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(Circulation. 2003;108:II-68.)
© 2003 American Heart Association, Inc.

Surgery for Valvular Heart Disease

A New Scoring System to Determine Thromboembolic Risk After Heart Valve Replacement

Eric G. Butchart, FRCS, FETCS, FESC; Adrian Ionescu, MRCP (UK); Nicola Payne, MPhil; John Giddings, PhD, FRCPath, FIBMS; Gary L. Grunkemeier, PhD; Alan G. Fraser, FRCP, FESC

From the Departments of Cardiothoracic Surgery, Cardiology and Hematology, University Hospital of Wales, Cardiff, UK and the Medical Data Research Center, Providence Health System, Portland, OR, USA

Correspondence to Eric G. Butchart, FRCS, Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK. Phone: 44-29-2074-3284, Fax: 44-29-2074-5439, E-mail: egbutchart{at}aol.com

Objective— To determine the most important inflammatory and hematologic predictors of thromboembolism (TE) in patients undergoing valve replacement (VR) to be used in conjunction with clinical risk factors for preoperative risk profiling.

Methods and Results— Preoperative and immediately postoperative clinical, echocardiographic, hematologic, biochemical and microbiological parameters were examined prospectively in 370 patients undergoing VR (249 AVR, 93 MVR, 28 DVR). Mean follow-up was 4.4 years (max 6.6 years; total 1566 pt/yrs), and 96 TE events were documented (28 major and 68 minor). INR data were collected on all patients. Laboratory values were considered elevated if they exceeded the 80^th percentile of those of 70 controls with the same distribution of age and gender. IgA antibody to Chlamydia pneumoniae (CP)1:64 was considered indicative of significant infection. Predictors of TE on multivariate analysis following AVR were (hazard ratios): CP infection (2.6), previous TE (2.5), raised eosinophils (2.4), cancer history (2.1), postoperative infection (2.0), hypertension (2.0), CABG x 3/4 (2.0), and diabetes (1.9). Predictors of TE following MVR/DVR were raised mean platelet volume (4.0), raised factor VII (3.1), CP infection (2.7), previous mitral valvotomy (2.5), raised fibrinogen (2.2), and raised reticulocytes (2.0). These risk factors were additive when present in the same patient, enabling a scoring system to be developed that accurately predicted risk of TE based on number of risk factors.

Conclusions— Selected blood tests and clinical risk factors provide a scoring system that accurately predicts TE risk and may guide prosthesis choice and antithrombotic management.

Key Words: heart valve prosthesis • embolism • risk factors