Absolute and relative risk prediction in patients candidate to isolated aortic valve replacement: should we change our mind?

Di Giammarco, Gabriele; Rabozzi, Roberto; Chiappini, Bruno; Tamagnini, Gabriele
February 2010
European Journal of Cardio-Thoracic Surgery;Feb2010, Vol. 37 Issue 2, p255
Academic Journal
Abstract: Objective: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) calculator performance in 30-day outcome prediction after isolated aortic valve replacement (AVR) was evaluated to assess its absolute reliability and usefulness as selection criteria to percutaneous aortic valve implantation (PAVI). Methods: We carried out a retrospective statistical analysis on 379 patients (group 0) consecutively submitted to isolated AVR in the past 10 years of surgical activity. We discriminated two periods of 5 years each, so we considered two subgroups of patients: group 1 (200 patients operated during 1999–2003); group 2 (179 patients operated during 2004–2008). We used receiver operating characteristics (ROC) curves for discriminatory power analysis. Model calibration was evaluated with the Hosmer–Lemeshow goodness-of-fit test and Pseudo R 2 analysis. Results: The overall expected mortality rate at the logistic calculator was 9.37% compared with an observed 10-year mortality of 5.2% (p =0.006). Absolute risk prediction in group 1 fitted the observed outcome (p =0.24) while expected mortality in group 2 was significantly higher than observed (p =0.005). Applying threshold values used as PAVI selection criteria (logistic EuroSCORE >20 or >15), against 29% and 24.3% expected mortality rate, respectively, we registered a significant difference in the observed values (11.4%, p =0.022; 8.6%, p =0.005, respectively). The Hosmer–Lemeshow test demonstrated a lack of model fit in the overall group (p =0.019). ROC analysis revealed a sufficient discriminatory power for either total population (logistic area under curve (AUROC) 0.706; 95% confidence interval (CI): 0.604–0.809; p =0.002) and group 1 (logistic AUROC 0.752; 95% CI: 0.643–0.860; p =0.002). Group 2 showed a lack of risk stratification (logistic AUROC 0.613; 95% CI: 0.401–0.824; p =0.348). Conclusions: EuroSCORE appears to be an invalid model in absolute and relative risk prediction for isolated AVR. On this basis, its use in selecting candidates to PAVI should be carefully weighted. Correct stratification and sufficient calibration of absolute risk estimate of high-risk patients are, therefore, mandatory in the aim of assigning those patients who show risk factors really responsible for the worst surgical outcome to new techniques. The goal should be reached by exploring the weight of each independent predictor of death in each single institution involved in PAVI procedures, evaluating local surgical results in terms of absolute risk and analysing those variables significantly affecting relative risk.


Related Articles

  • Validation of a modified EuroSCORE risk stratification model for cardiac surgery: the Swedish experience Nozohoor, Shahab; Sjögren, Johan; Ivert, Torbjörn; Höglund, Peter; Nilsson, Johan // European Journal of Cardio-Thoracic Surgery;Jul2011, Vol. 40 Issue 1, p185 

    Abstract: Objective: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is used to identify patients at high risk for aortic valve replacement (AVR) in whom alternative procedures, such as trans-catheter aortic valve implantation (TAVI), may be appropriate. The aim of the...

  • External validation of the EuroSCORE II risk stratification model in the USA. Hernández-Vaquero, Daniel; Díaz, Rocío; Meana, Blanca; Morís, César // European Journal of Cardio-Thoracic Surgery;Jul2015, Vol. 48 Issue 1, p177 

    A letter to the editor is presented in response to the article "Performance of EuroSCORE II in a large US database: implications for transcatheter aortic valve implantation," by R. L. Osnabrugge and colleagues in the 2014 issue is presented.

  • Transapical aortic valve implantation after previous heart surgery Drews, Thorsten; Pasic, Miralem; Buz, Semih; Unbehaun, Axel; Dreysse, Stephan; Kukucka, Marian; Mladenow, Alexander; Hetzer, Roland // European Journal of Cardio-Thoracic Surgery;May2011, Vol. 39 Issue 5, p625 

    Abstract: Objective: Transcatheter aortic valve implantation is a new method for the treatment of very-high-risk patients with aortic valve stenosis. Particularly in patients who have had previous cardiac surgery, the operative risk can be reduced. Nevertheless, this new procedure has some...

  • Editorial Comment: EuroSCORE II and the art and science of risk modelling. Nashef, Samer A.M.; Sharples, Linda D.; Roques, François; Lockowandt, Ulf // European Journal of Cardio-Thoracic Surgery;Apr2013, Vol. 43 Issue 4, p695 

    The authors reflect on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. The authors mention the misused on the evaluation of patients for transcatheter aortic valve implantation (TAVI). The authors state that risk factors in conventional surgery differs from TAVI. The...

  • Major risk stratification models do not predict perioperative outcome after coronary artery bypass grafting in patients with previous percutaneous intervention Bonaros, Nikolaos; Vill, David; Wiedemann, Dominik; Fischler, Klaus; Friedrich, Guy; Pachinger, Otmar; Grimm, Michael; Schachner, Thomas // European Journal of Cardio-Thoracic Surgery;Jun2011, Vol. 39 Issue 6, pe164 

    Abstract: Objective: To investigate whether common risk stratification models in cardiac surgery predict perioperative outcome of coronary artery bypass grafting (CABG) in patients with previous percutaneous coronary interventions (PCIs). Methods: We retrospectively analyzed the perioperative...

  • Is the new EuroSCORE II a better predictor for transapical aortic valve implantation?†. Haensig, Martin; Holzhey, David Michael; Borger, Michael Andrew; Schuler, Gerhard; Shi, William; Subramanian, Sreekumar; Rastan, Ardawan Julian; Mohr, Friedrich Wilhelm // European Journal of Cardio-Thoracic Surgery;Aug2013, Vol. 44 Issue 2, p302 

    OBJECTIVES Conventional surgical risk scores are used to identify suitable candidates for transapical aortic valve implantation (TA-AVI) at present. However, these scores do not consider multiple high-risk conditions, including porcelain aorta, mediastinal irradiation or frailty. The aim of this...

  • Validation of a new predictive risk model: measuring the impact of the major modifiable risks of death for patients and populations. Lim, Stephen S.; Carnahan, Emily; Nelson, Eugene C.; Gillespie, Catherine W.; Mokdad, Ali H.; Murray, Christopher J. L.; Fisher, Elliott S. // Population Health Metrics;10/2/2015, Vol. 13 Issue 1, p1 

    Background: Modifiable risks account for a large fraction of disease and death, but clinicians and patients lack tools to identify high risk populations or compare the possible benefit of different interventions. Methods: We used data on the distribution of exposure to 12 major behavioral and...

  • Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure Klein, Patrick; Holman, Eduard R.; Versteegh, Michel I.M.; Boersma, Eric; Verwey, Harriette F.; Bax, Jeroen J.; Dion, Robert A.E.; Klautz, Robert J.M. // European Journal of Cardio-Thoracic Surgery;May2009, Vol. 35 Issue 5, p847 

    Abstract: Objective: Advanced ischemic heart failure can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent heart failure have been identified, no plain predictor for identifying SVR patients with left ventricular damage beyond...

  • An evaluation of POSSUM and P-POSSUM scoring in predicting post-operative mortality in a level 1 critical care setting. Scott, Sarah; Lund, Jonathan N.; Gold, Stuart; Elliott, Richard; Vater, Mair; Chakrabarty, Mallicka P.; Heinink, Thomas; Williams, John P. // BMC Anesthesiology;2014, Vol. 14 Issue 1, p1 

    Background POSSUM and P-POSSUM are used in the assessment of outcomes in surgical patients. Neither scoring systems' accuracy has been established where a level 1 critical care facility (level 1 care ward) is available for perioperative care. We compared POSSUM and P- POSSUM predicted with...


Read the Article


Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics