Adults with congenital heart disease make up a
rapidly growing segment of the cardiovascular patient
population.[
2] In their study, Gilboa et al.[
3] estimated
that the number of patients reached 1.4 million. The
incidence of congenital heart disease in Türkiye is
about 1%, and there are approximately 12,000 new
patients each year.[
4] Today, more than 85% of children with congenital heart disease are expected to reach
adulthood.[
5,
6]
Risk stratification regarding the procedures is
important in determining surgical mortality. In
2004, Lacour-Gayet et al.[7] developed the ABC score
to assess surgeon performance in congenital heart
surgery. In 2006, Kang et al.[8] demonstrated that this
score is somewhat useful in determining mortality but
cannot be used as a statistically significant tool. In
2007, O'Brien et al.[9] argued that the ABC score is
useful for differentiating low-and high-risk patients.
A 2011 study by Photiadis et al.[10] supported this
opinion but indicated that the ABC score is based on
the complexity of surgical procedures and does not
take into account patient-related factors. In their 2012
study, Hörer et al.[11] demonstrated that the ABC score
is not suitable for predicting mortality in combined
surgical procedures.
In 2014, Kogon et al.[12] published a study
comparing the STAT and ABC scores. In this retrospective study, they argued that the scoring
systems used in pediatric patients were also valuable
in the adult group. They suggested that ABC and
STAT scores had similar results in determining
mortality; however, ABC score was more effective
in determining major complications and length of
hospitalization.
In 2015, Cavalcanti et al.[13] argued that the ABC
and STAT scores were not significantly different in
predicting mortality. A 2016 study by Hörer et al.[14]
suggested that the ABC score had a low predictive
value but outperformed the STAT score. In 2019,
Bobillo-Perez et al.[15] indicated that the predictive
performance of the STAT score was better than that
of the ABC score.[16]
The controversial state of scoring systems in the
adult group caused the search for a new scoring
system. In their study published in 2015, Fuller et
al.[1] suggested that the ACHS mortality score was
effective. In this study, they divided the patients into
152 groups and determined an ACHS mortality score ranging from 0.1 to 3.0 for each. In 2019, Abouelella et
al.[17] stated that the ACHS score is currently the best
predictor of mortality in GUCH patients and that the
mortality rate was 4%.
In our study, we investigated the effectiveness
of GUCH using this scoring system. In the present
study, hospital mortality was 4.4% (n=9). In terms
of mortality, statistically significant differences
were identified for ABC, STAT (p=0.001; p<0.01),
and ACHS scores (p=0.037; p>0.05); the scores
of patients with mortality were higher (Table 3).
In our study, we calculated the cut-off values and
performed ROC curve analysis for the prediction of
mortality. The ROC curve results for ABC, STAT,
and ACHS scores for predicting mortality are
given in Table 3. Based on this significance, cut-off
points were calculated for the scoring systems. The
incidence of mortality was 13.455 times higher in
patients with a cut-off value of ≥0.7 in their ACHS
mortality scores.
Abouelella et al.[17] reported a postoperative
complication rate of 18%, similar to the rate of 28%
stated by Mascio et al.[18] The reported incidence of
neurological complications is 7%.[19] In our study,
postoperative complications were detected in 13.7%
of the cases (n=28), and it is consistent with the
literature (Table 4). In our study, extracorporeal
membrane oxygenation was required in 10.7% (n=3)
of patients (aortopulmonary shunt, n=1; pulmonary
artery reconstruction, n=1; mitral valve repair, n=1) due
to low cardiac output. All of these patients died while
on support. Neurological complications were observed
in 10.7% (n=3) of our patients, including one patient
who underwent right ventricle to pulmonary artery
conduit replacement and later died due to intracranial
bleeding, as well as two patients who underwent
pulmonary valve replacement and mitral valve
replacement. These patients developed postoperative
convulsions, but no pathologies were detected in their
examinations; therefore, the condition was attributed
to temporary ischemia and completely resolved with
medical treatment.
A statistically significant relationship was found
between postoperative complication rates according
to the occurrence of reoperation (p=0.002; p<0.01);
the rate of postoperative complication incidents in
those reoperated was higher than in those who were
not reoperated. The ABC, STAT, and ACHS results
of reoperated patients are demonstrated in Table 5. The ABC, STAT, and ACHS scores of the patients
who underwent reoperation were significantly higher
than the scores of those who did not. The areas
under the ROC curves were 0.81 (p=0.001, p<0.01),
0.69 (p=0.001, p<0.01), and 0.62 (p=0.034, p<0.05),
respectively.
When the areas undser the ROC curve were
compared, the ABC score was found to be more
effective in predicting mortality than the ACHS score
(p=0.001; p<0.01). The STAT mortality score and
ACHS score were not significantly different (p=0.626;
p>0.05; Table 6).
The small sample size of the study is its main
limitation. Some complex surgeries, such as Fontan
operation, are rare in adulthood, and therefore
the number of patients to be compared is small.
Additionally, some data losses are not excluded due to
the retrospective design.
In conclusion, for primary operations, all scoring
systems could significantly predict mortality;
however, the ABC and STAT scores had better
predictive value compared to the ACHS score. The
predictive value of STAT and ACHS scores was
similar in reoperations, whereas the ABC score had
a higher predictive value. The ACHS mortality score
has good predictive power in adult congenital heart
patients. Preoperative risk prediction could be used
safely to analyze surgical results.
Ethics Committee Approval: The study protocol was
approved by the Koşuyolu High Specialization Education and
Research Hospital Ethics Committee (Date: 08.12.2020, no:
2020/13/390). The study was conducted in accordance with
the principles of the Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design:B.Z.T.R.;
Control/supervision: H.C., E.T.; Data collection and/or
processing, analysis and/or interpretation: B.Z.T.R.;
Literature review: B.Z.T.R., E.T.; Writting the article:
B.Z.T.R.; Critical review: B.Z.T.R., H.C.; References and
funding, materials: N.C.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.