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Background  Cardiac surgery patients at very high risk are difficult to stratify with the existing risk scores. The objective of this study is to assess the clinical performance of two existing risk stratification scores (EuroSCORE II and ACEF score) in the setting of very high-risk patients undergoing cardiac surgery, and to identify a possible strategy to better address this patient population.    Methods  Three-thousand-four-hundred-twenty eight (3,428) consecutive adult patients receiving cardiac operations at a single institution were investigated. Patients having an operative mortality risk >25 % at either the EuroSCORE II or the ACEF score were selected (105 patients). The discrimination power and calibration of the EuroSCORE II and the ACEF score were investigated. Factors associated with operative mortality were included in a multivariable logistic regression model and a new model was re-built for this patient population.    Results  The observed mortality rate was 26 %. The expected mortality rate was underestimated by the EuroSCORE II (16 %) and overestimated by the ACEF Score (36 %). The EuroSCORE maintained a good discrimination (c-statistics 0.75) while the ACEF score did not (c-statistics 0.52). Within this patient population, the independent risk factors for operative mortality were emergency surgery, serum creatinine levels, pulmonary hypertension, and preoperative anemia. A model based on these factors provided an expected mortality risk of 26 % with a good discrimination (c-statics 0.82). Applying this model to extremely high-risk patients (expected mortality rate > 50 %) resulted in the re-classification of 25 % of the patient population.    Conclusions  The existing risk models have a poor clinical relevance in the segment of patients at very high mortality risk. This is particularly frustrating, because these patients are those where the decision-making process is more important. A two-stage classification strategy (first stage: EuroSCORE II/ACEF score risk > 25 %; second stage: reclassification based on pulmonary hypertension, serum creatinine, and anemia) seems a possible strategy to correctly address very high-risk patients.

In search of the ideal risk-scoring system for very high-risk cardiac surgical patients: a two-stage approach