Rodolfo A. Ahuad Guerrero

Prospective validation of EuroSCORE II in patients undergoing cardiac surgery in Argentinean centres

OBJECTIVES The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is an updated version of the original EuroSCORE that must be extensively validated. The objective was to prospectively evaluate the efficacy of EuroSCORE II in predicting the immediate results of cardiac surgery in Argentinean centres. METHODS A prospective consecutive series of 503 adults who underwent cardiac surgery between January 2012 and April 2013 was studied. EuroSCORE II discrimination and accuracy were assessed in the overall cohort and in two surgically defined subgroups: isolated coronary artery bypass graft (CABG) surgery and non-CABG surgery. Additionally, a risk-adjusted cumulative sum control chart analysis was performed. RESULTS In-hospital overall mortality rate was 4.17%, while the mortality rate predicted by the EuroSCORE II was 3.18% (P = 0.402). Receiver operating characteristic curve analysis demonstrated a good overall (area 0.856) and non-CABG subgroup (area 0.857) discrimination (P = 0.0001), while discrimination in the CABG subgroup was poorer (area 0.794, P = 0.014). The model showed good calibration in predicting in-hospital mortality, both overall (Hosmer-Lemeshow, P = 0.082) and for each subgroup (non-CABG, P = 0.308, and CABG, P = 0.150). CONCLUSIONS EuroSCORE II reflects a better current surgical performance and offers a new quality standard to evaluate local outcomes. EuroSCORE showed an overall good discriminative capacity and calibration in this local population; nevertheless, the model performed optimally in non-CABG surgery and in highest-risk patients, underestimating in-hospital mortality in lowest-risk cases. The latter finding may be interpreted as an inadequate behaviour of the model, as a poor performance of surgeons or both. Larger prospective studies will elucidate this hypothesis.

Intracardiac sewing needle in a women with autoaggressive behavior

Heart lesions produced by the introduction of sewing needles into the thorax by people with autoagressive behavior patterns are very rare.1-4 Such patients usually suffer psychiatric disorders and present at hospital manifesting that they have introduced a foreign object into their chest, or with chest pain, dyspnea and sometimes pneumothorax. We recently treated a female drug addict with psychiatric problems who had managed to introduce a sewing needle into the myocardium. The migration of such objects into the heart chambers can cause intramural hematomas, tamponade, infection, embolism, valve dysfunction and death, and their extraction is recommended.3,4 The present patient was 44 years old, had a background of schizophrenia and drug abuse, and had been institutionalized after a suicide attempt. She was admitted to our hospital after having inserted a sewing needle into the precordium. She complained of pain in the fifth midclavicular intercostal space, where an area of ecchymosis was visible. A physical examination showed several scars on the left arm. Radioscopy revealed a metallic object that moved with the cardiac silhouette. Echocardiography and computed tomography showed a needle to be lodged in the heart (Figure 1). Since the patient was hemodynamically stable, videothoracoscopic exploration and extraction of the object was attempted, but this proved fruitless. Given the risk of migration and tamponade it was decided to undertake direct surgery. Following sternotomy, a hematoma was noticed on the back side of the left hemithorax and in the pericardial fat. Following pericardiotomy, a small serohematic hemorrhage and granuloma were seen on the anterior face of the left ventricle close to the left descending coronary artery. The remainder of the heart and the pericardial cavity were normal. Intraoperative radioscopy showed the needle to be in the left ventricle. The granuloma was explored, positioning the heart with a stabilizer (Octopus®). The dissection of the beating heart proved unfruitful, and given the danger of perforating the left ventricle the decision was made to continue with extracorporeal circulation and cardioplegic arrest. Figure 2 shows the dissection of the granuloma and the extraction of a 7 cm long sewing needle (this needle was completely within the myocardium; the figure shows it partially extracted). Ventricular closure was performed with 2 Teflon patches. The patient progressed satisfactorily with no complications. Heart lesions caused by the introduction of pins or needles in an attempt to inflict self-injury have been described only on very few occasions. Such self-mutilatory behavior has been observed in patients with schizophrenia, depression, and in the mentally disabled. As in the present case, drug or alcohol abuse increases the probability of such behavior. In published cases, these needles have been found free in the pericardial cavity or in the left ventricle, extraction being performed with or without extracorporeal circulation as required.1,5 Although some authors have suggested that these objects might be removed by performing a small anterior thoracotomy without the help of extracorporeal circulation,5 in the present case, conventional midline sternotomy was decided upon following the failure of thoracoscopy. Intraoperative radioscopy was successful in finding the end of the needle, thus showing where ventriculotomy was required.

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.

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.