Clinical features and outcomes in patients with cardiogenic shock complicating acute myocardial infarction: early vs recent experience with impella.

OBJECTIVES: To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND: Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS: We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS: Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS: Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.

Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy.

OBJECTIVE: Carotid revascularization procedures, carotid artery stenting (CAS) and carotid endarterectomy (CEA), are among the most common vascular interventions performed in the United States, with significant resource utilization. Whereas multiple studies have reported outcomes after these procedures, data regarding 30-day readmission rates after these interventions remain scant. METHODS: The U.S. Nationwide Readmission Database (2010-2014) was queried to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for CEA or CAS. RESULTS: Among 476,260 patients included, 13.5% underwent CAS and 86.5% underwent CEA. The combined 30-day readmission rate for all carotid revascularization procedures was 9.2% (10.6% after CAS and 9.0% after CEA). After 1:3 propensity matching, CAS was associated with higher risk of readmission compared with CEA (10.4% vs 9.4%). Neurologic complications and cardiac conditions were the two most common causes of readmission after both CAS (29.7% and 23.7%, respectively) and CEA (28.2% and 21.7%, respectively). The 30-day readmission rates were higher in CAS patients across all age groups as well as in those with a low or high baseline burden of comorbidities. CONCLUSIONS: In this large nationwide study, CAS was associated with higher 30-day readmission rates compared with CEA irrespective of age or baseline burden of comorbidities. Neurologic or cardiac adverse events were responsible for >50% of readmissions after CAS and CEA.

Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions.

OBJECTIVES: To determine the efficacy and safety of drug-eluting stents (DESs) and bare metal stents (BMSs) when used with short or tailored dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients. BACKGROUND: DES have been shown to reduce target lesion revascularization (TLR) as well as stent thrombosis (ST) compared to BMS in patients undergoing percutaneous coronary intervention (PCI). However, patients at HBR continue to receive BMS given the fear of bleeding or ST from premature discontinuation of DAPT in patients receiving DES. METHODS: We performed a meta-analysis of randomized controlled trials by performing systematic search for studies comparing DES with BMS in HBR patients using PUBMED, MEDLINE, and Cochrane Central, reported until March 1, 2018. RESULTS: Three randomized controlled studies met the inclusion criteria with total of 4,460 patients; 50% received DES. Major adverse cardiovascular event (MACE); composite of death, myocardial infarction (MI), and TLR, at 1 year was significantly lower (RR = 0.63, 95% CI 0.50-0.80) in DES group compared to BMS. This difference was primarily driven by lower TLR (RR = 0.46, 95% CI 0.35-0.61) in DES group. Definite or probable ST (RR = 0.59, 95% CI = 0.32-1.08) and major (RR = 0.94, 95% CI = 0.74-1.20) bleeding were similar. CONCLUSIONS: DES was associated with lower MACE without increased risk of bleeding or ST compared to BMS when used with short or tailored DAPT in patients with HBR.

Long-term outcomes of patients with diabetes mellitus undergoing percutaneous intervention for popliteal and infrapopliteal peripheral arterial disease.

OBJECTIVES: To evaluate the association of diabetes mellitus (DM) with clinical and angiographic characteristics and outcomes of patients with popliteal and infrapopliteal peripheral arterial disease (PAD) undergoing peripheral vascular intervention (PVI). BACKGROUND: Clinical features and outcomes in patients with DM and popliteal or infrapopliteal PAD undergoing PVI are not well described. METHODS: Using the data from the laser in popliteal and infrapopliteal stenosis study, we retrospectively examined the association of diabetes with clinical and angiographic characteristics and risk adjusted short- and intermediate term outcomes (all cause death, major adverse events (MAE) [composite of death, ipsilateral major amputation, or repeat revascularization]) in patients with popliteal and infrapopliteal PAD undergoing PVI for critical limb ischemia treated either with laser-assisted balloon angioplasty or balloon angioplasty alone. RESULTS: Of 714 patients, 418 had DM (58.5%). Patients with DM were younger with higher prevalence of history of coronary artery disease, heart failure, end-stage renal disease, and prior contralateral limb amputation compared to those without DM. At 5 years, mean event free survival for all cause mortality (39.9 vs. 45.5 months; P = 0.001), MAE (29.3 vs. 36.8 months; P < 0.001), ipsilateral major amputation (55.3 vs. 57.4 months; P = 0.001), and repeat revascularization (42.0 vs. 45.8 months; P = 0.03) were significantly lower in DM patients. On multivariate analysis, DM was associated with significantly higher all cause mortality (HR = 1.83, 95% CI 1.33-2.52), MAE (HR = 1.73, 95% CI 1.35-2.23), and ipsilateral major amputation (HR = 5.52, 95% CI 1.82-16.71). CONCLUSIONS: Among patients with popliteal and infrapopliteal PAD undergoing PVI, DM was associated with higher mortality, major amputations and MAE that was independent of baseline comorbidities. Our data suggested the need for future studies evaluating existing and/or novel therapies to improve the poor long-term outcomes in diabetic patients with popliteal and infrapopliteal PAD.

The association of race with quality of health in peripheral artery disease following peripheral vascular intervention: The Q-PAD Study.

Black patients have a higher prevalence of peripheral artery disease (PAD) than white patients, and also tend to have a greater extent and severity of disease, and poorer outcomes. The association of race with quality of health (QOH) after peripheral vascular intervention (PVI), however, is less well-known. In our study, we hypothesized that after PVI, black patients experience worse QOH than white patients. We retrospectively assessed racial differences in health status using responses to the Peripheral Arterial Questionnaire (PAQ) at baseline (pre-PVI) and up to 6 months following PVI among 387 patients. We used the PAQ summary score (which includes physical limitation, symptoms, social function and quality of life) as a measure of QOH. We compared QOH scores at baseline and at follow-up after PVI between black ( n=132, 34.1%) and white ( n=255, 65.9%) patients. We then computed the change in score from baseline to follow-up for each patient (the delta) and compared the median delta between the two groups. Multivariable regression was used to model the delta QOH after controlling for factors associated with race or with the delta QOH. There was no significant difference in mean QOH by race either at baseline ( p=0.09) or at follow-up ( p=0.45). There was no significant difference in the unadjusted median delta by race (white 25.3 vs black 21.5, p=0.28) and QOH scores improved significantly at follow-up in both groups, albeit the improvement was marginally lower in black compared with white patients after adjustment for baseline confounders ( b = -6.6, p=0.05, 95% CI -13.2, -0.11).

Differences in sex-related bleeding and outcomes after percutaneous coronary intervention: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry.

BACKGROUND: Bleeding after percutaneous coronary intervention (PCI) is more common in women than in men. However, the relationship of sex and bleeding with outcomes is less well studied. METHODS: We examined the sex-related differences in the incidence of bleeding and its association with in-hospital outcomes among 96,637 patients undergoing PCI enrolled in the BMC2 registry (2010-2012). RESULTS: Women had higher bleeding rate than did men (3.9% vs 1.8%) and thus received more blood transfusions (59% vs 41%). Both men (odds ratio [OR] 2.25, 95% CI 1.70-2.97) and women (OR 3.13, 95% CI 2.42-4.07) who bled had higher risk-adjusted death compared with their counterparts without bleeding. Although there was no difference in adjusted mortality between women and men without bleeding (OR 1.14, 95% CI 0.99-1.32), among patients who bled, adjusted death was higher in women (OR 1.28, 95% CI 1.11-1.47). Among patients with bleeding, transfusion was associated with similar increased risk of death in both men (OR 2.00, 95% CI 1.23-3.25) and women (OR 2.18, 95% CI 1.31-3.63) compared with their counterparts without transfusion(s). CONCLUSIONS: Post-PCI bleeding was more common and associated with higher-than-expected in-hospital death in women compared with men with bleeding. This trend for higher death in women with bleeding was independent of transfusion. Quality efforts geared toward reducing bleeding in general, with a special focus on women, need to be explored to help reduce post PCI-bleeding and mortality and decrease sex-related disparity in adverse events.

CHA(2)DS(2)-VASc versus CHADS(2) for stroke risk assessment in low-risk patients with atrial fibrillation: a pilot study from a single center of the NCDR-PINNACLE registry.

The CHADS(2) score is widely used to assess the risk of stroke in patients with atrial fibrillation (AF). Patients with score of 0 and 1 are considered 'low risk' and are often treated with aspirin. In a Danish Study, the CHA(2)DS(2)--VASc score was shown to identify low and high-risk subgroups among patients with CHADS(2) score of 0 and 1, with annual risk ranging from 0.84 to 8.18%. This study seeks to assess whether using CHA(2)DS(2)--VASc score will identify high-risk subset of patients with low CHADS(2) scores in an American population. This pilot study examined data from our cardiology fellowship ambulatory clinics from January 2009 to May 2012 using the NCDR-PINNACLE registry. Each cardiology fellow entered patients' data using on-line software developed by the American College of Cardiology. Among 2,048 patients followed at our clinics, 478 had AF. Of those, 161 patients had CHADS(2) score of 0 (44 patients) or 1 (117 patients). Calculating the CHA(2)DS(2)--VASc score in these patients, 12 (7.4%) had score of 0, 50 (31.1%) had score of 1, 66(41%) had score of 2, 31 (19.3%) had score of 3 and 2 (1.2%) had score of 4. Using original CHADS(2) recommendation, warfarin would not be strongly recommended in any of these patients. Utilizing the CHA(2)DS(2)--VASc score, 61.5% of the 161 patients would have a score of 2 or more signifying increased risk where anticoagulation may be indicated. Compared to CHADS(2), CHA(2)DS(2)--VASc may more precisely predict the risk of stroke and anticoagulation strategy in low-risk patients with non-valvular AF.

The association between patient race, treatment, and outcomes of patients undergoing contemporary percutaneous coronary intervention: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

BACKGROUND: The aim of this study was to examine if racial disparities exist in the treatment and outcomes of patients undergoing contemporary percutaneous coronary intervention (PCI). METHODS: We examined the association between race, process of care, and outcomes of patients undergoing PCI between January 1, 2010, and December 31, 2011, and enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. We used propensity matching to compare the outcome of black and white patients. RESULTS: The study cohort comprised 65,175 patients, of whom 6,873 (10.5%) were black and 55,789 (85.6%) were white. Black patients were more likely to be younger, be female, have more comorbidities, and be uninsured. Overall, black patients were less likely to receive prasugrel (10.0% vs 14.5%, P < .001) and drug-eluting stents (62.5% vs 67.7%, P < .001), largely related to lower use of these therapies in hospitals treating a higher proportion of black patients. No differences were seen between white and black patients with regard to inhospital mortality (odds ratio 1.34, 95% CI 0.82-2.2, P = .24), contrast-induced nephropathy (OR 1.06, 95% CI 0.81-1.40, P = .67), and need for transfusion (OR 1.27, 95% CI 0.98-1.64, P = .06). White race was associated with increased odds of heart failure (OR 1.48, 95% CI 1.05-2.08, P = .024) and vascular complications (OR 1.40, 95% CI 1.03-1.90, P = .032). CONCLUSIONS: Compared with white patients, black patients undergoing PCI have a greater burden of comorbidities but, after adjusting for these differences, have similar inhospital survival and lower odds of vascular complications and heart failure after PCI.

Race and epicardial fat: the impact of anthropometric measurements, percent body fat and sex.

OBJECTIVE: Epicardial fat is known to be thicker in White men than in Black men. The impact of sex, % body fat, and other anthropometric measures on epicardial fat thickness has not been described. Therefore we sought to evaluate how the racial differences in epicardial fat thickness would differ by these factors. METHODS: We used two-dimensional transthoracic echocardiography to measure the epicardial fat thickness in 150 patients who were admitted to our clinical decision unit for chest pain. Standard anthropometric measurements were performed and body mass index (BMI) and % body fat were calculated. Data were analyzed using analysis of variance and multiple regression. RESULTS: Epicardial fat measured at the mid right ventricular wall was significantly greater in Whites than Blacks (4.9 +/- 2.1 mm vs 3.8 +/- 1.8 mm, for males, and 5.8 +/- 3.2 mm vs 3.7 +/- 1.7 mm, for females). The results from regression analysis showed that after controlling for age, sex, BMI and waist circumference, race remained a significant predictor of epicardial fat, with Whites having higher amounts of fat than Blacks. The difference by race remained even after controlling for % body fat, which was also a significant predictor. CONCLUSION: Anterior epicardial fat thickness is greater in White than Black men and women of the same race and is independent of anthropometric measurements and % body fat. Race may be an important consideration when analyzing the relationship between epicardial fat and cardiovascular risk.

Evaluating Statin Tolerability in Historically Intolerant Patients After Correcting for Subclinical Hypothyroidism and Vitamin D Insufficiency.

INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) is the major cause of morbidity and mortality worldwide. Statins provide primary and secondary ASCVD prevention. Intolerance due to statin-associated myalgias reduces long-term adherence, thus muting potential benefits. AIM: Our analysis sought to determine whether transition from a lipophilic statin to a water-soluble statin, or correction of subclinical hypothyroidism and/or vitamin D insufficiency/deficiency (metabolic abnormalities), improved statin tolerance. METHODS: We performed a retrospective analysis of the data from patients referred to our lipid clinic because of statin intolerance. Patients intolerant to a lipophilic statin were switched to a water-soluble statin. Patients having vitamin D insufficiency/deficiency or subclinical hypothyroidism were re-challenged with a water-soluble statin (or lipophilic statin with minimal systemic exposure) after correction of the metabolic abnormality. RESULTS: 169 patients were statin intolerant. 86% (n = 145) were white and 48% (n = 81) were male. 82 of these patients had one or both metabolic abnormalities. The remaining patients (n = 87) had no metabolic abnormality, however, were unable to tolerate a lipophilic statin. 72% (n = 73) of eligible patients (n = 101), defined as those with a corrected metabolic abnormality or without a metabolic abnormality on a lipophilic statin, were able to tolerate a water-soluble statin or lipophilic statin with minimal systemic exposure. In addition, 75% (n = 127) of this total cohort met their LDL-C goal. CONCLUSIONS: Our findings suggest that either correction of subclinical hypothyroidism and/or vitamin D insufficiency/deficiency or transition from a lipophilic statin to water-soluble statin (or lipophilic statin with minimal systemic exposure) improves statin tolerance.

Unmasking Severe Tricuspid Valve Regurgitation After Percutaneous Debulking of Large Tricuspid Vegetation.

A 27-year-old man admitted with tricuspid valve endocarditis with a large vegetation, persistent bacteremia, and pulmonary and systemic septic embolization was deemed not a suitable surgical candidate. He underwent percutaneous vegetation debulking using the AngioVac system. The patient defervesced post-operatively with clinical improvement but with abruptly worsened tricuspid regurgitation. (Level of Difficulty: Beginner.).

Differences in Baseline Characteristics and Outcomes in Young Caucasians and African Americans with Acute Myocardial Infarction.

BACKGROUND: The incidence of acute myocardial infarction (AMI) in young patients is increasing. While race-related differences in clinical characteristics and outcomes for older AMI patients have been well-studied, such differences in young patients are unknown. METHODS: We performed a retrospective review of charts of Caucasian and African American (AA) patients <50 years of age, presenting with AMI between 2010 and 2017 in an urban, community hospital in Detroit, Michigan. RESULTS: A total of 271 patients were identified with 156 being AAs (57.5%). Mean age was 43 years which was similar in both groups. AAs with AMI were 2.2 times more likely to be women and to have a history of diabetes and 1.2 times more likely to have BMI >30 kg/m2. History of coronary artery disease (1.8-fold) and hypertension (1.5-fold) were also more common in AAs. Overall presenting features were similar, other than that AAs presented more often with non-ST-elevation MI and tended to present less often with cardiac arrest. No differences were observed in the angiographic findings or in-hospital outcomes in the two groups, with the exception of lower need of mechanical support in AAs. CONCLUSIONS: In conclusion, our data provide important, not previously described information on race-related differences in history, presentation, clinical and angiographic features and outcomes in AAs compared with Caucasians younger than 50 with AMI. These findings may have implications for tailoring specific preventive strategies to decrease the incidence of AMI and its associated adverse events in both racial groups.

Cardiogenic Shock Complicating Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention Supported by Impella: Implications of Advanced Age and Refractory Shock on Outcomes.

With percutaneous left ventricular mechanical circulatory support devices becoming increasingly available for patients with cardiogenic shock due to acute myocardial infarction and the lack of a clear mortality benefit to date, identifying optimal candidates for this technology is crucial. We studied the effectiveness of Impella Cardiac Pow (Abiomed, Danvers, MA) in various stages of cardiogenic shock and elderly cohorts. DESIGN: Retrospective review. SETTING: Data were collected for patients at a single community hospital between January 1, 2018, and December 31, 2019. SUBJECTS: Thirty-one consecutive adult patients with cardiogenic shock due to acute myocardial infarction who received Impella Cardiac Pow support. Shock stages were defined by the Society for Cardiovascular Angiography and Intervention (Stages A-E). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital death across Society for Cardiovascular Angiography and Intervention cardiogenic shock stages and in patients greater than or equal to 80 and less than 80 years old. Secondary outcomes were Valve Academic Research Consortium-2 vascular and bleeding complications, stroke, and renal failure requiring dialysis. The median age of the study population was 64 years, with seven patients (23%) being greater than or equal to 80 years old. No patients were in Society for Cardiovascular Angiography and Intervention Stage A, whereas there were seven in B, eight in C, six in D, and 10 (32%) in E. Overall in-hospital mortality occurred in 61% of patients. All 10 patients in Stage E died before hospital discharge. Mortality occurred in 54% of patients (13/24) age less than 80 years compared with 86% of those 80 years or older (6/7). A total of 38.7% of patients (12/31) and 32.3% of patients (10/31) experienced Valve Academic Research Consortium-2 bleeding and vascular events, which were evenly distributed across Society for Cardiovascular Angiography and Intervention cardiogenic shock Stages. CONCLUSIONS: In conclusion, patients with shock in extremis and those 80 years old and older may have a prohibitively high mortality despite Impella use. These findings merit further prospective investigation in a larger number of patients to evaluate the effectiveness of Impella (and other left ventricular mechanical circulatory devices) and the inherent resource utilization in advanced cardiogenic shock and the elderly.

Impact of the prehospital ECG on door-to-balloon time in ST elevation myocardial infarction.

BACKGROUND: National guidelines have been set to achieve door-to-balloon time (D2B) is less than 90 minutes to improve outcomes for patients with STEMI. The purpose of this study is to see if a more aggressive approach utilizing prehospital ECGs could improve reperfusion times. METHODS: The EMS personnel obtained a 12-lead ECG during initial assessment in the field from patients with chest pain. The ECG was immediately transmitted to the ER physician by cellular link to a computer receiving station. The ER physician reviewed the ECG digital tracing. The cardiac catheterization laboratory (CCL) team was activated from the patients' homes. Patients were transported from the field directly to the CCL by EMS bypassing the emergency department. RESULTS: The mean D2B for patients with initial ECG in hospital in all three hospitals combined was 90.5 minutes, compared to 60.2 minutes in patients with prehospital ECG. (P < 0.0001). When analyzing the mean D2B in regards to times of presentation, we found a significant reduction in mean D2B in patients presenting during working hours (75 minutes) compared with those presenting during off hours (98 minutes) in the control group. However, with the use of prehospital ECGs, there was a significant reduction in D2B regardless of what time the patient arrived in the ER. CONCLUSIONS: Utilizing the prehospital ECG as a tool to bypass ER triage significantly decreases D2B times in patients with STEMI. This technology has the potential to substantially expedite reperfusion therapy in patients with STEMI.

Retroperitoneal hematoma in patients undergoing cardiac catheterization.

OBJECTIVE: To retrospectively study demographic, clinical and hospital outcomes in patients who developed RPH following cardiac catheterization. METHODS: Charts of patients with RPH from cardiac catheterization, between January 1, 2000 and July 30, 2005 were reviewed and compared with two control groups (Grp-I, 90 patients with local groin complications and Grp-II, 98 patients with no bleeding complications). RESULTS: 31 cases of RPH (0.13%) were identified with 84% females. Most common presentation was hypotension (87%) and hemoglobin drop (96%). CT scan was the diagnostic modality in 93% cases. The mean body surface area in RPH group (1.77 ± .23) was significantly lower than in control group I (1.93 ± .28) and II (1.98 ± .27). The use of larger sheath size was significantly higher in the RPH group (61.3%) than control groups I (26.7%) and II (21.4%). Left groin access was significantly more in RPH group (16.1%) and control group I (17.8) than control group II (0%). The use of antiplatelets and anticoagulants were significantly higher in the RPH group. 13% of patients with RPH were treated surgically. The average hospital stay was 8.6 days, 4.5 days and 3.5 days and mortality 12.9%, 3.3% and 1% in RPH group, control group I and II respectively. CONCLUSION: Our study is the second largest series of RPH following cardiac catheterization and predicts female gender, large sheath size, left groin access and low body surface area as risk factors for RPH.

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

Epinephrine is indicated for various medical emergencies, including cardiac arrest and anaphylaxis, but the dose and route of administration are different for each indication. For anaphylaxis, it is given intramuscularly at a low dose, whereas for cardiac arrest a higher dose is required intravenously. We encountered a patient with suspected anaphylaxis who developed transient severe systolic dysfunction because of inappropriately received cardiac arrest dose, ie, larger dose given as an intravenous push. Three additional patients who experienced potentially lethal cardiac complications after receiving inappropriately higher doses intravenously were also identified. These iatrogenic errors resulted from underlying confusion by physicians about proper dosing of epinephrine for anaphylaxis. The risk of error was amplified by the need for rapid decision making in critically ill anaphylactic patients. An e-mail survey of local hospitals in southeast Michigan revealed that 6 of 7 hospitals did not stock prefilled intramuscular dose syringes for emergency use in anaphylaxis. At our institution, we have introduced prefilled and appropriately labeled intramuscularly dosed epinephrine syringes in crash carts, which are easily distinguished from intravenously dosed epinephrine syringes. In this Concepts article, we describe the clinical problem of inadvertent epinephrine overdose and propose a potential solution. Epinephrine must be clearly packaged and labeled to avoid inappropriate usage and unnecessary, potentially lethal complications in patients with anaphylaxis.

Giant Right Coronary Artery Aneurysm: An Association With Primary Varicose Veins?

Coronary artery aneurysms are rare conditions with potentially devastating consequences. We describe the case of an athletic 40-year-old woman who received a diagnosis of giant right coronary artery aneurysm while she was undergoing a work-up for lower extremity varicose veins. She underwent successful surgical treatment without any complications. (Level of Difficulty: Intermediate.).

Association of Operator and Hospital Experience With Procedural Success Rates and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Chronic Total Occlusions: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: An inverse relationship has been described between procedural success and outcomes of all major cardiovascular procedures. However, this relationship has not been studied for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). METHODS: We analyzed the data on patients enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry in Michigan (January 1, 2010 to March 31, 2018) to evaluate the association of operator and hospital experience with procedural success and outcomes of patients undergoing CTO-PCI. CTO-PCI was defined as intervention of a 100% occluded coronary artery presumed to be ≥3 months old. RESULTS: Among 210 172 patients enrolled in the registry, 7389 (3.5%) CTO-PCIs were attempted with a success rate of 53%. CTO-PCI success increased with operator experience (45% and 65% in the lowest and highest experience tertiles) and was the highest for highly experienced operators at higher experience centers and the lowest for inexperienced operators at low experience hospitals. Multivariable logistic regression models (with spline transformed prior operator and institutional experience) demonstrated a positive relationship between prior operator and site experience and procedural success rates (likelihood ratio test=141.12, df=15, P<0.001) but no relationship between operator and site experience and major adverse cardiac event (likelihood ratio test=19.12, df=15, P=0.208). CONCLUSIONS: Operator and hospital CTO-PCI experiences were directly related to procedural success but were not related to major adverse cardiac event among patients undergoing CTO-PCIs. Inexperienced operators at high experience centers had significantly higher success but not major adverse cardiac event rates compared with inexperienced operators at low experience centers. These data suggested that CTO-PCI safety and success could potentially be improved by selective referral of these procedures to experienced operators working at highly experienced centers.

Percutaneous Coronary Intervention for Chronic Total Occlusion-The Michigan Experience: Insights From the BMC2 Registry.

OBJECTIVES: The aim of this study was to describe the performance and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in Michigan. BACKGROUND: CTO PCI has been associated with reduction in angina, but previous registry analyses showed a higher rate of major adverse cardiac events with this procedure. METHODS: To study uptake and outcomes of CTO PCI in Michigan, patients enrolled in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry (2010 to 2017) were evaluated. CTO PCI was defined as intervention in a 100% occluded coronary artery ≥3 months old. RESULTS: Among 210,172 patients enrolled in the registry, 7,389 CTO PCIs (3.5%) were attempted, with 4,614 (58.3%) achieving post-procedural TIMI (Thrombolysis In Myocardial Infarction) flow grade 3. The proportion of PCIs performed on CTOs increased over the study period (from 2.67% in 2010 to 4.48% in 2017). Thirty of 47 hospitals performed >50 CTO interventions in 2017. Pre-procedural angina class ≤2 was present in one-quarter, and functional assessment for ischemia was performed in 46.6% of patients. Major complications occurred in 245 patients (3.3%) and included death (1.4%), post-procedural stroke (0.4%), cardiac tamponade (0.5%), and urgent coronary artery bypass graft surgery (1.3%). Procedural success improved modestly from 44.5% in 2010 to 54.9% in 2017 (p for trend < 0.001). Rates of in-hospital mortality (p for trend = 0.247) and major adverse cardiac event (p for trend = 0.859) for CTO PCI remained unchanged over the study period. CONCLUSIONS: The rate of CTO PCI in Michigan increased over the study period. Although the success rate of CTO PCI has increased modestly in contemporary practice, it remained far below the >80% reported by select high-volume CTO operators. The rate of periprocedural major adverse cardiac events or death remained unchanged over time. These data suggest room for improvement in the selection and functional assessment of CTO lesions before subjecting patients to the increased procedural risk associated with CTO PCI.