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The PROMISE-ACHD Score: Prediction of Perioperative Mortality and Major Morbidity in Adult Congenital Heart Disease
Mike Saji1, Teiji Akagi2, Satoshi Yazaki3
1Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan; Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan.
Insights
A new surgical risk model, PROMISE-ACHD, accurately predicts mortality and major complications in adults with complex congenital heart disease. This tool aids in individualized surgical decision-making for ACHD patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Informatics
Background:
- Perioperative complications significantly impact prognosis and quality of life in adults with congenital heart disease (ACHD).
- Existing risk models inadequately predict mortality and morbidity in complex ACHD cases.
- There is a critical need for improved risk stratification tools in this patient population.
Purpose of the Study:
- To develop and validate a surgical risk model for predicting perioperative mortality and major morbidity.
- To create a practical tool for risk stratification in adults with moderate-to-great complexity ACHD undergoing surgery.
- To enhance individualized surgical decision-making for complex ACHD patients.
Main Methods:
- Analysis of a registry of 1,002 patients with moderate or great ACHD complexity undergoing open-heart surgery.
- Identification of independent predictors for a composite endpoint of in-hospital mortality and major perioperative complications.
- Validation of the derived point-based score (PROMISE-ACHD) using bootstrap resampling and temporal/center-based cohorts.
Main Results:
- The PROMISE-ACHD score demonstrated superior discrimination (AUC: 0.724) compared to existing models.
- The model showed improved reclassification and good calibration in the derivation cohort.
- Validation cohorts confirmed preserved discrimination (AUC: 0.784 and 0.773) and acceptable calibration.
Conclusions:
- The PROMISE-ACHD score is a validated, practical tool for predicting mortality and major complications in complex ACHD surgery.
- It utilizes contemporary clinical and imaging variables for accurate risk stratification.
- The score can inform individualized surgical decision-making for ACHD patients.
Objectives:
This study aimed to develop and validate a surgical risk model predicting perioperative mortality and major morbidity in adults with congenital heart disease (ACHD) of moderate-to-great complexity.
Background:
Perioperative complications can adversely affect prognosis and quality of life. Existing ACHD risk models have limited ability to predict both mortality and morbidity in patients with complex ACHD.
Methods:
We analyzed a registry of 1,002 patients with moderate or great ACHD complexity who underwent open-heart surgery at 11 centers between 2013 and 2024. Baseline data were collected, and perioperative complications were adjudicated using standardized protocol definitions. The primary endpoint was a composite of in-hospital mortality and major perioperative complications defined by the Society of Thoracic Surgeons. Multivariable logistic regression identified independent predictors to derive a point-based score (Perioperative Risk Of Morbidity and mortalIty for Surgical Evaluation in complex ACHD [PROMISE-ACHD]), validated using bootstrap resampling and prespecified temporal and center-based cohorts.
Results:
In-hospital mortality and major perioperative complications occurred in 2.6% and 19.8%. Nine variables predicted the primary endpoint. The PROMISE-ACHD score demonstrated better discrimination than the PErioperative ACHd score (AUC: 0.724 [95% CI: 0.687-0.761] vs 0.658 [95% CI: 0.616-0.700]; P < 0.001), improved reclassification (net reclassification improvement 0.49; integrated discrimination improvement 0.058), and good calibration (Hosmer-Lemeshow P = 0.711). Discrimination was preserved in temporal and center-based validation cohorts (AUC: 0.784 and 0.773), with acceptable calibration and stepwise risk stratification.
Conclusions:
The PROMISE-ACHD score is a practical model that predicts both mortality and major complications after complex ACHD surgery. Using contemporary clinical and imaging variables, it enables accurate risk stratification and may inform individualized surgical decision-making.
