- Email: [email protected]
Aristotle Comprehensive Complexity Score for Closure of Patent Ductus Arteriosus
786
CORRESPONDENCE
Aristotle Comprehensive Complexity Score for Closure of Patent Ductus Arteriosus To the Editor: The Aristotle Comprehensive Complexity score (ACCS) has been demonstrated to predict mortality and morbidity [1, 2], but the article by Chang and colleagues [3] contains a fundamental error about ACCS calculation. ACCS is the sum of Aristotle basic complexity score (1.5–15 points) and patient-adjusted complexity score (0–10 points). The patient-adjusted complexity score includes proceduredependent factors (0–5 points) and procedure-independent factors (general, clinical, extracardiac, and surgical: 0–5 points) [4]. Because the basic complexity score after surgery of patent ductus arteriosus (PDA) is equal to 3 points, ACCS can vary only from a minimum of 3 points to a maximum of 13 points. Procedure-dependent factors for PDA closure are the following three: active endocarditis, calcification, removal of ductus closure device. These factors are rarely accounted for in preterm infants. The score pertaining to procedure-dependent factors is therefore usually 0 points. Consequently, ACCS in these patients is rarely more than 8 points (3 points for basic score plus maximum 5 points for procedure-independent factors). In conclusion, the figures of “mean ACCS of 11.8 2.26 (range, 9 to 16)” estimated by the authors are certainly erroneous, and all related and subsequent calculations need correction. Nicodeme Sinzobahamvya, MD Unit of Thoracic and Cardio-Vascular Surgery Kira Hospital 47, Av. Nzero, Kinindo Bujumbura, Burundi e-mail: [email protected]
Ann Thorac Surg 2014;98:782–7
points) and procedure independent factors (0 to 5 points) [3]. Procedure independent factors (81 factors) adjust for each patient’s clinical status to a specific complexity and are composed of general factors (n ¼ 3), clinical factors (n ¼ 31), extra-cardiac factors (n ¼ 39), and surgical factors (n ¼ 8). Each factor is scored (0.5 to 4 points) for contribution to mortality, morbidity, and difficulty [3]. Because the maximum point contributing to the procedure independent factors is 5 points, the ACCS in our cohort is rarely more than 8 points if the published Aristotle methodology is applied [3]. All patients in our cohort will actually have the same 8 points of ACCS, and the application of the Aristotle score to preterm PDA baby is meaningless. Therefore, as we discussed in our article, the published Aristotle methodology was modified in this study by not limiting (or capping) the contribution of procedure independent factors to only 5 points, since the minimal value of the procedure independent factors was 6 in our cohort [2]. In this modification, the ACCS in our patients ranged from 9 to 16 points. The preterm babies with hemodynamically significant patent ductus arteriosus (PDA) will have several unfavorable medical or surgical conditions, such as coagulation disorder, mechanical ventilator dependency, renal impairment, intraventricular hemorrhage or seizure, necrotizing enterocolitis, and septicemia [2]. Each patient’s clinical status can significantly affect poor postoperative outcomes of PDA patients. The modified Aristotle score is highly useful for evaluating the compounding procedure independent factors and stratifying patients at risk of a poor outcome. To our knowledge, no article has modified the published Aristotle methodology, and this is the first article in which the Aristotle score has been applied to preterm infants with PDA. We hope that many pediatric cardiac surgeons and neonatologist will benefit from this modification of the Aristotle score. Yun Hee Chang, MD
References 1. Sinzobahamvya N, Photiadis J, Kumpikaite D, et al. Comprehensive Aristotle score: implications for the Norwood procedure. Ann Thorac Surg 2006;81:1794–801. 2. Heinrichs J, Sinzobahamvya N, Arenz C, et al. Surgical management of congenital heart disease: evaluation according to Aristotle score. Eur J Cardiothorac Surg 2010;37: 210–7. 3. Chang YH, Lee JY, Kim JE, et al. The Aristotle score predicts mortality after surgery of patent ductus arteriosus in preterm infants. Ann Thorac Surg 2013;96:879–84. 4. Lacour-Gayet F, Clarke D, Jacobs J, et al. The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 2004;25:911–24.
Reply To the Editor: MISCELLANEOUS
Thank you for the opportunity to reply to the letter from Sinzobahamvya [1]. We understand Sinzobahamvya’s comments on our recent article [2]. As indicated, the Aristotle comprehensive complexity score (ACCS) is the sum of Aristotle basic complexity score (1.5 to 15 points) and patient-adjusted complexity score (0 to 10 points). The patient-adjusted complexity score includes procedure dependent factors (0 to 5
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Department of Thoracic and Cardiovascular Surgery Seoul St. Mary’s Hospital College of Medicine The Catholic University of Korea Seoul, Republic of Korea Jae Young Lee, MD Department of Pediatrics Seoul St. Mary’s Hospital College of Medicine The Catholic University of Korea 222 Banpo-daero, Seocho-gu Seoul 137-701, Republic of Korea e-mail: [email protected]
References 1. Sinzobahamvya N. Aristotle comprehensive complexity score for closure of patent ductus arteriosus (letter). Ann Thorac Surg 2014;98:786. 2. Chang YH, Lee JY, Kim JE, et al. The Aristotle score predicts mortality after surgery of patent ductus arteriosus in preterm infants. Ann Thorac Surg 2013;96:879–84. 3. Lacour-Gayet F, Clarke D, Jacobs J, et al. The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 2004;25:911–24.
0003-4975/$36.00
CORRESPONDENCE
Aristotle Comprehensive Complexity Score for Closure of Patent Ductus Arteriosus To the Editor: The Aristotle Comprehensive Complexity score (ACCS) has been demonstrated to predict mortality and morbidity [1, 2], but the article by Chang and colleagues [3] contains a fundamental error about ACCS calculation. ACCS is the sum of Aristotle basic complexity score (1.5–15 points) and patient-adjusted complexity score (0–10 points). The patient-adjusted complexity score includes proceduredependent factors (0–5 points) and procedure-independent factors (general, clinical, extracardiac, and surgical: 0–5 points) [4]. Because the basic complexity score after surgery of patent ductus arteriosus (PDA) is equal to 3 points, ACCS can vary only from a minimum of 3 points to a maximum of 13 points. Procedure-dependent factors for PDA closure are the following three: active endocarditis, calcification, removal of ductus closure device. These factors are rarely accounted for in preterm infants. The score pertaining to procedure-dependent factors is therefore usually 0 points. Consequently, ACCS in these patients is rarely more than 8 points (3 points for basic score plus maximum 5 points for procedure-independent factors). In conclusion, the figures of “mean ACCS of 11.8 2.26 (range, 9 to 16)” estimated by the authors are certainly erroneous, and all related and subsequent calculations need correction. Nicodeme Sinzobahamvya, MD Unit of Thoracic and Cardio-Vascular Surgery Kira Hospital 47, Av. Nzero, Kinindo Bujumbura, Burundi e-mail: [email protected]
Ann Thorac Surg 2014;98:782–7
points) and procedure independent factors (0 to 5 points) [3]. Procedure independent factors (81 factors) adjust for each patient’s clinical status to a specific complexity and are composed of general factors (n ¼ 3), clinical factors (n ¼ 31), extra-cardiac factors (n ¼ 39), and surgical factors (n ¼ 8). Each factor is scored (0.5 to 4 points) for contribution to mortality, morbidity, and difficulty [3]. Because the maximum point contributing to the procedure independent factors is 5 points, the ACCS in our cohort is rarely more than 8 points if the published Aristotle methodology is applied [3]. All patients in our cohort will actually have the same 8 points of ACCS, and the application of the Aristotle score to preterm PDA baby is meaningless. Therefore, as we discussed in our article, the published Aristotle methodology was modified in this study by not limiting (or capping) the contribution of procedure independent factors to only 5 points, since the minimal value of the procedure independent factors was 6 in our cohort [2]. In this modification, the ACCS in our patients ranged from 9 to 16 points. The preterm babies with hemodynamically significant patent ductus arteriosus (PDA) will have several unfavorable medical or surgical conditions, such as coagulation disorder, mechanical ventilator dependency, renal impairment, intraventricular hemorrhage or seizure, necrotizing enterocolitis, and septicemia [2]. Each patient’s clinical status can significantly affect poor postoperative outcomes of PDA patients. The modified Aristotle score is highly useful for evaluating the compounding procedure independent factors and stratifying patients at risk of a poor outcome. To our knowledge, no article has modified the published Aristotle methodology, and this is the first article in which the Aristotle score has been applied to preterm infants with PDA. We hope that many pediatric cardiac surgeons and neonatologist will benefit from this modification of the Aristotle score. Yun Hee Chang, MD
References 1. Sinzobahamvya N, Photiadis J, Kumpikaite D, et al. Comprehensive Aristotle score: implications for the Norwood procedure. Ann Thorac Surg 2006;81:1794–801. 2. Heinrichs J, Sinzobahamvya N, Arenz C, et al. Surgical management of congenital heart disease: evaluation according to Aristotle score. Eur J Cardiothorac Surg 2010;37: 210–7. 3. Chang YH, Lee JY, Kim JE, et al. The Aristotle score predicts mortality after surgery of patent ductus arteriosus in preterm infants. Ann Thorac Surg 2013;96:879–84. 4. Lacour-Gayet F, Clarke D, Jacobs J, et al. The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 2004;25:911–24.
Reply To the Editor: MISCELLANEOUS
Thank you for the opportunity to reply to the letter from Sinzobahamvya [1]. We understand Sinzobahamvya’s comments on our recent article [2]. As indicated, the Aristotle comprehensive complexity score (ACCS) is the sum of Aristotle basic complexity score (1.5 to 15 points) and patient-adjusted complexity score (0 to 10 points). The patient-adjusted complexity score includes procedure dependent factors (0 to 5
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Department of Thoracic and Cardiovascular Surgery Seoul St. Mary’s Hospital College of Medicine The Catholic University of Korea Seoul, Republic of Korea Jae Young Lee, MD Department of Pediatrics Seoul St. Mary’s Hospital College of Medicine The Catholic University of Korea 222 Banpo-daero, Seocho-gu Seoul 137-701, Republic of Korea e-mail: [email protected]
References 1. Sinzobahamvya N. Aristotle comprehensive complexity score for closure of patent ductus arteriosus (letter). Ann Thorac Surg 2014;98:786. 2. Chang YH, Lee JY, Kim JE, et al. The Aristotle score predicts mortality after surgery of patent ductus arteriosus in preterm infants. Ann Thorac Surg 2013;96:879–84. 3. Lacour-Gayet F, Clarke D, Jacobs J, et al. The Aristotle score: a complexity-adjusted method to evaluate surgical results. Eur J Cardiothorac Surg 2004;25:911–24.
0003-4975/$36.00