Ravi Nair

Cause of Death Within 30 Days of Percutaneous Coronary Intervention in an Era of Mandatory Outcome Reporting

OBJECTIVES This study sought to ascertain causes of death and the incidence of percutaneous coronary intervention (PCI)-related mortality within 30 days. BACKGROUND Public reporting of 30-day mortality after PCI without clearly identifying the cause may result in operator risk avoidance and affect hospital reputation and reimbursements. Death certificates, utilized by previous reports, have poor correlation with actual cause of death and may be inadequate for public reporting. METHODS All patients who died within 30 days of a PCI from January 2009 to April 2011 at a tertiary care center were included. Causes of death were identified through detailed chart review using Academic Research Consortium consensus guidelines and compared with reported death certificates. The causes of death were divided into cardiac and noncardiac and PCI and non-PCI-related categories. RESULTS Of the 4,078 PCI, 81 deaths (2%) occurred within 30 days. Of these, 58% died of cardiac and 42% of noncardiac causes. However, only 42% of 30-day deaths were attributed to PCI-related complications. Patients with non-PCI-related, compared with PCI-related, death presented with a higher incidence of cardiogenic shock (15 of 47 [32%] vs. 2 of 34 [6%]; p < 0.01) and cardiac arrest (19 of 47 [40%] vs. 1 of 34 [3%]; p < 0.01). Death certificates had only 58% accuracy (95% confidence interval: 45% to 72%) for classifying patients as experiencing cardiac versus noncardiac death. CONCLUSIONS Less than one-half of 30-day deaths are attributed to a PCI-related complication. Death certificates are inaccurate and do not report PCI-related deaths, which may represent a better marker of PCI quality.

Enhanced Prediction of Mortality After Percutaneous Coronary Intervention by Consideration of General and Neurological Indicators

OBJECTIVES This study sought to improve methodology for predicting post-percutaneous coronary intervention (PCI) mortality. BACKGROUND Recently, an increased proportion of post-PCI deaths caused by noncardiac causes has been suggested, often in rapidly triaged patients resuscitated from sudden cardiac death or presenting with cardiogenic shock. Older risk adjustment algorithms may not adequately reflect these issues. METHODS Consecutive patients undergoing PCI from 2000 to 2009 were randomly divided into training (n = 8,966) and validation (n = 8,891) cohorts. The 2010 ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) mortality algorithm was applied to the training cohort and its highest risk decile, separately. Variables describing general and neurological status at admission were then tested for their additional predictive capability and new algorithms developed. These were tested in the validation cohort, using receiver-operator characteristic curve, Hosmer-Lemeshow, and reclassification measures as principal outcome measures. RESULTS In-hospital mortality was 1.0%, of which 52.2% had noncardiac causes or major contributions. Baseline model C-statistics for the total and upper decile training cohorts were 0.904 and 0.830. The Aldrete score (addressing consciousness, respiration, skin color, muscle function, and circulation) and neurology scores added incremental information, resulting in improved validation cohort C-statistics (entire group: 0.883 to 0.914, p < 0.001; high-risk decile: 0.829 to 0.874, p < 0.001). Reclassification of the ACC-NCDR <90th and ≥90th risk percentiles by the new score yielded improved mortality prediction (p < 0.001 and p = 0.033, respectively). CONCLUSIONS Half of in-hospital deaths in this series were of noncardiac causation. Prediction of in-hospital mortality after PCI can be considerably improved over conventional models by the inclusion of variables describing general and neurological status.

From mice to men. Commonalities in physiology for stem cell-based cardiac repair.

Current treatments for acute myocardial infarction (AMI) involving successful restoration of blood flow into the infarct-related artery either by percutaneous methods or by fibrinolytic therapy have shown to be of benefit in reduction of short-term mortality. While the advantages of these

Fractional flow reserve guided percutaneous coronary intervention results in reduced ischemic myocardium and improved outcomes

To determine if fractional flow reserve guided percutaneous coronary intervention (FFR‐guided PCI) is associated with reduced ischemic myocardium compared with angiography‐guided PCI.

Percutaneous coronary revascularization in coronary artery disease: lessons from a single center experience.

To determine the role of percutaneous coronary intervention (PCI) and its impact on mortality in coronary artery disease (CAD).

TCT-291 Predictors of Successful Hybrid-Approach CTO Stenting: An Improved Model with Refined Correlates

Chronic total occlusion (CTO)s are common and often result in referral for bypass surgery without attempted PCI. When PCI is attempted, success rates are variable and current predictive models for success have major limitations. We sought to develop a hybrid approach-specific model to predict CTO

Robotically Assisted Totally Endoscopic Coronary Artery Bypass Grafting

Totally endoscopic coronary artery bypass grafting (TECAB) is feasible and safe using robotic technology. During more than a decade of technological and surgical development multivessel TECAB has become a reality both on the beating and the arrested heart. In this book chapter we outline the indications for this procedure, describe the preoperative workup and the surgical techniques, and give guidelines for postoperative care.

Comparison of outcomes of unprotected left main versus multivessel coronary artery interventions.

Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.