The ESL and the ESII are results of clinical data analysis of about 20,000 patients each risk score.[4–7] Although both risk scores identify analogous risk factors and with comparable relevance, the ESL and the ESII results of risk stratification differ, especially for high-risk patients. Thus, the population, which the ESII was based on, was partially recruited in Central Europe; by intuition, the ESII appears to be more adequate for this population than the ESL. However, only about 10% of patients included into ESII formulation were recruited in Central Europe.
Regardless of the type of surgery, result in the ESL was better correlated with the risk of in-hospital death; the goodness of fit with H–L tests was significant only for the ESL. In the literature, we can find publications presenting results H–L test supporting better calibration of the ESL than ESII, similar to our findings.[9–11]
It is worth pointing that the risk scores were evaluated independently among patients with CABG, AVR, and MVR. Most of the patients underwent isolated CABG. However, about 100 patients with valve replacement were sufficient to observe 15 in-hospital deaths and observe statistically significant correlations between the ESL and the ERII and patients’ outcomes. Moreover, the value of the ESL was comparable to observed hospital mortality after AVR and MVR. It is an interesting finding, as more patients underwent valvular replacement in the ESII-baseline population (close to 50%) than the ESL-baseline population. Hence, to the best of our knowledge, the study is consistent with previous reports suggesting reflection on the position of the ESL in the guidelines, at least in risk stratification among patients with isolated VD.[9–11]
The median length of hospitalization at the ICU in studied group was about 3 days. As the prolonged hospitalization at the ICU is related with worse patient's prognosis, we expected that the ESL and the ESII will efficiently predict prolonged hospitalization at the ICU. The thesis was supported by the results of single-center studies, wherein the AUC for prolonged hospitalization at ICU for the ESL and ESII was 0.83 and 0.79, respectively.[9,12] In one of the most largest study, including 18,377 consecutive patients, the AUC for prolonged hospitalization at ICU for both ESA and ESL was 0.73. Atashi et al indicated the importance of identifying reliable risk scores for prediction of prolonged hospitalization at ICU in a large systematic review published in 2018. They pointed difficulties in defining new risk factors and possible advantages of validating currently available risk scores. Although in our study the ELS and the ESII achieved the AUC > 0.6 in the prediction of secondary endpoint in the subgroups of CABG and AVR patients, neither of the risk scores well-fitted the model in the H-L test. In our opinion, it is an important voice in the discussion due to high volume of patients included.
Most of the studies validating EuroSCORE (ES) model in Europe enhanced its value in differentiating patients according to perioperative risk.[14–17] However, recent articles have suggested the unsatisfactory calibration of these algorithms; the original ES tends to overpredict mortality, while ESII underpredicts mortality. In study by Garcia-Valentin et al, including 4000 Spanish patients undergoing cardiac surgery, the observed mortality rate was 6.5%, while predicted mortality rate by ESII was 5.7%. Similarly, in a single-center validation study in Dutch, the observed mortality was 2.4%, while both the ESA and ESL overestimated mortality (median predictive mortality of ESA and ESL: 5.0% and 10.7%, respectively), and ESII underestimated mortality (median predictive mortality: 1.6%). It is important to point out that the ESL and ESII tend to overestimate even the risk of minimally invasive cardiac surgery (MICS).[18,19] Margaryan et al reported that the ESII is not optimally calibrated for MICS and should be avoided in high-risk patients of more than 8% estimated morality. It could be explained by the fact that MICS is not performed routinely and applied in a limited group of patients; thus, general risk scoring systems may not be appropriate for this type of surgery.
The poor discrimination and calibration of the EuroSCORE models were also demonstrated in very high-risk octogenarians’ patients. Provenchère et al reported a high discriminatory power for the ESII among patients aged <80 years (AUC 0.81) but less satisfying among those aged ≥80 years (AUC 0.67) with acceptable calibration of ESII until 10%-predicted mortality in octogenarians. It should be an incentive to use the EuroSCORE values with extreme caution when taking medical decision or to use another risk evaluation system, for example, SinoSCORE, which appeared to have better predictive efficiency than ESII among the elderly patients.
Although some risk scores are available, such as the Society of Thoracic Surgeons (STS) risk score, and may appear better prognostic predictors than the EuroSCORE,[21,22] these scores also have major limitations for practical use in this setting by insufficiently considering disease severity and not including major risk factors such as frailty, porcelain aorta, and chest radiation.[23,24] Therefore, it should be kept in mind that multidisciplinary heart team, instead of a risk score, is highly recommended as the best procedural strategy for any single patient.[3,25]
4.1 Study limitations
The main limitation of the study, common in the comparable publications, is the single-center character of the population. Consequently, the number of patients with isolated VD is limited, as they represent the real-life population treated in the facility. Noteworthy, the number of patients was sufficient to observe relations between the ESL and the ESII scoring and the prevalence of primary endpoint. Due to risk scores validations for in-hospital mortality, observation ended with subject's discharge. Long-term follow-up is being performed to validate the ESL and the ESII prediction values for longer time-scale. Due to relatively low percentage of patients in AVR and MVR group, analysis per type of operation was not performed.
In the study, the perioperative risk estimated with the ESL and the ESII risk scores was compared with a real-life outcome among over 500 patients. Regardless of the type of surgery, result in the ESL was better correlated with the risk of in-hospital death.
Conceptualization: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
Data curation: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
Formal analysis: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
Methodology: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
Writing – original draft: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
Writing – review & editing: Paweł Czub, Andrzej Cacko, Monika Gawałko, Emanuel Tataj, Jakub Poliński, Kacper Pawlik, Romuald Cichoń, Piotr Hendzel
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Keywords:Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
cardiac surgery; EuroSCORE II; logistic EuroSCORE; mortality; preoperative evaluation; risk assessment