Simple bedside clinical evaluation versus established scores in the estimation of operative risk in valve replacement for severe aortic stenosis.
BACKGROUND
The operative risk of cardiac surgery is ascertained preoperatively on the basis of scores validated in multinational studies. However, the value they add to a simple bedside clinical evaluation (CE) remains controversial.


OBJECTIVE
To compare operative mortality (defined as death from all causes before the 31st postoperative day) predicted by CE with that predicted by additive and logistic EuroSCOREs, EuroSCORE II and Society of Thoracic Surgeons (STS), Ambler and age-creatinine-ejection fraction (ACEF) scores in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis.


METHODS
Overall, 314 consecutive patients were included who underwent AVR between October 2009 and November 2011 (22% with coronary artery bypass graft); mean age 73.4 ± 9.7 years (29% aged>80 years). Based on CE, patients were divided into four predefined groups of increasing estimated mortality risk: I ≤ 3.9%; II 4-6.9%; III 7-9.9%; IV ≥ 10%. The positive and negative predictive values of the six scores and CE were compared.


RESULTS
The observed overall operative mortality was 5.7%. The distribution of the four predicted mortality groups by each score was highly variable. The positive predictive value, calculated for the 64 patients classified at highest risk by CE (groups III or IV) or each score, was 17.2% for EuroSCORE II, 14.1% for CE and STS scores, 10.9% for additive and logistic EuroSCOREs, 10.6% for ACEF and 10.2% for Ambler. The positive predictive value of each score in the low-risk groups (I and II) ranged from 2.8% to 4.4%.


CONCLUSIONS
A simple bedside CE appears as reliable as the various established scores for predicting operative risk in patients undergoing surgical aortic valve replacement. The development and validation of more comprehensive risk stratification tools, including risk factors thus far neglected, seems warranted.
Cardiology Department, University Hospital, 35033 Rennes, France. Electronic address: marcel.laurent@chu-rennes.fr.
Marcel
M
Laurent
Maxime
M
Fournet
Bertrand
B
Feit
Emmanuel
E
Oger
Erwan
E
Donal
Christophe
C
Thébault
Yves
Y
Biron
Xavier
X
Beneux
Michel
M
Sellin
Sophie
S
Le Reveillé
Erwan
E
Flecher
Alain
A
Leguerrier
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D003404:Creatinine / Q000097:blood; D003661:Decision Support Techniques; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D016896:Treatment Outcome; D055815:Young Adult
D015415:Biomarkers; D003404:Creatinine
ACEF; AVR; Aortic valve replacement; CABG; CE; CI; ES-add; ES-log; LVEF; Mortalité opératoire; Operative mortality; Operative risk; Operative risk assessment; Remplacement valvulaire aortique; Risque opératoire; STS; Society of Thoracic Surgeons; TAVI; additive EuroSCORE; age-creatinine-ejection fraction; aortic valve replacement; clinical evaluation; confidence interval; coronary artery bypass graft; left ventricular ejection fraction; logistic EuroSCORE; transcatheter aortic valve implantation; Évaluation du risque opératoire