"The PEACH score can be easily calculated in the outpatient clinic or at the bedside by professionals who manage adult congenital heart disease (ACHD) patients, identifying those at increased risk of perioperative mortality who may benefit from alternative therapeutic approaches (e.g., percutaneous intervention or transplantation) or strategies to reduce risk and address potential complications (e.g., perioperative extracorporeal membrane oxygenation or ventricular assist device cover)," said Dr. Konstantinos Dimopoulos of the Royal Brompton Hospital and the National Heart and Lung Institute at Imperial College London, UK.
"Risk stratification is at the heart for ACHD practice, and we believe that the PEACH score will prove invaluable to our ACHD colleagues and our patients alike," he told Reuters Health by email.
As reported in the Journal of the American College of Cardiology, the PEACH development cohort included 1,782 procedures performed in ACHD patients between 2003 and 2019. The mean age at procedure was 35.6 and about 55% were men.
CHD complexity was classified as "moderate" in 59.7% of patients and "great" in 9.4%, including 1.3% with a systemic right ventricle. The majority of patients (60.6%) were in NYHA functional class II; 25.5% were in functional class I.
Re-sternotomy was performed in 897 (50.3%), and 31 (1.7%) died in the hospital.
The PEACH score showed "excellent" discrimination ability (area under the curve, 0.88), according to the authors, and performed better than the Adult Congenital Heart Surgery (ACHS) score (AUC, 0.69).
A 3-tiered risk stratification was formed for the PEACH score: 0 (in-hospital mortality 0.2%); 1-2 (3.6%); and 3 or higher (17.2%).
In a validation cohort of 975 procedures, the PEACH score retained its discriminative ability (AUC, 0.75) and was well calibrated.
Further, there was agreement in both expected and observed perioperative mortality between the two cohorts.
Dr. Yves d'Udekem of Children's National Hospital in Washington, DC, author of a related editorial, told Reuters Health by email, "While there are multiple scoring tools to enlighten us of the predicted mortality of adults undergoing cardiac surgery, very few take into account important variables related to adults with congenital heart disease."
"The existing variables focus instead on cardiac surgery for those with acquired heart disease," he said. "As just one example, many of the common comorbidities of acquired heart disease, like diabetes, are not seen in adult patients with congenital heart disease."
"Today, there are more adults with congenital heart disease than children," he noted. "We know that a very large proportion of all but the ones with the simplest lesions will need reoperation, but we do not know at what time to reoperate them and the risks of these procedures."
"The PEACH score...is extremely attractive because of its simplicity, its specificity to this population, and its discriminatory power," he said. "It shows us that parameters such as how sick the patients are and the need for emergency operations increase...the risk of postoperative mortality, (and) is an excellent first step towards specifying risks of operation for adults with congenital heart diseases."
"It points to the fact, if we want these adults to survive, we should operate them earlier, before they get too sick." Dr. d'Udekem concluded.
SOURCE: https://bit.ly/3eoTbVU and https://bit.ly/2U7bisA Journal of the American College of Cardiology, online July 12, 2021.
By Marilynn Larkin
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