Anatomic and Physiologic Scoring is Associated with Mortality and Morbidity Following Operative Intervention for Adult Congenital Heart Disease Patients

BACKGROUND: The revised 2018 AHA/ACC guidelines introduced the Adult Congenital Heart Disease Anatomic and Physiologic classification (ACHD-AP) to better categorize disease severity and prognosis in the ACHD population. The ACHD-AP has not been rigorously studied as a perioperative prediction tool. OBJECTIVE: We aimed to assess the accuracy of the ACHD-AP classification in predicting perioperative morbidity and mortality. METHODS: This retrospective cohort study included 295 ACHD patients at a single academic institution between 2018 to 2022. Patients were identified by the STS congenital surgery registry and had undergone a congenital surgical procedure. The primary outcome was overall mortality. Secondary outcomes included short-term post-operative morbidity and comparison of the ACHD-AP score to other existing surgical mortality risk scores. Kaplan-Meier and area under the curve (AUC) of Receiver Operating Characteristic curves were used to evaluate mortality. Logistic regression was used to compare short-term morbidity. RESULTS: A total of 295 patients were included with a median age of 30 years (interquartile range 21-41 years) and 52% were female. There was a total of 14 deaths with 5 (2%) early post-operative deaths and 9 (3%) long-term deaths. By increasing anatomy complexity, overall mortality was 0%, 4% (n=10), and 8% (n=4), respectively. By increasing physiologic severity, overall mortality was 0%, 3% (n=2), 4% (n=7), and 14% (n=5). Moderate and complex anatomy trended towards increased mortality but were not statistically significant (p-value > 0.9). More severe physiology scores predicted increased mortality (p-value = 0.02). Higher physiologic or anatomic complexity scores were associated with longer post-operative length of stay (>5 days). The ACHD-AP AUC was 0.711 for mortality, which was comparable to the Adult Congenital Heart Surgery (ACHS) score (AUC 0.798) and better than the PEACH score (AUC 0.575). CONCLUSION: The ACHD-AP score revealed comparable or better predictive power to existing risk models. Worsening physiologic and anatomy scores were associated with worse post-operative outcomes. Further prospective studies are needed to validate the ACHD-AP score as a prognostic factor for patients undergoing ACHD surgery.