Scales for pre-operative risk assessment

Objectives

The Ontario scoring system

(source: http://circ.ahajournals.org/content/91/3/677.long)

• For predicting risk of mortality, ICU length of stay, and overall PostOp length of stay following cardiac surgery

The Parsonnet score

• For predicting risk of mortality following cardiac surgery

euroSCORE II

• For predicting risk of mortality following cardiac surgery

Cleveland Clinic score

• For predicting risk of morbidity and mortality following cardiac surgery

(original publication: Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. J Am Med Assoc 1992;267:2344±2348.)

French score

• For predicting risk of morbidity and mortality following cardiac surgery

(original publication: Roques F, Gabrielle F, Michel P, De Vincentiis C, David M, Baudet E.
Quality of care in adult heart surgery: proposal for a self-assessment approach based on a French multicenter study. Eur J Cardiothorac Surg 1995;9:433-439; discussion 439-440.)

Quality Measurement and Management Initiative (QMMI)

• For predicting risk of morbidity and mortality following coronary artery bypass grafting (CABG) surgery

Variables

The Ontario scoring system

• Gender
• Age
  • <65
  • 65 to 74
  • >74
• Urgency of surgery
  • Elective
  • Urgent
  • Emergency
• Type of surgery
  • CABG only
  • Single valve
  • Complex
• Ejection fraction (EF)
  • EF > 50%
  • 35 to 50%
  • 20 to 34%
  • EF < 20%
• Repeat operation
  • No
  • Yes

The Parsonnet score

Patient related factors

• Gender
• Age
  • < 70
  • 70 to 74
  • 75 – 79
  • ¿ 80
• Morbid obesity
  • Yes (¿ 1.5 x ideal weight)
  • No
• Diabetes
  • Yes (unspecific type)
  • No
• Ejection fraction (EF)
  • ¿ 50%
  • 30 – 49%
  • <30 %
• Hypertension
  • Yes (BP > 140/90 mmHg) or on antihypertensive medications
  • No
• Reoperation
  • None
  • First
  • Second
• Preoperative Intra-aortic balloon pump
  • Yes
  • No
• Left ventricular aneurysm
  • Yes
  • No
• Emergency surgery
  • Yes (following PTCA or catheterisation complications)
  • No
• Dialysis
  • Yes
  • No
• Severity of catastrophic states (e.g. acute structural defect, cardiogenic shock, acute renal failure or others)
  • One
  • Two
  • Three
  • Four
  • Five
• Severity of other rare circumstances (e.g. paraplegia, pacemaker dependency, congenital health disease, severe asthma, others)
  • One
  • Two
  • Three
  • Four
  • Five

Surgery related factors

• Aortic valve surgery
  • Yes (with AV pressure gradient ¿ 120 mmHg)
  • Yes (with AV pressure gradient > 120 mmHg)
  • No
• Mitral valve surgery
  • Yes (with systolic PAP < 60 mmHg)
  • Yes (with systolic PAP ¿ 60 mmHg)
  • No
• CABG at time of valve surgery
  • Yes
  • No

euroSCORE II

Patient related factors

• Gender
• Age
• Renal impairment (creatinine clearance)
  • Normal (CC > 85 ml/min)
  • Moderate (CC > 50 & < 85 ml/min)
  • Severe (CC < 50 ml/min)
  • Dialysis
• Extracardiac arteriopathy
  • Claudication
  • Carotid occlusion or >50% stenosis
  • Amputation for arterial disease
  • Previous or planned intervention on the abdominal aorta, limb arteries or carotids
• Poor mobility
  • Yes
  • No
• Previous cardiac surgery
  • Yes
  • No
• Chronic lung disease
  • Yes
  • No
• Active endocarditis
  • Yes
  • No
• Critical preoperative state
  • Yes
  • No
• Diabetes on insulin
  • Yes
  • No

Cardiac related factors

• NYHA (New York Heart Association Functional Classification)
  • I: no symptoms and no limitation in ordinary physical activity
  • II: mild symptoms and slight limitation during ordinary activity
  • III: Marked limitation in activity due to symptoms, even during less than ordinary activity
  • IV: Severe limitation, experience symptoms even while at rest.
• CCS class 4 angina (angina at rest)
  • Yes
  • No
• Left Ventricular (LV) Function (EF: ejaculation fraction)
  • LVEF: > 50% (good)
  • LVEF: 31 – 50% (moderate)
  • LVEF: 21 – 30% (poor)
  • LVEF: 20% or less (very poor)
• Recent MI
  • Yes
  • No
• Pulmonary hypertension
  • No
  • Moderate (Pulmonary Artery systolic: 31-50 mmHg)
  • Severe (Pulmonary Artery systolic: >50 mmHg)

Operation related factors

• Urgency
  • Elective
  • Urgent
  • Emergency
  • Salvage
• Weight for the intervention
  • Isolated CABG
  • Single non CABG
  • Two procedures
  • Three procedures
• Surgery on thoracic aorta
  • Yes
  • No

Cleveland Clinic score

• Emergency case – 6
• Serum creatinine
  • ¿ 141 and ¿ 167 ¿mol/L – 1
  • ¿ 168 ¿mol/L – 4
• Severe left ventricular dysfunction – 3
• Reoperation – 3
• Operative mitral valve insufficiency – 3
• Age ¿ 65 and ¿ 74y – 1
• Age ¿ 75 – 2
• Prior vascular surgery
• Chronic obstructive pulmonary disease
• Anaemia (haematocrit ¿ 0.34) – 2
• Operative aortic valve stenosis – 1
• Weight ¿ 65 kg – 1
• Diabetes, on oral or insulin therapy – 1
• Cerebrovascular disease – 1

French score

Quality Measurement and Management Initiative (QMMI)

• Age
  • < 60
  • 60 – 69
  • 70 – 79
  • ¿ 80
• Emergency
  • Elective
  • Urgent
  • Emergent
• Female gender
  • Yes
  • No
• Prior CABG
  • Yes
  • No
• Cardiogenic shock
  • Yes
  • No
• Ejection fraction
  • ¿ 50%
  • 30 – 49%
  • <30%
• Pre-CABG creatinine
  • < 132 ¿mol/L
  • 132 – 265 ¿mol/L
  • > 265 ¿mol/L
• Liver disease (history)
  • Yes
  • No
• Stroke or TIA (history)
  • Yes
  • No
• C.O.P.D
  • Yes
  • No
• Hypertension
  • Yes
  • No

Stratification & other info

The Ontario scoring system

(Adapted from: http://circ.ahajournals.org/content/91/3/677.long)

• Data collected from 13 098 patients at all nine adult cardiac surgery institutions in Ontario, Canada.

The Parsonnet score

euroSCORE II

• Predicted mortality = e (¿o + åbi Xi) / 1+ e (¿o + åbi Xi)
• Data collected from 22,381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May-July 2010)

Cleveland Clinic score

(Adapted from: Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. J Am Med Assoc 1992;267:2344-2348)

• Data collected from a retrospective analysis of 5051 patients in Cleveland Clinic Foundation, U.S.

French score

Quality Measurement and Management Initiative (QMMI)

• Data collected from 9,498 patients who underwent CABG and no other concomitant surgery at 12 academic medical centers from August 1993 to October 1995 in the U.S.