High-volume Percutaneous Coronary Intervention Center Research Articles

Sheathless radial approach in contemporary coronary rotational atherectomy: data from two high-volume centers

Aim: To analyze the feasibility and procedural outcome of percutaneous coronary intervention (PCI) using rotational atherectomy (RA), performed via transradial sheathless guiding catheter, as compared to a standard radial and femoral vascular approach. Methods: All consecutive patients undergoing RA at two high-volume PCI centers from May 2011 to May 2023 were included. Comparisons were made between the two transradial approaches and between the three types of vascular access. Results: Two hundred twenty-three patients were enrolled. Baseline characteristics were similar, with the exception of gender. We observed, in percentages, fewer cases of failure for sheathless than standard transradial attempts (7.5% vs. 11.5%, respectively), whereas all trans-femoral attempts were successful. Transfemoral procedures were longer and more frequently performed under mechanical circulatory support. There was no difference in procedural success between the three vascular approaches. A trend towards a higher rate of vascular and bleeding complications was found in the femoral group. Conclusion: Sheathless transradial vascular access is a viable option when performing RA during complex PCI procedures, tending to result in fewer failures than the standard transradial approach and reduced bleeding and vascular complications compared to the femoral method.

Association between cholesterol crystals and 6-month prognosis in patients with acute coronary syndrome: an optical coherence tomography study

Abstract Background Optical coherence tomography (OCT) guided percutaneous coronary intervention (PCI) has been demonstrated to improve short and long-term outcomes compared with standard angiography-guided PCI. However, little is known about the impact of cholesterol crystals on the prognosis of patients with acute coronary syndrome (ACS) in the setting of receiving OCT-guided PCI. Purpose This study aims to investigate the association between cholesterol crystals and 6-month outcomes in ACS patients who underwent OCT-guided PCI. Methods Patients with ACS who underwent OCT-guided PCI in a high-volume PCI center between July 2020 and June 2022 were retrospectively enrolled and were further divided into two groups according to the presence or absence of cholesterol crystals. OCT imaging characteristics including plaque morphology before the PCI procedure in target lesions were assessed. The primary outcome was a composite of all-cause death, ischemia-driven revascularization, or readmission for heart failure in a 6-month follow-up period. The association between cholesterol crystals and 6-month outcomes was evaluated using Kaplan-Meier curves. Independent predictors for cholesterol crystals and 6-month outcomes were evaluated by the logistic regression and Cox proportional hazards regression analyses, respectively. Results 403 patients were enrolled in this study. The mean age was 61 years old and 79.4% were men. Cholesterol crystals were presented in 224 (55.6%) target lesions in patients with ACS. Baseline characteristics were not statistically different between the two groups in age, sex, smoke, previous hyperlipidemia, and other clinical features, except for diabetes, multivessel disease, and ACS classification (p <0.05). In the multivariable logistic regression analysis, cholesterol crystals were associated with diabetes, plaque rupture, lipid length, calcification, macrophage infiltration, and thin-capped fibroatheroma (all p <0.05). Patients with cholesterol crystals had higher risks of poor 6-month composite outcomes when compared to those without cholesterol crystals (13.4% vs. 6.7%, HR 2.09, 95%CI 1.07-4.09, p = 0.031), even after confounders adjustment for age, sex, diabetes, multivessel disease and ACS classification using inverse probability of treatment weighting (p = 0.027). Subgroup analysis showed significant interactions between cholesterol crystals and 6-month outcomes with respect to the male (HR 2.82, 95%CI 1.22-6.51, p = 0.015), target lesions in LAD (HR 4.47, 95%CI 1.29-15.44, p = 0.018), and incomplete revascularization (HR 3.08, 95%CI 1.04-8.98, p = 0.042). The Cox regression analysis identified cholesterol crystal as an independent predictor for 6-month composite outcomes (HR 2.12, 95%CI 1.08-4.19, p = 0.030). Conclusions The presence of cholesterol crystals was associated with a poor 6-month prognosis in patients with ACS, even in the setting of receiving OCT-guided PCI.

Abstract 13825: Post-PCI Outcomes in Patients on SGLT2 Inhibitor Therapy

Introduction: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to improve cardiorenal outcomes among patients with and without diabetes mellitus. Hypothesis: We aimed to investigate their impact on the risk of acute kidney injury (AKI) and major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI). Methods: Consecutive patients undergoing PCI at a high-volume PCI center between 2015 and 2022 were analyzed. Patients on SGLT2 inhibitors prior to PCI were compared to those not on SGLT2 inhibitors. The primary outcome was AKI, as defined as serum creatinine increase of ≥0.5 mg/dL or ≥25% from baseline within 30 days of PCI. MACE was defined as death or myocardial infarction (MI) and was assessed at 1 year post PCI. Results: There were significant differences in baseline clinical characteristics between patients on (n = 347) vs. not on (n = 16,594) SGLT2 inhibitors. Patients on SGLT2 inhibitors had higher prevalence of diabetes (90.5% vs. 45.5%), hypertension (96.8% vs. 92.1%), hyperlipidemia (95.7% vs. 90.5%), and prior CABG (21.0% vs 15.8%). SGLT2 inhibitor use was associated with a decreased rate of post-PCI AKI (3.3% vs. 6.6%; adjusted odds ratio [OR] 0.33; 95% confidence interval [CI] 0.08-0.89, P=0.025). At one year after PCI, patients on SGLT2 inhibitors had increased rates of MACE (8.2% vs. 3.9%; adjusted hazard ratio [HR] 1.74, 95% CI 0.99-3.06, P=0.052), driven by an increased risk of MI (6.9% vs. 2.1%; HR 2.63, 95% CI 1.42-4.90, P=0.002). Conclusions: SGLT2 inhibitor use was associated with lower post-PCI AKI, but was associated with an increased risk of MACE. The latter finding was driven by increased risk of MI, which may be explained by unmeasured confounders in these heterogeneous groups of patients.

Survival of Myocardial Infarction Patients with Diabetes Mellitus at the Invasive Era (Results from the Városmajor Myocardial Infarction Registry).

Due to the lifelong nature of diabetes mellitus (DM), it has been demonstrated to have significant effects on patients' morbidity and mortality. The present study aimed to assess the effects of DM on the clinical outcome and survival in patients who underwent percutaneous coronary intervention (PCI) due to myocardial infarction (MI) and to examine the relationship of DM to the type of the MI and to left ventricular (LV) and renal functions. A total of 12,270 patients with ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI) were revascularized at our Institution between 2005 and 2013. In this pool of patients, 4388 subjects had DM, while 7018 cases had no DM. In both STEMI and NSTEMI, the 30-day and 1-year survival were worse in diabetic patients as compared to non-diabetic cases. In the patients with DM, NSTEMI showed worse prognosis within 1-year than STEMI similarly to non-diabetic subjects. Regarding survival, the presence of DM seemed to be more important than the type of MI. Regardless of the presence of DM, reduced LV function was a maleficent prognostic sign and DM significantly reduced the prognosis both in case of reduced and normal LV function. Survival is primarily affected by LV function, rather than DM. Worse renal function is associated with worse 30-day and 1-year survival in both cases with and without DM. Considering different renal functions, the presence of DM worsens both short- and long-term survival. Survival is primarily affected by renal function, rather than DM. The results from a high-volume PCI center confirm significant the negative prognostic impact of DM on survival in MI patients. DM is a more important prognostic factor than the type of the MI. However, survival is primarily affected by LV and renal functions, rather than DM. These results could highlight our attention on the importance of recent DM treatment with new drugs including SGLT-2 inhibitors and GLP-1 antagonists with beneficial effects on survival.

Development and validation of a risk prediction nomogram for in-stent restenosis in patients undergoing percutaneous coronary intervention

BackgroundThis study aimed to develop and validate a nomogram to predict probability of in-stent restenosis (ISR) in patients undergoing percutaneous coronary intervention (PCI).MethodsPatients undergoing PCI with drug-eluting stents between July 2009 and August 2011 were retrieved from a cohort study in a high-volume PCI center, and further randomly assigned to training and validation sets. The least absolute shrinkage and selection operator (LASSO) regression model was used to screen out significant features for construction of nomogram. Multivariable logistic regression analysis was applied to build a nomogram-based predicting model incorporating the variables selected in the LASSO regression model. The area under the curve (AUC) of the receiver operating characteristics (ROC), calibration plot and decision curve analysis (DCA) were performed to estimate the discrimination, calibration and utility of the nomogram model respectively.ResultsA total of 463 patients with DES implantation were enrolled and randomized in the development and validation sets. The predication nomogram was constructed with five risk factors including prior PCI, hyperglycemia, stents in left anterior descending artery (LAD), stent type, and absence of clopidogrel, which proved reliable for quantifying risks of ISR for patients with stent implantation. The AUC of development and validation set were 0.706 and 0.662, respectively, indicating that the prediction model displayed moderate discrimination capacity to predict restenosis. The high quality of calibration plots in both datasets demonstrated strong concordance performance of the nomogram model. Moreover, DCA showed that the nomogram was clinically useful when intervention was decided at the possibility threshold of 9%, indicating good utility for clinical decision-making.ConclusionsThe individualized prediction nomogram incorporating 5 commonly clinical and angiographic characteristics for patients undergoing PCI can be conveniently used to facilitate early identification and improved screening of patients at higher risk of ISR.

Viability and functional recovery after chronic total occlusion percutaneous coronary intervention.

ObjectivesThis study evaluated myocardial viability as well as global and regional functional recovery after successful chronic coronary total occlusion (CTO) percutaneous coronary intervention (PCI) using sequential quantitative cardiac magnetic resonance (CMR) imaging.BackgroundThe patient benefits of CTO PCI are being questioned.MethodsIn a single high‐volume CTO PCI center patients were prospectively scheduled for CMR at baseline and 3 months after successful CTO PCI between 2013 and 2018. Segmental wall thickening (SWT) and percentage late gadolinium enhancement (LGE) were quantitatively measured per segment. Viability was defined as dysfunctional myocardium (<2.84 mm SWT) with no or limited scar (≤50% LGE).ResultsA total of 132 patients were included. Improvement of left ventricular ejection fraction was modest after CTO PCI (from 48.1 ± 11.8 to 49.5 ± 12.1%, p < 0.01). CTO segments with viability (N = 216, [31%]) demonstrated a significantly higher increase in SWT (0.80 ± 1.39 mm) compared to CTO segments with pre‐procedural preserved function (N = 456 [65%], 0.07 ± 1.43 mm, p < 0.01) or extensive scar (LGE >50%, N = 26 [4%], −0.08 ± 1.09 mm, p < 0.01). Patients with ≥2 CTO segments viability showed more SWT increase in the CTO territory compared to patients with 0–1 segment viability (0.49 ± 0.93 vs. 0.12 ± 0.98 mm, p = 0.03).ConclusionsDetection of dysfunctional myocardial segments without extensive scar (≤50% LGE) as a marker for viability on CMR aids in identifying patients with significant regional functional recovery after CTO PCI.

One‐year mortality in NSTEMI patients is unaffected by timing of PCI within the first week of admission: Results of a real‐world cohort analysis

We aimed to explore the impact of time to percutaneous coronary intervention (PCI) (T2P) on 1-year mortality in non-ST-elevation myocardial infarction (NSTEMI) patients. The current guidelines recommend an early invasive strategy for NSTEMI patients. However, impact of an early invasive strategy on mortality is a matter of debate. For that reason, real world data are of great value to determine the optimal treatment window. This retrospective single center cohort study was performed in a high-volume PCI center in Amsterdam, The Netherlands. Intermediate- and high-risk NSTEMI patients undergoing PCI were included. The main discriminant was timing of PCI after admission (T2P), stratified according to different time windows (<24 h, 24-72 h, 72 h-7 days or >7 days). We analyzed 1-year mortality and the time distribution of overall survival. In total, 848 patients treated between January 1, 2016 and January 1, 2018 were included in the analysis. T2P was <24 h in 145 patients, 24-72 h in 192 patients, 72 h-7 days in 275 patients, and >7 days in 236 patients. The mean GRACE-risk score was 127.1 (SD 28.7), 130.0 (33.1), 133.8 (32.1), and 148.7 (34.6) respectively, p=<0.001. After adjusting for confounders, 1-year mortality in patients with T2P <24 h did not significantly differ when compared with T2P 24-72 h (OR=1.08; 95% CI=0.33-3.51) and T2P 72 h-7 days (OR 1.72; 95% CI=0.57-5.21) but was significantly higher in T2P >7 days (OR=3.20; 95% CI=1.06-9.68). In an unselected cohort of patients with NSTEMI, treatment by PCI <24 h did not lead to improved survival as compared to aT2P <7 days strategy. Delay in PCI >7 days after admission resulted in worse outcome.

Consequences of COVID-19 Pandemic on Myocardial Infarction Reperfusion Therapy and Prognosis in a High-Volume PCI Center in Chile

Background: Characterize the clinical profile, treatment, and evolution of patients with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic and compare them to a historical cohort. Methods: This was a case-control study comprising of AMI patients who were transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March 3 and July 15, 2020 (n=96), and a historical cohort of patients who were transferred during the same weeks in 2019 (n=269). Results: Differing results during pandemic vs pre-pandemic included age (63±12 vs 68±12 years, p 12 hours from onset of symptoms (44.4% vs 0%, p<0.01), median door-to-device time (4 vs 3 hours, p<0.01), primary PCI (97% vs 71%, p<0.01), cardiogenic shock (19.8% vs 4.1%, p<0.01), mechanical complication (10.4% vs 1.7%, p<0.01), follow-up mortality at 30-days (19.8% vs 1.4% p<0.01) and cardiovascular deaths (12.5% vs 1.4%, p<0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for 30-day overall mortality (RR 2.90;95% CI 1.14-7.36). Conclusions: We observed a 67.4% reduction in AMI patient referrals during the pandemic. AMI patients exhibited delays in consults and treatment, higher morbidity and increased mortality. COVID-19 positivity was associated with a worse 30-day overall survival.

Ischemic Burden Reduction and Long-Term Clinical Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention

The authors sought to evaluate the impact of ischemic burden reduction after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on long-term prognosis and cardiac symptom relief. The clinical benefit of CTO PCI is questioned. In a high-volume CTO PCI center, 212 patients prospectively underwent quantitative [15O]H2O positron emission tomography perfusion imaging before and three months after successful CTO PCI between 2013-2019. Perfusion defects (PD) (in segments) and hyperemic myocardial blood flow (hMBF) (in ml · min-1 · g-1) allocated to CTO areas were related to prognostic outcomes using unadjusted (Kaplan-Meier curves, log-rank test) and risk-adjusted (multivariable Cox regression) analyses. The prognostic endpoint was a composite of all-cause death and nonfatal myocardial infarction. After a median [interquartile range] of 2.8 years [1.8 to 4.3 years], event-free survival was superior in patients with≥3 versus<3 segment PD reduction (p<0.01; risk-adjusted p=0.04; hazard ratio [HR]: 0.34 [95% confidence interval (CI): 0.13 to 0.93]) and with hMBF increase above (Δ≥1.11ml · min-1 · g-1) versus below the population median (p<0.01; risk-adjusted p<0.01; HR: 0.16 [95%CI: 0.05 to 0.54]) after CTO PCI. Furthermore, event-free survival was superior in patients without versus any residual PD (p<0.01; risk-adjusted p=0.02; HR: 0.22 [95%CI: 0.06 to 0.76]) or with a residual hMBF level >2.3 versus≤2.3ml · min-1 · g-1 (p<0.01; risk-adjusted p=0.03; HR: 0.25 [95%CI: 0.07 to 0.91]) at follow-up positron emission tomography. Patients with residual hMBF >2.3ml · min-1 · g-1 were more frequently free of angina and dyspnea on exertion at long-term follow-up (p=0.04). Patients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal myocardial infarction. Long-term cardiac symptom relief was associated with normalization of hMBF levels after CTO PCI.

Four-year outcomes after percutaneous coronary intervention of unprotected left main coronary artery disease in patients with stable angina and acute coronary syndrome.

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

Randomized Trial of Interleukin-6 Receptor Inhibition in Patients With Acute ST-Segment Elevation Myocardial Infarction

BackgroundPrompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response. ObjectivesThis study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI. MethodsThe ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days. ResultsWe randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups. ConclusionsTocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703)

Ischemic burden reduction after chronic total occlusion percutaneous coronary intervention related to patient prognosis

Abstract Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) leads to major reductions in ischemic burden. However, to date, studies investigating if more ischemia reduction after CTO PCI translates into an improved patient prognosis, are lacking. Purpose To evaluate if change in absolute myocardial perfusion after CTO PCI is related to patient prognosis. Methods Between 2013–2019, 219 prospectively recruited patients with a CTO underwent quantitative [15O]H2O positron emission tomography perfusion imaging before and 3 months after successful CTO PCI in a single high-volume CTO PCI center (175 procedures/year). Changes in perfusion defect size (in myocardial segments) and hyperemic myocardial blood flow (MBF, in mL min–1 g–1) within the CTO territory after PCI were related to the combined endpoint of death or myocardial infarction (MI). Kaplan-Meier curves (log-rank test) and multivariable Cox regression (including covariates age, gender, prior MI, and left ventricular function) were used to analyze unadjusted and risk-adjusted event-free survivals with HR [95% CI]. Results Out of 213 (97%) patients with a median follow-up of 3.2 [2.1–4.7] years, 22 (10%) patients experienced the composite of death (19, 9%) or MI (5, 2%). Event-free survival was significantly improved in patients with a perfusion defect size reduction of ≥3 segments (N=132, 62%) after CTO PCI compared to &amp;lt;3 segments (p=0.01, risk-adjusted: p=0.02 with HR 0.36 [0.15–0.87]), as well in patients with increase in hyperemic MBF above the median of the population (delta &amp;gt;1.13 mL min–1 g–1) as compared to below the median (p&amp;lt;0.01, risk-adjusted: p=0.01 with HR 0.27 [0.10–0.75]). After PCI, patients with ≥1 segment residual perfusion defect size in the CTO territory at follow-up (N=114, 54%) had a significantly worse event-free survival compared to patients with no residual defect size (p&amp;lt;0.01, risk-adjusted: p=0.01 with HR 4.12 [1.35–12.59]), whereas patients with a residual hyperemic MBF &amp;gt;2.30 mL min–1 g–1 (N=105, 49%) showed a better event-free survival compared to patients with lower residual hyperemic MBF levels (p=0.02, risk-adjusted: p=0.04 with HR 0.33 [0.12–0.95]). Conclusions Patients with more ischemic burden reduction and less residual ischemia following CTO PCI showed a major improved survival free of death or MI. A limitation was the low absolute number of events that prohibited more extensive risk-adjustment of the analyses. Funding Acknowledgement Type of funding source: None

Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients with Diabetes Mellitus: a Treatment-Risk Paradox.

Diabetes mellitus (DM) is highly prevalent among patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). This review aims to summarize the available evidence on CTO recanalization in patients with DM. Coronary artery bypass grafting (CABG) surgery is the recommended revascularization modality for patients with DM and multivessel coronary artery disease (CAD). However, the optimal management strategy in diabetic patients with CTO and single-vessel disease or prior CABG remains a clinical dilemma. Contemporary, large-scale, observational registries support the notion that CTO PCI, if performed at high-volume CTO PCI centers by highly experienced operators, conveys similar high procedural success and low complication rates in patients with and without DM. Although DM patients have more frequently CTOs and may derive greater benefit from complete revascularization, they are less frequently exposed to CTO PCI than non-DM patients (treatment-risk paradox). CTO PCI performed by highly experienced operators constitutes a safe and effective treatment option for selected diabetic CTO patients who are not candidates for CABG. Randomized studies are warranted to compare long-term outcomes of CTO PCI and medical therapy in this high-risk subset.

ST-segment elevation myocardial infarction, systems of care. An urgent need for policies to co-ordinate care in order to decrease in-hospital mortality

BackgroundRegional trends for ST-segment elevation myocardial infarction (STEMI) treatment is not known in the state of Nevada. HypothesisGreat disparity exists for treatment for STEMI in different geographical areas of Nevada. There is a great potential to improve treatment and outcomes of STEMI patients in the State of Nevada. MethodsAdmissions to non-federal hospitals in the state of Nevada, using 2011 to 2013 discharge data from the Nevada State Inpatient Data Base (acquired from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), were analyzed. Outpatient-onset STEMI patients were identified. The state of Nevada was divided into three divisions based on population densities, defined as population per square mile. Division A included counties with population density of <50 per square mile, Division B included counties with population density of 50 to 200 per square mile, and Division C included counties with population density of >200 per square mile. Trends in use of STEMI-related therapies and the impact on in-hospital mortality rates were compared. ResultsAlmost 20% of the patients with outpatient-onset STEMI do not get any STEMI-related therapy and have significantly higher mortality rate. Patients from Division A do not have direct access to percutaneous coronary intervention (PCI) centers. These patients receive less STEMI-related therapies. Low-volume PCI centers had equivalent mortality rates for STEMI patients who got PCI, compared to high-volume PCI centers. ConclusionsPolicies must be created and processes streamlined so all STEMI patients in Nevada receive appropriate treatment.

Carotid artery stenting outcomes in high-risk patients receiving best medical therapy: Results from a single high-volume interventional cardiology practice

BackgroundCarotid artery stenting (CAS) is now being widely used in the treatment of carotid artery stenosis. Recent clinical studies have demonstrated low adverse event rates after CAS. This study evaluates the 30-day and 1-year results in patients treated with CAS and receiving intensive medical therapy in a high-volume percutaneous coronary intervention center. MethodsA total of 184 patients underwent CAS between January 2011 and December 2013. In addition to antiplatelet therapy, patients received intensive antihypertensive treatment, high intensity statin and heart rate normalization therapy. Patients were stratified according to age and symptomatic status. ResultsMost of the patients (86.4%) had at least one high surgical risk criteria. The procedural success rate was 98.4%. The 30-day and 1-year incidence of stroke were 4.1% and 4.5%, respectively. At 30 days the combined rate of stroke/cardiovascular (CV) death/myocardial infarction (MI) was 5.8% and 10.9% in 1 year. The 30-day incidence of stroke/CV death in asymptomatic and symptomatic patients was 5.4% and 4.2%, respectively. Age ≥80 years increased the risk of stroke/CV death/MI at 1 year (OR 4.41; 95% CI 1.06–18.36; P=0.04). ConclusionsThe study demonstrated acceptable clinical outcome results in patients with high medical comorbidities treated with CAS and intensive medical therapy. Adverse event rate in symptomatic patients did not exceed the guideline recommended range while in asymptomatic patients it was increased.

Application of the “Hybrid Approach” to Chronic Total Occlusions in Patients With Previous Coronary Artery Bypass Graft Surgery (from a Contemporary Multicenter US Registry)

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been traditionally associated with lower success rates in patients with previous coronary artery bypass graft surgery (CABG). We sought to examine the success and complication rates of CTO PCI using the "hybrid" crossing algorithm among patients with a history of previous CABG. The procedural outcomes of 496 consecutive CTO PCIs performed at 5 high-volume PCI centers in the United States from January 2012 to August 2013 were assessed. The outcomes of patients with previous CABG were compared with those of patients without previous CABG. Compared with patients without previous CABG (n = 320), patients with previous CABG (n = 176, 35%) were older, had more coronary artery disease risk factors, and had less favorable baseline angiographic CTO characteristics. Technical and procedural success was slightly lower among patients with previous CABG (88.1% vs 93.4%, p = 0.044 and 87.5 vs 92.5%, p = 0.07, respectively). Patients with previous CABG more commonly underwent CTO PCI using the retrograde approach (39% vs 24%, respectively, p <0.001) and received higher air kerma radiation exposure (4.8 [interquartile range 3.0 to 6.4] vs 3.1 [1.9 to 5.3] Gray, p <0.001) and fluoroscopy time (59 [38 to 77] vs 34 [21 to 55] minutes, p <0.001). Major procedural complications were similar in the 2 groups: 2 of 176 (1.1%) patients with previous CABG versus 7 of 320 (2.1%) patients without previous CABG (p = 0.40). In conclusion, with application of the "hybrid" approach to CTO PCI, success was slightly lower, and complication rates were similar between patients with and without previous CABG.

The transition from the transfemoral to transradial approach in the high-volume percutaneous coronary intervention center

The transition from the transfemoral to transradial approach in the high-volume percutaneous coronary intervention center

Mortality in Patients With ST-Segment Elevation Myocardial Infarction Who Do Not Undergo Reperfusion

Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥ 3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.

Abstract 17083: Progress and Paradox in the Real World Penetration of Percutaneous Coronary Intervention for Treatment of ST-Elevation Myocardial Infarction

Background: Much of the surveillance data on the use of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) comes from patient registries with voluntary hospital participation or from Medicare data. Non-PCI capable hospitals are significantly underrepresented in registry data, and large hospitals are over-represented; consequently registry data is likely to signficantly overestimate the use of PCI in STEMI on a true population basis. Medicare data are more comprehensive, but include only the elderly population. In this study, we used an unselected population-based hospital surveillance system to investigate temporal trends in the use of PCI for STEMI in Florida from 2001-2009. Florida is the 4th largest state with over 18 million persons. Methods: We used statewide hospital discharge data, including detailed diagnosis and procedure codes to identify STEMI patients who did vs. did not receive same-day PCI. We created county maps for 2001, 2003, 2005, 2007, and 2009 to observe geographic disparities in the use of primary PCI. Data for over 100,000 STEMI patients were analyzed. Results: Statewide, same-day PCI for STEMI increased from 23.4% in 2001 to 63.5% in 2009. County-level maps revealed marked and persistent geographic disparities. In 2009, some major metropolitan areas fell below the state average, while some small rural counties had &gt;80% of STEMI patients receiving PCI. Small urban counties with one non-PCI providing hospital had lower rates than many rural counties with no hospital. Counties with only one high-volume PCI center had the highest rates of primary PCI. Conclusions: Few studies have reported population-based rates of primary PCI usage. We found significant progress in the use of same-day PCI from 2001 to 2009 in Florida, but also paradox with some major metropolitan areas lagging behind smaller urban and rural areas. Rural counties adjacent to major metro areas with high-volume PCI centers had high rates of PCI usage. In contrast, major metro areas with many hospitals had average or below average usage rates. Our results suggest that excessive hospital competition creates barriers for STEMI patients to receive primary PCI.

Abstract P321: Hospital Angioplasty Volumes and ST-Elevation Myocardial Infarction Patient Admission Patterns: Improvement in Florida from 2001-2007

Background: The ACC/AHA guidelines recommend percutaneous coronary intervention (PCI) at high-volume centers with at least 400 procedures per year for ST-elevation myocardial infarction (STEMI), but fewer than 25% of acute care hospitals in the US are PCI capable. In Florida, a statewide system for regional STEMI patient care does not yet exist, but some local STEMI care coalitions have formed. We examined trends over time in the percent of STEMI patients admitted to hospitals categorized by PCI volume. Methods: Using comprehensive statewide hospital discharge data, we classified 191 acute care hospitals according to annual PCI volume: no PCI capability (n=90), low-volume (1-199 PCIs; n=33) medium volume (200-399 PCIs; n=4) and high-volume (400+ PCIs; n=64). Hospital classifications were specific for a 3-month time window; therefore a single hospital's category could vary over time. We determined the percent of STEMI patients treated at each type of hospital for the first and second half of each year from 2001-2007. Results: From early 2001 to late 2007, the percent of STEMI patients treated at non-PCI capable hospitals declined from 31.0 to 7.9%, while the proportion at high-volume PCI centers rose from 58.3 to 72.3%. Low- and medium-volume hospitals typically accounted for &lt;15% of total patient volume but realized slight increases from 2001 to 2007. The percentage of STEMI patients seen at low-volume PCI hospitals rose from 6.6 to 8.7% from 2001-2007, and from 4.2% to 11.1% at medium-volume hospitals. No differences in the hospital admission trends were observed by race/ethnicity or gender. Conclusions: The pattern of STEMI care has changed substantially from 2001-2007 in Florida, with a greater proportion of patients seen at high-volume PCI hospitals and fewer than 10% admitted to non-PCI hospitals by 2007. These trends are likely due to implementation of STEMI protocols by many large emergency medical services (EMS) providers across the state and the positive impact of local STEMI care coalitions in some metropolitan areas. Further research is needed to determine if there has been increased STEMI patient awareness of the value of undergoing PCI at high-volume centers. A positive trend toward regionalized STEMI care appears to be in progress in Florida.