Temporal Trends and Site Variation in High‐Risk Coronary Intervention and the Use of Mechanical Circulatory Support: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking (CART) Program

Abstract

Background Patients undergoing percutaneous coronary intervention ( PCI ) are older with greater medical comorbidities and anatomical complexity than ever before, resulting in an increased frequency of nonemergent high‐risk PCI ( HR ‐ PCI ). We thus sought to evaluate the temporal trends in performance of HR ‐ PCI and utilization of mechanical circulatory support in the largest integrated healthcare system in the United States. Methods and Results A cohort of high‐risk adult patients that underwent nonemergent PCI in the Veterans Affairs Healthcare System between January 2008 and June 2018 were identified by objective clinical, hemodynamic, and anatomic criteria. Temporal trends in the performance of HR ‐ PCI , utilization of mechanical circulatory support, and site‐level variation were assessed. Of 111 548 patients assessed during the study period, 554 met 3 high‐risk criteria whereas 4414 met at least 2 criteria for HR ‐ PCI . There was a significant linear increase in the proportion of interventions that met 3 ( P <0.001) or at least 2 ( P <0.001) high‐risk criteria over time, with rates approaching 1.9% and 11.2% in the last full calendar year analyzed. A minority of patients who met all high‐risk criteria received PCI with mechanical support (15.7%) without a significant increase over time ( P =0.193). However, there was significant site‐level variation in the probability of performing HR ‐ PCI (4.0‐fold higher likelihood) and utilizing mechanical circulatory support (1.9‐fold higher likelihood) between high and low utilization sites. Conclusions The proportion of cases categorized as HR ‐ PCI has increased over time, with significant site‐level variation in performance. The majority of HR ‐ PCI cases did not utilize mechanical support, highlighting a discrepancy between current recommendations and clinical practice in an integrated healthcare system.

SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease

“… 39,40 Heart team management decisions should also weigh the relative risks and benefits of both MCS‐assisted and unassisted PCI compared with available surgical therapeutic options including surgical revascularization, durable LV assist device implantation, and heart transplantation. Appropriate patient selection is particularly critical in light of the potential for device‐related complications 44‐46 …”

Clinical Characteristics and Outcomes Among Patients Undergoing High‐Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

“…Accordingly, HR‐PCI was defined as the presence of at least 1 of the following criteria: (1) medical comorbidities resulting in >1.1% estimated periprocedural mortality by the National Cardiovascular Data Registry CathPCI mortality model, (2) left ventricular ejection fraction ≤35%, or (3) VA synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score ≥15, as previously published. 3 , 10 , 24 A multioperator procedure was defined as the participation of ≥2 attending operators. Patients undergoing PCI for cardiac arrest, ST‐segment–elevation myocardial infarction, or other emergent indications were excluded to focus the analysis on cases with a conscious, premeditated decision for multioperator intervention.…”

“…4 , 5 , 6 Advances in percutaneous coronary intervention (PCI) techniques and the advent of percutaneous mechanical circulatory support have provided new avenues to treat these challenging patients, at the price of increased procedural complexity and cost. 7 , 8 , 9 , 10 , 11 , 12 , 13 Although the overall morbidity and complexity of patients referred for percutaneous intervention has increased, there has been a concomitant decrease in PCI volumes, creating a challenge for today’s operators. PCI is becoming more and more complex to treat a sicker population, but there is less case volume to support the development of operators’ technical skills and experience.…”

Complex interventions in the failing heart

“…The STICH trial (Surgical Treatment for Ischemic Heart Failure) revealed fewer all-cause mortality, cardiovascular and heart failure hospitalizations in CABG with optimal medical therapy when compared with medical therapy alone [8,9]. The role of PCI in patients with heart failure has evolved tremendously during the past decade, given that the population undergoing this procedure is now older, with significantly greater comorbidities, and thus, at a higher risk for invasive surgical interventions [10]. This has resulted in the development of sophisticated techniques and numerous adjunct supportive therapies to provide hemodynamic support and reduce the risk of this procedure, often described as high-risk PCI (HR-PCI).…”