Julio Baldi

In-hospital Outcomes of Surgical Aortic Valve Replacement: the Benchmark for Transcatheter Valve Implant

Background: The aim of this study was to analyze the current in-hospital outcomes of aortic valve replacement (AVR) surgery in order to serve as a benchmark for comparing the local results of transcatheter aortic valve implantation (TAVI). Methods: We retrospectively analyzed the in-hospital outcomes of 422 patients undergoing isolated AVR between 2012 and 2017 in our institutions associated with the University of Buenos Aires. Results: Overall in-hospital mortality was 3.6%, and 3.8% at 30 days, while the in-hospital and 30-day mortality rate of 71 patients older than 80 years was 4.2%. In the entire series, in-hospital mortality in the low-risk group (EuroSCORE II <4%) was 2.2%, and in the moderate risk group (EuroSCORE II between 4% and 7%) it was 5.0%. Conclusions: This updated information on the local outcomes of AVR surgery stratified by risk could serve as a standard for comparing TAVI results.

Risk of de novo dialysis after elective cardiac surgery according to preoperative renal dysfunction

OBJECTIVES The aim was to estimate the risk of dialysis postoperative de novo dialysis in patients undergoing elective cardiac surgery, according to varying degrees of pre-existing renal dysfunction, and to compare the outcomes with the expected prevalence of dialysis based on several risk scores. METHODS A retrospective analysis was performed over a 5-year period (2012-16) from a series of 1332 adult patients who underwent elective cardiac surgery. Patients were divided into 3 estimated creatinine clearance (eCrCl) groups: eCrCl >60 ml/min, eCrCl from 50 ml/min to 60 ml/min and eCrCl ≤49 ml/min. The primary outcome was any renal failure requiring first-time dialysis during the postoperative hospital stay. The expected risk for postoperative dialysis was calculated with 3 predictive scores: the Society of Thoracic Surgeons Bedside Risk Tool, the Cleveland Clinic Score and the Simplified Renal Index. The global accuracy of eCrCl and the different scores was evaluated in terms of calibration and discrimination. RESULTS In the overall population, 26.6% of patients presented moderate or severe pre-existing renal dysfunction, and the need for de novo dialysis varied from 0.6% to 5.0% depending on the degree of preoperative eCrCl (P < 0.0001). Preoperative renal dysfunction with eCrCl <50 ml/min was associated with nearly 8-fold increase of risk for postoperative dialysis; eCrCl between 50 ml/min and 60 ml/min showed a 2-fold increase, though this last difference did not reach statistical significance. CONCLUSIONS In elective cardiac surgery, isolated preoperative eCrCl seemed to be an accurate indicator of risk for postoperative de novo dialysis. More complex models did not provide additional information to stratify that risk.

Mortality in low- and very low-risk patients undergoing cardiac surgery: Evaluation according to the EuroSCORE II as a new standard

BACKGROUND Only a few reports have analyzed low-risk patient outcomes and in every case, the risk was based on a logistic EuroSCORE ≤ 2. Since this original EuroSCORE overestimates surgical risk, we developed this study to prospectively evaluate the immediate results of cardiac surgery in patients with an expected mortality risk ≤ 2% according to the EuroSCORE II as a new gold standard. We also examined the cause of death and whether it could be considered preventable. METHODS A prospective risk stratification of all cardiac surgical patients treated at the Bue-nos Aires University Hospital of Argentina was performed between 2012 and 2014 using the EuroSCORE II. Causes of death were classified as preventable or not preventable. RESULTS From a total of 990 patients, 63.2% had EuroSCORE II ≤ 2 (low-risk group) and 32.5% EuroSCORE II < 1 (very low-risk group). In the low-risk group, in-hospital mortal-ity was 1.8%, whereas predicted mortality was 1.04% (AUC 0.765). The observed/expected ratio was 1.73 (95% CI 0.68-4.43) and the observed-expected difference was 0.76 (95% CI -0.68-2.10). Fifty-four percent of deaths were considered preventable. CONCLUSIONS We propose to use and further validate the EuroSCORE II as a new standard for assessing low-risk patients. This model proved to be useful in evaluating the quality standards of local cardiac surgery. The review of cause of death in low-risk patients provided valuable information, which revealed potentially correctable issues. Adoption of a more demanding standard, as the EuroSCORE II to identify low-risk patients, avoids the sense of safety offered by previous versions of the score.