Predicting outcomes in cardiac surgery: risk stratification matters?

Dupuis, Jean‐Yves

doi:10.1097/hco.0b013e32831217ed

Cited by 27 publications

(24 citation statements)

References 65 publications

(60 reference statements)

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“…The increase in c-statistic of 0.03 to 0.05 and IDI of 5.9% compare favorably with other commonly used prognostic tests, such as coronary artery calcium testing (increase in c-statistic +0.04, IDI 1.5%) or high-sensitivity c-reactive protein testing (increase in c-statistic +0.01, IDI 0.2%) above traditional risk factors to predict incident cardiovascular events. 16 The modest baseline c-statistic of 0.68 to predict major morbidity in this study is consistent with previous reports (c-statistic 0.65-0.70 to predict morbidity versus 0.75-0.80 to predict mortality) 17 and confirms the limitations in predicting who will suffer a postoperative complication.…”

Section: Discussionsupporting

confidence: 81%

“…17 Using echocardiography to improve risk prediction would allow clinicians and patients to be better informed in their shared decision-making and planning. Because higher-risk patients are often those who derive greater benefits from revascularization, the main clinical utility of echocardiography in identifying higher-risk patients would not be to withhold CABG from such patients but rather to tailor the revascularization strategy to the individual patient.…”

Section: Discussionmentioning

confidence: 99%

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Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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Background— Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. Methods and Results— Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. Conclusions— Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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“…The magnitude of the incremental value provided by the echocardiogram is important, comparable to other well‐accepted cardiovascular prognostic tests, such as the coronary artery calcium scan in primary prevention (increase in c‐statistic, +0.04; IDI, 1.5%) 17, 18. In the current study, as in our previous study of patients undergoing isolated CABG,7 measures of LV diastolic dysfunction and RV dysfunction emerged as the main incremental predictors of postoperative outcomes.…”

Section: Discussionsupporting

confidence: 73%

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

Tan

Flynn

Chen‐Tournoux

et al. 2015

JAHA

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BackgroundRisk prediction is a critical step in patient selection for aortic valve replacement (AVR), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high‐risk surgical candidates before AVR.Methods and ResultsA cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in‐hospital mortality or major morbidity: E/e’ ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end‐diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% (P<0.0001). After a median follow‐up of 2 years, Cox regression revealed 5 echocardiographic predictors of all‐cause mortality: small LV end‐diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient <40 mm Hg.ConclusionsEchocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR. In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2‐year mortality.

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“…34 Calibration assesses the closeness of the observed and predicted mortality rates in an individual patient. This is statistically evaluated by goodness-of-fit test.…”

Section: Discussionmentioning

confidence: 99%