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PEACH Score for Perioperative Mortality in Adults With CHD
Quick Takes
- Common perioperative prognostic scores for adults undergoing cardiac surgery have generally excluded patients with congenital heart disease (CHD). CHD-specific scores are required to accurately prognosticate perioperative risk in this patient population.
- The Perioperative ACHD (PEACH) score was developed and validated, demonstrating good discrimination ability.
- The PEACH score includes components of the EuroSCORE II scoring system, as well as the CHD-specific Adult Congenital Heart Surgery (ACHS) score.
Study Questions:
What is the discrimination ability of a risk score for predicting in-hospital mortality after adult congenital heart disease (ACHD) surgery?
Methods:
Perioperative survival was assessed in patients aged >16 years undergoing congenital heart surgery at a large tertiary center between 2003 and 2019. A risk variable-derived PEACH (Perioperative ACHD) score was calculated for each patient. The PEACH score includes components of the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) tool as well as the procedure-related Adult Congenital Heart Surgery (ACHS) score. Internal and external validation of the model was undertaken, including testing in a validation cohort of patients undergoing surgery at a second European ACHD center.
Results:
The development cohort included 1,782 procedures performed during the study period, of which 897 (50.3%) involved redo sternotomy. There were 31 (1.7%) in-hospital deaths. Discrimination ability (area under the curve [AUC]) was 0.88; 95% confidence interval [CI], 0.83-0.94, as compared with the ACHS score (ACHS AUC, 0.69; 95% CI, 0.6-0.78; p = 0.0003). A three-tiered risk stratification was formed: PEACH score 0 (in-hospital mortality 0.2%), 1-2 (3.6%), and ≥3 (17.2%). In a validation cohort of 975 procedures at a second center, the discrimination ability (AUC) was 0.75; 95% CI, 0.72-0.77). There was agreement in expected and observed perioperative mortality between cohorts.
Conclusions:
The authors concluded that the PEACH score is a simple, novel perioperative risk score developed and validated specifically for ACHD patients undergoing cardiac surgery.
Perspective:
Risk calculators such as the Society for Thoracic Surgeons (STS) score and EuroSCORE II have proven useful in assessing perioperative risk in adults undergoing cardiac surgery. As patients with CHD were excluded in the development of these systems, they have limited value in prognosticating surgical risk for ACHD patients. The final components of the PEACH score included New York Heart Association functional class (I/II vs. III/IV), procedural urgency, renal function (glomerular filtration rate ≥60 vs. <60), presence of active endocarditis, presence of multiple (≥2) sternotomies, hemoglobin (higher risk for patients with either high or low hemoglobin), and ACHS score (0.1-1.5 vs. 1.6-3.0). The ACHS score is a procedure-specific scoring system for patients undergoing cardiac surgery, with the lowest score of 0.1 (atrial septal defect) and the highest score of 3 (Fontan revision). The only relevant procedures in the high-risk category for the ACHS score (>1.5) were Fontan revision and coronary artery bypass. For the PEACH score, the low (0 points), intermediate (1-2 points), and high risk (≥3 points) groups had operative risks of 0.2%, 3.6%, and 17%, respectively. The PEACH score will be helpful as a simple ACHD-specific risk score to serve as a basis for patient-specific discussions regarding perioperative mortality.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease
Keywords: Cardiac Surgical Procedures, Endocarditis, Fontan Procedure, Glomerular Filtration Rate, Heart Defects, Congenital, Heart Septal Defects, Atrial, Hemoglobins, Hospital Mortality, Perioperative Period, Risk Assessment, Risk Factors, Secondary Prevention, Sternotomy, Thoracic Surgery
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