Risk scores' performance and their impact on operative decision-making in left-sided endocarditis: a cohort study.

The accuracy of contemporary risk scores in predicting perioperative mortality in infective endocarditis (IE) remains controversial. The aim is to evaluate the performance of existent mortality risk scores for cardiovascular surgery in IE and the impact on operability at high-risk thresholds. A single-center retrospective review of adult patients diagnosed with acute left-sided IE undergoing surgery from May 2014 to August 2019 (n = 142) was done. Individualized risk calculation was obtained according to the available mortality risk scores: EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS scores. A cross-validation analysis was performed on the score with the best area under the curve (AUC). The 30-day survival was 96.5% (95%CI 91-98%). The score with worse area under the curve (AUC = 0.6) was the STS-IE score, while the higher was for the RISK-E score (AUC = 0.89). The AUC of the majority of risk scores suggested acceptable performance; however, statistically significant differences in expected versus observed mortalities were common. The cross-validation analysis showed that a large number of survivors (> 75%) would not have been operated if arbitrary high-risk threshold estimates had been used to deny surgery. The observed mortality in our cohort is significantly lower than is predicted by contemporary risk scores. Despite the reasonable numeric performance of the analyzed scores, their utility in judging the operability of a given patient remains questionable, as demonstrated in the cross-validation analysis. Future guidelines may advise that denial of surgery should only follow a highly experienced Endocarditis Team evaluation.

Long-term outcome of high-urgency heart transplant patients with and without temporary ventricular assist device support.

BACKGROUND: The use of short-term ventricular assist devices (VAD) in patients awaiting high-urgency (HU) heart transplantation (HTx) in Spain has steadily increased due to longer waiting times and the new heart allocation system. It is unknown whether the use of short-term VAD support in patients with cardiogenic shock affects HTx outcome. We sought to investigate long-term outcomes of HU transplanted patients with VAD compared with HU transplanted patients without device support. METHODS: We retrospectively evaluated all HTx patients transplanted between 1999 and 2011 in our institution. Patients were categorized by urgency: elective HTx, HU-HTx with VAD (status 0), and HU-HTx without VAD (status 1). Actuarial survival rates were compared. RESULTS: Of 237 transplanted patients, 55 (23%) were HU-HTx, including 16 on VAD support and 39 without VAD. Mean time in the HU waiting list was 6.5 ± 6 days and mean VAD support was 8.4 ± 8 days (range, 1 to 31 days). Assist devices used were Levitronix Centrimag (6), Abiomed (9), and extracorporeal membrane oxygenation (ECMO) (1). After a mean follow-up of 4.6 ± 4.1 years (range 0 to 13 years), 22 patients had died: 5 VAD and 17 non-VAD. The 1- and 5-year survival rates were 73% and 61% for the VAD and 74% and 62% for the non-VAD group, respectively (P = ns). Kaplan-Meier and Cox regression analyses did not show survival differences, HR 1.11 (95% CI 0.41-3.02), P = 0.84. The presence of renal failure was associated with increased mortality risk, HR 1.9 (95% CI 1.1-3.2), P = 0.02. The presence of renal failure was associated with increased mortality risk [HR 1.9 (95% CI 1.1-3.2), P = .02.). CONCLUSIONS: In our experience, the long-term outcome of patients receiving HU-HTx under short-term VAD support is comparable to that of patients undergoing HU-HTx without VAD support. Patients with renal failure had an increased risk for overall mortality in this set of patients.