Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery

doi:10.1016/j.jtcvs.2020.12.099

The Journal of Thoracic and Cardiovascular Surgery

Volume 164, Issue 4, October 2022, Pages 1140-1149.e3

https://doi.org/10.1016/j.jtcvs.2020.12.099 Get rights and content

Abstract

Objective

Malnutrition is a well-recognized risk factor for poor prognosis and mortality. We investigated whether preoperative malnutrition diagnosed with objective nutritional scores affects 1-year mortality in patients undergoing valvular heart surgery.

Methods

In this retrospective cohort observational study, we evaluated the association among the Controlling Nutritional Status score, Prognostic Nutritional Index, and Geriatric Nutritional Risk Index with 1-year mortality in 1927 patients undergoing valvular heart surgery. We identified factors for mortality using multivariable Cox proportional hazard analysis and investigated the utility of nutritional scores for risk stratification.

Results

Malnutrition, as identified by a high Controlling Nutritional Status score and low Prognostic Nutritional Index and Geriatric Nutritional Risk Index, was significantly associated with higher 1-year mortality. Kaplan–Meier survival curve showed that mortality significantly increased as the severity of malnutrition increased (log-rank test, P < .001). The predicted discrimination (C-index) was 0.79 with the Controlling Nutritional Status score, 0.77 with the Prognostic Nutritional Index, and 0.73 with the Geriatric Nutritional Risk Index. Each nutritional index (Controlling Nutritional Status; hazard ratio, 1.31, 95% confidence interval, 1.21-1.42, P < .001), the European System for Cardiac Operative Risk Evaluation II (hazard ratio, 1.07, 95% confidence interval, 1.04-1.09, P < .001), and chronic kidney disease (hazard ratio, 2.26, 95% confidence interval, 1.31-3.90, P = .003) were independent risk factors for mortality. The Controlling Nutritional Status score added to the European System for Cardiac Operative Risk Evaluation II significantly increased the predictive discrimination ability for mortality (C-index 0.82, 95% confidence interval, 0.78-0.87, P = .014) compared with the Controlling Nutritional Status or European System for Cardiac Operative Risk Evaluation II alone.

Conclusions

Preoperative malnutrition as assessed by objective nutritional scores was associated with 1-year mortality after valvular heart surgery. The Controlling Nutritional Status score had the highest predictive ability and, when added to the European System for Cardiac Operative Risk Evaluation II, provided more accurate risk stratification.

Graphical abstract

Section snippets

Study Population

The study protocol was approved by the Institutional Review Board and Hospital Research Ethics Committee of the Severance Hospital at Yonsei University College of Medicine (#4-2020-0024) and registered at clinicaltrials.gov (Ref: NCT04307732). The requirement for informed consent was waived because of the retrospective nature of the study. Patients undergoing valvular heart surgery from January 2013 to February 2018 were included. Patients who presented for surgery primarily due to valvular

Results

From an initial group of 1948 patients, 6 patients undergoing combined congenital heart surgery and 15 patients lacking necessary data for nutritional assessment were excluded. The remaining 1927 patients had no missing preoperative nutritional data or postoperative follow-up data and were included in the analysis (Figure E1).

Discussion

In this retrospective review, preoperative malnutrition assessed by the CONUT score, PNI, and GNRI was associated with a proportional increase in 1-year mortality after valvular heart surgery. The CONUT score, PNI, and GNRI, euroSCORE II, and CKD all were identified as independent predictors for 1-year mortality. The CONUT score added to the euroSCORE II significantly improved the predictive discrimination ability for 1-year mortality (Figure 2), whereas it did not provide any additive value to

Conclusions

Malnutrition assessed by the CONUT score, PNI, and GNRI was independently and proportionally associated with higher 1-year mortality in patients undergoing valvular heart surgery, with the CONUT score showing the highest predictive ability. Routine preoperative assessment of CONUT score for risk stratification deserves further consideration.

References (35)

M.T. La Rovere et al.
Additional predictive value of nutritional status in the prognostic assessment of heart failure patients
Nutr Metab Cardiovasc Dis
(2017)
V.V. Lomivorotov et al.
Evaluation of nutritional screening tools for patients scheduled for cardiac surgery
Nutrition
(2013)
O. Bouillanne et al.
Geriatric Nutritional Risk Index: a new index for evaluating at-risk elderly medical patients
Am J Clin Nutr
(2005)
M.R. Alvares-da-Silva et al.
Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients
Nutrition
(2005)
R. Gonzalez Ferreiro et al.
Nutritional risk index predicts survival in patients undergoing transcatheter aortic valve replacement
Int J Cardiol
(2019)
C. Contal et al.
An application of changepoint methods in studying the effect of age on survival in breast cancer
Comput Stat Data Anal
(1999)
G. Galyfos et al.
The effect of body mass index on major outcomes after vascular surgery
J Vasc Surg
(2017)
A.W. Weverling-Rijnsburger et al.
Total cholesterol and risk of mortality in the oldest old
Lancet
(1997)
M. Keskin et al.
A novel and useful predictive indicator of prognosis in ST-segment elevation myocardial infarction, the prognostic nutritional index
Nutr Metab Cardiovasc Dis
(2017)
T. Narumi et al.
Prognostic importance of objective nutritional indexes in patients with chronic heart failure
J Cardiol
(2013)

M. Rauchhaus et al.

The endotoxin-lipoprotein hypothesis

Lancet

(2000)

Y.N. Youn et al.

Can the EuroSCORE predict the early and mid-term mortality after off-pump coronary artery bypass grafting?

Ann Thorac Surg

(2007)

R. Tepaske et al.

Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial

Lancet

(2001)

H. Lin et al.

Review of nutritional screening and assessment tools and clinical outcomes in heart failure

Heart Fail Rev

(2016)

A. Hill et al.

Current evidence about nutrition support in cardiac surgery patients-what do we know?

Nutrients

(2018)

V.V. Lomivorotov et al.

Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery

Interact Cardiovasc Thorac Surg

(2013)

C. Stoppe et al.

Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery

Crit Care

(2017)

Cited by (14)

Predictive Role of Preoperative Nutritional Status on Early Postoperative Outcomes in Different-Aged Patients Undergoing Heart Valve Surgery
2024, Journal of Cardiothoracic and Vascular Anesthesia
The authors sought to elucidate the role and predictive effects of preoperative nutritional status on postoperative outcomes across different age groups undergoing heart valve surgery.
A retrospective study with intergroup comparison, receiver operating characteristic curve analysis, and logistic regression analysis.
A hospital affiliated with a medical university.
Three thousand nine hundred five patients undergoing heart valve surgery between October 2016 and December 2020.
None.
Patients were categorized into 3 age subgroups: young (aged 18-44 years), middle-aged (aged 45-59 years), and older (aged ≥60 years) adults. The Nutritional Risk Index (NRI), Prognostic Nutritional Index, and Controlling Nutritional Status scores were evaluated. Young adults with an NRI <99 experienced a significantly higher rate of prolonged intensive care unit stay (28.3% v 4.1%, p < 0.001), with a relative risk of 4.58 (95% CI: 2.04-10.27). Similarly, young adults with an NRI <97 had a significantly increased occurrence of mortality within 30 days after surgery (6.3% v 0.2%, p < 0.001), with a relative risk of 41.11 (95% CI: 3.19-529.48).
In patients who undergo heart valve surgery, early postoperative outcomes can be influenced by nutritional status before the surgery. In the young-adult group, NRI <99 and NRI <97 effectively could predict prolonged intensive care unit stay and 30-day mortality, respectively.
The Prognostic Value of Johns Hopkins Hospital Nutrition Support Score in Older Patients Undergoing Cardiovascular Surgery
2023, Journal of Cardiothoracic and Vascular Anesthesia
Clarify the prognostic value of the Johns Hopkins Hospital Nutrition Support (JHHNS) score on clinical outcomes in older patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB).
A retrospective observational study.
A teaching and university hospital and tertiary referral center.
The authors analyzed 328 older patients aged ≥65 who underwent cardiovascular surgery with CPB in 2020.
Malnutrition risk was identified by the JHHNS score calculated based on specific preoperative and intraoperative objective parameters. Patients were divided into low- and high-JHHNS groups. Early morbidity, including pneumonia, bacteremia, wound infection, cerebrovascular accident, gastrointestinal bleeding, acute kidney injury, delirium, requirement for extracorporeal membrane oxygenation, and readmission to the intensive care unit (ICU), were the primary outcome; whereas in-hospital mortality, length of ICU and hospital stay, duration of mechanical ventilation and short-term mortality were secondary outcomes. The independent risk factors for postoperative complications were analyzed by logistic regression analyses.
The JHHNS score identified 21.0% of patients at risk for malnutrition. Patients in the high-JHHNS group had prolonged median length hospital stay (21 v 24 days, p = 0.002) and mechanical ventilation (13.0 v 16.0 hours, p = 0.038), and more patients in this subgroup stayed longer than 3 days in ICU (30.1% v 43.5%, p = 0.036). Besides, they experienced more postoperative complications (11.2% v 39.1%, p < 0.001). Furthermore, multivariate logistic regression analysis demonstrated that the JHHNS score independently predicted the risk of postoperative complications. No significant intergroup difference was observed for the short-term mortality.
The JHHNS score was an independent predictor for postoperative complications but did not significantly affect short-term mortality in older patients undergoing cardiovascular surgery with CPB.
Does the Geriatric Nutritional Risk Index Play a Predictive Role in Postoperative Atrial Fibrillation and Outcomes in Cardiac Surgery?
2023, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Therefore, the authors chose the GNRI for nutritional screening before cardiac surgery. Although several studies30,31 investigated the prognosis after cardiac surgery using different nutritional assessment methods (including GNRI), to the best of the authors’ knowledge, this was the first study to illustrate the predictive role of GNRI in the development of POAF in patients after cardiac surgery. POAF is a common complication after cardiac surgery, associated with increased risk of all-cause mortality and associated comorbidities, such as ischemic stroke and heart failure.
Malnutrition is associated with adverse surgical outcomes. The Geriatric Nutritional Risk Index, a nutritional screening tool, could be a predictor of postoperative atrial fibrillation and outcomes in cardiac surgery.
The authors enrolled 292 patients who underwent cardiac surgery and showed postoperative atrial fibrillation during hospitalization, and assessed mortality and readmission during a 90-day follow-up period.
A large academic hospital in China.
Participants were divided into low-risk (Geriatric Nutritional Risk Index <98) and no-risk malnutrition groups (Geriatric Nutritional Risk Index ≥98).
Univariate and multivariate logistic regression analyses were used to validate the role of the Geriatric Nutritional Risk Index in predicting postoperative atrial fibrillation. Kaplan–Meier analysis was used to examine the effect of Geriatric Nutritional Risk Index scores on mortality and readmission after cardiac surgery.
A total of 136 patients were in the low-risk malnutrition group. Postoperative atrial fibrillation was more common in the low-risk group (63.2% v 28.8%, p < 0.001). Duration of intensive care unit stays and hospitalization were significantly longer than in the no-risk group (44 [43] v 39 [47] hours, p < 0.001; 18 [7] v 15 [6] days, p < 0.001). Multivariate analysis showed that Geriatric Nutritional Risk Index, age, and NYHA class independently predicted postoperative atrial fibrillation. Kaplan–Meier analysis showed that 90-day all-cause readmission, but not 90-day all-cause mortality, was different between groups based on the Geriatric Nutritional Risk Index (log-rank p < 0.001, log-rank p = 0.09).
The easily accessible Geriatric Nutritional Risk Index used for nutritional assessment before cardiac surgery has a predictive role in postoperative atrial fibrillation, and is related to short-term readmission.
Commentary: Preoperative nutritional status and mortality from cardiac surgery: Do we have your attention yet?
2022, Journal of Thoracic and Cardiovascular Surgery
Commentary: Nutritional status before cardiac surgery—at the 11th hour
2022, Journal of Thoracic and Cardiovascular Surgery
Commentary: Let food be thy medicine?—Hippocrates
2022, Journal of Thoracic and Cardiovascular Surgery

View all citing articles on Scopus

: Clinical trial registry number: clinicaltrials.gov (Ref: NCT04307732).

: The Institutional Review Board and Hospital Research Ethics Committee of Severance Hospital at Yonsei University College of Medicine approved the study protocol (#4-2020-0024) on February 27, 2020.

View full text

Adult: Perioperative ManagementImpact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery

Abstract

Objective

Methods

Results

Conclusions

Graphical abstract

Section snippets

Study Population

Results

Discussion

Conclusions

Nutr Metab Cardiovasc Dis

Nutrition

Am J Clin Nutr

Nutrition

Int J Cardiol

Comput Stat Data Anal

J Vasc Surg

Lancet

Nutr Metab Cardiovasc Dis

J Cardiol

Lancet

Ann Thorac Surg

Lancet

Review of nutritional screening and assessment tools and clinical outcomes in heart failure

Heart Fail Rev

Current evidence about nutrition support in cardiac surgery patients-what do we know?

Nutrients

Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery

Interact Cardiovasc Thorac Surg

Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery

Crit Care

Adult: Perioperative Management
Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery