AI-Automated Risk Operative Stratification for Severe Aortic Stenosis: A Proof-of-Concept Study

Background: Accurate operative risk stratification is essential for treatment selection in severe aortic stenosis. We developed an automated workflow using large language models (LLMs) to replicate Heart Team risk assessment. Methods: We retrospectively analyzed 231 consecutive patients with severe aortic stenosis evaluated by multidisciplinary Heart Teams (January 2022-December 2024). An automated system using GPT-4o was developed, comprising the following: (1) structured data extraction from clinical dossiers; (2) EuroSCORE II calculation via two methods (algorithmic vs. LLM-based); (3) clinical vignette generation; and (4) risk stratification comparing EuroSCORE-based thresholds versus guideline-integrated LLM approaches with/without EuroSCORE values. The primary endpoint was the risk stratification accuracy of each method compared to Heart Team decisions. Results: Mean age was 79.5 ± 7.7 years, with 58.4% female. The automated workflow processed patients in 32.6 ± 6.4 s. The LLM-calculated EuroSCORE II showed a lower mean difference from Heart Team values (-1.42%, 95% CI -2.32 to -0.53) versus algorithmic calculation (-1.88%, 95% CI -2.38 to -1.38). For risk stratification, the guideline-integrated LLM without EuroSCORE achieved the highest accuracy (90.0%) and AUC (0.93), outperforming both the EuroSCORE-based (accuracy 50.2% for high-risk, AUC 0.63) and guideline-integrated LLM with EuroSCORE approaches (accuracy 82.4%, AUC 0.76). However, systematic hallucinations occurred for cardiovascular risk factors when data were missing. Conclusions: LLMs accurately calculated EuroSCORE II and achieved 90% concordance with multidisciplinary Heart Team decisions. However, hallucinations, reproducibility concerns, and the absence of clinical outcome validation preclude direct clinical application.