Stephen W Waldo1, Eric A Secemsky1, Cashel O'Brien1, Kevin F Kennedy1, Eugene Pomerantsev1, Thoralf M Sundt1, Edward J McNulty1, Benjamin M Scirica1, Robert W Yeh2. 1. From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.). 2. From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.). ryeh@partners.org.
Abstract
BACKGROUND: Decisions to proceed with surgical versus percutaneous revascularization for multivessel coronary artery disease are often based on subtle clinical information that may not be captured in contemporary registries. The present study sought to evaluate the association between surgical ineligibility documented in the medical record and long-term mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. METHODS AND RESULTS: All subjects undergoing nonemergent percutaneous coronary intervention for unprotected left main or multivessel coronary artery disease were identified at 2 academic medical centers from 2009 to 2012. Documentation of surgical ineligibility was assessed through review of electronic medical records. Cox proportional hazard models adjusted for known mortality risk factors were created to assess long-term mortality in patients with and without documentation of surgical ineligibility. Among 1013 subjects with multivessel coronary artery disease, 218 (22%) were deemed ineligible for coronary artery bypass graft surgery. The most common explicitly cited reasons for surgical ineligibility in the medical record were poor surgical targets (24%), advanced age (16%), and renal insufficiency (16%). After adjustment for known risk factors, documentation of surgical ineligibility remained independently associated with an increased risk of in-hospital (odds ratio, 6.26; 95% confidence interval, 2.16-18.15; P<0.001) and long-term mortality (hazard ratio, 2.98; 95% confidence interval, 1.88-4.72, P<0.001) after percutaneous coronary intervention. CONCLUSIONS: Documented surgical ineligibility is common and associated with significantly increased long-term mortality among patients undergoing percutaneous coronary intervention with unprotected left main or multivessel coronary disease, even after adjustment for known risk factors for adverse events during percutaneous revascularization.
BACKGROUND: Decisions to proceed with surgical versus percutaneous revascularization for multivessel coronary artery disease are often based on subtle clinical information that may not be captured in contemporary registries. The present study sought to evaluate the association between surgical ineligibility documented in the medical record and long-term mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. METHODS AND RESULTS: All subjects undergoing nonemergent percutaneous coronary intervention for unprotected left main or multivessel coronary artery disease were identified at 2 academic medical centers from 2009 to 2012. Documentation of surgical ineligibility was assessed through review of electronic medical records. Cox proportional hazard models adjusted for known mortality risk factors were created to assess long-term mortality in patients with and without documentation of surgical ineligibility. Among 1013 subjects with multivessel coronary artery disease, 218 (22%) were deemed ineligible for coronary artery bypass graft surgery. The most common explicitly cited reasons for surgical ineligibility in the medical record were poor surgical targets (24%), advanced age (16%), and renal insufficiency (16%). After adjustment for known risk factors, documentation of surgical ineligibility remained independently associated with an increased risk of in-hospital (odds ratio, 6.26; 95% confidence interval, 2.16-18.15; P<0.001) and long-term mortality (hazard ratio, 2.98; 95% confidence interval, 1.88-4.72, P<0.001) after percutaneous coronary intervention. CONCLUSIONS: Documented surgical ineligibility is common and associated with significantly increased long-term mortality among patients undergoing percutaneous coronary intervention with unprotected left main or multivessel coronary disease, even after adjustment for known risk factors for adverse events during percutaneous revascularization.
Authors: F Feit; M M Brooks; G Sopko; N M Keller; A Rosen; R Krone; P B Berger; R Shemin; M J Attubato; D O Williams; R Frye; K M Detre Journal: Circulation Date: 2000-06-20 Impact factor: 29.690
Authors: J Matthew Brennan; Jeptha P Curtis; David Dai; Susan Fitzgerald; Akshay K Khandelwal; John A Spertus; Sunil V Rao; Mandeep Singh; Richard E Shaw; Kalon K L Ho; Ronald J Krone; William S Weintraub; W Douglas Weaver; Eric D Peterson Journal: JACC Cardiovasc Interv Date: 2013-08 Impact factor: 11.195
Authors: Mark A Hlatky; Derek B Boothroyd; Laurence Baker; Dhruv S Kazi; Matthew D Solomon; Tara I Chang; David Shilane; Alan S Go Journal: Ann Intern Med Date: 2013-05-21 Impact factor: 25.391
Authors: Chuntao Wu; Fabian T Camacho; Songyang Zhao; Andrew S Wechsler; Alfred T Culliford; Stephen J Lahey; Spencer B King; Gary Walford; Jeffrey P Gold; Craig R Smith; Desmond Jordan; Robert S D Higgins; Edward L Hannan Journal: Ann Thorac Surg Date: 2013-02-04 Impact factor: 4.330
Authors: Michael E Farkouh; Michael Domanski; Lynn A Sleeper; Flora S Siami; George Dangas; Michael Mack; May Yang; David J Cohen; Yves Rosenberg; Scott D Solomon; Akshay S Desai; Bernard J Gersh; Elizabeth A Magnuson; Alexandra Lansky; Robin Boineau; Jesse Weinberger; Krishnan Ramanathan; J Eduardo Sousa; Jamie Rankin; Balram Bhargava; John Buse; Whady Hueb; Craig R Smith; Victoria Muratov; Sameer Bansilal; Spencer King; Michel Bertrand; Valentin Fuster Journal: N Engl J Med Date: 2012-11-04 Impact factor: 91.245
Authors: James M McCabe; Kevin F Kennedy; Andrew C Eisenhauer; Howard M Waldman; Elizabeth A Mort; Eugene Pomerantsev; Frederic S Resnic; Robert W Yeh Journal: Circulation Date: 2013-11-18 Impact factor: 29.690
Authors: David van Klaveren; Yvonne Vergouwe; Vasim Farooq; Patrick W Serruys; Ewout W Steyerberg Journal: J Clin Epidemiol Date: 2015-02-27 Impact factor: 6.437
Authors: Stephen W Waldo; James M McCabe; Cashel O'Brien; Kevin F Kennedy; Karen E Joynt; Robert W Yeh Journal: J Am Coll Cardiol Date: 2015-03-24 Impact factor: 24.094
Authors: Javier A Valle; Thomas J Glorioso; Rory Bricker; Anna E Barón; Ehrin J Armstrong; Deepak L Bhatt; Sunil V Rao; Mary E Plomondon; Patrick W Serruys; Arie P Keppetein; Joseph F Sabik; Ovidiu Dressler; Gregg W Stone; Stephen W Waldo Journal: JAMA Cardiol Date: 2019-08-01 Impact factor: 14.676
Authors: Lloyd W Klein; Kishore J Harjai; Fred Resnic; William S Weintraub; H Vernon Anderson; Robert W Yeh; Dmitriy N Feldman; Osvaldo S Gigliotti; Kenneth Rosenfeld; Peter Duffy Journal: Catheter Cardiovasc Interv Date: 2016-11-10 Impact factor: 2.692
Authors: Anna K Krawisz; Kenneth Rosenfield; Christopher J White; Michael R Jaff; Joseph Campbell; Kevin Kennedy; Thomas Tsai; Beau Hawkins; Schuyler Jones; Eric A Secemsky Journal: J Am Coll Cardiol Date: 2021-02-23 Impact factor: 24.094