Dysregulation of metalloproteins in ischemic heart disease patients with systolic dysfunction.

Ischemic heart disease (IHD) is the leading cause of mortality worldwide. Metalloproteins have been linked to human health and diseases. The molecular functions of metalloproteins in IHD is not well understood and require further exploration. The objective of this study was to find out the role of metalloproteins in the pericardial fluid of IHD patients having normal (EF > 45) and impaired (EF < 45) left ventricular ejection fraction (LVEF). IHD patients were grouped into two categories: LVEF<45 (n = 12) and LVEF >45 (n = 33). Pooled samples of pericardial fluid were fractionated by using ZOOM-isoelectric focusing (IEF) followed by further processing using one-dimensional gel electrophoresis (1D SDS-PAGE) and filter-aided sample preparation (FASP). Tryptic peptides of each fraction and differential bands were then analyzed by nano-LC-ESI-MS/MS. Protein identification was performed through a Mascot search engine using NCBI-Prot and SwissProt databases. A total of 1082 proteins including 154 metalloproteins were identified. In the differential bands, 60 metalloproteins were identified, while 115 metalloproteins were identified in all ZOOM-IEF fractions. Twelve differentially expressed metalloproteins were selected in the intense bands according to their molecular weight (MW) and isoelectric point (pI). The 12 differentially expressed metalloprotein includes ceruloplasmin, Prothrombin, Vitamin K-dependent protein, Fibulin-1, Ribosomal protein S6 kinase alpha-6, nidogen, partial, Serum albumin, Hemopexin, C-reactive protein, Serum amyloid P-component, and Intelectin-1 protein which were all up-regulated while serotransferrin is the only metalloprotein that was down-regulated in impaired (LVEF<45) group. Among the metalloproteins, Zn-binding proteins are 36.5 % followed by Ca-binging 32.2 %, and Fe-binging 12.2 %. KEGG, pathway analysis revealed the association of ceruloplasmin and serotransferrin with the ferroptosis pathway. In conclusion, 154 metalloproteins were identified of them the Zn-binding protein followed by Ca-binding and Fe-binding proteins were the most abundant metalloproteins. The two metalloproteins, the Cu-binding protein ceruloplasmin, and Fe-binding protein serotransferrin are involved in the ferroptosis pathway, an iron-dependent form of regulated cell death that has been linked to cardiac pathology, especially in IHD patients having impaired systolic (LVEF<45) dysfunction. However, further research is required to validate these findings.

Late presenting partially displaced atrial septal closure device: Surgical vs percutaneous correction? A case report.

INTRODUCTION: Atrial Septal Defect (ASD) is one of the most common congenital cardiac defect. Even though surgical repair of ASD is the current method of choice but percutaneous device closure is rapidly gaining popularity as it is less invasive. Dislodgment and embolization of the device may occur requiring urgent surgical retrieval. CASE PRESENTATION: We report a case of 54-years-old female patient with a history of ASD device closure 4 years ago, presenting with progressive shortness of breath for past 2 months. She had a partial dehiscence of an ASD device causing a residual ASD of 17 mm. She underwent urgent surgical repair of an ASD with a bovine pericardial patch without ASD device being explanted. CLINICAL DISCUSSION: Management of a dislodged ASD device may be percutaneous or surgical. Dislodged ASD devices that present months after deployment may become fibro-adhered to the site of embolization. Hence its retrieval can be challenging even via open surgical method. Our case describes a novel method to repair a residual ASD and prevent complications associated with dislodgement of device without completely explanting the device. CONCLUSION: In this case, the late presentation of the patient with a partially dehisced device makes it a distinctive case with a novel way on how to treat such a presentation surgically, ensuring that the device doesn't embolize further causing fatal complications.

A Comparison of AKIN, KDIGO, and RIFLE Definitions to Diagnose Acute Kidney Injury and Predict the Outcomes after Cardiac Surgery in a South Asian Cohort.

BACKGROUND: Acute kidney injury (AKI) after cardiac surgery is associated with an increased mortality and morbidity. Different definitions for AKI have been used such as Acute Kidney Injury Network (AKIN), Kidney Disease: Improving Global Outcomes (KDIGO), or risk, injury, failure, loss, end-stage kidney disease (RIFLE). Each of these definitions has their own benefits and limitations for predicting the degree of AKI and adverse outcomes following cardiac surgery. This study was aimed to compare the three AKI definitions to diagnose AKI and their predictive ability for mortality and morbidity after isolated coronary artery bypass surgery (CABG) in a South Asian cohort. MATERIAL AND METHODS: A single-center retrospective review was conducted on 1,508 patients having undergone isolated CABG surgery from January 2015 to January 2019. AKI was assessed on three definitions, and comparative receiver operating characteristics curves were built against the outcomes to assess discriminative power of each. RESULTS: Mean age of participants was 59.43 (±1.12) years, predominantly males (82.6%). Patients with AKI were elder, more likely to be diabetic and hypertensive. AKI by any definition occurred in 58.7% (885/1,508) patients. Frequency of AKI was 508 (33.7%), 517 (34.4%), and 871 (57.8%) on AKIN, KDIGO, and RIFLE criteria, respectively. The proportion of patients with RIFLE-risk 619 (41%) was greater compared with AKIN stage 1 (342 [22.7%]) and KDIGO stage 1 (330 [21.9%]), while for stages 2 and 3 the proportions were comparable across the three systems. Area under the curve (AUC) for 30-day mortality for AKIN was (0.786, [95% CI: 0.764-0.806]), KDIGO: (0.796, [95% CI: 0.775-0.816]) and for RIFLE (0.844, [95% CI: 0.825-0.862]). AUC for overall morbidity was in undesirable ranges (i.e., >0.5-≤0.7) for all three definitions. CONCLUSION: In a South Asian cohort, performance of AKIN and KDIGO criteria was comparable to diagnose AKI, while RIFLE definition, though overestimated the incidence of AKI particularly stage 1, and had an excellent discriminatory power to predict mortality compared to other two definitions.

Temporary epicardial pacing wires in isolated Coronary Artery Bypass Graft: Necessity or force of habit?

OBJECTIVE: To determine the frequency of Temporary epicardial pacing wires usage and its predictors in the immediate postoperative period in isolated coronary artery bypass graft surgery. METHODS: The longitudinal study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to August 2020, and comprised adult patients of either gender who underwent isolated coronary artery bypass graft in the Department of Cardiothoracic Surgery. Demographic, peri-operative and post-operative Temporary Epicardial Pacing Wires use data was extracted from patient's files and the institutional electronic database. Logistic regression models were built to explore predictors of Temporary epicardial pacing wires usage. Data was analysed using SPSS 22. RESULTS: Of the 322 cases evaluated, 27(8.4%) required the use of Temporary Epicardial Pacing Wires. Mean age of the patients requiring temporary epicardial pacing wires was 66.3±8.9 years compared to 58.7±8.9 years in those who did not require it (p<0.001), while the left ventricular ejection fraction percentage was 44.1±12.8 and 48.9±12.8 respectively (p=0.032). After adjusting for clinically plausible demographics and peri-operative variables, increasing age and low left ventricular ejection fraction were significantly associated with the use of temporary epicardial pacing wires in post-operative period of isolated coronary artery bypass graft patients (p<0.05). CONCLUSIONS: The frequency of temporary epicardial pacing wires usage in the post-operative period of coronary artery bypass graft was found to be low.

Understanding of metals dysregulation in patients with systolic and diastolic dysfunction in ischemic heart disease.

Ischemic heart disease (IHD) is the leading cause of death and chronic disability in the world. IHD affects both the systolic and diastolic function of the heart which progressively leads to heart failure; a structural and functional impairment of filling or ejection of blood from the heart. In this study, the progression of systolic and diastolic dysfunction characterized according to their echocardiographic parameters including left ventricular ejection fraction (EF), grades of diastolic dysfunction and ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), were correlated with differential regulation of various metals in patients sera samples (n = 62) using inductive coupled plasma-mass spectrometry (ICP-MS). Chromium, nickel and selenium were found significant (p < 0.05) in patients having EF < 45% compared with EF > 45%. In patients with systolic dysfunction (EF < 45%), the level of selenium was decreased while the level of chromium and nickel was increased compared to patients with EF > 45%. Selenium level was also decreased significantly (p < 0.05) in grade 1A and 2 patients that are considered as higher grades of diastole dysfunction in comparison to grade 0-1. Overall, selenium deficiency was identified in both systolic and diastolic dysfunctions of IHD patients corresponding to the progression of disease that could be related to many metabolic and translational pathways specifically which involve selenoproteins.

Pericardial fluid proteomic label-free quantification of differentially expressed proteins in ischemic heart disease patients with systolic dysfunction by nano-LC-ESI-MS/MS analysis.

Left ventricular systolic dysfunction (LVSD) is common in patients with pre-existing ischemic heart disease (IHD) and myocardial infarction. An untargeted proteomic approach is used to improve the understanding of the molecular mechanisms associated with LVSD and to find out potential proteomic signatures in pericardial fluid. The pericardial fluid of IHD (n = 45) patients was grouped into two categories according to the left ventricular ejection fraction, LVEF ≥45 (n = 33) and LVEF <45 (n = 12), and analyzed by using nano-liquid chromatography-mass spectrometry (nano-LC-MS/MS) technique. The nano-LC-MS/MS analysis resulted in the identification of 709 pericardial fluid (PF) proteins in both normal and impaired systolic functional groups (LVEF ≥45 vs. LVEF <45). Sixteen proteins were found to be differentially expressed (p < 0.05, fold change >2) including 12 down-regulated and 4 up-regulated in the impaired systolic functional group (LVEF <45) compared to the normal group (LVEF ≥45). Among the differentially expressed proteins the inflammatory marker albumin, atherosclerosis marker apolipoprotein A-IV and hedgehog-interacting protein marker of angiogenesis were predominantly associated with the impaired LVEF <45 group. KEGG pathway analysis revealed that the hedgehog (Hh) signalling pathway is up-regulated in LVSD reflecting the underlying molecular and pathophysiological processes.

Ionomic profiling of pericardial fluid in ischemic heart disease.

Metals are essential cofactors that play a crucial role in heart function at the cell and tissue level. Information regarding the role of metals in the pericardial fluid and its ionome in ischemic heart disease (IHD) is limited. We aimed to determine the association of elements in pericardial fluid and serum samples of IHD patients and their correlation with systolic and diastolic function. IHD patients have been studied with systolic and diastolic dysfunction categorized on the basis of echocardiographic parameters. We measured concentrations of sixteen elements in the pericardial fluid and serum of 46 patients obtained during open heart surgery with IHD by ICP-MS. The levels of chromium and nickel in pericardial fluid were significantly higher as compared with serum samples of IHD patients (p < 0.05). The chromium, nickel and manganese levels in pericardial fluid were lower in patients with ejection fraction (EF) < 45% as compared to EF > 45% (p < 0.05). There was no significant difference in pericardial concentrations of elements in diastolic dysfunction grade 0-1 with 2 in IHD patients. We also found that decreased concentration of these elements in pericardial fluid is associated with decreased systolic function. These results suggest that pericardial fluid concentrations of these metals may reflect the extent of ischemic heart disease. These findings are hypothesis generating with regards to a role in the pathogenesis of the disorder.

Untargeted metabolomic analysis of coronary artery disease patients with diastolic dysfunction show disturbed oxidative pathway.

INTRODUCTION: Left ventricular diastolic dysfunction (LVDD) is common in patients with coronary artery disease (CAD) with prevalence estimates of 34% and constitutes a predictor of all-cause mortality. Although diastolic dysfunction is induced by myocardial ischemia and has been shown to alter the clinical course, the role of coronary artery disease in the diastolic dysfunction and its progression into heart failure has not been completely elucidated. OBJECTIVE: The present study was conducted to identify possible metabolites in coronary artery disease patients that are differentially regulated in patients with diastolic dysfunction. METHODS: The serum of CAD (n = 75) patients and young healthy volunteers (n = 43) were analysed by using gas chromatography mass spectrometry (GC-MS) technique. Pre-processing of data results in 1547 features; among them 1064 features were annotated using NIST library. RESULTS AND CONCLUSION: Fifteen metabolites were found to be statistically different between cases and control. Variation in metabolites were identified and correlated with several clinically important echocardiography parameters i.e. LVDD grades, ejection fraction (EF) and E/e' values. The results suggested that metabolic products of fatty acid oxidation and glucose oxidation pathways such as oleic acid, stearic acid, palmitic acid, linoleic acid, galactose, pyruvic and lactic acids are predominantly up regulated in patients with coronary artery disease and severity of diastolic dysfunction appears to be linked to increase in fatty acid oxidation and inflammation. The metabolic fingerprints of these patients give us an insight into the pathophysiological mechanism of diastolic dysfunction in coronary artery disease patients although it did not identify validated novel markers.

Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction.

ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.

Microbiological and clinical profile of infective endocarditis patients: an observational study experience from tertiary care center Karachi Pakistan.

BACKGROUND: The study analyzed microbiological and antimicrobial susceptibility profile of organisms isolated from patients with infective endocarditis (2015-17) and compared disease outcomes in cohorts of endocarditis patient with history of prior invasive vascular intervention (high risk group) vs those without (native valve group). We hypothesized that high risk group would be more likely to have severe disease outcomes. METHODS: This was a prospective cohort study (2015-17). All blood and cardiac tissue samples of enrolled patients suspected of endocarditis according to modified Duke's criteria were followed for microbiological and antimicrobial susceptibility profile. The high risk group was compared with the native valve group with 90 day follow up to determine difference in clinical course and outcome in terms of disease severity (defined as any patient with endocarditis undergoing surgical management, readmission or dying). The data was analyzed using SPSS 21.0 software and chi-square test. 90 day mortality was calculated using Kaplan Meier survival curves. RESULTS: Total 104 patients with endocarditis were enrolled. Overall culture positivity rate was 71.2%. Streptococcus species were the most common isolate (36.7%), followed by S. aureus (17.3%) cases. In Streptococcus species, 14.2% showed intermediate susceptibility to penicillin. Thirty six patients were included in the cohort analysis. A poor outcome was seen in 85.7% high risk group as compared to 50% of native valve group. The overall mortality rate was 19.4%. CONCLUSIONS: We found Streptococcus species to be the predominant pathogen for endocarditis overall. However Staphylococcus aureus predominated native valve group. High risk group showed more complicated clinical course.

Bringing efficiency into practice: A quality improvement initiative to reduce operating room turnaround time.

Operating room (OR) turnaround time (TAT) is the minimal essential time required for cleaning of OR and preparation for the next case. The TAT inversely affects OR efficiency. Several factors related to personnel, equipment and scheduling have been identified as causes of increased TAT. We conducted the study to identify factors that affect OR TAT and to propose recommendations for its reduction. The retrospective study, conducted at Aga Khan University Hospital, Karachi, comprised TAT records related to March 2014. Of the 88 cases, 22(25%) showed a delay. Upon Pareto analysis it was found that in 8(36.6%) cases there was a delay of 70% related to scheduling of OR list and 5(22.7%) related to movement of patients from wards to OR. As such, improvement in these two broad areas can take care of majority of delays. We also recommend documentation of all processes as part of continuous improvement.

Innovations in cardiovascular care: Historical perspective, contemporary practice, recent trends and future directions.

Cardiovascular diseases continue to be a major cause of mortality and morbidity in the world population. First open heart procedure was performed by Gibbon in 1953, since then many advancements have been introduced to the field of cardiac surgery. Minimally invasive techniques were introduced, which include minimally invasive coronary artery bypass grafting (CABG), off-pump technique, minimally invasive valve surgery or transcatheter techniques to implant stentless or sutureless valves. The hybrid strategy to address coronary disease combines catheterisation procedures with standard surgical techniques. Cardiac imaging has also progressed to provide three-dimensional images of the heart, enabling surgeons to plan procedures with greater accuracy. Left ventricular assist devices can be used in patients suffering from cardiogenic shock or awaiting heart transplantation. Total artificial heart can be used for biventricular mechanical support. As technology becomes increasingly used for patient management, the future surgeon needs to be trained in minimally invasive surgical techniques.

Predictive Model for Blood Product Use in Coronary Artery Bypass Grafting.

OBJECTIVE: To build a clinical predictive model to determine the need for transfusing blood and its products in coronary artery bypass grafting (CABG) procedures in South East Asian population. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Section of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, from January 2006 to October 2014. METHODOLOGY: Information on pre-, intra- and postoperative variables were collected for all adult patients who underwent on-pump CABG. The patients grouped into those who received blood and its components, and those who did not. Aunivariate as well as multivariate logistic model was built to determine the predictors of transfusion. RESULTS: A total of 3,550 patients underwent CABG and males were dominant in both groups (75 vs. 93%). The transfusion rate was 56.4% (n=2001). Age (adjusted OR 1.03, p < 0.001), obesity (1.50, p=0.001), tobacco use (1.29, p=0.001), and male gender (4.51, p < 0.001) found to be a stronger predictor. Among preoperative comorbidities, diabetes (1.20, p=0.016), myocardial infarction (1.22, p=0.009), preoperative creatinine (1.12, p=0.033), and left main vessel disease of > 50% (1.49, p < 0.001) were independently associated with the outcome. Compared to elective cases, transfusion rates were high in urgent and emergent cases (OR: 1.93 and 3.36 respectively, p < 0.001 for both). CONCLUSION: Age, male gender, obesity, tobacco use, diabetes, myocardial infarction, high creatinine, urgent and emergent cases were independent predictors of transfusion in CABG procedure. This model can be utilized for preoperative risk stratification of patients and their management to improve the outcomes.

Fast Track Extubation In Adult Patients On Pump Open Heart Surgery At A Tertiary Care Hospital.

BACKGROUND: Fast-track cardiac surgery programs have been established as the standard of cardiac surgical care. Studies have shown that early extubation in elective cardiac surgery patients, including coronary and non-coronary open-heart surgery patients does not increase perioperative morbidity and mortality. The objective of this observational study was to determine the success and failure profile of fast track extubation (FTE) practice in adult open-heart surgical patients. METHODS: The study was conducted at cardiac operating room and Cardiac Intensive Care Unit (CICU) of a tertiary care hospital for a period of nine months, i.e., from Oct 2014 to June-2015. All on pump elective adult cardiac surgery patients including isolated CABG, isolated Valve replacements, combined procedures and aortic root replacements were enrolled in the study. Standardized anesthetic technique was adopted. Surgical and bypass techniques were tailored according to the procedure. Success of Fast track extubation was defined as extubation within 6 hours of arrival in CICU. RESULTS: A total of 290 patients were recruited. The average age of the patients was 56.3±10.5 years. There were 77.6% male and 22.4% female patients. Overall success rate was 51.9% and failure rate was 48.1%. The peri-operative renal insufficiency, cross clamp time and CICU stay (hours) were significantly lower in success group. Re-intubation rate was 0.74%. CONCLUSION: The perioperative parameters were significantly better in success group and the safety was also demonstrated in the patients who were fast tracked successfully. To implement the practice in its full capacity and benefit, a fast track protocol needs to be devised to standardize the current practices and to disseminate the strategy among junior anaesthesiologists, perfusionists and nursing staff.

Pulmonary scedosporiosis mimicking aspergilloma in an immunocompetent host: a case report and review of the literature.

A case of localized lung scedosporiosis is reported here that mimicked aspergilloma in an immunocompetent host. Through this case the importance of considering Scedosporium spp. in differential diagnosis of locally invasive lung infections and fungal ball is highlighted. As it is difficult to differentiate Scedosporium from Aspergillus on clinical grounds, microscopy, radiology and histopathology, this case is further emphasizing the significance of the definitive etiological characterization of Scedosporium through culture or molecular diagnostic tools. Accurate identification of Scedosporium, surgical resection and high-dose voriconazole has been associated with favorable outcome in most reported cases of scedosporiosis.

Towards excellence in cardiac surgery: experience from a developing country.

OBJECTIVE: The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark. DESIGN: Cross-sectional (prospectively collected data analysed and compared retrospectively). SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons' National Cardiac Database (STS-NCD). RESULTS: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%). CONCLUSIONS: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world.

Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan.

BACKGROUND: Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease. METHODS: Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed. RESULTS: Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (≥2 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively. CONCLUSION: Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.

EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons risk algorithm.

INTRODUCTION: This study presents a validation series for EuroSCORE II compared with the previous additive and logistic EuroSCORE and the Society of Thoracic Surgeons risk prediction algorithm. PATIENTS AND METHODS: Clinical data of 2004 patients undergoing isolated coronary artery bypass surgery between 2006 and 2010 were retrospectively collected and individual expected risks of death were calculated by all 3 risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration. RESULTS: There were 76 deaths (3.8%) among 2004 patients. The mean EuroSCORE II predicted mortality was 3.72% ± 5.11%, additive EuroSCORE was 4.35% ± 3.65% and logistic EuroSCORE was 6.41% ± 10.06%. The additive EuroSCORE was better than EuroSCORE II in terms of both discrimination and calibration (C-statistic 0.866 and Hosmer-Lemeshow p value 0.230 vs. C-statistic 0.836 and Hosmer-Lemeshow p value 0.013 for EuroSCORE II). In a subset of 380 patients, we compared EuroSCORE II with the Society of Thoracic Surgeons risk prediction. Actual mortality was 2.89%. Predicted mortality by EuroSCORE II was 4.27% ± 5.22% and Society of Thoracic Surgeons risk prediction was 2.30% ± 4.16%. The area under the curve was 0.759 for EuroSCORE II and 0.898 for the Society of Thoracic Surgeons risk prediction, whereas the Hosmer-Lemeshow p value was 0.267 for EuroSCORE II and 0.981 for Society of Thoracic Surgeons risk prediction. CONCLUSION: The Society of Thoracic Surgeons risk prediction algorithm is a better risk assessment tool compared to additive and logistic EuroSCORE and EuroSCORE II in Pakistani patients.

Heart valve surgery: EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons score.

BACKGROUND: This is a validation study comparing the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with the previous additive (AES) and logistic EuroSCORE (LES) and the Society of Thoracic Surgeons' (STS) risk prediction algorithm, for patients undergoing valve replacement with or without bypass in Pakistan. PATIENTS AND METHODS: Clinical data of 576 patients undergoing valve replacement surgery between 2006 and 2013 were retrospectively collected and individual expected risks of death were calculated by all four risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration. RESULTS: There were 28 deaths (4.8%) among 576 patients, which was lower than the predicted mortality of 5.16%, 6.96% and 4.94% by AES, LES and EuroSCORE II but was higher than 2.13% predicted by STS scoring system. For single and double valve replacement procedures, EuroSCORE II was the best predictor of mortality with highest Hosmer and Lemmeshow test (H-L) p value (0.346 to 0.689) and area under the receiver operating characteristic (ROC) curve (0.637 to 0.898). For valve plus concomitant coronary artery bypass grafting (CABG) patients actual mortality was 1.88%. STS calculator came out to be the best predictor of mortality for this subgroup with H-L p value (0.480 to 0.884) and ROC (0.657 to 0.775). CONCLUSIONS: For Pakistani population EuroSCORE II is an accurate predictor for individual operative risk in patients undergoing isolated valve surgery, whereas STS performs better in the valve plus CABG group.