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J Thorac Cardiovasc Surg 2008;135:186-187
© 2008 The American Association for Thoracic Surgery

Evolving Technology

Discussion

Dr Eugene H. Blackstone (Cleveland, Ohio). Dr Dewey, I congratulate you and your colleagues on this particularly timely study. Decisions are being made, at least temporarily, about appropriate candidates for early trials of percutaneous AVR. Further, survival after device placement is being compared with that expected were open surgery performed using some of these algorithms. Your study simultaneously addresses the issue of risk stratification to identify the highest risk patients and risk calibration to quantify expected risk. You paint a somewhat disturbing picture.

As an aside, I particularly appreciate your recognizing that early risk does not stop at hospital discharge or even at 30 days, but extends further—in patients with complex problems sometimes many months—a fact that none of these models accounts for explicitly.

Your study is in the same vein as the one recently presented by the Heidelberg group at the European Association. It augments it, however, by looking at three algorithms for risk stratification and expected survival rather than just at the EuroSCORE. Let me highlight three findings of that group, because they lead to a question about your study.

First, in the highest-risk patients, EuroSCORE greatly overestimated risk, just as you have found. This means that expected risk is not well calibrated to actual risk and calls into question not just which patient is at high risk but also any attempt to use estimated risk as a barometer to assess observed risk of alternative procedures.

Second, they found that calibration progressively worsened with era of operation. The EuroSCORE . . . [Full Text of this Article]

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Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement

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J. Thorac. Cardiovasc. Surg. 2008 135: 180-187. [Abstract] [Full Text] [PDF]