The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Era ...
Background <ul><li>The performance of percutaneous coronary intervention (PCI) at centers without cardiothoracic surgery r...
Methods - Study Population <ul><li>Single-center observational study.  </li></ul><ul><li>The study population consisted of...
Patient Characteristics 0.1 3572 (16.6) 20 (22.7) Peripheral vascular disease, n (%) 0.6 5739 (27.5) 26 (29.9) Prior PCI, ...
Patient Characteristics 0.3 47±14 45±14 Left ventricular ejection fraction, % ±SD <0.001 2.0±0.9 2.5±0.7 Number of disease...
Results <ul><li>Emergent CABG surgery was required in 90 patients (incidence-0.41%).  </li></ul><ul><li>Indications for CA...
Predictive factors of emergent CABG  0.001 1.5-5.2 2.8 <0.001 1.7-4.0 2.6 Type C lesion 0.004 1.2-2.4 1.7 <0.001 1.8-3.0 2...
Results <ul><li>Independent correlates of emergent CABG surgery post PCI were acute ST segment elevation MI presentation, ...
Rates of emergent CABG surgery per number of predictors per patient   Number of Predictors   Emergent CABG, %
Distribution of indications for CABG
In–hospital outcomes in patients requiring emergent CABG   % incidence
Conclusions <ul><li>In keeping with previous reports, the need for emergent CABG in a large patient population undergoing ...
Limitations <ul><li>This was a single center observational study with the limitations inherent to this type of analysis. <...
References <ul><li>1.  Smith SC  Jr ,  Feldman TE ,  Hirshfeld  JW  Jr ,  Jacobs AK ,  Kern MJ ,  King SB 3rd ,  Morrison ...
References <ul><li>5.  Peels JO, Hautvast RW, de Swart JB, Huybregts MA, Umans VA, Arnold AE, Jessurun A, Zijlstra F.   Pe...
References <ul><li>9.  Yang EH ,  Gumina  RJ ,  Lennon RJ ,  Holmes DR  Jr ,  Rihal  CS ,  Singh M . Emergency coronary ar...
Upcoming SlideShare
Loading in …5
×

Emergent Coronary Bypass Surgery following Percutaneous Coronary ...

1,030 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,030
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
22
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Emergent Coronary Bypass Surgery following Percutaneous Coronary ...

  1. 1. The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Era Probal Roy, Axel de Labriolle, Nicholas Hanna, Laurent Bonello , Teruo Okabe, Tina Pinto-Slottow, Daniel Steinberg, Kimberly Smith, Zhenyi Xue, Lowell Satler, Kenneth M. Kent, William O. Suddath, Augusto D. Pichard and Ron Waksman. Division of Cardiology, Washington Hospital Center, Washington DC
  2. 2. Background <ul><li>The performance of percutaneous coronary intervention (PCI) at centers without cardiothoracic surgery remains a contentious issue. </li></ul><ul><li>Though this practice allows greater access to care there continues to be safety concerns. </li></ul><ul><li>This study aimed to assess the requirement for emergent coronary artery bypass graft (CABG) surgery following PCI and to establish a risk score based on the predictors identified. </li></ul>
  3. 3. Methods - Study Population <ul><li>Single-center observational study. </li></ul><ul><li>The study population consisted of 21,957 patients who underwent PCI between August 1994 (FDA stent approval) till present. </li></ul><ul><li>Patients requiring emergent CABG surgery (defined as within 24 hours of the index procedure) were identified. CABG and No CABG groups were compared. </li></ul><ul><li>Logistic regression analysis was performed to assess for independent correlates of emergent CABG surgery and a risk score was formulated. </li></ul>
  4. 4. Patient Characteristics 0.1 3572 (16.6) 20 (22.7) Peripheral vascular disease, n (%) 0.6 5739 (27.5) 26 (29.9) Prior PCI, n (%) <0.001 5464(25.2) 8 (8.9) Prior CABG, n (%) 0.01 8831 (42.9) 49 (56.3) Prior myocardial infarction, n (%) 0.1 2546 (11.8) 6 (6.7) Chronic renal insufficiency, n (%) 0.6 12019 (57.1) 53 (60.2) Familial history, n (%) 0.9 17396 (80.5) 72 (80.0) Dyslipidemia, n (%) 0.5 16488 (75.9) 71 (78.9) Hypertension, n (%) 0.7 4489 (20.5) 20 (22.2) Current smoker, n (%) 0.6 2305 (10.7) 11 (12.2) Insulin requiring diabetes, n (%) 0.3 7030 (32.5) 34 (37.8) Diabetes, n (%) 0.5 64.0±40.8 64.7±10.2 Age, yrs, mean ±SD 0.5 14621 (67.0) 63 (70.0) Male gender, n (%) Demographics & Clinical history p No CABG (N=21867) CABG (N=90)
  5. 5. Patient Characteristics 0.3 47±14 45±14 Left ventricular ejection fraction, % ±SD <0.001 2.0±0.9 2.5±0.7 Number of diseased vessels, n ± SD <0.001 765 (3.5) 26 (28.9) Cardiogenic shock, n (%) <0.001 2466 (11.4) 26 (28.9) Acute myocardial infarction, n (%) 0.9 11546 (53.2) 47 (52.2) Unstable angina, n (%) 0.005 5171 (23.8) 10 (11.1) Stable angina, n (%) p No CABG (N=21867) CABG (N=90) Presentation
  6. 6. Results <ul><li>Emergent CABG surgery was required in 90 patients (incidence-0.41%). </li></ul><ul><li>Indications for CABG surgery were: triple vessel disease (40.3%), dissection (27.4%), acute closure (16.1%), perforation (8.1%) and failure to cross (8.1%). </li></ul><ul><li>These patients had significantly higher in-hospital cardiac death (7.8% vs. 0.7%, p<0.01) along with higher rates of Q-wave MI, neurological events and renal insufficiency. </li></ul>
  7. 7. Predictive factors of emergent CABG 0.001 1.5-5.2 2.8 <0.001 1.7-4.0 2.6 Type C lesion 0.004 1.2-2.4 1.7 <0.001 1.8-3.0 2.3 3 vessel disease <0.001 2.3-9.7 4.8 <0.001 6.2-20.9 11.4 Cardiogenic shock 0.003 1.4-5.3 2.7 <0.001 2.0-5.0 3.2 Acute MI 0.2 0.8-3.0 1.5 0.01 1.1-2.6 1.7 Prior acute MI P CI OR P CI OR Multivariate analysis Univariate analysis
  8. 8. Results <ul><li>Independent correlates of emergent CABG surgery post PCI were acute ST segment elevation MI presentation, cardiogenic shock, triple vessel disease and type C lesion. </li></ul><ul><li>Risk stratification using these predictors identified 0.3% of the patient population to have a substantial risk (9.3%) of requiring emergent CABG surgery. </li></ul><ul><li>Conversely, 97.9% of the study cohort had a <0.9% incidence of needing urgent surgery. </li></ul>
  9. 9. Rates of emergent CABG surgery per number of predictors per patient Number of Predictors Emergent CABG, %
  10. 10. Distribution of indications for CABG
  11. 11. In–hospital outcomes in patients requiring emergent CABG % incidence
  12. 12. Conclusions <ul><li>In keeping with previous reports, the need for emergent CABG in a large patient population undergoing PCI in the stent era was low and associated with poor in-hospital outcomes. </li></ul><ul><li>The patient subset identified to be at substantial risk for needing emergency surgery was small (0.3%). </li></ul><ul><li>These findings support the practice of PCI without on-site surgery. </li></ul>
  13. 13. Limitations <ul><li>This was a single center observational study with the limitations inherent to this type of analysis. </li></ul><ul><li>The definition of emergent CABG, as surgery required within 24 hours of PCI, may have been over-inclusive. </li></ul><ul><li>Clinical outcome was limited to in-hospital events. </li></ul><ul><li>Correlates of emergent CABG were not weighted when assessing contribution to risk. </li></ul>
  14. 14. References <ul><li>1. Smith SC Jr , Feldman TE , Hirshfeld JW Jr , Jacobs AK , Kern MJ , King SB 3rd , Morrison DA , O'Neil WW , Schaff HV , Whitlow PL , Williams DO , Antman EM , Adams CD , Anderson JL , Faxon DP , Fuster V , Halperin JL , Hiratzka LF , Hunt SA , Nishimura R , Ornato JP , Page RL , Riegel B ; American College of Cardiology/American Heart Association Task Force on Practice Guidelines ; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention . ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006; 113(7):e166-286. </li></ul><ul><li>2.. Ting HH , Raveendran G , Lennon RJ , Long KH , Singh M , Wood DL , Gersh BJ , Rihal CS , Holmes DR Jr . A total of 1,007 percutaneous coronary interventions without onsite cardiac surgery: acute and long-term outcomes. J Am Coll Cardiol. 2006; 47(8):1713-21. </li></ul><ul><li>3 . Zavala-Alarcon E , Cecena F , Ashar R , Patel R , Van Poppel S , Carlson R . Safety of elective--including &quot;high risk&quot;--percutaneous coronary interventions without on-site cardiac surgery. Am Heart J. 2004; 148(4):676-83. </li></ul><ul><li>4. Ting HH , Garratt KN , Singh M , Kjelsberg MA , Timimi FK , Cragun KT , Houlihan RJ , Boutchee KL , Crocker CH , Cusma JT , Wood DL , Holmes DR . Low-risk percutaneous coronary interventions without on-site cardiac surgery: two years' observational experience and follow-up. Am Heart J. 2003; 145(2):278-84 </li></ul>
  15. 15. References <ul><li>5. Peels JO, Hautvast RW, de Swart JB, Huybregts MA, Umans VA, Arnold AE, Jessurun A, Zijlstra F. Percutaneous coronary intervention without on site surgical back-up; two-years registry of a large dutch community hospital. Int J Cardiol. 2008 Jan 30. </li></ul><ul><li>6. Frutkin AD , Mehta SK , Patel T , Menon P , Safley DM , House J , Barth CW 3rd , Grantham JA , Marso SP . Outcomes of 1,090 consecutive, elective, nonselected percutaneous coronary interventions at a community hospital without onsite cardiac surgery. Am J Cardiol. 2008; 101(1):53-7. </li></ul><ul><li>7. Paraschos A, Callwood D, Wightman MB, Tcheng JE, Phillips HR, Stiles GL, Daniel JM, Sketch MH Jr. Outcomes following elective percutaneous coronary intervention without on-site surgical backup in a community hospital. Am J Cardiol. 2005; 95(9):1091-3. </li></ul><ul><li>8. Seshadri N , Whitlow PL , Acharya N , Houghtaling P , Blackstone EH , Ellis SG . Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation. 2002; 106(18):2346-50. </li></ul>
  16. 16. References <ul><li>9. Yang EH , Gumina RJ , Lennon RJ , Holmes DR Jr , Rihal CS , Singh M . Emergency coronary artery bypass surgery for percutaneous coronary interventions: changes in the incidence, clinical characteristics, and indications from 1979 to 2003. J Am Coll Cardiol. 2005; 46(11):2004-9. </li></ul><ul><li>10. Keeley EC , Boura JA , Grines CL . Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361(9351):13-20. </li></ul><ul><li>11. Peels HO, de Swart H, Ploeg TV, Hautvast RW, Cornel JH, Arnold AE, Wharton TP, Umans VA. Percutaneous coronary intervention with off-site cardiac surgery backup for acute myocardial infarction as a strategy to reduce door-to-balloon time. Am J Cardiol. 2007; 100(9):1353-8. </li></ul><ul><li>12. Kutcher MA.Percutaneous Coronary Interventions at Facilities Without On-Site Cardiac Surgery (National Cardiovascular Data Registry). ACC 2008. </li></ul><ul><li>13. Wennberg DE , Lucas FL , Siewers AE , Kellett MA , Malenka DJ . Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery. JAMA. 2004; 292(16):1961-8. </li></ul>

×