society of Thoracic Surgeons (STS) database analyses. One of the momentums toward this trend is the future utilization of transcatheter valve-in-valve (TViV) techniques when bioprosthetic valves fail. We compared the results of reoperative TViV to surgical aortic valve replacement (SAVR) for degenerated bioprosthetic valves. From January 2002 to January 2015, we identified 91 patients with degenerated bioprosthetic valves who underwent isolated AVR (SAVR n= 69, TViV n=22). Patients with prior homografts or active endocarditis were excluded. The STS risk score was used to create 22 matched pairs of SAVR and TViV for comparison. Before matching, mean STS risk scores were 4.36 ± 3.1 and 7.54 ± 3.0 for SAVR and TViV, respectively (p= 0.001), but were 7.70 ± 3.4 and 7.54 ± 3.0, respectively (p= 0.360), after matching. Mean age was 74.5 ± 10.4 years for SAVR and 75.0 ± 9.6 years for TViV (p= 0.749). Operative mortality was 4.3% (1 of 22) in the SAVR group and zero for TViV (p= 1.00). Mean postoperative gradient was 13.5 ± 13.2 mm Hg for SAVR and 12.4 ± 6.2 mm Hg for TViV (p= 0.584). There was no coronary obstruction in either group, but 22% of TViV (5 of 22) had mild paravalvular leaks versus none in the SAVR group (p= 0.048). Postoperative stroke rate was 9% (2 of 22) for SAVR and zero for TViV (p= 0.488). The TViV group had shorter median length of stay (5 versus 11 days, p= 0.001). Actuarial survival at 3 years was 76.3% (95% confidence interval: 58.1 to 94.5) versus 78.7 (95% confidence interval: 56.2 to 100) for SAVR and TViV, respectively (p= 0.410). For degenerated bioprosthetic aortic valves, TViV has similar operative mortality, strokes rates, and survival as SAVR in this high-risk cohort. Therefore, TViV is a viable alternative to SAVR, although studies using registry data are needed to establish noninferiority.

Safety of Continuous Infusion Ketorolac in Postoperative Coronary Artery Bypass Graft Surgery Patients.

Background:Continuous infusion ketorolac is sometimes utilized for analgesia in postoperative coronary artery bypass graft (CABG) patients despite contraindications for use. Limited literature surrounds this topic; therefore, this study was conducted to evaluate the safety of this practice. Methods: This retrospective cohort study evaluated the primary outcome of mortality and secondary outcomes of incidence of bleeding and myocardial infarction (MI). All patients who underwent isolated CABG surgeries and received continuous infusion ketorolac during the study period were included. An equal number of randomly selected isolated CABG patients served as control patients. Electronic medical records and the Society of Thoracic Surgeons (STS) database were utilized to determine baseline characteristics and outcomes; Results: One hundred and seventy-eight patients met inclusion; 89 in each group. More patients in the control group underwent on-pump surgeries (78.6% vs. 29.2%, p = 0.01) and had higher STS risk scores (1.1% vs. 0.6%, p = 0.003). There was no difference in mortality between the ketorolac group and control group (2.2% vs. 3.3%, p = 0.605). Additionally, no patients experienced a MI and there was no difference in bleeding incidence (5.5% vs. 6.7%, p = 0.58); Conclusions: No association was found between continuous infusion ketorolac and increased risk of mortality, MI, or bleeding events in postoperative CABG patients. Considerations to differences in baseline characteristics must be made when interpreting results.

Choice of Treatment for Aortic Valve Stenosis in the Era of Transcatheter AorticValve Replacement in EasternDenmark (2005 to 2015).

The aim of this study was to evaluate the choice of treatment for severe aortic valve stenosis in the era oftranscatheter aortic valve replacement (TAVR) in Eastern Denmark. Until the early 21st century, the only therapeutic option for aortic valve stenosis was surgical aortic valve replacement (SAVR), but this has changed with the introduction of TAVR. Using the East Denmark Heart Registry, the evolution of AVR over time was studied for the period 2005to2015. TAVR has since its introduction in 2007 seen steady growth, with currently more than 35% of AVR procedures-and 45% of isolated AVR procedures-being performed by transcatheter-based technology. The number of SAVR procedures remained rather stable over the study period and even saw a slight decline since 2012-there was a marked decrease in the age at which surgical bioprostheses are considered appropriate. The age profile of TAVR patients remained unchanged over the study period, with a recent trend toward more low- and intermediate-risk patients. Currently, patients age ≥80 years and/or with a Society of Thoracic Surgeons (STS) surgical risk score >6 are automatically referred for TAVR, and one-half of patients age 70 to 80 years with an STS risk score of 4 to 6 are treated withTAVR. The number of TAVR procedures has increased steadily in recent years, with a TAVR penetration rateof35% in 2015 and close to 45% when considering isolated AVR. The number of SAVR procedures remained stableover the study period, and surgical bioprostheses are currently used at a much younger age than in2005.

Comparison of EuroSCORE II, Original EuroSCORE, and The Society of Thoracic Surgeons Risk Score in Cardiac Surgery Patients

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was developed to reflect a more current dataset and evidence-based improvements in cardiac surgery. In the United States, The Society of Thoracic Surgeons (STS) risk score is more accepted owing to relatively high predictive value despite less user friendliness and inapplicability to some cardiac surgeries. We compared the precision of EuroSCORE II with EuroSCORE I and the STS risk score for operative mortality. Data were collected prospectively for all cardiac surgery patients at a single center since 2001 (N= 11,788). A secondary analysis for patients with cardiac surgery not accommodated by the STS model compared only EuroSCORE II and I (N= 5,880). Receiver-operating characteristic analyses were performed for operative mortality to determine the discriminative ability for each score. Observed operative mortality was 1.8%. Mean predicted mortality for STS risk score, EuroSCORE II, and EuroSCORE I was 2.7%, 3.3%, and 7.8%, respectively. The discriminative ability for operative mortality by area under the curve for EuroSCORE II, EuroSCORE I, and STS risk score was 0.844, 0.819, and 0.846, respectively. In secondary analyses comparing EuroSCORE II with EuroSCORE I, risk scores were correlated (rs= 0.83, p < 0.001). However, for operative mortality (observed, 4%), EuroSCORE II had better absolute prediction and discriminative ability (expected, 5.8%; area under the curve 0.754) than EuroSCORE I (expected, 12.5%; area under the curve 0.688). EuroSCORE II had better predictive discrimination for operative mortality than EuroSCORE I, which greatly overestimated this risk. EuroSCORE II fared well compared with the STS risk score. The inclusive nature of EuroSCORE II for numerous procedures provides more flexibility than the STS score for complex procedures. EuroSCORE II should be considered for calculating risk score for complex cardiac surgical patients.

Preoperative pulmonary function tests predict mortality after surgical or transcatheter aortic valve replacement

ObjectivesTo determine the role of preoperative pulmonary function tests (PFTs) in patients with aortic stenosis (AS) evaluated for aortic valve replacement (AVR), and to evaluate the association between lung disease and mortality in specific subgroups. MethodsBetween 2008 and 2013, 535 patients with preoperative PFTs underwent AVR (transcatheter AVR [TAVR], n = 246; surgical AVR [SAVR], n = 289). The severity of lung disease determined by the Society of Thoracic Surgeons (STS) definition was evaluated in those with and without a clinical suspicion for lung disease (smoking, inhaled steroids/bronchodilators, or home oxygen). The association between lung disease and 1-year mortality was evaluated. ResultsOf the 186 patients (35%) without suspected lung disease, 39 (21%) had moderate/severe lung disease by PFT analysis. Among all patients, 1-year mortality was 12% in those with no lung disease, 17% in those with no mild lung disease, 22% in those with moderate lung disease, and 31% in those with severe lung disease (P < .001, log-rank test). After adjustment, moderate/severe lung disease was associated with increased 1-year mortality (adjusted hazard ratio, 2.07; 95% confidence interval, 1.30-3.29; P = .002); this association was not altered by smoking history, suspicion of lung disease, New York Heart Association class, or AVR type (interaction P value nonsignificant for all). ConclusionsIn patients with AS evaluated for AVR, the STS risk score is significantly influenced by the severity of lung disease, which is determined predominantly by PFT results. Even when lung disease is not suspected, PFTs are abnormal in many patients undergoing AVR. Moderate/severe lung disease, diagnosed predominantly by PFTs, is an independent predictor of mortality after SAVR or TAVR. Collectively, these findings suggest that PFTs should be a routine part of the risk stratification of patients considered for AVR.

Transcatheter Aortic Valve Replacement Versus Aortic Valve Bypass: A Comparison of Outcomes and Economics

Transcatheter aortic valve replacement (TAVR) is currently offered to patients who are high-risk candidates for conventional surgical aortic valve replacement. For the past 37 years, off-pump aortic valve bypass (AVB) has been used in elderly patients at our center for this similarly high-risk group. Although TAVR and AVB were offered to similar patients at our center, comparisons of clinical outcomes and hospital economics for each strategy were not reported. We reviewed the clinical and financial records of 53 consecutive AVB procedures performed since 2008 with the records of 51 consecutive TAVR procedures performed since 2012. Data included demographics, hemodynamics, The Society of Thoracic Surgeons (STS) risk score, extent of coronary disease, and ventricular function. Follow-up was 100% in both groups. Hospital financial information for both cohorts was obtained. Mean risk score for the TAVR group was 10.1% versus 17.6% for AVB group (p < 0.001). Kaplan-Meier hospital rates of 3- and 6-month survival and of 1-year survival were 88%, 86%, 81%, and 61% and 89%, 83%, 83%, and 70% for the TAVR and AVB groups, respectively (p = 0.781). Two patients who had undergone TAVR had a procedure-related stroke. The one stroke in an AVB recipient was late and not procedure related. At discharge, mild and moderate perivalvular and central aortic insufficiency were present in 31% and 16% of TAVR recipients, respectively; no AVB valve leaked. Transvalvular gradients were reduced to less than 10 mm Hg in both groups. The average hospital length of stay for the AVB-treated patients was 13 days, and it was 9 days for the TAVR-treated patients. Median hospital charges were $253,000 for TAVR and $158,000 for AVB. Mean payment to the hospital was $65,000 (TAVR) versus $64,000 (AVB), and the mean positive contribution margin (profit) to the hospital was $14,000 for TAVR versus $29,000 for AVB. TAVR and AVB relieve aortic stenosis and have similar and acceptable procedural mortality rates. AVB-treated patients had 1.75 times the STS risk score when compared with the TAVR cohort. Hospital charges for TAVR were nearly twofold those of AVB. Hospital reimbursement was similar, but AVB had two to four times the profit margin of TAVR. Longer follow-up for the TAVR cohort will determine whether survival is comparable to that after AVB at 3 and 5 years.

Transcatheter Aortic Valve Replacement Has Improved Short-Term but Similar Midterm Outcomes in Isolated Aortic Valve Replacement After Prior Coronary Artery Bypass Grafting

An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG. A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model. TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p= 0.61). The preoperativeejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p= 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p= 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p= 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients.Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p= 0.46). Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.