Elsevier

Cardiovascular Revascularization Medicine

Volume 12, Issue 6, November–December 2011, Pages 345-349
Cardiovascular Revascularization Medicine

Clinical
Comparison between Society of Thoracic Surgeons Score and logistic EuroSCORE for predicting mortality in patients referred for transcatheter aortic valve implantation

https://doi.org/10.1016/j.carrev.2011.04.005Get rights and content

Abstract

Background

The primary inclusion criteria from both the Society of Thoracic Surgeons (STS) score and the logistic EuroSCORE are currently used to identify high-risk and inoperable patients eligible for transcatheter aortic valve implantation (TAVI). We aimed to examine the correlation between STS and logistic EuroSCOREs and their performance characteristics in patients referred for TAVI.

Methods

The study cohort consisted of 718 high-risk patients with severe aortic stenosis who were considered for participation in a TAVI clinical trial. The performance of the STS and logistic EuroSCOREs was evaluated in three groups: (a) medical management or balloon aortic valvuloplasty (BAV), 474 (66%); (b) 133 patients (18.5%) with surgical aortic valve replacement (AVR); (c) 111 (15.4%) with TAVI. The mean age was 81.8±8.1 years, and 394 (54.8%) were female.

Results

The mean STS score was 11.5±6.1, and the mean logistic EuroSCORE was 39.7±23.0. Pearson correlation coefficient showed moderate correlation between the STS and logistic EuroSCOREs (r=0.61, P<.001). At a median follow-up of 190 days (range, 67–476), 282 patients (39.2%) died. The STS and logistic EuroSCOREs were both higher in patients who died as compared to those in survivors (13.1±6.2 vs.10.0±5.8 and 43.4±23.1 vs. 37.5±22, respectively; P<.001). The observed and predicted 30-day mortality rates in the medical/BAV group were 10.1% observed, 12.3% by STS and 43.1% by logistic EuroSCORE. In the surgical AVR group, the rates were 12.8% observed, 8.4% by STS and 25.6% by logistic EuroSCORE. In the TAVI group, the rates were 11.7% observed, 11.8% by STS and 41.2% by logistic EuroSCORE. The odds ratio (OR) for 30-day mortality in the medical/BAV group was 1.05 (P=.01) with STS and 1.003 (P=.7) with logistic EuroSCORE. In the surgical AVR group, the OR was 1.09 (P=.07) with STS and 1.007 (P=.6) with logistic EuroSCORE. In the TAVI group, the OR was 1.14 (P=.03) with STS and 1.03 (P=.04) with logistic EuroSCORE.

Conclusion

In high-risk patients with severe aortic stenosis, STS score is superior to the logistic EuroSCORE in predicting mortality. Clinical judgment should play a major role in the selection of patients with severe aortic stenosis for the different therapeutic options.

Introduction

Transcatheter aortic valve implantation (TAVI) was recently shown to improve outcomes in high-risk or inoperable patients with severe, symptomatic aortic stenosis as compared to medical treatment or balloon aortic valvuloplasty (BAV) [1]. Because the use of TAVI is limited to such patients, the definition of “high-risk or inoperable” is crucial.

To be included in a current randomized TAVI trial and/or registry (PARTNER trial), a patient candidate must have a Society of Thoracic Surgeons (STS) risk score of >10 or a logistic EuroSCORE of >20. Both were developed to assess mortality risk for cardiac surgical procedures. The EuroSCORE is based on mortality from all cardiac surgery; however, patients undergoing coronary bypass surgery constituted the great majority of the data set used in its design. It has, however, been shown to predict long-term mortality after valve surgery [2]. It is pertinent that the STS score is superior to the EuroSCORE for determining mortality in high-risk patients undergoing isolated aortic valve replacement (AVR) [3]. In low-risk patients, the estimated mortality is similar for the two scores, but in high-risk patients, the estimated mortality varies considerably depending on the risk model employed.

Here we compare the accuracy of the STS and logistic EuroSCOREs in predicting 30-day mortality in three groups of high-risk patients with severe aortic stenosis who were referred for possible entry into a TAVI trial. Group assignment was made based on a complete cardiovascular evaluation.

Section snippets

Methods

This prospective cohort study was approved by the Institutional Review Board of the MedStar Health Research Institute and Washington Hospital Center. We consecutively enrolled 718 patients with symptomatic severe aortic stenosis who were referred for TAVI consideration from April 2007 to July 2010. All data were prospectively entered into a dedicated database. All patients underwent systematic screening, including clinical examination, electrocardiogram, laboratory assessment and

Results

The 718 patients were divided into three cohorts: (a) medical/BAV [n=474 (66%)], (b) surgical AVR [n=133 (18.5%)] and (c) TAVI [n=111 (15.4%)]. Their baseline, laboratory and hemodynamic parameters are summarized in Table 1. They were nearly evenly divided with regard to gender as 54.8% were female. As a group, they exhibited not only advanced age (mean, 81.8±8.0 years) but also considerable comorbidity: diabetes, 243 (33.8%); renal failure, 285 (39.6%); and peripheral vascular disease, 207

Discussion

In this series of patients with severe, symptomatic aortic stenosis and high or prohibitive surgical risk, neither the STS nor the logistic EuroSCORE demonstrated an optimal ability to predict 30-day mortality. The ROC curve analysis demonstrated that STS score was superior in patients managed with medications and/or BAV as well as in those who underwent operative AVR (Table 2). In patients treated with TAVI, the ROC analysis using both risk scores for 30-day mortality risk gave equal

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