Is the EuroSCORE II best suited for reoperative risk estimation in patients with structural deterioration of aortic bioprostheses?

BACKGROUND: Operative risk prediction systems (logistic EuroSCORE I, EuroSCORE II and STS Score) are employed together with multidisciplinary discussion to contraindicate conventional surgery in patients with valvular heart disease and propose the employment of alternative transcatheter procedures. The EuroSCORE I has been reported to underperform in these circumstances; we hypothesize that the EuroSCORE II is best suited for the stratification of risk in patients with structural deterioration (SVD) of valvular bioprostheses and potential candidates to the Valve-in-Valve procedure (deployment of a transcatheter valve within a failing valvular bioprosthesis). METHODS AND EVALUATION OF THE HYPOTHESIS: A multi-institutional collaboration is required to fully address such hypothesis. Therefore, we performed a preliminary validation study by retrieval of the complete records of 81 patients undergoing reoperative aortic valve replacement for preoperative diagnosis of bioprosthetic SVD at our Institution. Logistic EuroSCORE I, EuroSCORE II and STS Score were calculated by preoperatively available data. Faced to an observed reoperative mortality of 4.9%, average EuroSCORE I was 15.8%±13.4, EuroSCORE II was 7.3%±7.4 and the STS Score was 15%±9.8. The three systems provided sufficient adequacy (Hosmer-Lemeshow p=0.847, p=0.999 and p=0.9948, respectively). Yet, the area under the ROC curve was significantly higher for the EuroSCORE II (0.9903) vs. the EuroSCORE I (0.8994) (p=0.044). The STS Score yielded an intermediate figure (0.9643). The odds ratios (logistic regression) were 1.079 for EuroSCORE I, 1.223 for the STS Score and 1.474 for EuroSCORE II. CONCLUSIONS: The three investigated algorithms showed reasonable calibration in the prediction of mortality for reoperative aortic valve replacement, but they evenly overestimated the observed mortality. The hypothesis that the EuroSCORE II is better suited for the selection of candidates to Valve-in-Valve implantation is worth of further multi-institutional investigations on the basis of our preliminary findings and due to the expanding role of transcatheter techniques.

Can we predict poor hemodynamic tolerance of intermittent hemodialysis with echocardiography in intensive care patients?

OBJECTIVES: Tolerance of intermittent hemodialysis is potentially poor for patients hospitalized in the intensive care unit, particularly those in shock. The aim of this study was to determine whether an evaluation of the hemodynamic state by echocardiography before an intermittent hemodialysis session could predict tolerance during the session. METHODS: Before an intermittent hemodialysis session, transesophageal echocardiography was performed on sedated patients, and transthoracic echocardiography was performed on nonsedated patients. Poor tolerance during intermittent hemodialysis was defined by the following criteria: greater than 20% decrease in mean arterial pressure, need for fluid loading (≥500 mL), a 15% increase in catecholamine if the dose was stable before the session or doubling the speed of catecholamine infusion if necessary, arrhythmia, and the necessity to stop the session before its prescribed end. RESULTS: A total of 54 patients were included: 20 (37%) were intubated under controlled mechanical ventilation (group 1) and underwent transesophageal echocardiography; 14 (26%) were intubated under pressure support ventilation (group 2) and underwent transthoracic echocardiography; and 20 (37%) had no ventilation support (group 3). Twenty-four patients (46%) had poor tolerance criteria. A comparison of groups showed no significant difference in tolerance. Similarly, there was no difference with and without ultrafiltration. Increased respiratory variation of the vena cava was not predictive of poor tolerance in groups 1 and 2. In group 3, there was greater variation in patients with poor tolerance. In patients receiving mechanical ventilation, greater respiratory variability of the maximum velocity measured in the pulmonary artery was predictive of poor tolerance. CONCLUSIONS: The hemodynamic profile of patients receiving mechanical ventilation was unable to predict tolerance of an intermittent hemodialysis session. In patients without mechanical ventilation, hypovolemia before the session appeared to be predictive of poor tolerance.

Predictive value of global longitudinal strain in a surgical population of organic mitral regurgitation.

BACKGROUND: Because of the lack of reliable echocardiographic parameters to predict recovery after surgery, the optimal timing of surgery for severe mitral regurgitation remains controversial. The aim of this study was to determine whether global longitudinal strain (GLS) recorded preoperatively could help in predicting left ventricular (LV) ejection fraction (LVEF) postoperatively. METHODS: A total of 88 patients (mean age, 63 ± 13 years; 59 men) with severe degenerative mitral regurgitation were included prospectively in this study. Rest echocardiography was performed before and 6 ± 1 months after mitral valve surgery. Patients were divided into two groups: group A (postoperative LVEF ≥ 50%) and group B (postoperative LVEF < 50%). RESULTS: In group B, patients had larger preoperative LV end-systolic diameters (21.6 ± 2.6 vs 19.2 ± 3.7 mm/m(2), P = .02) and impaired preoperative GLS (-17 ± 2.8% vs -19.6 ± 3.6%, P = .01), whereas there was no difference in preoperative LVEF. Preoperative LV end-systolic diameter ≥ 22 mm/m(2) and GLS < -18% were independent predictors of postoperative LV dysfunction. CONCLUSIONS: LV end-systolic diameter is a well-recognized prognostic marker. In addition, this study demonstrates the additive and independent predictive value of preoperative GLS for predicting postoperative LV dysfunction.

Prediction of left ventricular ejection fraction 6 months after surgical correction of organic mitral regurgitation: the value of exercise echocardiography and deformation imaging.

AIMS: Left ventricular (LV) end-systolic diameter and LV ejection fraction (LVEF) are correlated with postoperative LVEF and prognosis in patients with organic mitral regurgitation (MR). However, in some patients, the LVEF does not return to normal 6 months postoperatively, despite normal preoperative diameters. Thus, our study aimed to evaluate whether preoperative LV strain values assessed by echocardiography at rest and during exercise were predictors of postoperative LVEF at 6-month follow-up in patients undergoing surgery for severe organic MR. METHODS AND RESULTS: In total, 88 patients with severe organic MR (mean age 62.6 ± 1.4 years) were prospectively recruited. All patients underwent an echocardiogram at rest and submaximal exercise (110 ± 10 bpm) prior to surgery and then at rest 6 months after surgery. Exclusion criteria were significant coronary artery disease, other organic valvular diseases, uncontrolled arrhythmia, and haemodynamic instability. Among the 88 patients, 77 had complete data sets with rest and exercise echocardiograms and underwent isolated mitral valve surgery (repaired, n= 72). Global longitudinal strain (GLS) at rest (R= -0.42, P= 0.011) and during exercise (R= -0.36, P= 0.034) correlated with postoperative LVEF. When normalized for LV end-systolic diameter, GLS during exercise was more closely correlated with postoperative LVEF and was its best predictor based on a multivariate linear regression model. At a cut-off of -5.7%/cm, sensitivity was 0.83, specificity 0.70, negative predictive value 0.64, and positive predictive value 0.86 for predicting a 6-month postoperative LVEF of <50%. CONCLUSION: In patients undergoing surgery for severe organic MR, GLS normalized for LV end-systolic diameter at submaximal exercise may be used as a predictor of postoperative LVEF.