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J Thorac Cardiovasc Surg 2007;133:874-875
© 2007 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Discussion

Dr Marc R. de Leval (London, UK). I would like to congratulate Dr Al-radi and his colleagues for an important contribution to outcome analysis. The work is a validation study of 2 procedure-adjusted risk stratification methods based both on subjective opinions of a panel of experts. The hospital mortality predicted by the 2 scoring systems is compared with the observed hospital mortality following 13,675 operations performed in a single institution over a 22-year period. Two main findings can be extracted from their analysis.

First, the RACHS-1 categories more consistently represented the probability of hospital deaths compared with the ABC scoring system. We made similar observations in our institution. We assigned the ABC score and the RACHS-1 risk categories to 1085 open cardiac operations performed in the current era. Multiple logistic regression identified RACHS-1 category to be a powerful predictor of mortality, with a P value of <.0001, whereas the ABC score was only weakly associated with mortality, with a P value of .03.

The second finding is that both methods are weak discrimination tools in predicting hospital mortality. The authors claim that it is difficult to expect that knowing little else than the procedure, one can accurately predict the outcome. They imply that much more data, both patient- and anomaly specific, would be required. It will be interesting, of course, to see whether the comprehensive ABC score will be a more effective predictor of outcome. We must accept, however, that it will always be impossible to completely predict outcome, and the question is, how complicated should a risk adjustment be?

If the purpose is to be able to compare institutions or individual surgeons, it is important that patient- and procedure-specific factors do not overwhelm potential institution- or surgeon-specific factors. It would be better to try to understand the reasons for . . . [Full Text of this Article]

Related Article

Case complexity scores in congenital heart surgery: A comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system

Osman O. Al-Radi, Frank E. Harrell, Jr, Christopher A. Caldarone, Brian W. McCrindle, Jeffrey P. Jacobs, M. Gail Williams, Glen S. Van Arsdell, and William G. Williams
J. Thorac. Cardiovasc. Surg. 2007 133: 865-875. [Abstract] [Full Text] [PDF]