Article

Validation and Re-Evaluation of a Discriminant Model Predicting Anatomic Suitability for Biventricular Repair in Neonates With Aortic Stenosis

Harvard University, Cambridge, Massachusetts, United States
Journal of the American College of Cardiology (Impact Factor: 15.34). 06/2006; 47(9):1858-65. DOI: 10.1016/j.jacc.2006.02.020
Source: PubMed

ABSTRACT The purpose of this study was to validate and re-evaluate our previously reported scoring systems for predicting optimal management in neonates with aortic stenosis (AS).
In 1991, we reported a multivariate discriminant equation and an ordinal scoring system for predicting which neonates with AS are suitable for biventricular repair and which are better served by single ventricle management.
Retrospective analysis was performed to: 1) validate our scoring systems in 89 additional neonates with AS and normal mitral valve area, 2) assess the effects of 5% measurement variation on predictive scores, 3) evaluate our cohort with the Congenital Heart Surgeons' Society scoring system, and 4) repeat the discriminant analysis on the basis of all 126 patients.
The original scores each predicted outcome accurately in 68 patients (77%). Minor (5%) measurement variation changed the outcome predicted by the discriminant equation in 8 patients (9%) and by the threshold system in 13 patients (15%). The most accurate model for predicting survival with a biventricular circulation among the full cohort is: 10.98 (body surface area) + 0.56 (aortic annulus z-score) + 5.89 (left ventricular to heart long-axis ratio) - 0.79 (grade 2 or 3 endocardial fibroelastosis) - 6.78. With a cutoff of -0.65, outcome was predicted accurately in 90% of patients.
Both of our original scoring systems are less accurate at predicting outcome than in our original analysis. Revised discriminant analysis yielded a model similar to our original equation that was 90% accurate at predicting survival with a biventricular circulation among neonates with AS and a mitral valve area z-score >-2.

0 Followers
 · 
61 Views
  • Source
    • "The Rhodes score involves the variables of body surface area, indexed aortic root size, left ventricle to heart long axis ratio and indexed mitral valve area (Rhodes et al., 1991). In the Colan score, the equation is based on body surface area, aortic annulus z-score, left ventricle to heart long axis ratio and degree of endocardial fibroelastosis (Colan et al., 2006). The Univentricular Repair Survival Advantage Tool is based on morphologic, functional and pathologic information; the exact equation is not published but the score can be calculated at the freely accessible Congenital Heart Surgeons' Society website www.chss.org "
    Aortic Stenosis - Etiology, Pathophysiology and Treatment, 10/2011; , ISBN: 978-953-307-660-7
  • Source
    • "Mitral dysfunction — particularly important regurgitation — was especially common, in addition to left ventricular impairment and endocardial fibroelastosis. The latter features have both been previously identified as strong determinants of poor outcome following other biventricular repair strategies [1] [18]. Therefore, the presence of these features should prompt caution before pursuing the Ross operation (and also other biventricular strategies). "
    [Show abstract] [Hide abstract]
    ABSTRACT: To define the outcomes following Ross and Yasui procedures for complex biventricular repair of critical left ventricular outflow tract obstruction (LVOTO). Of 1217 neonates presenting with critical LVOTO enrolled in the Congenital Heart Surgeons Society studies (1994-2008), 52 underwent the Ross or Yasui procedure and their outcomes were investigated using univariate and multivariable parametric models. Results: ROSS (N=39): The Ross procedure (median age 87 days) was rarely the primary intervention (5/39, 13%). A significant number of cases were performed to treat iatrogenic aortic regurgitation after other previous interventions (25/39, 64%). Co-existing functional morphological defects were also common: 72% had preoperative evidence of mitral dysfunction, moderate-to-severe left ventricular dysfunction or endocardial fibroelastosis. Emergency iatrogenic aortic regurgitation (P=0.005) and co-existing abnormalities (mitral stenosis, P=0.02; mitral regurgitation, P=0.05; LV dysfunction, P=0.03) were strong determinants of death. Severe postoperative ventricular dysfunction or need for extracorporeal membrane oxygenation (ECMO) conferred negligible survival. Younger age was associated with disproportionately worse late outcome (5-year survival 44+/-10% for neonates vs 76+/-8% for age >3 months, P=0.0013). However, mitral and left ventricular dysfunction and emergency presentation were significantly more common in the younger age groups. Infants less than 3 months of age without co-existing abnormalities had acceptable late survival ( approximately 75+/-20%). YASUI (N=13): Yasui repair (median age 22 days) was usually the primary intervention (nine of 13) but occasionally followed Norwood palliation (four of 13). None was an emergency. All had a ventricular septal defect. Survival was 69+/-13% at 10 years, which is not significantly different from other biventricular repair strategies in neonates. Aortic atresia was associated with better survival than stenosis (90+/-12% vs 30+/-14% at 3 years, P=0.039). None reverted to univentricular physiology later. Case selection is key for complex biventricular repair and the importance of appropriate case selection is exaggerated at young ages. All available options should be considered before pursuing the Ross operation in the presence of co-existing functional morphological abnormalities or emergent iatrogenic aortic regurgitation. However, both the Ross and Yasui operations in children (including neonates and young infants) with favourable functional morphology offer good survival, at least matching that of other biventricular repair strategies.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 09/2009; 37(2):279-88. DOI:10.1016/j.ejcts.2009.06.060 · 2.81 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This paper treats the computational solution of terminating stochastic games using concepts from deterministic matrix games and Markovian decision processes. The algorithms due to Shapley and Pollatschek/ Avi-Itzhak are discussed and a suboptimal approach suitable for large problems is presented. Numerical results are given from an example comparing the three approaches.
    Decision and Control including the 16th Symposium on Adaptive Processes and A Special Symposium on Fuzzy Set Theory and Applications, 1977 IEEE Conference on; 01/1978
Show more

Preview

Download
2 Downloads
Available from