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Influence of chronic total occlusions on coronary bypass surgical outcomes
Abstracts / Cardiovascular Revascularization Medicine 12 (2011) e1–e46
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PCI procedures number 10,284 from January 1, 2000, through December 31, 2009. Trend analysis was used to understand clinically apparent bleeding rates with and without transfusion over time. Univariate analysis was used to identify characteristics that lead to bleeding or transfusion events. These complication rates were then applied to hospital length of stay, and associated costs were calculated. Results: Among the 10,284 patients, the rate of clinically apparent bleeding decreased from 6.0% to 4.3% during the years 2000 to 2009. However, clinically apparent bleeding with transfusion stayed the same at 1.5% in 2000 and 1.6% in 2009. There were 349 transfused patients with 544 bleeding events. When a transfusion occurs, there is a 9.1-day increase in length of stay and a hospital-associated cost of $25,094 for that PCI admission. Conclusions: In this large, real-world, multicenter study of unselected patients, transfusion post-PCI results in increased length of stay and increased costs. Strategies to reduce the incidence of transfusion such as the use of bivalirudin, transradial access, and patient identification prior to PCI are being explored and will be discussed. Outcome: Transfusion Patients vs. Non- Transfusion Patients
Outcome Clinical Apparent Bleeding (%) Clinical Apparent Bleeding with Transfusion (%) Inhospital Death (%) Lenght of Stay (day) (Mean ± SD) Cost of Hospitalization (Mean ± SD)
Transfusion (n = 310)
No Transfusion (n = 6,421)
34.8 34.8
3.8 NA
11.0 11.7 ± 9.7
0.8 2.6 ± 2.7
$39,852 ± $32,283
$14,758 ± $8,503
Premier perspective database. Univariate results.
Fig. 1.
and clopidogrel use. CTO length (HR 3.45 95% CI 1.33–8.93), prior percutaneous coronary intervention (HR 3.46 95% CI 1.56–7.70) and stroke (HR 4.96 95% CI 1.59–15.43) were independently associated with higher incidence of MACE. Conclusion: Among patients undergoing uncomplicated CABG, CTO length is independently associated with higher 1-year all-cause mortality and MACE. doi:10.1016/j.carrev.2011.04.343
doi:10.1016/j.carrev.2011.04.342
Chronic total occlusions Influence of chronic total occlusions on coronary bypass surgical outcomes Ryan Master a, Iqbal Ahmad a, Bernice Willis b, Matthias Peltz a, Michael DiMaio a, Michael Jessen a, Emmanouil S. Brilakis a, Subhash Banerjee a a UT Southwestern Medical Center and Dallas VA Medical Center, Dallas, TX, USA b Dallas VA Medical Center, Dallas, TX, USA Background: The influence of coronary chronic total occlusions (CTOs) on the outcomes of patients undergoing coronary bypass surgery (CABG) remains unclear. Objective: We analyzed the impact of coronary CTOs on 1-year all-cause mortality, nonfatal myocardial infarction (MI), repeat revascularization and major adverse cardiovascular events (MACE) among 610 patients undergoing uncomplicated CABG at VA North Texas between January 2004 and December 2008 using multivariable adjusted analysis. Results: Mean age was 62.6±7.9 years, mean SYNTAX score was 27.5 ±10.5 and Charlson comorbidity index (CCI) was 1.7. A CTO was present in 42.5%, and 26.3% had multiple CTOs (1.3 CTOs per patient). The CTO location was the left anterior descending artery (27.4%), the circumflex (24.7%) or the right coronary artery (48.3%). The CTO length was ≤20 mm in 37.8%, 20–40 mm in 37.1% and N40 mm in 25.1%. The 12-month incidence of death (1.9%), death or MI (2.5%) and MACE (2.5%) was low. On multivariable analysis, CTO length [hazard rate (HR): 4.1, 95% confidence intervals (CI) 1.01–16.23, Fig. 1] and CCI index (HR 1.81, 95% CI 1.18–2.78) were associated with higher mortality independent of age, traditional cardiovascular risks, presence of chronic kidney disease
Impact of PCI with BMS implantation for CTO on left ventricular ejection fraction Denis V. Fettser a, Talantbek A. Batyraliev b, Dmitry V. Preobrazhensky c, Igor V. Pershukov c, Boris A. Sidorenko c a Lipetsk Regional Clinical Hospital, Lipetsk, Russian Federation b Sani Konukoglu Medical Center, Gaziantep, Turkey c Presidential Medical Center Central Clinical Hospital, Moscow, Russian Federation Background: Left ventricular ejection fraction (LVEF) is a powerful predictor of prognosis in patients with coronary artery disease. The effect of PCI with coronary stent implantation on left ventricular (LV) performance in patients with coronary occlusion is not well known. Objectives: The aim of this study was to assess the effect of bare metal stents implantation on LVEF and to examine what clinical and angiographic factors may have an effect on recovery of LVEF. Methods: One hundred and fifty-four patients who underwent successful stent implantation for total coronary occlusion of a major epic ardial coronary artery were included into this study. All patients were asked to return for a 6-month follow-up control, regardless of symptomatic status. Clinical and echocardiographic examinations were performed before and 6 months after PCI. Results: Most patients were men (82.5%) with a mean age of 57.1±11.2 years; 20.1% of the patients had diabetes mellitus, and 56.5% of the patients were under antihypertensive treatment. The majority of patients (63%) had a history of previous MI in the territory of the occluded artery. The mean duration of occlusion was 6.4±6.8 months. The occluded vessel was the left anterior descending artery in 42.2%, the left circumflex artery in 25.3% and the right coronary artery in 32.5%. A single stent was implanted in 74.7% of cases; more than one bare metal stent was used per patient in 25.3%. A significant increase in LVEF (50.4%±10.7% to 56.1%±11.3%; Pb.0001) with a decrease in both LV end-diastolic volume index (86.2±17.9 to
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PCI procedures number 10,284 from January 1, 2000, through December 31, 2009. Trend analysis was used to understand clinically apparent bleeding rates with and without transfusion over time. Univariate analysis was used to identify characteristics that lead to bleeding or transfusion events. These complication rates were then applied to hospital length of stay, and associated costs were calculated. Results: Among the 10,284 patients, the rate of clinically apparent bleeding decreased from 6.0% to 4.3% during the years 2000 to 2009. However, clinically apparent bleeding with transfusion stayed the same at 1.5% in 2000 and 1.6% in 2009. There were 349 transfused patients with 544 bleeding events. When a transfusion occurs, there is a 9.1-day increase in length of stay and a hospital-associated cost of $25,094 for that PCI admission. Conclusions: In this large, real-world, multicenter study of unselected patients, transfusion post-PCI results in increased length of stay and increased costs. Strategies to reduce the incidence of transfusion such as the use of bivalirudin, transradial access, and patient identification prior to PCI are being explored and will be discussed. Outcome: Transfusion Patients vs. Non- Transfusion Patients
Outcome Clinical Apparent Bleeding (%) Clinical Apparent Bleeding with Transfusion (%) Inhospital Death (%) Lenght of Stay (day) (Mean ± SD) Cost of Hospitalization (Mean ± SD)
Transfusion (n = 310)
No Transfusion (n = 6,421)
34.8 34.8
3.8 NA
11.0 11.7 ± 9.7
0.8 2.6 ± 2.7
$39,852 ± $32,283
$14,758 ± $8,503
Premier perspective database. Univariate results.
Fig. 1.
and clopidogrel use. CTO length (HR 3.45 95% CI 1.33–8.93), prior percutaneous coronary intervention (HR 3.46 95% CI 1.56–7.70) and stroke (HR 4.96 95% CI 1.59–15.43) were independently associated with higher incidence of MACE. Conclusion: Among patients undergoing uncomplicated CABG, CTO length is independently associated with higher 1-year all-cause mortality and MACE. doi:10.1016/j.carrev.2011.04.343
doi:10.1016/j.carrev.2011.04.342
Chronic total occlusions Influence of chronic total occlusions on coronary bypass surgical outcomes Ryan Master a, Iqbal Ahmad a, Bernice Willis b, Matthias Peltz a, Michael DiMaio a, Michael Jessen a, Emmanouil S. Brilakis a, Subhash Banerjee a a UT Southwestern Medical Center and Dallas VA Medical Center, Dallas, TX, USA b Dallas VA Medical Center, Dallas, TX, USA Background: The influence of coronary chronic total occlusions (CTOs) on the outcomes of patients undergoing coronary bypass surgery (CABG) remains unclear. Objective: We analyzed the impact of coronary CTOs on 1-year all-cause mortality, nonfatal myocardial infarction (MI), repeat revascularization and major adverse cardiovascular events (MACE) among 610 patients undergoing uncomplicated CABG at VA North Texas between January 2004 and December 2008 using multivariable adjusted analysis. Results: Mean age was 62.6±7.9 years, mean SYNTAX score was 27.5 ±10.5 and Charlson comorbidity index (CCI) was 1.7. A CTO was present in 42.5%, and 26.3% had multiple CTOs (1.3 CTOs per patient). The CTO location was the left anterior descending artery (27.4%), the circumflex (24.7%) or the right coronary artery (48.3%). The CTO length was ≤20 mm in 37.8%, 20–40 mm in 37.1% and N40 mm in 25.1%. The 12-month incidence of death (1.9%), death or MI (2.5%) and MACE (2.5%) was low. On multivariable analysis, CTO length [hazard rate (HR): 4.1, 95% confidence intervals (CI) 1.01–16.23, Fig. 1] and CCI index (HR 1.81, 95% CI 1.18–2.78) were associated with higher mortality independent of age, traditional cardiovascular risks, presence of chronic kidney disease
Impact of PCI with BMS implantation for CTO on left ventricular ejection fraction Denis V. Fettser a, Talantbek A. Batyraliev b, Dmitry V. Preobrazhensky c, Igor V. Pershukov c, Boris A. Sidorenko c a Lipetsk Regional Clinical Hospital, Lipetsk, Russian Federation b Sani Konukoglu Medical Center, Gaziantep, Turkey c Presidential Medical Center Central Clinical Hospital, Moscow, Russian Federation Background: Left ventricular ejection fraction (LVEF) is a powerful predictor of prognosis in patients with coronary artery disease. The effect of PCI with coronary stent implantation on left ventricular (LV) performance in patients with coronary occlusion is not well known. Objectives: The aim of this study was to assess the effect of bare metal stents implantation on LVEF and to examine what clinical and angiographic factors may have an effect on recovery of LVEF. Methods: One hundred and fifty-four patients who underwent successful stent implantation for total coronary occlusion of a major epic ardial coronary artery were included into this study. All patients were asked to return for a 6-month follow-up control, regardless of symptomatic status. Clinical and echocardiographic examinations were performed before and 6 months after PCI. Results: Most patients were men (82.5%) with a mean age of 57.1±11.2 years; 20.1% of the patients had diabetes mellitus, and 56.5% of the patients were under antihypertensive treatment. The majority of patients (63%) had a history of previous MI in the territory of the occluded artery. The mean duration of occlusion was 6.4±6.8 months. The occluded vessel was the left anterior descending artery in 42.2%, the left circumflex artery in 25.3% and the right coronary artery in 32.5%. A single stent was implanted in 74.7% of cases; more than one bare metal stent was used per patient in 25.3%. A significant increase in LVEF (50.4%±10.7% to 56.1%±11.3%; Pb.0001) with a decrease in both LV end-diastolic volume index (86.2±17.9 to