450
[2]
[3]
[4]
[5]
[6] [7] [8]
[9] [10]
[11]
[12]
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[14] [15]
[16]
[17]
T. Nishida et al. / Interactive CardioVascular and Thoracic Surgery EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999;15:816–22; discussion 22–3. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9–13. Holinski S, Claus B, Christ T, Kasperiunaite R, Konertz W. Overestimation of the operative risk by the EuroSCORE also in high-risk patients undergoing aortic valve replacement with a stentless biological prosthesis. Heart Surg Forum 2010;13:E13–6. Gummert JF, Funkat A, Osswald B, Beckmann A, Schiller W, Krian A et al. EuroSCORE overestimates the risk of cardiac surgery: results from the national registry of the German Society of Thoracic and Cardiovascular Surgery. Clin Res Cardiol 2009;98:363–9. Osswald BR, Gegouskov V, Badowski-Zyla D, Tochtermann U, Thomas G, Hagl S et al. Overestimation of aortic valve replacement risk by EuroSCORE: implications for percutaneous valve replacement. Eur Heart J 2009;30:74–80. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734–44; discussion 44–5. Shahian DM, Edwards FH. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: introduction. Ann Thorac Surg 2009;88(1 Suppl):S1. Nishida T, Masuda M, Tomita Y, Tokunaga S, Tanoue Y, Shiose A et al. The logistic EuroSCORE predicts the hospital mortality of the thoracic aortic surgery in consecutive 327 Japanese patients better than the additive EuroSCORE. Eur J Cardiothorac Surg 2006;30:578–82; discussion 82–3. Nishida T, Masuda M. Risk prediction of cardiovascular surgery in Japanese patients. Gen Thorac Cardiovasc Surg 2011;59:597–8. Kawachi Y, Nakashima A, Toshima Y, Arinaga K, Kawano H. Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model. Eur J Cardiothorac Surg 2001;20:961–6. Barmettler H, Immer FF, Berdat PA, Eckstein FS, Kipfer B, Carrel TP. Risk-stratification in thoracic aortic surgery: should the EuroSCORE be modified? Eur J Cardiothorac Surg 2004;25:691–4. Huijskes RV, Wesselink RM, Noyez L, Rosseel PM, Klok T, van Straten BH et al. Predictive models for thoracic aorta surgery. Is the EuroSCORE the optimal risk model in the Netherlands? Interact CardioVasc Thorac Surg 2005;4:538–42. Matsuura K, Ogino H, Matsuda H, Minatoya K, Sasaki H, Yagihara T et al. Limitations of EuroSCORE for measurement of risk-stratified mortality in aortic arch surgery using selective cerebral perfusion: is advanced age no longer a risk? Ann Thorac Surg 2006;81:2084–7. Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003;24:881–2. Carnero-Alcazar M, Silva Guisasola JA, Reguillo Lacruz FJ, Maroto Castellanos LC, Cobiella Carnicer J, Villagran Medinilla E et al. Validation of EuroSCORE II on a single-centre 3800 patient cohort. Interact CardioVasc Thorac Surg 2013;16:293–300. Chalmers J, Pullan M, Fabri B, McShane J, Shaw M, Mediratta N et al. Validation of EuroSCORE II in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg 2013;43:688–94. Kurazumi H, Mikamo A, Fukamitsu G, Kudou T, Sato M, Suzuki R et al. Validation of the JapanSCORE versus the logistic EuroSCORE for predicting operative mortality of cardiovascular surgery in Yamaguchi University Hospital. Gen Thorac Cardiovasc Surg 2011;59:599–604.
eComment. Risk-adjusted mortality ratio for EuroSCORE II in everyday clinical practice Author: Ovidio A. Garcia-Villarreal Cardiovascular Surgeon, Department of Cardiac Surgery, Hospital of Cardiology, UMAE 34, IMSS, Monterrey, Mexico doi: 10.1093/icvts/ivu001 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I have read with great interest the article by Nishida et al. [1]. The article includes up-to-date information on EuroSCORE II, and the results shown by the authors validate the superiority of the EuroSCORE II over the additive and logistic EuroSCOREs for predicting risk mortality in thoracic aortic surgery. EuroSCORE II is highly recommended for assessing risk in adult cardiac surgery. However, one must not forget that no risk model is perfect, nor do all risk factors appear in all models. EuroSCORE II now offer us the capacity to virtually create a reality. However, this issue must be addressed much more consistently. The variation in outcomes between centres and surgeons should be taken into account [2]. Once a given risk model is in use, all units
and surgeons should calculate the risk-adjusted mortality ratio (RAMR) by dividing the actual mortality (observed) by the expected mortality. Then, the predicted mortality calculated by EuroSCORE II is multiplied by the unit’s or the individual surgeon’s RAMR. This reflects in a more faithful manner the current mortality for a given patient in a given surgical unit. If, for example, the unit’s RAMR for thoracic aortic surgery is 2, and the predicted mortality by EuroSCORE II is 7.4%, the corrected mortality rate for thoracic aortic surgery for this hypothetic unit would be 14.8%. In consequence, this is a more effective way to adapt the EuroSCORE II to the ‘real world’. Conflict of Interest: none declared References [1] Nishida T, Sonoda H, Oishi Y, Tanoue Y, Nakashima A, Shiokawa Y et al. The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms. Interact CardioVasc Thorac Surg 2014;18:446–50. [2] Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734–45.
eComment. EuroSCORE II and prediction of in-hospital mortality of thoracic aortic surgery Author: Michael Poullis Liverpool Heart and Chest Hospital, Liverpool, UK doi: 10.1093/icvts/ivu029 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Nishida et al. need to be congratulated for achieving an overall mortality rate of 7.2% in 461 patients undergoing aortic surgery [1]; however, their manuscript raises a number of issues. Mortality prediction models are classically assessed via receiver operating curve (ROC) and Hosmer-Lemeshow statistic assessment [2,3]. The use of a 20-year study period is probably too long, due to improvements in surgical, anaesthetic and medical care, hence the recalibration of EuroSCORE to create EuroSCORE II. With such a long study period the chronobiology of aortic dissection may be an important issue [4,5]. We agree with their interpretation that a ROC of nearly 0.8 is impressive for the EuroSCORE II risk model in aortic surgery in their patient group; however their demonstration that in high risk patients none of the models are accurate means clinical usage is limited. Unfortunately no Hosmer-Lemeshow statistic was presented. Failure to achieve an adequate ROC and Hosmer-Lemeshow statistic means adoption can not be recommended. The operation types for this study seem skewed, as 220 patients underwent isolated arch surgery, and only 7 patients underwent root and arch surgery. In addition no mention of redo numbers were made in the manuscript. Risk modelling for CABG or valve surgery requires 10,000 to 20,000 patients per procedure to be operated on in the modern era to avoid being underpowered. As aortic surgery can be simplistically divided into root, arch and descending aorta surgery, risk modelling for aortic surgery is probably beyond any single institution due to number restrictions. An international collaborative project is needed. Conflict of interest: none declared References [1] Nishida T, Sonoda H, Oishi Y, Tanoue Y, Nakashima A, Shiokawa Y et al. The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms. Interact CardioVasc Thorac Surg 2014;18:446–50. [2] Chalmers J, Pullan M, Fabri B, McShane J, Shaw M, Mediratta N et al. Validation of EuroSCORE II in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg 2013;43:688–94. [3] Poullis M, McShane J, Shaw M, Woolley S, Shackcloth M, Page R et al. Prediction of in-hospital mortality following pulmonary resections: improving on current risk models. Eur J Cardiothorac Surg 2013;44:238–42. [4] Mehta RH, Manfredini R, Hassan F, Sechtem U, Bossone E, Oh JK et al.; International Registry of Acute Aortic Dissection (IRAD) Investigators. Chronobiological patterns of acute aortic dissection. Circulation 2002;106:1110–5. [5] Poullis M, Fabri B, Pullan M, Chalmers J. Sampling time error in EuroSCORE II. Interact CardioVasc Thorac Surg 2012;14:640–1.
[2]
[3]
[4]
[5]
[6] [7] [8]
[9] [10]
[11]
[12]
[13]
[14] [15]
[16]
[17]
T. Nishida et al. / Interactive CardioVascular and Thoracic Surgery EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999;15:816–22; discussion 22–3. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9–13. Holinski S, Claus B, Christ T, Kasperiunaite R, Konertz W. Overestimation of the operative risk by the EuroSCORE also in high-risk patients undergoing aortic valve replacement with a stentless biological prosthesis. Heart Surg Forum 2010;13:E13–6. Gummert JF, Funkat A, Osswald B, Beckmann A, Schiller W, Krian A et al. EuroSCORE overestimates the risk of cardiac surgery: results from the national registry of the German Society of Thoracic and Cardiovascular Surgery. Clin Res Cardiol 2009;98:363–9. Osswald BR, Gegouskov V, Badowski-Zyla D, Tochtermann U, Thomas G, Hagl S et al. Overestimation of aortic valve replacement risk by EuroSCORE: implications for percutaneous valve replacement. Eur Heart J 2009;30:74–80. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734–44; discussion 44–5. Shahian DM, Edwards FH. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: introduction. Ann Thorac Surg 2009;88(1 Suppl):S1. Nishida T, Masuda M, Tomita Y, Tokunaga S, Tanoue Y, Shiose A et al. The logistic EuroSCORE predicts the hospital mortality of the thoracic aortic surgery in consecutive 327 Japanese patients better than the additive EuroSCORE. Eur J Cardiothorac Surg 2006;30:578–82; discussion 82–3. Nishida T, Masuda M. Risk prediction of cardiovascular surgery in Japanese patients. Gen Thorac Cardiovasc Surg 2011;59:597–8. Kawachi Y, Nakashima A, Toshima Y, Arinaga K, Kawano H. Risk stratification analysis of operative mortality in heart and thoracic aorta surgery: comparison between Parsonnet and EuroSCORE additive model. Eur J Cardiothorac Surg 2001;20:961–6. Barmettler H, Immer FF, Berdat PA, Eckstein FS, Kipfer B, Carrel TP. Risk-stratification in thoracic aortic surgery: should the EuroSCORE be modified? Eur J Cardiothorac Surg 2004;25:691–4. Huijskes RV, Wesselink RM, Noyez L, Rosseel PM, Klok T, van Straten BH et al. Predictive models for thoracic aorta surgery. Is the EuroSCORE the optimal risk model in the Netherlands? Interact CardioVasc Thorac Surg 2005;4:538–42. Matsuura K, Ogino H, Matsuda H, Minatoya K, Sasaki H, Yagihara T et al. Limitations of EuroSCORE for measurement of risk-stratified mortality in aortic arch surgery using selective cerebral perfusion: is advanced age no longer a risk? Ann Thorac Surg 2006;81:2084–7. Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003;24:881–2. Carnero-Alcazar M, Silva Guisasola JA, Reguillo Lacruz FJ, Maroto Castellanos LC, Cobiella Carnicer J, Villagran Medinilla E et al. Validation of EuroSCORE II on a single-centre 3800 patient cohort. Interact CardioVasc Thorac Surg 2013;16:293–300. Chalmers J, Pullan M, Fabri B, McShane J, Shaw M, Mediratta N et al. Validation of EuroSCORE II in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg 2013;43:688–94. Kurazumi H, Mikamo A, Fukamitsu G, Kudou T, Sato M, Suzuki R et al. Validation of the JapanSCORE versus the logistic EuroSCORE for predicting operative mortality of cardiovascular surgery in Yamaguchi University Hospital. Gen Thorac Cardiovasc Surg 2011;59:599–604.
eComment. Risk-adjusted mortality ratio for EuroSCORE II in everyday clinical practice Author: Ovidio A. Garcia-Villarreal Cardiovascular Surgeon, Department of Cardiac Surgery, Hospital of Cardiology, UMAE 34, IMSS, Monterrey, Mexico doi: 10.1093/icvts/ivu001 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I have read with great interest the article by Nishida et al. [1]. The article includes up-to-date information on EuroSCORE II, and the results shown by the authors validate the superiority of the EuroSCORE II over the additive and logistic EuroSCOREs for predicting risk mortality in thoracic aortic surgery. EuroSCORE II is highly recommended for assessing risk in adult cardiac surgery. However, one must not forget that no risk model is perfect, nor do all risk factors appear in all models. EuroSCORE II now offer us the capacity to virtually create a reality. However, this issue must be addressed much more consistently. The variation in outcomes between centres and surgeons should be taken into account [2]. Once a given risk model is in use, all units
and surgeons should calculate the risk-adjusted mortality ratio (RAMR) by dividing the actual mortality (observed) by the expected mortality. Then, the predicted mortality calculated by EuroSCORE II is multiplied by the unit’s or the individual surgeon’s RAMR. This reflects in a more faithful manner the current mortality for a given patient in a given surgical unit. If, for example, the unit’s RAMR for thoracic aortic surgery is 2, and the predicted mortality by EuroSCORE II is 7.4%, the corrected mortality rate for thoracic aortic surgery for this hypothetic unit would be 14.8%. In consequence, this is a more effective way to adapt the EuroSCORE II to the ‘real world’. Conflict of Interest: none declared References [1] Nishida T, Sonoda H, Oishi Y, Tanoue Y, Nakashima A, Shiokawa Y et al. The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms. Interact CardioVasc Thorac Surg 2014;18:446–50. [2] Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734–45.
eComment. EuroSCORE II and prediction of in-hospital mortality of thoracic aortic surgery Author: Michael Poullis Liverpool Heart and Chest Hospital, Liverpool, UK doi: 10.1093/icvts/ivu029 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Nishida et al. need to be congratulated for achieving an overall mortality rate of 7.2% in 461 patients undergoing aortic surgery [1]; however, their manuscript raises a number of issues. Mortality prediction models are classically assessed via receiver operating curve (ROC) and Hosmer-Lemeshow statistic assessment [2,3]. The use of a 20-year study period is probably too long, due to improvements in surgical, anaesthetic and medical care, hence the recalibration of EuroSCORE to create EuroSCORE II. With such a long study period the chronobiology of aortic dissection may be an important issue [4,5]. We agree with their interpretation that a ROC of nearly 0.8 is impressive for the EuroSCORE II risk model in aortic surgery in their patient group; however their demonstration that in high risk patients none of the models are accurate means clinical usage is limited. Unfortunately no Hosmer-Lemeshow statistic was presented. Failure to achieve an adequate ROC and Hosmer-Lemeshow statistic means adoption can not be recommended. The operation types for this study seem skewed, as 220 patients underwent isolated arch surgery, and only 7 patients underwent root and arch surgery. In addition no mention of redo numbers were made in the manuscript. Risk modelling for CABG or valve surgery requires 10,000 to 20,000 patients per procedure to be operated on in the modern era to avoid being underpowered. As aortic surgery can be simplistically divided into root, arch and descending aorta surgery, risk modelling for aortic surgery is probably beyond any single institution due to number restrictions. An international collaborative project is needed. Conflict of interest: none declared References [1] Nishida T, Sonoda H, Oishi Y, Tanoue Y, Nakashima A, Shiokawa Y et al. The novel EuroSCORE II algorithm predicts the hospital mortality of thoracic aortic surgery in 461 consecutive Japanese patients better than both the original additive and logistic EuroSCORE algorithms. Interact CardioVasc Thorac Surg 2014;18:446–50. [2] Chalmers J, Pullan M, Fabri B, McShane J, Shaw M, Mediratta N et al. Validation of EuroSCORE II in a modern cohort of patients undergoing cardiac surgery. Eur J Cardiothorac Surg 2013;43:688–94. [3] Poullis M, McShane J, Shaw M, Woolley S, Shackcloth M, Page R et al. Prediction of in-hospital mortality following pulmonary resections: improving on current risk models. Eur J Cardiothorac Surg 2013;44:238–42. [4] Mehta RH, Manfredini R, Hassan F, Sechtem U, Bossone E, Oh JK et al.; International Registry of Acute Aortic Dissection (IRAD) Investigators. Chronobiological patterns of acute aortic dissection. Circulation 2002;106:1110–5. [5] Poullis M, Fabri B, Pullan M, Chalmers J. Sampling time error in EuroSCORE II. Interact CardioVasc Thorac Surg 2012;14:640–1.
