Risky Business

Rather than reacting to every risk we hear and see, we should make an effort to discern which ones we can do something about.”

Ben Carson, Take the Risk, 2008

Benjamin Solomon “Ben” Carson[1] is a neurosurgeon and the former head of Pediatric Neurosurgery at the Johns Hopkins Hospital in Baltimore, Maryland, United States. He became well known in the medical community and beyond with his notorious operation in 1987, which for the first time separated craniopagus twins: Patrick and Benjamin Binder from Germany. Although technically successful, the children survived only with marked neurological deficits. Even with the improved technical developments of today, the separation of “Siamese” twins remains an undertaking of considerable risk.

Cardiac surgery could only develop because its pioneers were daring to take comparable enormous risks back in the 1950s and 1960s. Nowadays, it has principally become a rather “low-risk” surgery with mortalities for elective procedures in the low single-digit range. Achieving this, however, remains a constant challenge because our patients are changing. They have become older and sicker by the time they first encounter a cardiac surgeon, and thus their risk to suffer harm from an operation or even not to survive it should theoretically increase. That this is not necessarily the case is the result of careful preoperative evaluation and subsequent selection of the therapy considered most adequate, for instance when judging conventional versus transcatheter aortic valve procedures. To accomplish this, refined tools are essential.

Always at the forefront of quality control, cardiac surgeons continue to develop a variety of so-called risk evaluation scores, the EuroSCORE being one of the oldest and best known, which has only recently been adapted to our changing times. However, as you can see in this issue, Europe is a continent just as diverse as our patients, and application of the EuroSCORE and its modifications must be reflected against the peculiarities of the individual circumstances.[2] [3] If a very specific subset is to be evaluated, scores should be further refined to make them even more precise.[4] [5]

Ben Carson, by the way, originally wanted to become a cardiac surgeon but found that this field might not offer him enough variety (sic!). When he was contemplating the craniopagus problem for the first time, he discussed it with a pediatric cardiac surgeon because he was afraid of exsanguination. His friend told him about hypothermic circulatory arrest and this proved to be the technical solution, at least for this major operative risk.[6]

• References

• 1 Carson B. Take the Risk. Grand Rapids, MI: Zondervan Publishing; 2008: 58
• 2 Velicki L, Cemerlic-Adjic N, Pavlovic K , et al. Clinical performance of the EuroSCORE II compared with the previous EuroSCORE iterations. Thorac Cardiovasc Surg 2014; 62: 288-297
• 3 Arnaiz-Garcia ME, Gonzalez-Santos JM, Lopez-Rodriguez J, Dalmau-Sorli MJ, Bueno-Codoner M, Arevalo-Abascal A. Survival after major cardiac surgery: performance and comparison of predictive ability of Euroscore II and logistic Euroscore in a sample of mediterranean population. Thorac Cardiovasc Surg 2014; 62: 298-307
• 4 Kötting J, Beckmann A, Döbler K , et al. German CABG score: a specific risk model for patients undergoing isolated coronary artery bypass grafting. Thorac Cardiovasc Surg 2014; 62: 276-287
• 5 Kötting J, Schiller W, Beckmann A , et al. German Aortic Valve Score: a new scoring system for prediction of mortality related to aortic valve procedures in adults. Eur J Cardiothorac Surg 2013; 43 (5) 971-977
• 6 Biography and video interview of Benjamin Carson at the Academy of Achievement. . Available at: http://achievement.org/autodoc/page/car1int-1 . Accessed May 8, 2014