Does EuroSCORE predict length of stay and specific postoperative complications after coronary artery bypass grafting?

doi:10.1016/j.ijcard.2004.10.067

International Journal of Cardiology

Volume 105, Issue 1, 20 October 2005, Pages 19-25

https://doi.org/10.1016/j.ijcard.2004.10.067 Get rights and content

Abstract

Background

To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after coronary artery bypass grafting (CABG).

Methods

Data on 3760 consecutive patients with CABG were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, prolonged length of stay (> 12 days) and major postoperative complications (stroke, myocardial infarction, sternal infection, bleeding, sepsis and/or endocarditis, gastrointestinal complications, renal and respiratory failure). A C statistic (receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer–Lemeshow goodness-of-fit statistic.

Results

In-hospital mortality was 2.7%, and 13.7% of patients had one or more major complications. EuroSCORE showed very good discriminatory ability in predicting renal failure (C statistic: 0.80) and good discriminatory ability in predicting in-hospital mortality (C statistic: 0.75), sepsis and/or endocarditis (C statistic: 0.72) and prolonged length of stay (C statistic: 0.71). There were no differences in terms of the discriminatory ability between standard and logistic EuroSCORE. Standard EuroSCORE showed good calibration (Hosmer–Lemeshow: P > 0.05) in predicting these outcomes except for postoperative length of stay, while logistic EuroSCORE showed good calibration only in predicting renal failure.

Conclusions

EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also prolonged length of stay and specific postoperative complications such as renal failure and sepsis and/or endocarditis after CABG. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.

Introduction

Risk stratification has become an essential element in cardiac surgical practice. Early mortality and morbidity have been the clinical outcomes to be assessed by many models [1], [2], [3], [4], because their prediction is useful and range from helping determine the indications for surgery, estimate the need for resources, proper informed consent and quality monitoring of surgeons and institutions. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) based on a large patient database drawn across Europe has been developed for the prediction of in-hospital mortality in the whole context of cardiac surgery [5]. EuroSCORE was first introduced in 1999 [6] as an additive system (standard) and has gained wide acceptance in Europe [7], while it has also been validated in North America [8] and Japan [9]. Recently, the logistic algorithm became available [10] and it has been found to be a better risk predictor especially in high-risk patients [11]. The standard EuroSCORE model has also been evaluated in the prediction of direct costs [12], postoperative complications and postoperative length of stay [2], [13], [14], [15] with various successes.

We previously showed that EuroSCORE can be used to predict 3-month mortality, prolonged length of stay and major postoperative complications such as renal failure, sepsis and/or endocarditis and respiratory failure in the whole context of cardiac surgery [16]. Many predictive models however, such the ACC/AHA guidelines, include only CABG patients. The purpose of the present study was to evaluate and compare the performance of standard and logistic EuroSCORE in the prediction of in-hospital mortality, prolonged postoperative length of stay and major postoperative complications in our series of 3760 consecutive CABG patients at a single institution. In this study we evaluated major postoperative complications both as one variable as well as separate variables in order to test the performance of EuroSCORE in predicting specific complications.

Section snippets

Patient population and data

Our study consisted of 3760 consecutive adult patients who underwent CABG between January 1992 and March 2002 at the St. Luke's—Roosevelt Hospital Center affiliated with Columbia University. Registry databases were studied for pre-, intra- and postoperative data of the patients.

Data were prospectively collected during patient's admission as part of routine clinical practice and entered into the New York State adult cardiac surgery report. Risk stratification was performed according to the

Results

A total of 3760 patients underwent CABG in our institution. The median standard EuroSCORE was 6 (interquartile range, 4–9) and the median logistic EuroSCORE was 5.42 (interquartile range, 2.64–12.30). The mean age (± standard deviation) within the study sample was 64.1 ± 10.4 years. Table 1 shows patient and disease characteristics after dividing the patients into six subgroups according to the factors utilized by standard EuroSCORE. There was an increase in mean age and a percentage increase in

Discussion

Most risk stratification models in cardiac surgery use early mortality as an endpoint. Only a few models evaluate other relevant outcomes as morbidity and postoperative in-hospital length of stay or length of stay in the intensive care unit [2], [4], [13], [14], [15]. The EuroSCORE, however, was developed to score the mortality during the hospital stay [5]. There are some studies which tested the accuracy of EuroSCORE in predicting postoperative morbidity after CABG [2] or cardiac surgery [13],

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Comparing Performance of Risk Scores for Combined Aortic Valve Replacement and Coronary Bypass Grafting Surgery
2016, Heart Lung and Circulation
Citation Excerpt :
Accurate risk estimates of complications are also important as adverse outcomes can significantly reduce function and quality of life, however despite this, no studies have investigated this in the context of AVR+CABG surgery. A number of studies have found all three scores also to predict all the various STS defined morbidities in other cardiac operations, though generally not as good as predicting mortality [19–22]. This is expected, given that these scores were designed to estimate operative mortality rather than morbidities [4,10,11].
Aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) make up the majority of cardiac surgery with increasing demand as the population ages. Accuracy of risk stratification is important, in predicting adverse outcomes and selecting modality of intervention, but has been rarely studied for the combined AVR+CABG operation. We compared the prognostic utility of EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons’ (STS) Score for AVR+CABG.
All patients (n=450) undergoing AVR+CABG at Auckland City Hospital during 2005-2012 with mean follow-up of 4.7+/-2.5 years were included. The three risk scores were calculated and their discrimination and calibration for mortality and morbidities assessed.
Operative mortality was 6.4% (29), and mean scores were EuroSCORE 12.5+/-11.1%, EuroSCORE II 6.6+/-6.1% and STS Score 5.5+/-4.4%. C-statistics were 0.587, 0.669 and 0.699 respectively for operative mortality, Hosmer-Lemeshow test P-values were 0.064, 0.718 and 0.567, and Brier Score 0.716, 0.585 and 0.588. Independent predictors of operative mortality were history of myocardial infarction and impaired renal function. Society of Thoracic Surgeons’ score also was the most accurate score for predicting mortality during follow-up (c=0.663), composite morbidity (c=0.627), stroke (c=0.642), prolonged ventilation>24 hours (c=0.642), and return to theatre (c=0.612).
The STS score has the best discriminative ability for mortality and the majority of complications after AVR+CABG, while its calibration was similar to EuroSCORE II and superior to EuroSCORE. It should therefore be used for risk stratification and when considering surgical versus percutaneous intervention in those with concurrent aortic valve and coronary artery disease.
Comparison of Risk Scores for Prediction of Complications following Aortic Valve Replacement
2015, Heart Lung and Circulation
Citation Excerpt :
Stroke is potentially the most debilitating morbidity of cardiac surgery with long-term functional and cost implications, although it occurs at a slightly higher incidence following TAVI than AVR [3,4]. C-statistics in our cohort for the EuroSCORE, EuroSCORE II and STS Score for stroke were the highest at 0.77-0.85 amongst outcomes, and also compared to the 0.63-0.77 reported in other studies [15,18,19]. Independent predictors of stroke frequently found include a history of cerebrovascular disease, impaired ejection fraction, peripheral vascular disease and cardiopulmonary or cross-clamp times [20,21].
Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeon's (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context.
We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications.
Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications.
The STS Score was best overall at discriminating post-operative complications and their composite for AVR. All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications.
Comparison of four risk scores for contemporary isolated coronary artery bypass grafting
2014, Heart Lung and Circulation
EuroSCORE and the Society of Thoracic Surgeons’ (STS) Score have been the most widely used risk scores for cardiac surgery. The revised EuroSCORE II and the AusSCORE, based on an Australasian population, were recently developed. We compared the prognostic utility of these four scores for mortality as well as morbidity in patients undergoing isolated coronary artery bypass grafting (CABG).
The scores were retrospectively calculated for isolated CABG patients at Auckland City Hospital during July 2010-June 2012. Discrimination and calibration of outcomes were assessed.
818 patients were followed for 1.6+/-0.6 years. Mortality at 30 days was 1.6% and 2.9% on follow up. Median predicted 30 day mortality (Interquartile range) for EuroSCORE I were 2.8% (1.6%, 5.2%), EuroSCORE II 1.6% (1.0%, 2.8%), STS Score 2.3% (1.3%, 4.5%) and AusSCORE 0.5% (0.2%, 1.1%). C-statistics and Hosmer-Lemeshow test p-values for these scores for 30-day mortality were Euro score I 0.675 (95%CI 0.531-0.819)/0.061, EuroSCORE II 0.642 (0.503-0.780)/0.150, STS Score 0.641 (0.507-0.775)/0.243 and AusSCORE 0.661 (0.516-0.807)/0.420.
Only EuroSCORE I and STS scores were significant for predicting mortality at follow-up (c = 0.639 and 0.666). All scores predicted composite morbidity. C-statistics were EuroSCORE I 0.678, EuroSCORE II 0.634, STS score 0.584 and AusSCORE 0.645.
EuroSCORE II, STS Score and AusSCORE had slightly improved calibration but similar discrimination for 30-day mortality compared to EuroSCORE I.
Revision of risk models to fit contemporary surgical outcomes is important, but there may only be modest room for improvement in discrimination.
Transcatheter-based aortic valve implantations at midterm: What happened to our initial patients?
2012, Annals of Thoracic Surgery
Citation Excerpt :
Although these results are encouraging, immoderate enthusiasm is not indicated because of the well-described limitations of the EuroSCORE model. Although the EuroSCORE has been shown to be predictive of early mortality, postoperative complications, prolonged length of stay, and long-term mortality in patients undergoing heart valve procedures, the model has yet to be validated in predicting operative mortality for high-risk patients undergoing isolated aortic valve replacement [14–16]. Although the logistic EuroSCORE model has been shown to be a better predictor of mortality than the additive EuroSCORE in high-risk populations, several studies have found that the logistic EuroSCORE model may overestimate the mortality of such patients undergoing valve procedures [17–21].
This report analyzes a single institution's results with transapical aortic valve implantation (TAVI) from an initial series of patients over 5 years.
A series of 100 patients underwent TAVI at our institution between January 2005 and December 2008. The mean patient age was 85 ± 6 years. All patients had a high perioperative risk for aortic valve replacement (mean logistic EuroSCORE of 36% ± 12%; Society of Thoracic Surgeons [STS] score 16% ± 3%). Clinical and echocardiographic variables were entered prospectively into a database. Late follow-up for survival, clinical outcomes including the New York Heart (NYHA) Association functional class, and echocardiographic assessment was 100% complete.
After a mean follow-up of 3.8 ± 2 years, overall mortality was 13% (n = 13/100), 30-day mortality was 8% (8/100), and late mortality was 5% (5/100). There were 2 perioperative repeated thoracotomies for bleeding, 2 intraoperative conversions, 1 prosthesis embolization, and 2 cases of impairment of coronary arteries. The causes of late mortality were cardiac failure (n = 2), respiratory failure (n = 1), renal failure (n = 1), and cancer (n = 1). At late follow-up there were no cases of endocarditis or stroke in any of the patients. None of the valves showed structural valve degeneration. NYHA functional class improved from 3.4 ± 0.4 before operation to 1.9 ± 0.5 at late follow-up (p = 0.02). Only 4 patients did not improve in functional class.
Midterm outcomes after TAVI in high-risk patients at our institution show an improvement in functional capacity, with a good survival rate. Valve degeneration is not an issue at midterm follow-up.
Aortic valve replacement: Reliability of EuroSCORE in predicting early outcomes
2010, International Journal of Cardiology
EuroSCORE algorithms were developed to predict perioperative mortality in cardiac surgery. This study was designed to evaluate the reliability of EuroSCORE algorithms and to analyze the predicting role of the scoring system's factors on patients that undergo isolate AVR.
339 patients underwent aortic valve replacement. Data collection was prospective and the logistic and additive EuroSCORE algorithms were calculated according to published guidelines.
The observed-over-expected mortality ratio was 0.096. In the ROC curve analysis, the asymptotic significance was greater than 0.05. On multivariate analysis, only critical preoperative state remained significant independent predictor of in-hospital mortality (Odds Ratio 1.6, CI 1.2–2.1).
These outcomes suggest that EuroSCORE models may fail in predicting hospital mortality in subsets of cardiac surgery patients and dedicated risk models for isolate aortic valvular surgery may be useful to provide more precise estimates of hospital mortality.
Correlation between the European system for cardiac operative risk evaluation and sexual function after coronary artery bypass graft surgery
2010, Journal of Sexual Medicine
The published studies discussing the prognostic factors for expected sexual function after coronary artery bypass graft (CABG) are still limited.
Examining the correlation between the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the abridged form of International Index of Erectile Function questionnaire (IIEF-5), as a quick and inexpensive tool for the cardiologist to predict the sexual function after CABG.
Validated standardized questionnaire commonly used by cardiologists in identifying appropriate weight to various risk factors related to adult cardiac operations.
Preoperatively patients were evaluated as regards to the sexual function by (IIEF-5) and pharmaco-penile duplex ultrasound. Moreover all patients were evaluated bu EuroSCORE. Six months after surgery, the erectile function of all patients was revaluated according to the same preoperative procedures. The patients were categorized with EuroSCORE as follows: The low-risk group (EuroSCORE 0–2), the medium-risk group (EuroSCORE 3–5), and the high-risk group (EuroSCORE 6 plus).
The EuroSCORE was negatively correlated with the IIEF-5 score (r = −0.224, P = 0.025 or rs = −0.259, P = 0.009). Moreover, low-risk patients had significantly higher IIEF-5 scores compared with medium-risk patients (mean ± standard deviation = 15.27 ± 6.03 vs. 12.18 ± 6.07, P < 0.05).
There is an inverse correlation between the components of EuroSCORE and the IIEF-5 score. Patients with higher EuroSCORE had lower IIEF-5 scores and vice versa.The EuroSCORE is a useful, quick, and inexpensive tool that allows prediction of ED in those patients with coronary artery disease patients who are undergoing CABG. Mohamed OA, Hamed HA, Roaiah MF, Helmy T, Mahran A, and Bennett CJ. Correlation between the European System for Cardiac Operative Risk Evaluation and sexual function after coronary artery bypass graft surgery.

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Does EuroSCORE predict length of stay and specific postoperative complications after coronary artery bypass grafting?

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patient population and data

Results

Discussion

Ann Thorac Surg

An evaluation of existing risk stratification models as a tool for comparison of surgical performances for coronary artery bypass grafting between institutions

Eur J Cardiothorac Surg

Performance of three preoperative risk indices; CABDEAL, EuroSCORE and Cleveland models in a prospective coronary bypass database

Eur J Cardiothorac Surg

Prospective evaluation of 3 risk stratification scores in cardiac surgery

Thorac Cardiovasc Surg

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients

Eur J Cardiothorac Surg

European system for cardiac operative risk evaluation (EuroSCORE)

Eur J Cardiothorac Surg

Does EuroSCORE work in individual European countries?

Eur J Cardiothorac Surg

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery

Eur J Cardiothorac Surg

Evaluation of the quality of cardiovascular surgery care using risk stratification analysis according to the EuroSCORE additive model

Circ J

The logistic EuroSCORE

Eur Heart J

Logistic or additive EuroSCORE for high-risk patients?

Eur J Cardiothorac Surg