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

Area of Science:

• Cardiovascular Surgery
• Infective Endocarditis
• Medical Risk Stratification

Background:

• The accuracy of current risk scores for predicting perioperative mortality in infective endocarditis (IE) is debated.
• Evaluating these scores is crucial for determining surgical candidacy in IE patients.

Purpose of the Study:

• To assess the performance of existing cardiovascular surgery risk scores in IE patients.
• To analyze the impact of these scores on surgical operability decisions at high-risk thresholds.

Main Methods:

• Retrospective review of 142 adult patients with acute left-sided IE undergoing surgery (May 2014 - August 2019).
• Calculation of individualized risk using multiple established mortality risk scores (EuroScore I/II, PALSUSE, Risk-E, etc.).
• Cross-validation analysis performed on the best-performing score (highest AUC).

Main Results:

• Overall 30-day survival was 96.5%.
• RISK-E score demonstrated the highest Area Under the Curve (AUC=0.89), indicating best performance; STS-IE had the worst (AUC=0.6).
• Most scores showed acceptable AUC, but significant discrepancies between predicted and observed mortality were frequent. Cross-validation revealed over 75% of survivors might have been denied surgery based on arbitrary high-risk cutoffs.

Conclusions:

• Observed mortality in the cohort was substantially lower than predicted by contemporary risk scores.
• While scores offer reasonable numerical performance, their clinical utility in determining IE patient operability is questionable.
• Future guidelines should emphasize experienced Endocarditis Team evaluation over strict adherence to risk score thresholds for surgical denial.