Reducing the Risk of Emergency Bypass Surgery for Failed Percutaneous Coronary Interventions**Editorials published in the Journal of American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology

Meta-Analysis Evaluating the Effect of Left Coronary Dominance on Outcomes After Percutaneous Coronary Intervention

Prognostic significance of coronary circulation dominance remains controversial. The primary objective of this meta-analysis was to pool all the available evidence to assess the influence of left coronary dominance (LD) on outcomes in patients who underwent percutaneous coronary intervention (PCI). MEDLINE, Cochrane CENTRAL, and Scopus databases were searched for all observational studies and randomized controlled trials that investigated the association between coronary dominance and outcomes in patients who underwent PCI. Odds ratios (OR) and 95% confidence intervals from individual studies were pooled using a random effects model. A total of nine studies including 266,119 patients were included. On pooled analysis, it was noted that LD was associated with significantly increased odds of in-hospital (OR: 1.54 [1.12, 2.11]; p = 0.007), 30-day (OR: 2.16 [1.22, 3.84]; p = 0.008), and long-term mortality (OR: 1.83 [1.33 to 2.50]; p < 0.001). LD patients also experienced a significantly higher incidence of major adverse cardiac events (OR: 1.27 [1.03, 1.58]; p = 0.03) and failed PCI (OR: 1.30 [1.03, 1.65]; p = 0.03). In contrast, no significant difference was noted between LD and non-LD patients in the incidence of stent thrombosis (OR: 1.28 [0.55, 3.01]; p = 0.57; I² = 0%) or reinfarction (OR: 1.73 [0.90, 3.35]; p = 0.10; I² = 63%). In conclusion, this meta-analysis suggests that patients with LD coronary anatomy are at significantly increased risk for mortality after PCI compared with patients with a non-LD anatomy.

Predicting emergency coronary artery bypass graft following PCI: application of a computational model to refer patients to hospitals with and without onsite surgical backup

Background

Clinical tools to stratify patients for emergency coronary artery bypass graft (ECABG) after percutaneous coronary intervention (PCI) create the opportunity to selectively assign patients undergoing procedures to hospitals with and without onsite surgical facilities for dealing with potential complications while balancing load across providers. The goal of our study was to investigate the feasibility of a computational model directly optimised for cohort-level performance to predict ECABG in PCI patients for this application.

Methods

Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry data with 69 pre-procedural and angiographic risk variables from 68 022 PCI procedures in 2004–2007 were used to develop a support vector machine (SVM) model for ECABG. The SVM model was optimised for the area under the receiver operating characteristic curve (AUROC) at the level of the training cohort and validated on 42 310 PCI procedures performed in 2008–2009.

Results

There were 87 cases of ECABG (0.21%) in the validation cohort. The SVM model achieved an AUROC of 0.81 (95% CI 0.76 to 0.86). Patients in the predicted top decile were at a significantly increased risk relative to the remaining patients (OR 9.74, 95% CI 6.39 to 14.85, p<0.001) for ECABG. The SVM model optimised for the AUROC on the training cohort significantly improved discrimination, net reclassification and calibration over logistic regression and traditional SVM classification optimised for univariate performance.

Conclusions

Computational risk stratification directly optimising cohort-level performance holds the potential of high levels of discrimination for ECABG following PCI. This approach has value in selectively referring PCI patients to hospitals with and without onsite surgery.

Incidence, predictors, and outcomes of failed primary percutaneous coronary intervention: a 10-year contemporary experience

BACKGROUND

Limited contemporary data exist regarding the incidence, predictors, and outcomes of failure of primary percutaneous coronary intervention (PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

In this registry-based retrospective cohort study, all consecutive unselected patients (n=1725) who were hospitalized for STEMI and underwent primary PCI from January 2001 to December 2010 were included. PCI failure was defined as a final diameter stenosis greater than 30% or postdilatation Thrombolysis in Myocardial Infarction (TIMI) flow grade of 2 or less. We examined the predictors and survival among patients who failed primary PCI.

RESULTS

The overall PCI failure rate was 5.4% (94 of 1725 procedures). After adjusting for prespecified baseline characteristics, independent predictors of PCI failure included age greater than 65 years (P=0.02), procedure date between 2001 and 2005 (P=0.05), night-time PCI (P=0.008), calcific lesion (P=0.008), and lower preprocedural TIMI flow grade (P=0.006). Failed PCI was associated with a 1-year mortality rate of 22% as compared with 4.2% in the successful PCI group (P<0.001). Conservative medical management was preferred in the majority of patients with failed PCI (n=78, 83%). Patients who underwent emergent surgery (n=11), conservative management (n=78), and redo PCI (n=5) experienced 30-day mortality rates of 27, 16, and 0%, respectively.

CONCLUSION

Primary PCI failure in the setting of STEMI is not rare. It is associated with high-risk patient-related and angiographic-related characteristics. Primary PCI failure is associated with early and late mortality.

Operator volume and outcomes of primary angioplasty for acute myocardial infarction in a single high-volume centre

OBJECTIVE

The guidelines for the management of ST-elevation myocardial infarction (STEMI) state the minimum operator volume for percutaneous coronary interventions (PCIs), without strong evidence of a relationship between operator volume and outcomes of primary angioplasty, at variance with elective practice. We sought to investigate the effect of operator volume on primary PCI for STEMI.

METHODS

Three hundred and thirty-one consecutive STEMI patients were treated over 19 months with primary PCI in a high-volume centre without on-site cardiac surgery. Three skilled operators, with very different volumes of interventional practice, performed the PCI procedures around-the-clock.

RESULTS

Operators were divided into very high (A), intermediate high (B) and low high volume (C). Demographic, clinical, angiographic, and procedural characteristics of the patient population did not differ among operators, with the exception of three-vessel disease (P = 0.016), circumflex infarct-related artery (P = 0.002), mechanical support (P = 0.02), use of abciximab (P = 0.003) for operator C, use of tirofiban for operator B (P = 0.02), and type of stent for operator A (P = 0.0004). Similarly, no differences were observed among operators in in-hospital outcomes (death, a composite of major adverse cardiovascular events, ST-segment resolution, thrombolysis in myocardial infarction flow grade 3, length of hospitalization) and haemorrhagic complications.

CONCLUSIONS

Our data show that there is not a significant relationship between operator volume over the threshold indicated by the guidelines, and both primary PCI early outcomes and complications in STEMI, and suggest that expertise and experience of the whole professional team rather than just of the individual operator play a major role.

Nonemergent coronary angioplasty without on-site surgical backup: a randomized study evaluating outcomes in low-risk patients

BACKGROUND

Percutaneous coronary intervention (PCI) in nonemergent patients with coronary artery disease in hospitals without on-site cardiac surgery backup is still controversial. To prospectively evaluate a set of low procedural risk criteria for PCI, patients with stable or unstable angina were randomized to treatment in either a community hospital, which had all supportive services except for on-site cardiac surgery, or a regional surgical hospital 213 km away.

METHODS AND RESULTS

During a 4-year period, 609 (57%) of 1064 consecutive patients with stable or unstable angina who underwent coronary angiography at a teaching community hospital in Norway fulfilled the predefined low-risk criteria for PCI. The patients were randomized to treatment at either the community hospital (n = 305) or at the regional hospital (n = 304). The angiographic success rate (96% at both hospitals) and number of major periprocedural complications (overall 0.3%) were equal at the 2 hospitals. In particular, there were no deaths or need for urgent transfer to cardiac surgery. At 6 months of clinical follow-up, there was a significant higher major adverse cardiac event rate rate at the community hospital, compared with the regional hospital (6.9% vs 2.3%, respectively, P = .03) because of more repeat target vessel revascularizations. Improvement in angina functional class and exercise capacity was similar in both groups. The excluded high-risk PCI patients had higher 6-month major adverse cardiac event compared with all low-risk patients (8.4% vs 4.3%, respectively, P = .01).

CONCLUSION

Selected nonemergent patients can, based on angiography, safely undergo PCI at hospitals without cardiac surgery backup. The angiographic selection criteria identified high-risk patients, which had worsened outcome at 6 months of follow-up.

A Total of 1,007 Percutaneous Coronary Interventions Without Onsite Cardiac Surgery

OBJECTIVES

We sought to compare clinical outcomes of elective percutaneous coronary intervention (PCI) and primary PCI for ST-segment elevation myocardial infarction (STEMI) at a community hospital without onsite cardiac surgery to those at a tertiary center with onsite cardiac surgery.

BACKGROUND

Disagreement exists about whether hospitals with cardiac catheterization laboratories, but without onsite cardiac surgery, should develop PCI programs. Primary PCI for STEMI at hospitals without onsite cardiac surgery have achieved satisfactory outcomes; however, elective PCI outcomes are not well defined.

METHODS

A total of 1,007 elective PCI and primary PCI procedures performed from March 1999 to August 2005 at the Immanuel St. Joseph's Hospital-Mayo Health System (ISJ) in Mankato, Minnesota, were matched one-to-one with those performed at St. Mary's Hospital (SMH) in Rochester, Minnesota. Strict protocols were followed for case selection and PCI program requirements. Clinical outcomes (in-hospital procedural success, death, any myocardial infarction, Q-wave myocardial infarction, and emergency coronary artery bypass surgery) and follow-up survival were compared between groups.

RESULTS

Among 722 elective PCIs, procedural success was 97% at ISJ compared with 95% at SMH (p = 0.046). Among 285 primary PCIs for STEMI, procedural success was 93% at ISJ and 96% at SMH (p = 0.085). No patients at ISJ undergoing PCI required emergent transfer for cardiac surgery. Survival at two years' follow-up by treatment location was similar for patients with elective PCI and primary PCI.

CONCLUSIONS

Similar clinical outcomes for elective PCI and primary PCI were achieved at a community hospital without onsite cardiac surgery compared with those at a tertiary center with onsite cardiac surgery using a prospective, rigorous protocol for case selection and PCI program requirements.