Author + information
- Mark Hensey, MBBCh, BAO@hensey99,
- Janarthanan Sathananthan, MBChB, MPH,
- Dale J. Murdoch, MBBS,
- Abdullah Alkhodair, MD,
- Jian Ye, MD,
- Anson Cheung, MD,
- Philipp Blanke, MD,
- Jonathon Leipsic, MD@JonathonLeipsic,
- David A. Wood, MD and
- John G. Webb, MD∗ ()
- ↵∗St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
The Society of Thoracic Surgeons (STS) score is a risk-prediction model for cardiac surgery based on data from the STS National Adult Cardiac Surgery Database. Original scores were derived from patient data from 2002 to 2006. The score has had a recent major update based on STS data from 2011 to 2016 to incorporate evolving changes in patient characteristics and surgical practice (1,2). Several new parameters for risk calculation have been included. We aimed to evaluate the effect of the updated score on documented STS scores from a cohort of patients in our institution who had been included in the PARTNER (Placement of AoRTic TraNscathetER Valve) II trials.
We examined a cohort of 24 patients who were in the PARTNER II trials. Thirteen patients were included in PARTNER II A, which assessed transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients at intermediate risk (STS score: 4% to 8%) for surgical intervention (3). Eleven patients were included in the PARTNER II ViV (Valve-in-Valve) registry, which assessed the outcomes of patients who underwent transcatheter aortic ViV replacement and who were at high risk for surgical re-intervention (4). Updated STS scores were calculated using the updated STS Adult Cardiac Surgery Database version 2.9 using data from the time of trial enrollment. The p values were calculated using a paired Student’s t-test.
Mean STS score for predicted mortality in the combined group fell from 6.9 ± 3.3% to 4.7 ± 2.4% (p < 0.001). In the PARTNER II A cohort, mean STS score fell from 4.9 ± 0.6% to 3.3 ± 1.1% (p < 0.001), and in the ViV cohort, mean STS score fell from 9.3 ± 3.6% to 6.3 ± 2.6% (p = 0.001). All patients had a reduction in their calculated STS score (Figure 1A). In the total cohort, 15 patients (62.5%) dropped from either high to intermediate or intermediate to low risk groups (Figure 1B).
The updated STS score offers a contemporary assessment of risk for patients undergoing cardiac surgery and has been validated with up-to-date patient outcomes. Our study showed a statistically significant reduction in STS score when applying the updated score to historical patients being assessed for TAVR or SAVR compared with previous versions of the score. Although this was a small single-center study, we demonstrated a statistically and clinically significant change in patient risk categorization. The implication was that the use of the updated STS score will result in a lower risk estimation of cardiac intervention and may move patients from a higher risk group to a lower risk group. In our cohort, the intermediate-risk PARTNER II A group became a low-risk group with application of the new STS score; similarly, the ViV group moved from high risk to intermediate risk. The reasons for this reduction are complex and multifactorial, with improved surgical techniques and post-operative care likely being the most important factors. It could also be hypothesized that increasing numbers of complex patients being treated with TAVR for severe aortic stenosis rather than SAVR might have resulted in a reduction in adverse surgical outcomes, thus contributing to lower STS score prediction. Our study only examined those patients being assessed for TAVR or SAVR, so our results might not be generalizable to patients undergoing assessment for other interventions.
When calculating STS scores for patients being assessed for cardiac surgical or transcatheter interventions, one must be mindful that the current STS score may not correlate with previous versions; therefore, patients may not be comparable to those included in previous landmark trials.
Please note: Dr. Ye has been a consultant to Edwards Lifesciences. Dr. Blanke has been a consultant to Edwards Lifesciences, Tendyne, Circle Cardiovascular Imaging, Neovasc, and W.L. Gore. Dr. Leipsic has been a consultant to Edwards Lifesciences and CVI; has provided CT core lab services for Edwards Lifesciences, Medtronic, Neovasc, GDS, and Tendyne Holdings; holds stock in Circle CVI; and has stock options in, is a consultant to, and receives institutional research support from HeartFlow. Dr. Wood is a consultant to Edwards Lifesciences and Medtronic; and has received grant support from Abbott and Edwards Lifesciences. Dr. Webb has been a consultant to and has received research funding from Edwards Lifesciences, Abbott, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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