Outcome Prediction After Coronary Surgery and Redo Surgery for Bleeding (From the KROK Registry)

Re-exploration After Cardiac Surgery Impairs Outcome—But How to Stratify the Risk?

“…We know that urgent and more complex surgery, cardiac surgery performed under hypothermic circulatory arrest, and sicker patients with comorbidities such as hepatic or renal dysfunction are prone to a greater risk of postoperative bleeding and re-exploration. 12,13 The latter is supported in the present study 4 with its higher median EuroSCORE II in patients with surgical re-exploration. Several scoring models have been developed to predict the risk of transfusion and bleeding after cardiac surgery.…”

“…9 The relative low incidence of these complications makes survival analysis in this subset of patients difficult, emphasizing the value of the present study. 4 In agreement with the findings by Knapik et al, 4,7 the more recent studies included in the aforementioned meta-analysis showed a greater risk of morality related to reexploration than studies before the year 2000. 9 The poor performance of EuroSCORE II in the population with surgical reexploration is not surprising because surgical risk stratification models exclusively consider preoperative and easily predictable intraoperative risk factors.…”

“…EuroSCORE analyses in large registries generally tend to underestimate the risk score owing to inevitably missing data and required imputation in some patients. In agreement, the observed mortality of 2.2% in the analysis by Knapik et al 4 was nominally greater than the predicted mortality of 2.0% § 3.2%. In agreement with a former meta-analysis, 6 the authors found that the mortality in patients in the lowest quartile of EuroSCORE II (eg, <1%) was overestimated, whereas in the highest quartile of Euro-SCORE II (eg, >3%), mortality was underestimated.…”

“…Importantly, such models need regular reevaluation and periodic revisions, including recalibration and remodeling, because cardiac procedures and techniques and perioperative treatment continue to develop and patient risk factors may change over time. 2,3 In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Knapik et al 4 evaluated the predictive reliability of the EuroSCORE II 5 in more than 41,000 patients undergoing isolated coronary artery bypass graft (CABG) surgery from the Polish National Registry of Cardiac Surgical Procedures. In the first part of their study, the authors found that the EuroSCORE II was a reliable risk stratification tool in their cardiac surgery population, represented by an area under the curve of 0.76 for predicting 30-day mortality and an observedto-expected mortality ratio of 1.08.…”

“…Obviously, EuroSCORE II increases by 5 to 15 times, corresponding to the markedly increased mortality observed in patients with re-exploration. 4,7,9 However, it remains unclear whether an approach using a least squares method to drive a nomogram as suggested by the authors 4 is advantageous compared with a second recalculation of the EuroSCORE before reexploration.…”