Risk scores’ performance and their impact on operative decision-making in left-sided endocarditis: a cohort study

Abstract

The accuracy of contemporary risk scores in predicting perioperative mortality in infective endocarditis (IE) remains controversial. The aim is to evaluate the performance of existent mortality risk scores for cardiovascular surgery in IE and the impact on operability at high-risk thresholds. A single-center retrospective review of adult patients diagnosed with acute left-sided IE undergoing surgery from May 2014 to August 2019 (n = 142) was done. Individualized risk calculation was obtained according to the available mortality risk scores: EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS scores. A cross-validation analysis was performed on the score with the best area under the curve (AUC). The 30-day survival was 96.5% (95%CI 91–98%). The score with worse area under the curve (AUC = 0.6) was the STS-IE score, while the higher was for the RISK-E score (AUC = 0.89). The AUC of the majority of risk scores suggested acceptable performance; however, statistically significant differences in expected versus observed mortalities were common. The cross-validation analysis showed that a large number of survivors (> 75%) would not have been operated if arbitrary high-risk threshold estimates had been used to deny surgery. The observed mortality in our cohort is significantly lower than is predicted by contemporary risk scores. Despite the reasonable numeric performance of the analyzed scores, their utility in judging the operability of a given patient remains questionable, as demonstrated in the cross-validation analysis. Future guidelines may advise that denial of surgery should only follow a highly experienced Endocarditis Team evaluation.

ESC guidelines 2023 on the management of endocarditis

“…The complex decision of not offering surgery when indicated should therefore be made in the setting of an Endocarditis Team with experienced surgical input. 418 Determining when operative management for a specific patient is futile requires compassionate multidisciplinary insight along with consideration of the patient's and family's wills (see Section 13.2).…”

Capacidad predictiva de diferentes puntajes de riesgo quirúrgico en la endocarditis infecciosa

“…(13-15) En nuestra serie, el puntaje PALSUSE mostró mejor capacidad de predicción de muerte hospitalaria, por lo tanto, podría ser un buen recurso para la toma de decisiones, resultado semejante a lo publicado por otras series. (5,17) La población evaluada comparte características similares a la población registrada en el EIRA III, que es la serie más grande de estudios sobre EI en Latinoamérica, (4) aunque resulta relevante destacar que nuestra población presentó una mayor proporción de pacientes con EI de válvula protésica, lo cual puede estar relacionado con las características de nuestro centro. La mortalidad observada en nuestra serie es similar a la mortalidad detectada en otros registros (4,5).…”

“…Por lo tanto, consideramos que estos resultados no invalidan la utilización de estos puntajes, que constituyen herramientas recomendadas por diversos documentos de consenso. (8,17,22) Limitaciones El diseño retrospectivo y la participación de un solo centro, constituyen las mayores limitaciones para nuestro estudio. Además, el número de pacientes analizado podría considerarse bajo, ya que se trata de una patología poco frecuente, la cual sólo es intervenida quirúrgicamente en una fracción de pacientes.…”

Contemporary risk models for infective endocarditis surgery: a narrative review

“…The PALSUSE (AUC: 0.87), RISK-E (AUC: 0.89), and APORTEI (AUC: 0.87) scores had the best performance in their cohort. 60 Urso et al compared the performances of APORTEI, EuroSCORE, and EuroSCORE II on 111 patients who underwent IE cardiac surgery at a single center. The O/E ratio was 1.27 for logistic EuroSCORE, 3.27 for EuroSCORE II, and 0.94 for APORTEI.…”