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Eur J Cardiothorac Surg 2002;22:101-105
© 2002 Elsevier Science NL
a Cardiothoracic Surgical Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK
b CHU Fort-de-France, Martinique, France
c Dukes Clinical Research Institute, Durham, NC, USA
d CCECQA 12 rue Dubernat, 33404 Talence cedex, France
e The Society of Thoracic Surgeons National Database, London, UK
f Department of Cardiac Surgery, Hammersmith Hospital, London, UK
Received 17 September 2001; received in revised form 8 March 2002; accepted 25 March 2002.
* Corresponding author. Tel.: +44-1480-364-299; fax: +44-1480-364-744
e-mail: sam.nashef{at}euroscore.org
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Abstract |
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 Top Abstract 1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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Key Words: European System for Cardiac Operative Risk Evaluation • Society of Thoracic Surgeons • Database • Risk stratification
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1. Introductions |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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2. Methods |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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The American and European patient populations were compared for demographic characteristics, incidence of surgical procedures performed and prevalence of risk factors. The simple, additive EuroSCORE model was then tested on two groups of patients in the STS database: all patients who underwent adult cardiac surgery in 1995 and in the period spanning 1998 and 1999. The first was chosen because EuroSCORE was developed from a 1995 European patient cohort and the second because of greater similarity between the American and European datasets and greater recency and relevance. Nevertheless, the definitions of some of the risk variables were not identical in both Europe and America and some adjustments or approximate assumptions were made to enable complete analysis. The risk factors, together with their corresponding definitions are listed in Table 1.
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After applying the EuroSCORE algorithm to the STS data, a logistic regression of operative mortality on the resulting score was performed. This enabled the measurement of both the calibration and the discrimination of EuroSCORE on the STS population. Calibration was measured by comparing the observed mortality to the expected mortality for equal-sized quintiles of risk. Discrimination was measured by reporting the c-index of the above logistic regression model.
The c-index can be considered as a generalisation of the area under the receiver operating characteristic (ROC) curve and is calculated by analysing all possible pairs of patients that can be formed such that one patient died and the other did not. For a given pair, the predictions are said to be concordant with the outcome if the patient that died has a higher predicted probability of mortality than the patient that survived. The c-index is the proportion of these predictions that are concordant. Values of the c-index range from 0.5 (no ability to discriminate) to 1.0 (full ability to discriminate).
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3. Results |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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4. Discussion |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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The choice of a risk model must necessarily depend on the unit and the audit resources to which it has access. Currently, hospitals range from those without even rudimentary data about numbers and types of procedures to those with full risk-stratified outcome data and the ability to perform complex Bayesian and regression analysis of outcomes. Whatever the available resources, inter-hospital and international evaluation of outcomes would strongly benefit from a universal and easily applicable risk model that can be understood by all. The simple additive EuroSCORE model has been shown to work well in both coronary surgery [8], valve surgery [9] and in overall cardiac surgery across many European countries [10]. The STS database algorithms remain proprietary and confidential. The reasons given for this are the protection of intellectual property and the encouragement of data submission. This paper demonstrates that EuroSCORE performs remarkably well in North American cardiac surgery despite substantial differences in demographic, risk and surgical characteristics between European and American patients. This performance is sustained across years, types of surgery and risk groups.
The additive EuroSCORE model, by virtue of its nature, tends to underestimate risk in very high-risk patients. This is not readily seen in analyses of large, multicentre databases. Some very high-risk patients may be better assessed, for individual risk prediction, by using the full logistic EuroSCORE model (www.euroscore.org).
In an ideal future world, there will be an international database of cardiac surgery to which all units will contribute data. The resources for complex and comprehensive risk analysis will be available to all, and accurate and individualised risk assessment will be within reach of every surgeon and every patient. In the meantime, there is a need for an international risk standard which can be used as a benchmark for risk assessment in inter-hospital and international studies. This study, together with previous work in Europe and elsewhere, demonstrates that EuroSCORE can provide that standard.
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Footnotes |
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1 For the EuroSCORE Project Group. 
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Appendix A. Conference discussion |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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Dr Nashef: I believe you are referring to the original paper in which we divided patients into three equal groups in order to validate and calibrate the system. We did not really intend these divisions to be in tablets of stone. We think the most important thing is to produce groups that are statistically comparable. For example, there is not much point in having a group of a EuroSCORE 15 and above in a single hospital because the numbers of patients would be very small and the confidence interval around any kind of prediction would be extremely wide. On this occasion, we just took the patients and divided them into five equal groups across the risk spectrum, and there is no rule that says you cannot divide them into three, four or five risk groups. The original three risk groups were purely for calibration.
Dr U. Herold (Essen, Germany): I would like to ask you a question about your statement that you think that the American patients are sicker, but how can you explain the circumstance that the European patients have to be operated more upon the heart? Endocarditis doesn't explain these concerns from my point of view.
Dr Nashef: I am sorry, I don't think I understood the question. Could you just repeat the question?
Dr Herold: You stated that the American patients are termed to be sicker than the European ones.
Dr Nashef: Yes.
Dr Herold: But how can you explain the circumstance that European patients have to be operated upon the heart more often than the Americans? Your explanation of endocarditis doesn't fit to this.
Dr Nashef: Yes. The European patients in general have more valve surgery; valve surgery as a group represents a higher percentage in European surgery than it does in American surgery. There is more isolated coronary artery bypass grafting in the American database, but there are more redos in America. Understandably, if you have a large population of valve patients, then a substantial number of these, well, at least a slightly larger proportion of these, would have endocarditis compared with the American group.
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References |
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TopAbstract1. Introductions2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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J. Ye, A. Cheung, S. V. Lichtenstein, S. Pasupati, R. G. Carere, C. R. Thompson, A. Sinhal, and J. G. Webb Six-month outcome of transapical transcatheter aortic valve implantation in the initial seven patients Eur. J. Cardiothorac. Surg., January 1, 2007; 31(1): 16 - 21. [Abstract] [Full Text] [PDF]
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V. L. Vida, H. Berggren, W. J. Brawn, W. Daenen, D. Di Carlo, R. Di Donato, H. L. Lindberg, A. F. Corno, J. Fragata, M. J. Elliott, et al. Risk of Surgery for Congenital Heart Disease in the Adult: A Multicentered European Study Ann. Thorac. Surg., January 1, 2007; 83(1): 161 - 168. [Abstract] [Full Text] [PDF]
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T. Patila, S. Kukkonen, A. Vento, V. Pettila, and R. Suojaranta-Ylinen Relation of the Sequential Organ Failure Assessment Score to Morbidity and Mortality After Cardiac Surgery Ann. Thorac. Surg., December 1, 2006; 82(6): 2072 - 2078. [Abstract] [Full Text] [PDF]
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M. Mazzoni, R. De Maria, F. Bortone, M. Parolini, R. Ceriani, C. Solinas, V. Arena, and O. Parodi Long-Term Outcome of Survivors of Prolonged Intensive Care Treatment After Cardiac Surgery Ann. Thorac. Surg., December 1, 2006; 82(6): 2080 - 2087. [Abstract] [Full Text] [PDF]
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B E Keogh Logistic, additive or historical: is EuroSCORE an appropriate model for comparing individual surgeons' performance? Heart, December 1, 2006; 92(12): 1715 - 1716. [Abstract] [Full Text] [PDF]
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S. V. Lichtenstein, A. Cheung, J. Ye, C. R. Thompson, R. G. Carere, S. Pasupati, and J. G. Webb Transapical Transcatheter Aortic Valve Implantation in Humans: Initial Clinical Experience Circulation, August 8, 2006; 114(6): 591 - 596. [Abstract] [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): 598 - 675. [Full Text] [PDF]
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F. Biancari, O.-P. Kangasniemi, J. Luukkonen, S. Vuorisalo, J. Satta, R. Pokela, and T. Juvonen EuroSCORE predicts immediate and late outcome after coronary artery bypass surgery. Ann. Thorac. Surg., July 1, 2006; 82(1): 57 - 61. [Abstract] [Full Text] [PDF]
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C.-J. Jakobsen, P. Torp, and E. Sloth Assessment of left ventricular ejection fraction may invalidate the reliability of EuroSCORE. Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 978 - 982. [Abstract] [Full Text] [PDF]
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F. Seccareccia, C. A. Perucci, P. D'Errigo, and D. Fusco Concerning the Editorial comment by Dr Menicanti. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 858 - 859. [Full Text] [PDF]
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C.-H. Yap, C. Reid, M. Yii, M. A. Rowland, M. Mohajeri, P. D. Skillington, S. Seevanayagam, and J. A. Smith Validation of the EuroSCORE model in Australia. Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 441 - 446. [Abstract] [Full Text] [PDF]
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P. Gersbach, H. Tevaearai, J.-P. Revelly, P. Bize, R. Chiolero, and L. K. von Segesser Are there accurate predictors of long-term vital and functional outcomes in cardiac surgical patients requiring prolonged intensive care? Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 466 - 472. [Abstract] [Full Text] [PDF]
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N. Luciani, G. Nasso, A. Anselmi, F. Glieca, M. Gaudino, F. Girola, M. Piscitelli, M. Perisano, L. Martinelli, and G. Possati Repeat Valvular Operations: Bench Optimization of Conventional Surgery Ann. Thorac. Surg., April 1, 2006; 81(4): 1279 - 1283. [Abstract] [Full Text] [PDF]
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J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt Comparison of 19 pre-operative risk stratification models in open-heart surgery Eur. Heart J., April 1, 2006; 27(7): 867 - 874. [Abstract] [Full Text] [PDF]
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M. J. Price, E. Cristea, N. Sawhney, J. A. Kao, J. W. Moses, M. B. Leon, R. A. Costa, A. J. Lansky, and P. S. Teirstein Serial Angiographic Follow-Up of Sirolimus-Eluting Stents for Unprotected Left Main Coronary Artery Revascularization J. Am. Coll. Cardiol., February 21, 2006; 47(4): 871 - 877. [Abstract] [Full Text] [PDF]
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E. L. Hannan, C. Wu, E. V. Bennett, R. E. Carlson, A. T. Culliford, J. P. Gold, R. S.D. Higgins, O. W. Isom, C. R. Smith, and R. H. Jones Risk Stratification of In-Hospital Mortality for Coronary Artery Bypass Graft Surgery J. Am. Coll. Cardiol., February 7, 2006; 47(3): 661 - 668. [Abstract] [Full Text] [PDF]
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N. Newall, A. D. Grayson, A. Y. Oo, N. D. Palmer, W. C. Dihmis, A. Rashid, and R. H. Stables Preoperative White Blood Cell Count is Independently Associated With Higher Perioperative Cardiac Enzyme Release and Increased 1-Year Mortality After Coronary Artery Bypass Grafting Ann. Thorac. Surg., February 1, 2006; 81(2): 583 - 589. [Abstract] [Full Text] [PDF]
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J. M. Bernal, J. Lorca, D. Prieto-Salceda, I. Pulitani, A. Ponton, I. Garcia, and J. M. Revuelta Performance at 10 years of the CarboMedics 'Top-Hat' valve. Postclamping time is a predictor of mortality Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 144 - 149. [Abstract] [Full Text] [PDF]
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I. K. Toumpoulis, C. E. Anagnostopoulos, D. G. Katritsis, J. J. DeRose Jr, and D. G. Swistel The Impact of Preoperative Thrombolysis on Long-Term Survival After Coronary Artery Bypass Grafting Circulation, August 30, 2005; 112(9_suppl): I-351 - I-357. [Abstract] [Full Text] [PDF]
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R.E. Anderson, K. Klerdal, T. Ivert, N. Hammar, G. Barr, and A. Owall Are even impaired fasting blood glucose levels preoperatively associated with increased mortality after CABG surgery? Eur. Heart J., August 1, 2005; 26(15): 1513 - 1518. [Abstract] [Full Text] [PDF]
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I. K. Toumpoulis, C. E. Anagnostopoulos, S. K. Toumpoulis, J. J. DeRose Jr, and D. G. Swistel EuroSCORE Predicts Long-Term Mortality After Heart Valve Surgery Ann. Thorac. Surg., June 1, 2005; 79(6): 1902 - 1908. [Abstract] [Full Text] [PDF]
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R De Maria, M Mazzoni, M Parolini, D Gregori, F Bortone, V Arena, and O Parodi Predictive value of EuroSCORE on long term outcome in cardiac surgery patients: a single institution study Heart, June 1, 2005; 91(6): 779 - 784. [Abstract] [Full Text] [PDF]
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J. J. DeRose Jr, I. K. Toumpoulis, S. K. Balaram, J. P. Ioannidis, S. Belsley, R. C. Ashton Jr, D. G. Swistel, and C. E. Anagnostopoulos Preoperative prediction of long-term survival after coronary artery bypass grafting in patients with low left ventricular ejection fraction J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 314 - 321. [Abstract] [Full Text] [PDF]
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 I. K. Toumpoulis, C. E. Anagnostopoulos, J. J. DeRose Jr, and D. G. Swistel The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting Chest, February 1, 2005; 127(2): 464 - 471. [Abstract] [Full Text] [PDF]
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I. K. Toumpoulis, C. E. Anagnostopoulos, D. G. Swistel, and J. J. DeRose Jr Does EuroSCORE predict length of stay and specific postoperative complications after cardiac surgery? Eur. J. Cardiothorac. Surg., January 1, 2005; 27(1): 128 - 133. [Abstract] [Full Text] [PDF]
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C.-C. Chen, C.-C. Wang, S.-R. Hsieh, H.-W. Tsai, H.-J. Wei, and Y. Chang Application of European system for cardiac operative risk evaluation (EuroSCORE) in coronary artery bypass surgery for Taiwanese Interactive CardioVascular and Thoracic Surgery, December 1, 2004; 3(4): 562 - 565. [Abstract] [Full Text] [PDF]
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B. Zingone, A. Pappalardo, and L. Dreas Logistic versus additive EuroSCORE. A comparative assessment of the two models in an independent population sample Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1134 - 1140. [Abstract] [Full Text] [PDF]
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J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt EuroSCORE Predicts Intensive Care Unit Stay and Costs of Open Heart Surgery Ann. Thorac. Surg., November 1, 2004; 78(5): 1528 - 1534. [Abstract] [Full Text] [PDF]
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D. M. Shahian, E. H. Blackstone, F. H. Edwards, F. L. Grover, G. L. Grunkemeier, D. C. Naftel, S. A.M. Nashef, W. C. Nugent, and E. D. Peterson Cardiac Surgery Risk Models: A Position Article Ann. Thorac. Surg., November 1, 2004; 78(5): 1868 - 1877. [Abstract] [Full Text] [PDF]
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S. Karthik, A. K. Srinivasan, A. D. Grayson, M. Jackson, D. A.C. Sharpe, D. J.M. Keenan, B. Bridgewater, and B. M. Fabri Limitations of additive EuroSCORE for measuring risk stratified mortality in combined coronary and valve surgery{star} Eur. J. Cardiothorac. Surg., August 1, 2004; 26(2): 318 - 322. [Abstract] [Full Text] [PDF]
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B. Medalion, D. Meirson, E. Hauptman, L. Sasson, and A. Schachner Initial experience with the Heartstring proximal anastomotic system J. Thorac. Cardiovasc. Surg., August 1, 2004; 128(2): 273 - 277. [Abstract] [Full Text] [PDF]
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N. Kang, T. Cole, V. Tsang, M. Elliott, and M. de Leval Risk stratification in paediatric open-heart surgery Eur. J. Cardiothorac. Surg., July 1, 2004; 26(1): 3 - 11. [Abstract] [Full Text] [PDF]
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A. Gogbashian, A. Sedrakyan, and T. Treasure EuroSCORE: a systematic review of international performance Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 695 - 700. [Abstract] [Full Text] [PDF]
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M. J. Jurmann, H. Siniawski, M. Erb, T. Drews, and R. Hetzer Initial experience with miniature axial flow ventricular assist devices for postcardiotomy heart failure Ann. Thorac. Surg., May 1, 2004; 77(5): 1642 - 1647. [Abstract] [Full Text] [PDF]
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J. Nilsson, L. Algotsson, P. Hoglund, C. Luhrs, and J. Brandt Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm Ann. Thorac. Surg., April 1, 2004; 77(4): 1235 - 1239. [Abstract] [Full Text] [PDF]
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 C. Ugolini and L. Nobilio Risk adjustment for coronary artery bypass graft surgery: an administrative approach versus EuroSCORE Int. J. Qual. Health Care, April 1, 2004; 16(2): 157 - 164. [Abstract] [Full Text] [PDF]
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I. K. Toumpoulis, C. E. Anagnostopoulos, J. J. DeRose, and D. G. Swistel European system for cardiac operative risk evaluation predicts long-term survival in patients with coronary artery bypass grafting Eur. J. Cardiothorac. Surg., January 1, 2004; 25(1): 51 - 58. [Abstract] [Full Text] [PDF]
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