Analysis of sex differences in the clinical presentation, management and prognosis of infective endocarditis in Spain

IntroductionSex-dependent differences of infective endocarditis (IE) have been reported. Women suffer from IE less frequently than men and tend to present more severe manifestations. Our objective was to analyse the sex-based differences of IE in the clinical presentation, treatment, and prognosis.Material and methodsWe analysed the sex differences in the clinical presentation, modality of treatment and prognosis of IE in a national-level multicentric cohort between 2008 and 2018. All data were prospectively recorded by the GAMES cohort (Spanish Collaboration on Endocarditis).ResultsA total of 3451 patients were included, of whom 1105 were women (32.0%). Women were older than men (mean age, 68.4 vs 64.5). The most frequently affected valves were the aortic valve in men (50.6%) and mitral valve in women (48.7%). Staphylococcus aureus aetiology was more frequent in women (30.1% vs 23.1%; p<0.001).Surgery was performed in 38.3% of women and 50% of men. After propensity score (PS) matching for age and estimated surgical risk (European System for Cardiac Operative Risk Evaluation II (EuroSCORE II)), the analysis of the matched cohorts revealed that women were less likely to undergo surgery (OR 0.74; 95% CI 0.59 to 0.91; p=0.05).The observed overall in-hospital mortality was 32.8% in women and 25.7% in men (OR for the mortality of female sex 1.41; 95% CI 1.21 to 1.65; p<0.001). This statistical difference was not modified after adjusting for all possible confounders.ConclusionsFemale sex was an independent factor related to mortality after adjusting for confounders. In addition, women were less frequently referred for surgical treatment.

Comparison of EuroSCORE II with EuroSCORE in Cardiac Surgical Patients in a Tertiary Level Teaching Hospital in Nepal

Introduction European System for Cardiac Operative Risk Evaluation (EuroSCORE) is the standard tool for risk stratification of patients undergoing cardiac surgery. Its relevance has been validated in European, Asian countries and also in Nepal. Its limitations led to development of EuroSCORE II. This study was carried out to compare EuroSCORE II with EuroSCORE in Nepalese cardiac surgical patients. MethodsA retrospective analytical cohort study of 3 years duration in 972 adult cardiac surgeries was conducted. Scores obtained from EuroSCORE (Logistic and Additive) and EuroSCORE II was compared with the observed mortality. Calibration was calculated by Hosmer- Lemeshow (H-L) test (Chi Square test) and discrimination by calculating the area under the curve (AUC) of receiver operating characteristics (ROC) curve. ResultsObserved mortality was 4.11%. EuroSCORE additive, logistic and EuroSCORE II predicted mortality were 4.32%, 4.55% and 2.13% respectively. H-L chi square calculation for EuroSCORE additive model could not hold as all observed and expected frequencies match exactly. Hence it can be considered as a good fit. EuroSCORE logistic model (H-L, Chi-square 7.743, p<0.001) and EuroSCORE II (H-L, Chi-square 11.631, p = 0.168) also showed good fit i.e. both can predict mortality satisfactorily. AUC of ROC curve of EuroSCORE additive, logistic and EuroSCORE II were 0.632, 0.636 and 0.616 respectively, which showed fair discrimination power. ConclusionMortality prediction of adult cardiac surgical patients by EuroSCORE (additive and logistic) and EuroSCORE II was satisfactory.

Validation of Cardiac Surgery Score (CASUS) in Postoperative Cardiac Patients

Introduction. Cardiac Surgery Score (CASUS) was introduced in 2005 as the first postoperative scoring system specific for patients who had cardiac surgery. Prior to this, European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used preoperatively, while Intensive Care National Audit and Research Centre Score (ICNARC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, which are widely used in general intensive care unit population, have been used to score cardiac patients postoperatively. The development of CASUS by Hekmat and colleagues for use in postoperative cardiac patients aims to change this. We wanted to validate CASUS against the well-established preoperative Logistic EuroSCORE, and postoperative APACHE II and ICNARC scores. Method. Institutional approval for this study was granted by the Audit and Clinical Governance Committee. We analyzed prospectively collected data of patients who had cardiac surgery in Castle Hill Hospital between January 2016 and September 2018. All patients who underwent surgery in the unit would have had Logistic EuroSCORE, APACHE, and ICNARC scores calculated as standard. CASUS was then calculated for these patients based on their day 1 postoperative variables. The scoring systems were compared and data presented as area under the receiver operating characteristic curve. Result. Our study shows that CASUS is the best predictor of mortality followed by ICNARC, Logistic EuroSCORE, and APACHE II. ICNARC score remains the most accurate predictor of renal and pulmonary complication followed by CASUS. Conclusion. CASUS is a useful scoring system in post-cardiac surgery patients. The accuracy of CASUS and ICNARC scores in predicting mortality, pulmonary, and renal complications are comparable.

Failure to achieve a satisfactory cardiac outcome after isolated coronary surgery in low-risk patients

OBJECTIVES This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG). METHODS The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of &lt;2% and without any major comorbidity were the subjects of the present analysis. RESULTS Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3–346.3] and E-CABG bleeding grades 2–3 (OR 30.2, 95% CI 8.3–112.9) as independent predictors of hospital death. CONCLUSIONS Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery. Clinical Trial Registration NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).

Death in low-risk cardiac surgery revisited

BackgroundA systematic review of low-risk death has been shown successful in identifying system weaknesses. The aim was to analyse early mortality in low-risk patients undergoing cardiac surgery and to determine the cause of death, classify if they were unavoidable or potentially preventable as a result of technical or system errors.MethodsWe included all low-risk patients who underwent cardiac surgery at our institution from 1 September 2009 to 31 August 2019. In patients operated between 2009 and 2011, we defined low risk as an additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) I less than or equal to 3, and from 2012 and onwards as a EuroSCORE II less than or equal to 1.5. The medical records for the patients who died within 30 days of surgery were thoroughly examined and the cause of death was classified as cardiac or non-cardiac. Furthermore, deaths were categorised as not preventable, preventable (technical error) or preventable (system error).ResultsDuring the study period 3103 low-risk patients underwent surgery, and 11 patients died within 30 days of the operation (0.35%). Six of these (55%) were classified as preventable and five non-preventable. Four of the preventable deaths were classified as technical errors and two were due to system errors.ConclusionsA repeated systematic review of deaths in patients with a low preoperative risk showed that a majority of deaths were preventable, and therefore potentially avoidable. Similar to the previous assessment at our unit, mortality was very low and failure to communicate remains a modifiable factor that should be addressed.

Clinical value of the 20% logistic EuroSCORE cut-off for selecting TAVI candidates: a single-centre cohort study analysis

BackgroundA logistic European System for Cardiac Operative Risk Evaluation (logEuroSCORE) ≥20% is frequently recognised as a finite criteria for transcatheter aortic valve implantation (TAVI) reimbursement, despite guideline modifications to reflect the appropriacy of TAVI in selected lower-risk patients. The aim was to evaluate the clinical value of this threshold cut-off in TAVI patients and to identify factors associated with mortality in those below this threshold.MethodsWe analysed data from a single-centre, German, observational, TAVI-patient registry, gathered between 2008 and 2016. Patients were stratified by logEuroSCORE (≥ or <20%) for comparisons. Logistic regression was performed to identify predictors of mortality at 1 year, with this analysis used to generate a calculated (‘real’) risk value for each patient.Results1679 patients (logEuroSCORE <20%: n=789; logEuroSCORE ≥20%: n=890) were included. LogEuroSCORE <20% patients were significantly younger (80.1 vs 81.6 years; p<0.001) and less comorbid than logEuroSCORE ≥20% patients, with a higher rate of transfemoral TAVI (35.6% vs 26.1%; p<0.001) and predilation (70.0% vs 63.3%; p=0.004). Patients with a logEuroSCORE <20% experienced more vascular complications (3.4% vs 1.5%; p=0.010). One-year survival was 88.3% in the logEuroSCORE <20% and 81.8% in the logEuroSCORE ≥20% group (p=0.005), with the calculated mortality risk falling within 2% of the logEuroSCORE in just 12.9% of patients. In the logEuroSCORE <20% group, only coronary artery disease was significantly predictive of 1-year mortality (OR 2.408; 95% CI 1.361 to 4.262; p=0.003).ConclusionsAt our institution, patients with a logEuroSCORE <20% selected for TAVI have excellent outcomes. The decision not to reimburse TAVI in such patients may be viewed as inappropriate.

Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study

ObjectivesPostoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium.DesignProspective observational study.SettingSingle-centre at a European academic hospital.Primary and secondary outcome measuresIn our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD.ResultsA total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD.ConclusionsWe conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.