High-risk aortic valve replacement: are the outcomes as bad as predicted?

Area of Science:

• Cardiac Surgery
• Interventional Cardiology
• Health Outcomes Research

Background:

• Ongoing percutaneous aortic valve replacement (PAVR) trials focus on high-risk patients identified by elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs).
• The accuracy of the EuroSCORE model in predicting outcomes for these high-risk patients undergoing aortic valve replacement (AVR) is uncertain.
• This study evaluates the predictive accuracy of the EuroSCORE model against actual surgical outcomes in a high-risk AVR population.

Purpose of the Study:

• To assess the calibration of the EuroSCORE model in high-risk patients undergoing isolated aortic valve replacement (AVR).
• To compare predicted mortality with actual hospital mortality and long-term survival rates.
• To identify significant predictors of mortality and survival in this patient cohort.

Main Methods:

• A prospective study of 731 patients with EuroSCOREs of 7 or higher who underwent isolated AVR between January 1996 and March 2006.
• Data collected included patient demographics, comorbidities (e.g., age, previous cardiac procedures, atheromatous aortas, cerebrovascular disease), and surgical approach (minimally invasive in 64.2%).
• Long-term survival was tracked using the Social Security Death Benefit Index.

Main Results:

• The mean EuroSCORE was 9.7, with a mean logistic EuroSCORE of 17.2%. Actual hospital mortality was 7.8%.
• Significant predictors of hospital mortality included low ejection fraction, chronic obstructive pulmonary disease, and peripheral vascular disease.
• Five-year freedom from all-cause death was 72.4%. Predictors of worse survival included older age, previous cardiac operations, renal failure, and chronic obstructive pulmonary disease.

Conclusions:

• The logistic EuroSCORE significantly overpredicts mortality in high-risk AVR patients.
• Actual five-year survival rates are favorable, contradicting earlier EuroSCORE-based predictions.
• Further research is needed on long-term percutaneous prosthesis function, and future clinical trials should incorporate randomized surgical controls and long-term endpoints.