Cause and preventability of in-hospital mortality after PCI: A statewide root-cause analysis of 1,163 deaths.

BACKGROUND: Mortality is the most devastating complication of percutaneous coronary interventions (PCI). Identifying the most common causes and mechanisms of death after PCI in contemporary practice is an important step in further reducing periprocedural mortality. OBJECTIVES: To systematically analyze the cause and circumstances of in-hospital mortality in a large, multi-center, statewide cohort. METHODS: In-hospital deaths after PCI occurring at 39 hospitals included in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) between 2012 and 2014 were retrospectively reviewed using validated methods. A priori PCI-related mortality risk was estimated using the validated BMC2 model. RESULTS: A total of 1,163 deaths after PCI were included in the study. Mean age was 71±13 years, and 507 (44%) were women. Left ventricular failure was the most common cause of death (52% of cases). The circumstance of death was most commonly related to prior acute cardiovascular condition (61% of cases). Procedural complications were considered contributing to mortality in 235 (20%) cases. Death was rated as not preventable or slightly preventable in 1,045 (89.9%) cases. The majority of the deaths occurred in intermediate or high-risk patients, but 328 (28.2%) deaths occurred in low-risk patients (<5% predicted risk of mortality). PCI was considered rarely appropriate in 30% of preventable deaths. CONCLUSIONS: In-hospital mortality after PCI is rare, and primarily related to pre-existing critical acute cardiovascular condition. However, approximately 10% of deaths were preventable. Further research is needed to characterize preventable deaths, in order to develop strategies to improve procedural safety.

Impact of Left Ventricular End-Diastolic Pressure on the Outcomes of Patients Undergoing Percutaneous Coronary Intervention.

Left ventricular end-diastolic pressure (LVEDP) is an important hemodynamic marker of left ventricular performance and affects coronary perfusion. We evaluated the association of LVEDP with patient outcomes after elective or urgent percutaneous coronary intervention (PCI). We included n = 49,600 patients undergoing elective or urgent PCI. Patients were divided according to LVEDP tertile for descriptive analysis. The primary end point was in-hospital mortality. A recursive partitioning tree model for mortality was built to guide decision-making in patients with high LVEDP undergoing nonemergent PCI. Overall, n = 18,099 patients had an LVEDP <13 mm Hg, n = 15,416 had an LVEDP 13 to 18 mm Hg, and n = 16,085 had an LVEDP >18 mm Hg. Patients in the high LVEDP tertile had a worse clinical and angiographic/procedural profile and experienced a higher incidence of in-hospital post-PCI adverse outcomes, including death (LVEDP <13 mm Hg 0.3% vs LVEDP 13 to 18 mm Hg 0.4% vs LVEDP >18 mm Hg 0.8%, p <0.001). An elevated LVEDP was an independent predictor of adverse outcomes including mortality. An LVEDP ≥26 mm Hg was identified as a marker of high mortality (1.5%) in patients who underwent elective PCI, with rates varying from 0.5% to 10.4%, based upon a clinical profile defined by hemoglobin, systolic blood pressure, renal and left ventricular function, and atrial fibrillation. In conclusion, an elevated LVEDP is observed in 1/3 of the patients who underwent elective or urgent PCI and is associated with higher rates of in-hospital adverse outcomes, including death. Patients with an LVEDP ≥26 mm Hg who underwent elective PCI had markedly higher mortality rates, suggesting that such patients may warrant further optimization before PCI.

Intracoronary glycoprotein IIb/IIIa inhibitor infusion via a perfusion coronary catheter to decrease thrombus burden: results from the ClearWay™ Multicenter Registry.

OBJECTIVES: This multicenter registry aimed to assess the ClearWay™ (CW) perfusion catheter in reduction of thrombus burden and improvement of the coronary flow during percutaneous coronary intervention (PCI). BACKGROUND: The presence or development of thrombus during PCI is associated with poor prognosis. METHODS: The utility of the CW perfusion catheter was assessed in patients who presented with intracoronary thrombus and were subjected to PCI. Data were collected by online survey from 15 US sites. Angiographic assessment of the coronary thrombus burden and the coronary flow after intracoronary infusion of glycoprotein (GP) IIb/IIIa inhibitors via the CW catheter was evaluated at baseline, immediately after infusion, and at the end of the procedure. The cohort included 102 patients; 71.6% presented with ST-elevation myocardial infarction (MI), 21.6% with non-ST-elevation MI, 5.9% with stable angina pectoris, and 2.9% with silent ischemia. The mean cohort age was 59.9±14.5years and comprised mostly of men (72.5%). RESULTS: GP IIb/IIIa inhibitors were infused via the CW catheter on average 1.1±0.3 times, with a mean pressure of 4.2±2.7atm and a mean infusion time of 55±55s. Following the infusion, Thrombolysis In Myocardial Infarction (TIMI) flow improved by 1° in 71 patients (69.6%) and by 2° in 51 patients (50%), while visible thrombus was reduced by 52% (p<0.001). In the final angiogram, TIMI flow was restored in 90.2% and clearance of a visible thrombus was obtained in 91.8% of the lesions. CONCLUSION: Intracoronary infusion of GP IIb/IIIa inhibitors via the perfusion CW catheter is associated with significant reduction in thrombus burden and with improvement of the coronary flow in patients presenting or developing thrombus burden during PCI.