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• W2014506508 abstract "During the past 4 decades, heart surgery has evolved to encompass increasingly complex operations in increasingly complex patients. Today, patients with multiple noncardiac comorbidities, including old age and organ dysfunction, present with cardiac pathologies requiring multicomponent operations.1Shahian D.M. O'Brien S.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1: coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S2-22Abstract Full Text Full Text PDF PubMed Scopus (817) Google Scholar, 2Shahian D.M. O'Brien S.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3: valve plus coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S43-S62Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar, 3O'Brien S.M. Shahian D.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2: isolated valve surgery.Ann Thorac Surg. 2009; 88: S23-S42Abstract Full Text Full Text PDF PubMed Scopus (973) Google Scholar Yet, because most studies of risk factors focus on isolated procedures, a tool to explain, illustrate, and understand risk and survival is not readily available when patients with multiple comorbidities (complex patients) present for multicomponent heart operations (complex operations). Furthermore, cardiac surgery programs are evaluated on the basis of subsets of patients undergoing 1-component operations (isolated coronary artery bypass grafting [CABG], isolated aortic valve surgery [AV], isolated mitral valve surgery [MV]) or simple 2-component operations (CABG + AV, CABG + MV).1Shahian D.M. O'Brien S.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1: coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S2-22Abstract Full Text Full Text PDF PubMed Scopus (817) Google Scholar, 2Shahian D.M. O'Brien S.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3: valve plus coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S43-S62Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar, 3O'Brien S.M. Shahian D.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2: isolated valve surgery.Ann Thorac Surg. 2009; 88: S23-S42Abstract Full Text Full Text PDF PubMed Scopus (973) Google Scholar Risk adjustment is based on factors representing a subset of demographics and common comorbidities. When facing complex patients, we as surgeons use the traditional scores developed for simple operations and extrapolate the patient's risk as best we can, guessing at the contribution of factors not covered by these scores. Conceptually, it is easy to make a list of factors that contribute to morbidity and mortality after heart surgery. The weight of each factor can only be studied retrospectively; we estimate current risk based on these weights. Learning from experience means learning to master, reduce, or neutralize the weight of a given risk factor.4Kouchoukos N.T. Blackstone E.H. Doty D.B. Hanley F.L. Karp R.B. Cardiac surgery. Churchill Livingstone, Philadelphia2003Google Scholar, 5Kirklin J.W. Blackstone E.H. Bargeron Jr., L.M. Pacifico A.D. Kirklin J.K. The repair of atrioventricular septal defects in infancy.Int J Cardiol. 1986; 13: 333-360Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 6Bhudia S.K. McCarthy P.M. Kumpati G.S. Helou J. Hoercher K.J. Rajeswaran J. et al.Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction.J Am Coll Cardiol. 2007; 49: 1465-1471Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 7Blackstone E.H. Thinking beyond the risk factors.Eur J Cardiothorac Surg. 2006; 29: 645-652Crossref PubMed Scopus (10) Google Scholar Regardless of the sophistication of the statistics, the predictive value is, therefore, limited (as expressed by its confidence limits). No coding system is adequately comprehensive and inclusive, or granular and precise, or stable across time. Clinical information description and coding are performed by physicians and coders with different backgrounds and education. Understanding any risk estimate therefore requires an understanding of the data, and the coding and reporting on which they were based. Factors included and not included, their definitions, the accuracy and completeness of recorded clinical observations, and the faithfulness of their abstraction determine the reliability of the calculations. One solution is to develop ever-more elaborate multivariable risk scoring systems. We illustrate such a system in part 1 of this commentary. However, it is easy to get lost in the precision of a numeric estimate of expected mortality. Surgeons need to be able to explain to patients and families how the cardiac disease, planned operation, and other factors like physical strength or frailty, disabilities, and comorbidities add up to vulnerability and risk. A simplified approach will improve our understanding of this complicated interplay, and its constant change and development. Congenital heart surgeons have developed the Aristotle Complexity score8Lacour-Gayet F. Clarke D. Jacobs J. Gaynor W. Hamilton L. Jacobs M. et al.The Aristotle score for congenital heart surgery.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2004; 7: 185-191Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar and the Risk Adjustment for Congenital Heart Surgery (RACHS)-1 score,9Jenkins K.J. Risk adjustment for congenital heart surgery: the RACHS-1 method.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2004; 7: 180-184Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar both of which take into account operative complexity and expert opinion. In part 2 of this commentary, we present a simplified approach similar to these and the Charlson Comorbidity Index to describe patient and surgical complexity. Complexity was evaluated and analyzed in all patients undergoing cardiac surgery at the Cleveland Clinic from 1967 to 2010. Patients were divided into 2 cohorts: an evolution cohort including 111,390 patients from 1967 to 2007 and a contemporary risk cohort including 10,337 patients from 2007 to 2010. We defined patient complexity by comorbid disease components, excluding details related to the cardiac pathology that determined the operation. Patient comorbidities in this context included demographics, functional limitation according to symptoms and clinical acuity, and general cardiac and noncardiac comorbidities known to limit survival. A list of components used for the elaborate approach (part 1) is presented in Appendix E1, and the comparison of evolution and contemporary risk cohorts in Table 1. For the simplified approach (part 2), we used the strategy exemplified by the Charlson Comorbidity Index,10Charlson M.E. Pompei P. Ales K.L. MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383Abstract Full Text PDF PubMed Scopus (34228) Google Scholar with inclusion of comorbidities related to each physiologic system and complexity defined by count of comorbid disease components.Table 1Patient characteristics in evolution (1967-2007; n = 111,390) and contemporary risk (2007-2010; n = 10,337) cohortsCharacteristicEvolution CohortContemporary Risk Cohortn∗Number of patients with data available. Because the database dates back to the early 1970s, variables were added periodically, particularly in response to refinements of the Society of Thoracic Surgeons National Database. Thus, missing data were generally “block missing.”No. (%) or mean ± SDn∗Number of patients with data available. Because the database dates back to the early 1970s, variables were added periodically, particularly in response to refinements of the Society of Thoracic Surgeons National Database. Thus, missing data were generally “block missing.”No. (%) or mean ± SDDemography Age, y111,39060 ± 1210,33763 ± 14 Age >75 y†Comorbidities incorporated in count of patient complexity.111,39011,678 (10)10,3372130 (21) Male111,39083,246 (75)10,3376804 (66) BMI, kg·m-280,29127 ± 5.010,33729 ± 8.8 BMI >30 kg·m-2 or <18.5 kg·m-2†Comorbidities incorporated in count of patient complexity.80,29120,338 (25)10,3373423 (33)Acuity Preoperative NYHA class111,3228908 I19,670 (18)2344 (26) II44,692 (40)3714 (42) III17,553 (16)2320 (26) IV29,407 (26)530 (6.0) Emergency operation107,1413194 (3.0)10,329260 (2.5) Patient acuity†Comorbidities incorporated in count of patient complexity., ‡Preoperative intra-aortic balloon pump support, inotrope support, cardiogenic shock, or emergency operation.——10,3371047 (10)Cardiac comorbidity Previous or evolving MI†Comorbidities incorporated in count of patient complexity.111,11851,900 (47)10,3372448 (24) Ejection fraction <50%†Comorbidities incorporated in count of patient complexity.51,73820,579 (40)10,3372788 (27) Preoperative AF/flutter111,3908186 (7.3)98281123 (11) Preoperative arrhythmia†Comorbidities incorporated in count of patient complexity., §Preoperative atrial or ventricular arrhythmia or heart block.——10,3372,939 (28) Heart failure†Comorbidities incorporated in count of patient complexity.111,39026,416 (24)10,3372510 (24) Previous cardiac operation†Comorbidities incorporated in count of patient complexity.111,39019,296 (17)10,3372572 (25)Noncardiac comorbidity History of pharmacologically treated diabetes†Comorbidities incorporated in count of patient complexity.103,76416,642 (16)10,3372497 (24) History of PAD†Comorbidities incorporated in count of patient complexity.61,67525,056 (41)10,337812 (7.9) History of hypertension†Comorbidities incorporated in count of patient complexity.82,09250,031 (61)10,3377221 (70) History of COPD†Comorbidities incorporated in count of patient complexity.55,86510,654 (19)10,3191293 (13) History of malignancy†Comorbidities incorporated in count of patient complexity.80,7744881 (6.0)10,337315 (3.0) Renal failure†Comorbidities incorporated in count of patient complexity., ‖Preoperative dialysis or creatinine ≥2.5 mg/dL1.——10,337314 (3.0) History of renal disease¶Documentation of renal failure, renal artery stenosis, end-stage renal disease, chronic renal insufficiency, or creatinine ≥2 mg/dL.55,6993,098 (5.8)—— Dyslipidemia†Comorbidities incorporated in count of patient complexity., ∗∗Total cholesterol >200 mg/dL, low-density lipoprotein ≥130 mg/dL, or high-density lipoprotein <40 mg/dL.——10,3377120 (69) Cholesterol, mg/dL76,968218 ± 578616169 ± 45 Bilirubin, mg/dLFifteenth, 50th, and 85th percentiles.55,1590.4, 0.6, 1.110,1570.3, 0.5, 0.9 Liver dysfunction†Comorbidities incorporated in count of patient complexity., ‡‡Total bilirubin >1.0 mg/dL.55,1599188 (17)10,1571288 (13) Hematocrit, %48,35039 ± 5.510,33040 ± 5.6 Anemia†Comorbidities incorporated in count of patient complexity., §§Hematocrit <35%.48,3509869 (20)10,3302119 (20) Previous stroke†Comorbidities incorporated in count of patient complexity.111,3906710 (6.0)10,3371804 (17)SD, Standard deviation; BMI, body mass index; NYHA, New York Heart Association; MI, myocardial infarction; AF, atrial fibrillation; PAD, peripheral arterial disease; COPD, chronic obstructive pulmonary disease.∗ Number of patients with data available. Because the database dates back to the early 1970s, variables were added periodically, particularly in response to refinements of the Society of Thoracic Surgeons National Database. Thus, missing data were generally “block missing.”† Comorbidities incorporated in count of patient complexity.‡ Preoperative intra-aortic balloon pump support, inotrope support, cardiogenic shock, or emergency operation.§ Preoperative atrial or ventricular arrhythmia or heart block.‖ Preoperative dialysis or creatinine ≥2.5 mg/dL1Shahian D.M. O'Brien S.M. Filardo G. Ferraris V.A. Haan C.K. Rich J.B. et al.The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1: coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S2-22Abstract Full Text Full Text PDF PubMed Scopus (817) Google Scholar.¶ Documentation of renal failure, renal artery stenosis, end-stage renal disease, chronic renal insufficiency, or creatinine ≥2 mg/dL.∗∗ Total cholesterol >200 mg/dL, low-density lipoprotein ≥130 mg/dL, or high-density lipoprotein <40 mg/dL.†† Fifteenth, 50th, and 85th percentiles.‡‡ Total bilirubin >1.0 mg/dL.§§ Hematocrit <35%. Open table in a new tab SD, Standard deviation; BMI, body mass index; NYHA, New York Heart Association; MI, myocardial infarction; AF, atrial fibrillation; PAD, peripheral arterial disease; COPD, chronic obstructive pulmonary disease. Similar to patient complexity, surgical complexity was assessed by surgical components. All procedural components of the 111,390 heart operations performed in adults at the Cleveland Clinic from 1967 to 2007 were tabulated. Stand-alone components were those often performed as an isolated operation. Add-on components were those not commonly performed as an isolated operation. Ignored components were minor portions of an operation and were not counted. Eleven components were considered stand-alone:•CABG•AV•MV•Tricuspid valve surgery (TV)•Maze procedure, including non–cut-and-sew maze (AF)•Aortic root, ascending aorta, or arch replacement (aorta)•Major left ventricular procedure•Septal myectomy•Resection of cardiac tumor•Pericardectomy•Heart transplant Three components were considered add-on:•Carotid endarterectomy•Transmyocardial (laser) revascularization•Atrial septal defect or patent foramen ovale closure Ignored minor components included pacemaker or lead procedures, myocardial biopsy, coronary reimplantation, reimplantation of coronary graft, aortoplasty, aortic endarterectomy, aortic biopsy, aortic thrombectomy, femoral artery repair, left atrial appendage amputation or closure, pericardial procedure other than pericardectomy, minor ventriculotomy, and cell transplant. For the elaborate approach, every combination of these surgical components in the evolution cohort, for which there were at least 50 patients or 5 events (47 mutually exclusive surgical groups, isolated or combinations) was analyzed (Table 2). For the simplified approach, surgical complexity was defined by number of distinct stand-alone and add-on components comprising a given operation.Table 2Evolution cohort (1967-2007): Mutually exclusive surgical groups and associated mortalitySurgical groupsnHospital mortality, No. (%)One component CABG68,6261200 (1.7) Major LV procedure52244 (8.4) AV6864182 (2.7) Septal myectomy5786 (1.0) MV8728190 (2.2) AF1300 (0) TV21218 (7.8) Aorta44553 (12) Heart transplant104957 (5.4) Pericardectomy32516 (4.9) Resection of cardiac tumor1458 (5.5)Two components CABG + CEA164784 (5.1) CABG + TMR1532 (1.3) CABG + ASD/PFO1402 (1.4) Major LV procedure + CABG109586 (7.8) Major LV procedure + MV684 (5.6) AV + ASD/PFO650 (0) AV + CABG4843191 (3.9) AV + MV179594 (5.2) AV + TV1086 (5.6) Septal myectomy + AV844 (4.8) Septal myectomy + MV1525 (3.3) Septal myectomy + CABG1754 (2.3) MV + CABG3619219 (6.1) MV + TV120260 (5.0) MV + ASD/PFO2517 (2.8) AF + MV2512 (0.8) TV + CABG686 (8.8) Aorta + CABG32740 (12.2) Aorta + AV217952 (2.4)Three components Major LV procedure + MV + CABG16416 (9.8) AV + CABG + CEA575 (8.8) AV + MV + CABG91766 (7.2) AV + MV + TV41240 (9.7) AV + MV + TV + CABG20926 (12) Septal myectomy + AV + CABG553 (5.5) MV + CABG + ASD/PFO1245 (4.0) MV + TV + ASD/PFO701 (1.4) MV + TV + CABG46143 (9.3) AF + MV + CABG661 (1.5) AF + MV + TV942 (2.1) Aorta + AV + CABG106280 (7.5) Aorta + AV + MV18016 (8.9) Aorta + MV + CABG368 (22)Four components Aorta + AV + MV + CABG1419 (6.4) Aorta + AV + MV + TV387 (18)Miscellaneous142576 (5.3)CABG, Coronary artery bypass grafting; LV, left ventricle; AF, Maze procedure (including non–cut-and-sew Maze); CEA, carotid endarterectomy; TMR, transmyocardial (laser) revascularization; ASD/PFO, atrial septal defect or patent foramen ovale closure; MV, mitral valve surgery; AV, aortic valve surgery; TV, tricuspid valve surgery; Aorta, aortic root, ascending aorta, or arch replacement. Open table in a new tab CABG, Coronary artery bypass grafting; LV, left ventricle; AF, Maze procedure (including non–cut-and-sew Maze); CEA, carotid endarterectomy; TMR, transmyocardial (laser) revascularization; ASD/PFO, atrial septal defect or patent foramen ovale closure; MV, mitral valve surgery; AV, aortic valve surgery; TV, tricuspid valve surgery; Aorta, aortic root, ascending aorta, or arch replacement. Patient comorbidity factors such as age, body mass index, and proportions of female patients and patients with diabetes mellitus have increased across time, whereas New York Heart Association functional class has decreased, indicating that in recent time more complex patients were operated on earlier in the course of their heart disease (Table 1 and Figure 1). Surgical complexity increased across time, accelerating since the mid 1990s (Figure 2, A). The proportion of isolated CABG procedures steadily declined across time, whereas CABG combined with other procedures increased (Figure 2, B). Thus, the proportion of operations for which benchmarks have been developed by the Society of Thoracic Surgeons and included in Society of Thoracic Surgeons scores has declined such that more than half the operations performed at our institution are now more complex than these, and no benchmarks for risk are available (Figure 2, C). In the contemporary risk cohort, 49% of operations performed were 1 component; 33%, 2 component; 13%, 3 component; and 4%, ≥4 component. Coronary artery bypass grafting was performed in 86 different combinations, including isolated CABG, 13 combinations of CABG + 1 component, 28 combinations of CABG + 2 components, 31 combinations of CABG + 3 components, 11 combinations of CABG + 4 components, and 2 combinations of CABG + 5 components (Box 1). An aortic valve procedure (AV) was performed in 85 different combinations, including an isolated AV, 10 combinations of AV + 1 component, 26 combinations of AV + 2 components, 31 combinations of AV + 3 components, 15 combinations of AV + 4 components, and 2 combinations of AV + 5 components (Box E1). A mitral valve procedure (MV) was performed in 83 different combinations, including an isolated MV, 11 combinations of MV + 1 component, 25 combinations of MV + 2 components, 31 combinations of MV + 3 components, 13 combinations of MV + 4 components, and 2 combinations of MV + 5 components (Box E2). An aortic procedure was performed in 66 different combinations, including an isolated aortic procedure, 9 combinations of aortic procedure + 1 component, 21 combinations of aortic procedure + 2 components, 22 combinations of aortic procedure + 3 components, 11 combinations of aortic procedure + 4 components, and 2 combinations of aortic procedure + 5 components (Box E3). Risk factors for hospital mortality were identified and analyzed separately for patient comorbidity components and surgical components using logistic regression analysis. In total, 3046 hospital deaths occurred (2.7%) over 40 years from 1967 to 2007. Hospital mortality decreased substantially across time (Figure 3). Patient complexity alone was a powerful predictor of hospital mortality (C = 0.812; Figure 4, Table E1). This analysis was used to calculate a patient complexity score.Figure 4Receiver–operator curves for logistic regression analysis of patient (short-dash line) and surgical complexity (long-dash line).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Next, the association between hospital mortality and surgical complexity was assessed by logistic regression analysis in 3 models: (1) the operation accounted for by individual surgical components, (2) the operation accounted for by surgical groups as defined in Table 2, and (3) the operation accounted for by individual surgical components combined with statistically significant groups (interactions) (Figure 5). The C statistic for the unadjusted model containing the individual surgical components was only 0.647, but it was 0.824 after adjusting for patient complexity score (Figure 4 and Table E2). When using surgical groups instead of individual surgical components to calculate the contribution of the operation to risk, the C statistic for the unadjusted group model was 0.652 and was 0.827 after adjusting for patient complexity score. Certain surgical groups were poorly accounted for by components alone, as illustrated by outliers in Figure 5, indicating that important interactions existed. Aorta procedures with concomitant CABG, isolated TV, isolated aorta, major left ventricular procedure, and CABG with concomitant MV were associated with higher or lower risk. In the final model, interactions were accounted for by combining components and statistically significant groups to modulate risk, resulting in a C statistic of 0.694, and 0.827 after adjusting for patient complexity score (Table 3). In all 3 models, patient, rather than surgical, complexity accounted for most of the information predicting hospital mortality (Figure 4).Table 3Logistic model for hospital death incorporating surgical components and interactionsProcedureEstimate ± SEPPericardiectomy1.32 ± 0.22<.0001Major LV procedure1.07 ± 0.11<.0001Atrial myxoma0.93 ± 0.33.004Carotid endarterectomy0.92 ± 0.11<.0001Septal myectomy0.66 ± 0.20.001Aorta0.55 ± 0.088<.0001AV0.36 ± 0.053<.0001MV0.35 ± 0.065<.0001CABG0.33 ± 0.059<.0001Maze procedure0.20 ± 0.17.2TV0.16 ± 0.089.07Transplant0.093 ± 0.16.6Transmyocardial revascularization−0.092 ± 0.60.8Atrial septal defect or patent foramen ovale closure0.15 ± 0.21.4Interactions CABG + aorta1.20 ± 0.21<.0001 Isolated aorta1.04 ± 0.19<.0001 Isolated TV0.88 ± 0.29.002 Isolated major LV procedure0.48 ± 0.21.05 CABG + MV0.35 ± 0.11.0005Preoperative risk0.96 ± 0.016<.0001Intercept−0.70 ± 0.08<.0001C = 0.83. SE, Standard error; LV, left ventricle; aorta, aortic root, ascending aorta, or arch replacement; AV, aortic valve surgery; MV, mitral valve surgery; CABG, coronary artery bypass grafting; TV, tricuspid valve surgery. Open table in a new tab C = 0.83. SE, Standard error; LV, left ventricle; aorta, aortic root, ascending aorta, or arch replacement; AV, aortic valve surgery; MV, mitral valve surgery; CABG, coronary artery bypass grafting; TV, tricuspid valve surgery. The elaborate approach based on multivariable analysis is of great value for risk-adjusted national reporting of outcomes and quality improvement efforts. It is patient and risk factor specific, allowing the best possible direct comparison of treatment options and program outcomes. Developing such a score has allowed us to better understand issues related to risk scoring. Its limitations are its complexity, which is why only 1- and 2-component operations are covered by scores based on this approach. Practical implementation of an elaborate score, including even more granular data, requires a large data set with many variables solved automatically from entry into electronic medical records. It also requires constant updates as we learn and progress (Figure 6). The simplified approach defined patient complexity by count of comorbid disease components (Table 1) and defined surgical complexity by count of surgical components. For the 10,337 patients undergoing cardiac operations performed from 2007 to 2010, 4191 (40%) had ≥ 5 comorbidities (Figure 7). Postoperative mortality and morbidity increased, and late survival decreased with increasing patient (Table 4 and Figure 8, A) and surgical complexity (Table 5 and Figure 8, B). As patient complexity increased, the risk of multicomponent procedures became more evident (Figure 9). However, even for patients with many comorbidities, complex operations were performed with relatively low risk and acceptable survival. The relationship of surgical complexity and hospital mortality varied somewhat according to type of procedure (Figure 10), with particular variability for thoracic aorta procedures. Intermediate-term survival decreased incrementally as patient and surgical complexity increased (Figure 11, A and B).Table 4Contemporary risk cohort (2007-2010): Postoperative mortality and morbidity complications by number of patient comorbiditiesComplicationsComorbiditiesP∗Test for trend.None (n = 461) No. (%)1 (n = 978) No. (%)2 (n = 1348) No. (%)3-4 (n = 3086) No. (%)5-6 (n = 2451) No. (%)7-8 (n = 1404) No. (%)≥9 (n = 609) No. (%)Mortality In-hospital0 (0)3 (0.31)1 (0.07)50 (1.6)79 (3.2)60 (4.3)75 (12)<.0001 In-hospital or within 30-d1 (0.22)4 (0.41)3 (0.22)58 (1.9)94 (3.8)76 (5.4)80 (13)<.0001 6-Month survival, %99.899.198.396.792.68875<.0001 12-Month survival, %99.398.497.595.790.38370Morbidity STS composite†Composite event for any of the following STS complications: renal failure, stroke, prolonged ventilation, reoperation for bleeding, graft occlusion, valve dysfunction, or other cardiac reoperation.41 (8.9)87 (8.9)158 (12)568 (18)731 (30)586 (42)335 (55)<.0001 Renal failure4 (0.88)7 (0.72)15 (1.1)128 (4.2)191 (8.0)168 (12)106 (18)<.0001 Stroke7 (1.5)6 (0.62)25 (1.9)44 (1.5)48 (2.0)32 (2.4)19 (3.3).002 Reoperation for bleeding21 (4.6)40 (4.1)44 (3.3)119 (3.9)151 (6.3)96 (7.1)67 (12)<.0001 Prolonged ventilation (>24 h)10 (2.2)42 (4.3)98 (7.3)417 (14)587 (25)466 (34)294 (51)<.0001 Length of stay, 15th, 50th, and 85th percentilesICU, hours21, 25, 4821, 26, 5322, 27, 7322, 32, 9724, 52, 16027, 84, 23844, 106, 477<.0001Postoperative, days4, 5, 74, 5, 84, 6, 95, 7, 115, 8, 166, 11, 217, 13, 29<.0001STS, Society of Thoracic Surgeons; ICU, intensive care unit.∗ Test for trend.† Composite event for any of the following STS complications: renal failure, stroke, prolonged ventilation, reoperation for bleeding, graft occlusion, valve dysfunction, or other cardiac reoperation. Open table in a new tab Figure 8Contemporary complexity and hospital mortality. A, Hospital mortality according to number of comorbidities (patient complexity). B, Hospital mortality according to number of surgical components (surgical complexity).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 5Contemporary risk cohort (2007-2010): Postoperative mortality and morbidity complications by number of surgical componentsComplicationsSurgical componentsP∗Test for trend.1 (n = 5107) No. (%)2 (n = 3467) No. (%)3 (n = 1335) No. (%)4 (n = 366) No. (%)≥5 (n = 62) No. (%)Mortality In-hospital102 (2.0)78 (2.3)53 (4.0)30 (8.2)5 (8.1)<.0001 In-hospital or 30-d119 (2.3)95 (2.7)61 (4.6)34 (9.3)7 (11)<.0001 6-Month survival, %95.494.0918371<.0001 12-Month survival, %93.892.2897968Morbidity STS composite†Composite event for any of the following STS complications: renal failure, stroke, prolonged ventilation, reoperation for bleeding, graft occlusion, valve dysfunction, or other cardiac reoperation.1008 (20)854 (25)457 (34)153 (42)34 (55)<.0001 Renal failure241 (4.9)215 (6.3)105 (7.9)45 (12)13 (21)<.0001 Stroke77 (1.6)66 (1.9)29 (2.2)9 (2.5)0 (0).11 Reoperation for bleeding200 (4.0)198 (5.8)103 (7.8)31 (8.6)6 (9.7)<.0001 Prolonged ventilation (>24 h)728 (15)655 (19)375 (28)131 (36)25 (41)<.0001 Length of stay, 15th, 50th, and 85th percentilesICU, hours22, 30, 10523, 45, 14025, 67, 18227, 85, 33340, 106, 509<.0001Postoperative, days4, 6, 125, 7, 146, 9, 187, 11, 237, 13, 29<.0001STS, Society of Thoracic Surgeons; ICU, intensive care unit.∗ Test for trend.† Composite event for any of the following STS complications: renal failure, stroke, prolonged ventilation, reoperation for bleeding, graft occlusion, valve dysfunction, or other cardiac reoperation. Open table in a new tab Figure 9Nomogram for hospital mortality according to number of comorbidities for patients undergoing 1-, 2-, 3-, or ≥4-component operations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10Hospital mortality according to number of surgical components for operations including (A) coronary artery bypass grafting (CABG), (B) aortic valve procedure (AV), (C) mitral valve procedure (MV), or (D) aortic root, ascending aorta, or arch procedure.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 11Survival after cardiac operations. Symbols at yearly intervals are Kaplan-Meier estimates accompanied by vertical bars representing asymmetric confidence limits equivalent to ±1 standard error. Solid lines within dashed confidence bands represent parametric estimates. A, Unadjusted mortality stratified by the number of patient comorbidities (0-1, 2, 3-4, 5-6, 7-8, or ≥9; because of the small number of events in the 0-1 group, there are no parametric estimates). B, Unadjusted mortality stratified by the number of surgical components (1, 2, 3, 4, or ≥5).View Large Image Figure ViewerDownload Hi-res image Download (PPT) STS, Society of Thoracic Surgeons; ICU, intensive care unit. STS, Society of Thoracic Surgeons; ICU, intensive care unit. Discussions with patients and families about risk of complex operations are not only about providing percentages, but also about conveying an understanding of the relationship between patient factors, comorbidities, operative components, and outcomes. This is not easy to do, particularly for the complex patient about to undergo a complex operation. This is the primary advantage of a simple tool to illustrate the interplay of these factors. Patients undergoing simple operations tended to have few comorbidities; patients requiring more complex operations always had several comorbidities (Figure 12). The list of patient factors related to risk will continue to evolve. For example, recent discussions about patient frailty are an indication that we have not captured all deciding factors.11Chikwe J. Adams D.H. Frailty: the missing element in predicting operative mortality.Semin Thorac Cardiovasc Surg. 2010; 22: 109-110Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 12Cleveland Jr., J.C. Frailty, aging, and cardiac surgery outcomes: the stopwatch tells the story.J Am Coll Cardiol. 2010; 56: 1677-1678Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 13Lee D.H. Buth K.J. Martin B.J. Yip A.M. Hirsch G.M. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery.Circulation. 2010; 121: 973-978Crossref PubMed Scopus (506) Google Scholar, 14Sundermann S. Dademasch A. Praetorius J. Kempfert J. Dewey T. Falk V. et al.Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery.Eur J Cardiothorac Surg. 2011; 39: 33-37Crossref PubMed Scopus (266) Google Scholar Included operations and their components were also limited; we are aware of the possibility of further dividing these operations and components into subgroups, such as valve repair versus replacement, pathology, access, and technology. Counting operative components suggests that risk of each component is the same. Traditional models presume that variations in the operating room are absorbed by patient factors included in the model when, in fact, the same operation varies according to the pathology and etiology for which it is performed. Operative and cardiopulmonary bypass times are likely to influence risk, as can other factors related to surgeon skill and experience. Some variables do not fall neatly into patient or surgical factors because they carry information about both. Among these is surgical acuity, which reflects not only serious, possibly life-threatening, patient risk, but also interruptions in the surgical schedule, operations performed off hours with less experienced personnel, and fatigue. Other variables that span both categories are cardiac comorbidities, such as extent of coronary disease, endocarditis, previous cardiac surgery, and atrial fibrillation. These reflect a patient's condition, but also influence the surgical approach, which is tailored to the patient's anatomy and pathology, and may vary among surgeons. The surgeon may decide to address or not to address cardiac pathologies such as moderate valve and coronary lesions, and atrial fibrillation. We did not consider the severity of the cardiac pathologies (addressed or not addressed), or success or completeness of the operations. We did not study benefits of surgery relative to other treatment options; however, multiple publications from this institution have demonstrated increasing relative benefit as patients become sicker and higher risk.6Bhudia S.K. McCarthy P.M. Kumpati G.S. Helou J. Hoercher K.J. Rajeswaran J. et al.Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction.J Am Coll Cardiol. 2007; 49: 1465-1471Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 15Lytle B.W. Blackstone E.H. Sabik J.F. Houghtaling P. Loop F.D. Cosgrove D.M. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.Ann Thorac Surg. 2004; 78 (discussion, 14): 2005-2014Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar The traditional, elaborate multivariable approach to risk scores has an important place, but even with large national databases and ever richer variables, these scores do not yet apply to complex patients with complex heart disease. The need for a scoring system to benchmark outcomes of complex procedures is obvious. Benchmarking only the simplest procedures does not give credit to institutions making great efforts to care for complex patients requiring complex operations. When facing these patients, we as surgeons use traditional scores developed for simple operations and extrapolate the patient's risk as best we can, guessing at the contribution of factors not covered by these scores. The approach congenital heart surgeons have taken with the Aristotle and RACHS scores is also a compromise; these scores use patient data to calibrate expert opinion about the complexity of the operation." @default.
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