Validation of The European System For Cardiac Operative Risk Evaluation

(EuroSCORE) II As a Predictor of Major Morbidity

After Open Heart Surgery (Valve and Congenital Heart Disease)
at Dr. Sardjito General Hospital

Thesis Summary

Presented as partial fulfillment for the requirement to obtain degree of

Specialization in Anesthesiology and Intensive Therapy

Submitted by :
ACHMAD MUSTIKA
NIM: 13/359962/PKU/14294

DEPARTEMENT OF ANESTHESIOLOGY AND INTENSIVE THERAPY

FACULTY OF MEDICINE PUBLIC HEALTH AND NURSING
UNIVERSITAS GAJAH MADA
YOGYAKARTA
 2018

Thesis Summary

Validation of The European System For Cardiac Operative Risk Evaluation

(EuroSCORE) II As a Predictor of Major Morbidity
After Open Heart Surgery (Valve and Congenital Heart Disease)
at Dr. Sardjito General Hospital

Submitted by :
ACHMAD MUSTIKA
NIM : 13/359962/PKU/14294

Has been approved by :

Content Supervisor

dr. Yunita Widyastuti, Sp.An, KAP, Ph.D Date: ……………………………

Methods supervisor

DR. Med. dr. Untung Widodo Sp. An, KIC Date : ……………………………

DEPARTEMENT OF ANESTHESIOLOGY AND INTENSIVE THERAPY

FACULTY OF MEDICINE PUBLIC HEALTH AND NURSING
UNIVERSITAS GAJAH MADA
YOGYAKARTA
2018
 Validation of The European System For Cardiac Operative Risk Evaluation
(EuroSCORE) II As a Predictor of Major Morbidity
After Open Heart Surgery (Valve and Congenital Heart Disease)
at Dr. Sardjito General Hospital

Achmad Mustika 1, Yunita Widyastuti 2, Untung Widodo 2

Department of Anesthesiology & Intensive Therapy

Faculty of Medicine Public Health and Nursing
Universitas Gajah Mada / Dr Sardjito General Hospital
Yogyakarta

ABSTRACT

Background. Risk stratification plays an important role on open heart surgery all over
the world. Early morbidity and mortality has become primary outcome in many models,
which is useful and aimed to determined indications for surgery, an estimation of
resource’s need, and to determine informed consent. EuroSCORE II is a model of risk
stratification that has been used recently and validated. The aim of this research is to
validate EuroSCORE II as a predictor of major morbidity for open heart surgery patient
(valvular and congenital heart disease) at Dr. Sardjito General Hospital.

Methods. This is a cohort retrospective study. Data was taken from 92 patient post open
heart surgery in year 2006-2016 at Dr.Sardjito General Hospital. EuroSCORE II was
used to predict major morbidity. The discrimination ability was analyzed by the receiver
operating characteristics (ROC) curve. Calibration was assesed with area under the
receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test.

Results. There were 92 samples, of which 26 patients (28.26%) got major morbidity.
EuroSCORE II showed poor discrimination as predictor for morbidity (AUC=0.626)
and poor calibration outcome (Hosmer-Lemeshow: P<0.05). The predicted value of
EuroSCORE II is underestimate in comparison with actual value.

Conclusion. In this study EuroSCORE II had poor discrimination and calibration

ability. EuroSCORE II can not be used to discriminating between positive and negative
major morbidity groups. EuroSCORE II can not be used also for patient risk
stratification of major morbidity.

Keywords : EuroSCORE II, Open heart surgery, Major morbidity

_________________________________________________________________
1
Resident Anesthesiology and Intensive Therapy, Faculty of Medicine Public Health and Nursing UGM
2
Consultant Anesthesiology and Intensive Therapy, Faculty of Medicine Public Health and Nursing UGM
INTRODUCTION
Cardiac surgery has undergone rapid development in both quality and quantity, as
well as in surgical strategies, technological advances, and the development of science in
the field of cardiac anesthesia which makes heart surgery possible in high-risk
populations (1). These developments increase interest in continuing study of post
cardiac surgery outcome quality among patients, health care providers, and finance
regulators (2). One way to improve the quality of heart surgery is to develop a risk
stratification system to assess and analyze risk factors that lead to post heart surgery
death (3). Risk stratification plays an important role in cardiac surgical practice
worldwide where early mortality and morbidity have been the clinical outcomes
assessed by many models and useful to help determine surgical indications, estimate
resource requirements, determine informed consent and improve quality of surgeon and
the institute (4).
Predicting the cause of death is much more complex because there are many
variables, thus it is difficult to determine which predictor variables of death in which
risk of death following cardiac surgery will increase when followed by some major
morbidity events, where major morbidity which is not only associated with high
mortality rates, but also major cause of prolonged duration of intensive care, and
increased hospital costs (5).
There are five major morbidity complications following cardiac surgery that may
potentially lead to permanent disability and life-threatening condition, in which the
uniform reporting of various studies of postoperative morbidity showed the presence of
cerebrovascular injury, mediastinitis, acute renal failure, cardiovascular failure and
respiratory failure (6).
EuroSCORE II is a risk stratification model that has been widely used and
validated in various countries. In Indonesia alone, there is currently no model of risk
scoring system to predict mortality and morbidity following cardiac surgery, while the
need for a risk stratification model is urgently needed to help establish indications of
operations, estimation of resource needs, appropriate informed consent and
improvements in surgeon and institution monitoring. The purpose of this study was to
validate EUROSCORE II as a predictor of major morbidity in post-operative cardiac
surgery patients (valvular and congenital heart disease) in Dr. Sardjito General Hospital.
METHODS
This study used a retrospective cohort design in patients undergoing cardiac
surgery (valvular and congenital heart disease) in Dr. Sardjito General Hospital which
started from January 2006 to December 2016 and has been done in August 2017-
September 2017 in the installation of medical records of Dr. Sardjito General Hospital
in 92 patients undergoing cardiac surgery (valvular and congenital heart disease). The
target population in this study were all patients undergoing cardiac surgery (valvular
and congenital heart disease) in Dr. Sardjito General Hospital. Accessible population
were patients undergoing heart surgery (valvular and congenital heart disease) in Dr.
Sardjito General Hospital in January 2006-December 2016. The inclusion criteria for
this study were patients who underwent valve and congenital heart disease open heart
surgery (not catheterization) at Dr. Sardjito General Hospital. Patients with complete
data according to the data that became the parameters of EuroSCORE II and
postoperative major morbidity data and exclusion criteria in this study were patients
aged < 18 years and > 85 years, patients who died less than 48 hours after surgery,
patients using mechanical ventilation before surgery and patients with chronic renal
disease.
The operational definition in this study consists of the operational definition of
EuroSCORE II accessible via http://www.euroscore.org/calc.html, and the operational
definition of the study, in which the cut off point of acute renal injury (AKI) is defined
as a decrease in kidney function marked with an increase of serum creatinine ≥ 0.3
mg/dL ( ≥ 26.4 μmol/L) or serum creatinine increase percentage of ≥ 50% (1.5 fold
from the baseline) within 48 hours. Prolonged mechanical ventilator (PMV) is defined
as the cumulative duration of mechanical ventilator use 48 hours or more
postoperatively with endotracheal intubation from patient transfer to cardiac intensive
care unit after completion of surgery, patients not extubated within 48 hours or failure
of one or more extubation attempts that makes the accumulation duration of at least 48
hours of endotracheal intubation. The need for inotropic drugs is defined as the need for
two or more inotropic drug uses for more than 24 hours.
 The research procedure was started after ethical approval was issued by Ethics
Commission of Faculty of Medicine, Public Health and Nursing of Gadjah Mada
University.
Sampling was conducted using a non-probability sampling technique in which all
subjects who meet the criteria are recruited into the study sequentially. All forms of
identity of the study subjects will be converted to code and kept confidential and
recorded in the research instrument consisting of preoperative risk factor independent
variable contained in the EuroSCORE II assessment and intraoperative risk factors
(CPB time, AOX time and ischemic time) and dependent variable of major morbidity
incidence (PMV, AKI and need for inotropic drugs). Afterwards, the value of
EuroSCORE II was calculated online through the EuroSCORE II calculator accessed
through http://www.euroscore.org/calc.html. Data was input in the SPSS version 22.0
and STATA for analysis.
The data analysis in this study focuses on the ability of discrimination and
calibration. The discrimination test is performed using the characteristic curve of the
model and calculated the area under the curve (AUC) with the method of receiver
operating curve (ROC) and confidence intervals (CI) 95%. In number, an area with a
value of 1.0 signifies perfect discrimination ability, while the area of 0.5 indicates
inability to discriminate binary data (7).
The calibration used in this study was the Hosmer-Lemeshow test, which
compares the observed values with the predicted values through predicted probability
decile. A formula is said to have good calibration if p > 0.05 in Hosmer-Lemeshow test
(7).
In this study, additional analysis was conducted on intraoperative factor (ischemic
time, Cardiopulmonary Bypass (CPB) time, Cross Clamp (Aox) Time) which was not
present in the EuroSCORE II variable on the occurrence of major morbidity with
independent T-test. To determine which variables have an effect on the occurrence of
major morbidity, the logistic regression test, univariate and multivariate analysis were
performed.
RESULTS
The results of patient subject characteristics from 92 patients sampled in this study
is shown in table 1. The comparison between sample size and population from
EuroSCORE II samples, also characteristic of samples having major morbidity can be
seen in this table. EuroSCORE II preoperative data found that the mean age of patients
in this population was 36.59 ± 13.21 years and the mean age of patients with major
morbidity was 43.26 ± 12.8 years lower than the population data on EuroSCORE II
which is 64.6 ± 12.5 years, the mean value of BMI in this population was 20.59 ± 3.37
Kg/m2. In gender category, most patients were women (66 samples; 71.7%), which were
higher than the percentage of the population of EuroSCORE II (30.9%) and 14 samples
(21.2%) of them experienced major morbidity. In the creatinine clearance category,
most of the samples were in moderate category with 45 patients (48.9%).
Table 1. Sample characteristics (n = 98) (8)
EuroSCORE II
Study Population Population*
Sample Morbidity
Characteristic %/Mean ± SD %/Mean ± SD %/Mean ± SD
Age (years) 36,59±13,21 43,26±12,8 64,6±12,5
BMI (Kg/m2) 20,89±3,37 20,56±2,08 27,4±4,8
Gender Male 26(28,3%) 12(46.2%) 69,1%
Female 66(71,7%) 14(21.2%) 30,9%
CCr Category Normal 43(46,7%) 7(16.3%)
Moderate 45(48,9%) 17(37.8%)
Severe 4(4,3%) 2(50%)
Extracardiac Arteriopathy 0(0,0%) 0%
Poor Mobilization 0(0,0%) 0%
History of Cardiac Surgery 1(1,1%) 0%
Chronic lung disease 1(1,1%) 0% 11%
Infected endocarditis 5(5,4%) 2(40.0%) 2,2%
Perioperative Critical Status 0(0,0%) 0%
DM with Insulin Therapy 3(3,3%) 1(33.3%) 7,6%
CCS Angina 4 0(0,0%) 0%
Myocardial Infarction 2(2,2%) 1(50%)
Pulmonal Hypertension 33(35,9%) 6(18,2%)
Aortic Surgery 0(0,0%) 0% 7,3%
NYHA I 14(15,2%) 2(14.3%)
II 74(80,4%) 24(32.4%)
III 3(3,3%) 0%
IV 1(1,1%) 0%
Left Ventricle Function Good 85(92,4%) 24(28.2%)
Moderate 7(7,6%) 2(28.6%)
Poor 0(0,0%) 0%
Urgency of Surgery Elective 92(100,0%) 26(28.3%) 76,7%
Urgent 0(0,0%) 0% 18,5%
Emergency 0(0,0%) 0% 4,3%
Salvage 0(0,0%) 0% 0,5%
EuroSCORE II 1,26±0,83 1,46±0,95
Dobutamine (hour) 34,59±30,02 45,7±34,6
Noradrenaline (hour) 11,67±20,55 29,7±30,2
Adrenaline (hour) 0,77±3,30 2,3±5,56
Dopamine (hour) 0,13±0,89 0,0±0,0
Milrinone (hour) 0,57±3,49 1,15±4,8
Ventilator Duration (hour) 20,11±21,28 38,4±33,6
2 inotropic > 24 hours 13(14,1%)
AKI Post op 13(14,1%)
PMV 7(7,6%)
CPB Time (min) 89,66±47,13 110,4±52,8
Ischemic Time (min) 49,58±37,62 66,7±39,3
Aox Time (min) 59,62±39,00 75,7±40,7
*(Nashef, 2012) CCr (creatinine clearance), BMI (body mass index), DM (diabetes mellitus), CCS
(Canadian Cardiovascular Society), NYHA (New York Heart Association), AKI (acute kidney injury),
PMV (prolonged mechanical ventilator)
In infected endocarditis, there were 5 patients (5.4%) in which the percentage of
incidence was higher than the population of EuroSCORE II (2.2%), in DM with insulin
therapy, there were 3 patients (3.3%), in pulmonary hypertension there were 33 patients
(35.9%), of which 8 patients (18.2%) experienced major morbidity, most patients had
NYHA class II which was 74 patients (80.4%). In left vertical function in good
condition category, there were 85 patients (92,4%) and moderate category there were 7
patients (7,6%). In this study, data regarding patients with extrauterine arteriopathy,
poor mobilization, perioperative critical status, aortic thoracic surgery, and CCS angina
4 were not available.

Figure 1. ROC curve showed discrimination power of EuroSCORE II in

predicting major morbidity. AUC value (95% CI) 0.626 (0.507-0.748) falls under
weak category.

Out of 92 patients, 26 patients (28.3%) experienced major morbidity with an

average of EuroSCORE II of 1.46 ± 0.95 and 66 patients (71.7%) did not experience
major morbidity with an average of EuroSCORE II of 1.18 ± 0.78 (Table 2). The value
of the Under the Curve Area (AUC) was 0.626 (0,507-0,748) (Figure 1), which means
that EuroSCORE II discrimination ability against major post cardiac surgery morbidity
events of 62.6% was included in the poor category.
Table 2. Comparison between observed and predicted major morbidity based on EuroSCORE II
 Major Morbidity EuroSCORE II AUC p

(number/percentage) Mean ± SD CI 95% H-L test

Yes 26 (28,26%) 1,46 ± 0,95

0,626
0,009
(0,507-0,748)
No 66 (71,74%) 1,18 ± 0,78

P < 0.05
In the calibration results of the Hosmer-Lemeshow test, from the curve (Figure 2)
we found that the predicted value of EuroSCORE II underestimated the actual data of
major morbidity, with p = 0.009 (Table 3) statistically p > 0.05. Therefore, it can be
concluded that the EuroSCORE II scoring system has a poor calibration capability.

Figure 2. Predicted and actual analysis of major morbidity events based on

EuroSCORE II. Predicted value of EuroSCORE II was lower (underestimate) from
actual data of major morbidity.

To see the relation of other independent factors besides factors in preoperative

EuroSCORE II, this study analyzed the influence of intraoperative factor of Aox Time,
CPB Time and ischemic time on the occurrence of major morbidity after cardiac
surgery (Table 3) using independent T-test, which showed that intraoperative CPB time
(p = 0.004), ischemic time (p = 0.005) and Aox time (p = 0.004) to major morbidity
have p value of < 0.05, which mean there is a mean difference between intraoperative
factor experiencing major morbidity and not experiencing major morbidity.
Table 3. Comparison between major morbidity and intraoperative factor
Intraoperative Factor Major Morbidity (Mean ± SD) P-Value*
No Yes
CPB Time (min) 80,82±42,06 112,12±52,50 0,004
Ischemic Time (min) 42,81±34,87 66,77±39,54 0,005
Aox Time (min) 52,29±36,19 78,23±40,37 0,004
*P < 0.05 with T-Test

In this study, logistic regression was performed on each variable of EuroSCORE

II and intraoperative against the occurrence of major morbidity, which aims to know
which variables can affect the occurrence of major morbidity (Table 4). The results of
analysis of age variable (p = 0.004), creatinine level before surgery (p = 0.037), gender
(p = 0.019), creatinine clearance moderate category (p = 0.027) from EuroSCORE II
factors and CPB time (p = 0.007), Aox Time (p = 0.006) and Ischemic Time (p = 0.008)
from intraoperative factors as factors influencing major morbidity (p < 0.05).
Multivariate analysis found that only age variable (p = 0.025) had significant influence
on the occurrence of post cardiac surgery major morbidity (p < 0.05). The magnitude of
the effect of age to major post cardiac surgery major morbidity was as much as 1.059
times every increase in age/year.
Table 4. Univariate and multivariate analysis of perioperative variables to post
cardiac surgery major morbidity.

EuroSCORE II Univariate Multivariate

Variable P OR 95% CI P OR 95% CI

BMI 0,550 0,958 0,833-1,102

Age 0,004 1,059 1,019-1,101 0,025 1,059 1,007-1,113

Cr preop 0,037 7,370 1,129-48,095 0,294 0,124 0,002-6,149

Gender 0,019 3,184 1,206-8,406 0,084 0,257 0,055-1,197

Ccr Moderate 0,027 3,122 1,138-8,567 0,406 1,773 0,459-6,851

Ccr Severe 0,130 5,143 0,617-42,872 0,217 13,433 0,218-829,360

Infective endocarditis 0,553 1,750 0,275-11,129

DM on Insulin 0,843 1,280 0,111-14,753

Myocardial Infarction 0,505 2,600 0,157-43,183

Pulmonal Hypertension 0,114 0,433 0,154-1,221

Aortic Surgery 0,068 3,690 0,906-15,038

NYHA 0,788 1,142 0,434-3,098

Left Ventricle Function 0,985 1,017 0,185-5,601

Intraoperative

CPB Time 0,007 1,014 1,004-1,025 0,591 1,008 0,980-1,037

Aox Time 0,006 1,017 1,005-1,030 0,417 1,024 0,967-1,084

Ischemic Time 0,008 1,017 1,004-1,030 0,524 0,983 0,9333-1,036

Logistic regression (p < 0.05) bold numbers, univariate and multivariate analysis

DISCUSSION
Risk Stratification plays an important role in cardiac surgical practice worldwide.
Early death and morbidity have been the clinical outcomes assessed by many models, as
risk stratification prediction is useful and can help determine surgical indications,
estimate resource requirements, informed consent and quality monitoring of surgeons
and institutions (4). EuroSCORE was developed to predict mortality during
hospitalization, but there have been several studies that tested the accuracy of
EuroSCORE in predicting postoperative morbidity of cardiac surgery, using different
parameters (4,9-13). Because morbidity consists of heterogeneous parameters, it is
difficult to find models that predict overall postoperative complications. However, risk
stratification and preoperative prediction of postoperative morbidity are needed,
especially if this is done with a widely used and validated risk stratification model such
as EuroSCORE (4). The validation study of EuroSCORE II as a predictor of major
morbidity aims to analyze whether the improved version of EuroSCORE can be applied
in Dr. Sardjito General Hospital.
In this study, the patients who satisfied the inclusion and exclusion criteria were
93 patients, normality test was performed with Q-Q plots to see whether the distribution
of samples was normal or not. One sample outlier was obtained so the total number of
samples were 92 patients. The number of these subjects is small compared to previous
studies, Wang et al (2013) with 146 subjects in New Zealand, Najafi et al (2014) with
570 subjects in Iran, Toumpolis et al (2005) with 5051 subjects in the United States, and
Biancari et al (2012) with 1027 subjects in Finland (4,9,11,13).
Actually, the number of cardiac surgery in Dr. Sardjito General Hospital from
2006-2016 was quite a lot, which were 442 patients. However, administrative
completeness and policy of medical record management which regulates that patients
who do not come back to the hospital within 5 years then the data will be inactive, thus
not all subjects can be analyzed.
Discrimination ability test in this study can be seen in Figure and Table 2, Figure
1 showed the result of AUC value equal to 0.626 (95% CI: 0.507-0.748), thus it can be
concluded that the discrimination power of this scoring system is poor, where similar
result was found in a study that compared discrimination test to major morbidity, which
was Toumpoulis et al (2005) to 5051 patients with cardiac surgery in the United States
(having AUC value of 0.66) and Najafi et al (2014) to 570 patients undergoing isolated
CABG surgery in Iran (AUC 0.617), while other studies showed strong discrimination
analysis results of EuroSCORE II such as studies conducted by Wang et al (2014) with
AUC 0.720, Biancari et al (2012) with AUC 0.747, Wang et al (2017) with AUC value
of 0.719 and Hirose et al (2009) with an AUC value of 0.705 (4,9,11-14).
 In the calibration capability analysis of EuroSCORE II on major morbidity in
patient population in Dr. Sardjito General Hospital, p value = 0.009 (p < 0.05) was
found, thus calibration ability of EuroSCORE II to major morbidity showed poor
calibration. From the image of the Hosmer-Lemeshow test calibration curve in Figure 2,
the lower predicted (underestimated) value of the actual value of major morbidity is
shown. In other studies that tested the calibration of major morbidity, only 1 study of
Najafi et al (2014) in the patient population who underwent isolated CABG surgery
showed good calibration results p = 0.119 (p > 0.05) (9).
In this study, poor discrimination and calibration result is caused by several
limitations and weaknesses in this study, where this is a retrospective study, which can
produce minor bias which disturbed validity because of missing subject or incomplete
data, hard-to-find data (such as those on chronic lung disease), inaccurate data during
sampling (such as data on the number of procedures taken through anesthesia status,
whereas more accurate data can be extracted from operative surgery report data) and
there were some variables that were unavailable in our population such as extracardiac
arteriopathy, poor mobilization, perioperative critical status, aortic thoracic surgery,
CCS angina 4, category emergency surgery (emergency and saalvage). This study also
used a small sample size compared with other studies due to the policy of medical
record management in Dr Sardjito General Hospital. In this study, there were
differences in the characteristics of the subjects with the population of EuroSCORE II,
which is likely due to differences in demography and variation of medical care between
patients in European countries and this study population in which in this study, age,
BMI, chronic lung disease, DM with therapy insulin and chronic lung disease have a
lower population than EuroSCORE II. In this study population, all patients underwent
elective surgery and only infected endocarditis was greater in frequency than the
EuroSCORE II population, which may affect the outcome of this study. The difference
in the etiology of valvular heart disease between the EuroSCORE II population and our
study population may also have an effect on outcomes, where valve degenerative
etiology is more common in Europe whereas in our population, most causes are
rheumatic heart disease (15). This study also only took data from one data center only
so it cannot describe the condition of the population of the whole country. Differences
in the quality of human resources, facilities and infrastructure may influence the
outcomes, therefore looking for other important risk factors based on regional needs and
patient characteristics in Dr Sardjito General Hospital may be able to be used as a new
model to accurately predict the outcome.
There is only a preoperative factor in EuroSCORE II consisting of patient factor,
cardiac factor and surgical factor, so to determine other factors affecting other
outcomes, this study also observed intraoperative factors (ischemic time,
Cardiopulmonary Bypass (CPB) time, Cross Clamp (Aox) Time) which were not
present in the EuroSCORE II parameter. The result of independent T-test showed
difference of mean value of ischemic time, CPB time, Cross Clamp (Aox) Time
intraoperative factors between those who experienced and not experienced major
morbidity. Therefore, intraoperative factors may have an effect on the outcomes of
major postoperative morbidity of cardiac surgery in accordance to other studies, in
which many have reported that CPB time and Cross Clamp (Aox) time are independent
factors in predicting postoperative mortality and morbidity (16,17). However, the
purpose of this study was not to develop new model/score or to determine the impact of
other independent variables on the occurrence of postoperative major morbidity of
cardiac surgery which is known that for most risk factors, the predictive value for
morbidity is very complex and different from mortality, while the addition of
intraoperative parameter in future model may be able to increase its discrimination
ability.
Logistic regression test showed univariate analysis results of perioperative factors
that can affect the occurrence of major morbidity where age, creatinine level before
surgery, gender, creatinine clearance of moderate category, CPB time, Aox Time and
Ischemic Time were factors affecting the occurrence of major morbidity (p < 0.05).
Multivariate analysis found only age variable alone can have a significant effect on the
occurrence of major morbidity following cardiac surgery with p = 0.025 (p < 0.05). This
analysis may be used as a reference in the future to determine the development of
predictor model of the occurrence of major morbidity following cardiac surgery at Dr
Sardjito General Hospital.
CONCLUSION AND SUGGESTION
In this study, EuroSCORE II had poor discrimination ability and calibration
result. The predicted value of EuroSCORE II found in this study was underestimate in
comparison to the actual value. EuroSCORE II cannot be used to discriminating groups
experiencing major morbidity or not. EuroSCORE II cannot be used for patient
stratification based on the percentage of likelihood of major morbidity. It is necessary to
develop another model according to the characteristics of the population in Dr. Sardjito
General Hospital. Other factors need to be identified such as the addition of
intraoperative factor to predict the occurrence of major morbidity in Dr Sardjito General
Hospital. It is necessary to check the parameters contained in EuroSCORE II on the
medical records of each patient who will be undergoing open heart surgery for further
development and study.
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