http://repub.eur.nl/res/aut/27825/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/34226/ 2011-04-01T00:00:00Z Objective: At this moment, no risk stratification models are available for adult congenital cardiac surgery. This study aims to identify a suitable stratification tool for the adult congenital heart surgery population. Pediatric congenital cardiac surgery score models were therefore tested in an adult congenital population. In addition, an age component was added to these models and performance was compared with the original score systems. Methods: The Risk Adjustment in Congenital Heart Surgery (RACHS-1), Basic Aristotle Score, Society of Thoracic Surgeons (STS)-European Association for Cardiothoracic Surgery (EACTS) Score and Comprehensive Aristotle Score were calculated for all adult patients who underwent congenital cardiac surgery between January 1990 and January 2007 in a single center (N= 963). In addition, an age component was added to these models. Discrimination was then tested for all models with and without the age component. Results: Application of the original pediatric risk scores resulted in c-statistics for 30-day mortality of 0.60, 0.60, 0.60, and 0.66 respectively. Combining these models with the age component resulted in significantly higher c-statistics of 0.69, 0.70, 0.69, and 0.76 respectively. Age as a sole predictor already resulted in a c-statistic of 0.67. Comparable results were found for 1-year mortality. Conclusions: The discriminatory power of the pediatric risk scores was suboptimal, but increased when adding age as a score component. The best performance was achieved by the combination of age and the Comprehensive Aristotle Score, for both 30-day and 1-year mortality. http://repub.eur.nl/res/pub/22677/ 2010-11-10T00:00:00Z There is a steady increase in the number of patients undergoing cardiac surgery in The Netherlands [1]. As can be appreciated from Figure 1, 16,877 adult surgical cardiac procedures were performed in 2008. In addition, the number of transcatheter procedures, including valve and coronary stent implantation, is also growing rapidly. Given the ageing of the population and the increasing number of patients with congenital heart disease that reaches adulthood, the number of surgical and transcatheter interventions is likely to increase even further [2, 3]. The growing population requiring these cardiovascular interventions will lead to an increase in health care expenditure. This calls for a cost-effective approach of health care, with constant attention for the relation between cost-effectiveness and quality of care. Quality assessment is an inherent component of this approach. In addition, by improving the quality of care (including optimizing treatment selection), fewer adverse outcomes are to be expected, with a subsequent restraint of costs. http://repub.eur.nl/res/pub/28289/ 2010-11-01T00:00:00Z Objective: Surgery is the first choice of treatment for localised non-small-cell lung cancer (NSCLC). When making decisions regarding resection, physicians must balance the potential long-term benefits of surgery with the risk of surgery-related death, particularly among elderly patients with multiple co-morbid conditions. In 2005, a predictive model with a preoperative and a postoperative mode to predict survival of an individual patient after NSCLC surgery was created. This model combines the patient-, tumour- and treatment characteristics and can be used to assist in clinical decision making. Till present, this model has not been validated. The purpose of this study was to validate this model in patients operated on for primary NSCLC. Methods: A total of 126 patients underwent surgery for primary NSCLC between January 2002 and December 2006. Required model variables were collected for all patients and inserted into the model. To evaluate the performance of the two models, we assessed these models in terms of both discrimination (resolution) and calibration (reliability). The discriminative ability was measured using the c-index and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit test. Results: The median follow-up time was 3.4 years. Hospital mortality was 2.4%. One-, 2- and 3-year survival was 86%, 75% and 72%, respectively. The discriminative ability of the preoperative mode showed a c-statistic for 1-year survival of 0.68, for 2-year of 0.68 and for 3-year of 0.66. The postoperative model showed a discriminative ability for 1-year survival of 0.72, for 2-year of 0.76 and for 3-year of 0.77. Calibration was adequate for the first 2 years. The preoperative mode showed a p-value of 0.62 for 1-year survival and 0.14 for 2-year survival. Calibration was poor for 3-year survival (p= 0.0027). For the postoperative mode, calibration was quite similar with p-values of 0.4 for 1-year survival, 0.14 for 2-year survival and 0.003 for 3-year survival. Conclusions: The model adequately estimates the 1- and 2-year survival. Discrimination was good for 3-year survival. Inclusion of more factors with additional prognostic value could potentially further improve the accuracy of the model. http://repub.eur.nl/res/pub/27301/ 2010-02-01T00:00:00Z Background: Surgical risk scores, such as the logistic EuroSCORE (LES) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS) score, are commonly used to identify high-risk or "inoperable" patients for transcatheter aortic valve implantation (TAVI). In Europe, the LES plays an important role in selecting patients for implantation with the Medtronic CoreValve System. What is less clear, however, is the role of the STS score of these patients and the relationship between the LES and STS. Objective: The purpose of this study is to examine the correlation between LES and STS scores and their performance characteristics in high-risk surgical patients implanted with the Medtronic CoreValve System. Methods: All consecutive patients (n = 168) in whom a CoreValve bioprosthesis was implanted between November 2005 and June 2009 at 2 centers (Bern University Hospital, Bern, Switzerland, and Erasmus Medical Center, Rotterdam, The Netherlands) were included for analysis. Patient demographics were recorded in a prospective database. Logistic EuroSCORE and STS scores were calculated on a prospective and retrospective basis, respectively. Results: Observed mortality was 11.1%. The mean LES was 3 times higher than the mean STS score (LES 20.2% ± 13.9% vs STS 6.7% ± 5.8%). Based on the various LES and STS cutoff values used in previous and ongoing TAVI trials, 53% of patients had an LES ≥15%, 16% had an STS ≥10%, and 40% had an LES ≥20% or STS ≥10%. Pearson correlation coefficient revealed a reasonable (moderate) linear relationship between the LES and STS scores, r = 0.58, P < .001. Although the STS score outperformed the LES, both models had suboptimal discriminatory power (c-statistic, 0.49 for LES and 0.69 for STS) and calibration. Conclusions: Clinical judgment and the Heart Team concept should play a key role in selecting patients for TAVI, whereas currently available surgical risk score algorithms should be used to guide clinical decision making. http://repub.eur.nl/res/pub/27211/ 2009-12-01T00:00:00Z http://repub.eur.nl/res/pub/24345/ 2009-07-01T00:00:00Z Objective: With a growing number of children with congenital heart disease (CHD) reaching adulthood, an extensive experience with cardiac surgery in adults with CHD is accumulating. To increase insight in this patient category we report our 17-year single centre experience including predictors for adverse outcome and EuroSCORE performance. Methods: Patients and operative characteristics of all consecutive adult CHD patients operated upon between January 1990 and January 2007 were collected. Categorisation was done according to the EACTS/STS congenital database. Early and late morbidity and mortality were assessed with follow-up extending up to 17 years. EuroSCORE performance was assessed. Results: Nine hundred and sixty-three procedures were performed in 830 patients (mean age 39.3 years, 50.3% male). A total of 49% were re-do procedures, frequent procedures were for left heart lesions (37%), right heart lesions (31%) and septal defects (8%). The 51% primary procedures largely consisted of less complex procedures but also included 1.4% of tetralogy of Fallot repairs, 4.1% of aortic coarctation repairs and 2.7% of Ebstein's disease repairs. Thirty-day mortality was 1.5% (n = 14); predicted mortality by logistic EuroSCORE was 4.6%. c-index was 0.61 (95% CI 0.46-0.75). Major complications such as tamponade requiring intervention occurred in 3.2%, postoperative bleeding requiring re-exploration in 7.1% and renal insufficiency requiring dialysis in 4 (0.4%). Pulmonary hypertension was a strong predictor for short-term mortality; impaired ventricular function and cyanosis for long-term mortality. Overall 17-year survival was 71% (95% CI 61%-82%). Eighty percent of patients were in NYHA class I at last follow-up, 17% in II, 3% in III, 0% in IV. Conclusions: Surgery in adult CHD patients can be performed with low operative mortality and good clinical outcome. EuroSCORE is not a good model for risk assessment in this group of patients. http://repub.eur.nl/res/pub/27259/ 2009-07-01T00:00:00Z Results of surgical repair of atrioventricular septal defect (AVSD), both partial (PAVSD) and complete (CAVSD), have improved. However, reoperation is not uncommon. This report describes our experience in 59 patients who underwent reoperation after AVSD repair, between 1977 and 2008. Thirty-one patients had a PAVSD, 28 had a CAVSD. Mean interval between initial repair and reoperation was 10±11 years (PAVSD vs. CAVSD: 13±12 vs. 6±9 years, P=0.063). Reoperations were required for left atrioventricular valve regurgitation (LAVVR) in 53 patients (combined with right atrioventricular valve regurgitation in 10, atrial septal defect (ASD) in 11, ventricular septal defect (VSD) in 7, left ventricular outflow tract (LVOT) obstruction in 1, and aortic valve stenosis in 1), ASD in 3, and LVOT obstruction in 3. Valve repair was performed in 45 patients and replacement in 8. Repair techniques of the leftsided atrioventricular valve (LAVV) included cleft closure in 44 patients, commissuroplasty in 19, and annuloplasty in 1. Freedom from additional reoperation was 85%, and 80% at 5 and 15 years. Hospital mortality was 3%. Overall survival was 91%, and 86% after 5 and 15 years. The most common indication to undergo reoperation is LAVVR. Reoperation is safe and in the majority of cases, a durable repair of the LAVV can still be achieved. http://repub.eur.nl/res/pub/24344/ 2009-06-01T00:00:00Z Objective: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. Methods: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n = 179) were included. We studied their characteristics, treatment decisions, and survival. Results: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p = 0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p = 0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. Conclusions: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery. http://repub.eur.nl/res/pub/24279/ 2009-04-01T00:00:00Z Background: The SYNTAX score, a comprehensive angiographic scoring system, was recently developed as a tool for risk stratification during the SYNTAX trial (randomized trial comparing coronary artery bypass grafting with percutaneous coronary intervention). We applied the SYNTAX score in patients with left main coronary artery disease who underwent coronary artery bypass grafting to examine its role in predicting incidences of major adverse cardiac and cerebrovascular events (MACCE) within 30 days and 1 year. Methods: One hundred forty-eight patients were studied. Their angiograms were scored according to the SYNTAX score. The MACCE-free survival curves were estimated by the Kaplan-Meier method. Univariate and multivariate analyses determined risk factors for MACCE. Performance of the SYNTAX score was studied with respect to discrimination by receiver-operating characteristic curves with their area under the curve (c-index). Classification and regression tree analysis was performed to identify the best outcome predictors and develop a risk stratification model. Results: Overall SYNTAX score ranged from 11 to 53 (mean, 24 ± 9). At 30 days and 1 year, 15 (10%) and 19 (13%) patients experienced MACCE. Patients with a higher SYNTAX score had a significantly (p < 0.0001) poorer MACCE-free survival. In multivariate analysis, SYNTAX score, female sex, and incomplete revascularization were associated with a higher rate of MACCE in 30 days. The SYNTAX score was the single predictor for MACCE in 1 year. The c-index of the SYNTAX score was 0.88 for 30 days and 0.90 for 1 year, respectively. The SYNTAX score was the best single discriminator between patients with and those without MACCE, with a discrimination level of 36.5. Conclusions: The SYNTAX score is the first coronary vasculature complexity score predictive for postoperative outcome in patients with left main coronary artery disease undergoing coronary artery bypass grafting. The outcomes of the ongoing SYNTAX trial will definitively define the role of the SYNTAX score in predicting short-term and long-term incidence of MACCE. http://repub.eur.nl/res/pub/28779/ 2008-03-01T00:00:00Z Background: The EuroSCORE (European System for Cardiac Operative Risk Evaluation) is often used to benchmark and predict hospital mortality after cardiac surgery. Based mainly upon coronary surgery patients, EuroSCORE may not be optimal for valve surgery patients. We evaluated the New York (NY) State dedicated valve surgery models and compared their performance to the EuroSCORE model. Methods: Required model variables were collected prospectively for all patients, followed by calculation of predictive mortality rates using the logistic and additive EuroSCORE, the logistic and additive NY State models for valve surgery without concomitant coronary surgery (isolated valve surgery) and the logistic and additive NY State models for combined valve and coronary surgery. Results: Observed mortality was 2.8% (25 of 904) for isolated valve surgery and 6.8% (27 of 395) for valve plus coronary surgery. Logistic NY State and EuroSCORE expected mortality for isolated valve surgery was respectively 3.0% and 6.1%, and for valve plus coronary surgery 5.9% and 7.8%. The logistic NY State model for isolated valve surgery showed better discrimination (c-index 0.86 versus 0.76) and calibration than the logistic EuroSCORE. Discriminatory power for the logistic NY State model for valve plus coronary surgery was comparable to the logistic EuroSCORE (c-index 0.74 versus 0.72), as was calibration. Conclusions: Our results suggest that dedicated risk models for valve surgery may be useful to provide more valid estimates of hospital mortality after heart valve surgery. Further exploration is needed to demonstrate general applicability of our results and assess the possible additional value of separate models for isolated valve surgery and valve plus coronary artery surgery, or aortic and mitral valve surgery, or both.