JACC in a Flash

JACC in a Flash
NCDR Study Looks at Use of In-Hospital Risk-Adjusted Mortality to Determine PCI Quality

In-hospital risk-adjusted mortality rates should not be the only metric used to evaluate PCI quality, according to a study published April 3 in JACC: Cardiovascular Interventions.

The study, by Jacob A. Doll, MD, et al., gathered data from ACC’s CathPCI Registry between Oct. 1, 2009 and Sept. 30, 2014 to calculate the mean risk-standardized mortality rate (RSMR) for PCI operators with an average annual volume of ≥50 cases. Of the 2,352,174 PCIs performed by 3,760 operators, 242 (6.5 percent) were classified as high outliers, while 156 operators (4.1 percent) were classified as low outliers. The non-outlier group included the remaining 3,362 operators.

Results showed a median operator annual volume of 103 PCI procedures with 1.5 percent overall in-hospital mortality. The authors also found significant differences in annual operator RSMR, unexplained by case mix or procedure characteristics. Operator classifications also varied throughout the study, for example, the average non-outlier operator had a high RSMR 0.29 of the five years studied.

PCI mortality rates for individual doctors may be useful for both doctors and hospitals to assess and monitor their care and see where they need improvement, explains Doll. “It could drive hospitals and doctors to further improve the safety of a procedure that’s already low risk. However, I don’t see this measure as ready for widespread use as a publicly reported measure or to influence payment,” he adds.

In an accompanying editorial, Michael McDaniel, MD, FACC, notes that “in-hospital risk adjusted mortality is an imprecise and probably inaccurate reflection of the quality of a PCI procedure. Moreover, reporting mortality after PCI can promote risk averse behaviors.”

Moving forward, he suggests quality of care for patients with coronary artery disease would be more informed “if risk adjusted mortality were measured based on clinical presentation, included all patients regardless of treatment strategy, and evaluated over longer periods of time rather than in-hospital.”

Doll JA, Dai D, Roe MT, et al. JACC Cardiovasc Interv 2017;10:672-82.

JACC in a Flash
Surgeon Volume Influences Repair Rate in Mitral Valve Surgery

Surgeons performing lower volumes of mitral valve operations each year are significantly more likely to replace, rather than repair, mitral valves in patients with degenerative disease compared with those who perform higher volumes, according to research presented May 2 at the American Association for Thoracic Surgery’s annual meeting in Boston, MA, and simultaneously published in the Journal of the American College of Cardiology.

Joanna Chikwe, MD, et al., examined 5,475 patients with degenerative disease who underwent primary mitral surgery between 2002 and 2013. A total of 3,660 (66.8 percent) patients underwent mitral valve repair and 1,815 patients (33.2 percent) underwent mitral valve replacement. Median follow-up time was 6.8 years. Surgeons included in the study performed a median of 10 mitral valve operations per year.

Results showed that the repair rate for primary mitral procedures for any cause was 55 percent. In the degenerative subgroup, the mean repair rate was 66.8 percent, ranging from 48.4 percent for surgeons with total annual volumes <11 mitral cases to 77.2 percent for surgeons with total annual volumes of >50 mitral cases. After multivariable adjustment, total annual surgeon volume was independently associated with the probability of mitral repair; the chance of repair increased by 13 percent for every 10-case increment in total annual surgeon volume. Compared with patients operated on by surgeons with a total annual surgeon volume of ≤10, patients operated on by surgeons with a total annual surgeon volume of >50 cases were more than three times as likely to undergo mitral repair. There were improved mitral repair rates and survival in the patients of lower-volume surgeons if they operated at institutions where there was a surgeon performing >50 total mitral cases annually with a >70 percent degenerative repair rate.

The researchers conclude that a total annual surgeon volume of <25 cases was not only associated with lower mitral valve repair rates, but also was associated with increased one-year mortality and mitral valve reoperation, improvements in repair rates, survival and freedom from reoperation continued with increasing surgeon case volume. They write that the data provide strong support to the calls for systematically focusing experience in mitral valve surgery. Encouraging targeted referral, with the goal of concentrating surgical volume, should help to address the wide variation in mitral repair rates.

“With this important study, Chikwe et al., address the who and where in the treatment of degenerative mitral valve disease,” writes Marc Gillinov, MD, and colleagues in an accompanying editorial. “Surgeons (ideally, teams of surgeons) with a special focus, who have developed expertise via training and operative volume, should operate on patients with degenerative mitral valve disease in hospitals with appropriate infrastructure. This tenet should apply even to the ‘simple’ P2 prolapse. We recognize that this statement will generate controversy, as it challenges the status quo.”

Chikwe J, Toyoda N, Anyanwu AC, et al. J Am Coll Cardiol 2017;May 2:[Epub ahead of print].

JACC in a Flash
AKI-MATRIX Finds Reduced Risk of AKI With Radial Access

In patients with acute coronary syndrome (ACS) undergoing invasive management, radial access may be associated with a reduced risk of acute kidney injury (AKI) compared with femoral access, according to results of the AKI-MATRIX trial published May 17 in the Journal of the American College of Cardiology and presented at EuroPCR in Paris.

Giuseppe Andò, MD, et al., examined 8,210 patients enrolled in the MATRIX-Access trial between October 2011 and July 2014. Half were assigned to radial access and half to femoral access. Baseline demographics and procedural characteristics were similar for the two groups.

Results showed that AKI occurred in 1,345 patients (16.4 percent) based on the primary endpoint definition of a relative (>25 percent) increase in serum creatinine and in 387 patients (4.7 percent) based on an absolute increase in serum creatinine of >0.5 mg/dL. Patients with AKI were older, more frequently women and had a higher prevalence of diabetes and anemia. They were also more likely to have presented with STEMI and advanced Killip class and their access site crossover rate was twice as frequent.

Peak serum creatinine after intervention or at discharge did not differ with radial access vs. femoral access, but estimated glomerular filtration rate was lower in the femoral group during hospitalization and at follow-up. AKI occurred in 15.4 percent of radial access patients compared with 17.4 percent of femoral access patients. A >25 percent increase in serum creatinine was observed in 633 (15.4 percent) radial access patients and 710 (17.3 percent) femoral access patients, and a >0.5 mg/dL absolute increase in serum creatinine occurred in 175 (4.3 percent) radial access patients and 223 (5.4 percent) femoral access patients (5.4 percent). Post-intervention dialysis occurred in fewer patients with radial access than femoral access.

The authors note that moving forward, future studies should evaluate whether the use of radial access in patients with advanced chronic kidney disease affects or prevents a conduit for fistula for dialysis.

“[T]his analysis of the MATRIX trial suggests that radial access is beneficial in preventing AKI after coronary angiography or intervention,” write Sanjit S. Jolly, MD, and Ashraf Alazzoni, MBBS, in an accompanying editorial. “This provides another piece of evidence supporting a radial first approach in patients with ACS who are undergoing coronary angiography or intervention.”

Andò G, Cortese B, Russo F, et al. J Am Coll Cardiol 2017;May 17:[Epub ahead of print].

JACC in a Flash
Aspirin More Successful Than DAPT For Reducing Events After TAVR

Aspirin alone was more successful in reducing major adverse events following transcatheter aortic valve replacement (TAVR) compared with aspirin plus clopidogrel, according to small, open-label trial published May 16 in JACC: Cardiovascular Interventions and presented at EuroPCR in Paris.

Josep Rodes-Cabau, MD, et al., examined 222 TAVR candidates, with half randomized to receive dual antiplatelet therapy (DAPT) and half to aspirin alone. Baseline and procedural characteristics were similar in both groups.

At three-month follow-up, the incidence of death, myocardial infarction (MI), ischemic stroke/transient ischemic attack or major bleeding events tended to be higher in the DAPT group (15.3 vs. 7.2 percent; p = 0.065). Aspirin alone decreased the risk of major or life-threatening bleeding post TAVR while not increasing the risk of MI or stroke. All MI and stroke events occurred during the first 30 days post TAVR. All bleeding events also occurred within the first 30 days post TAVR; 56 percent were related to vascular or access site complications. Clopidogrel was stopped temporarily or definitely in 21 DAPT patients because of adverse events. The authors caution that these results should be interpreted as hypothesis-generating and should serve to design a definitive trial for determining the optimal antithrombotic treatment in TAVR candidates.

In a related editorial, Davide Capodanno, MD, and Dominick J. Angiolillo, MD, PhD, FACC, add: “Because life-threatening or disabling bleeding remains a substantial cause of morbidity in elderly patients who are currently offered TAVR, further investigations of strategies that positively affect the efficacy-safety trade-off of antithrombotic therapy are needed in this fragile population.”

Rodés-Cabau J, Masson JB, Welsh RC, et al. JACC Cardiovasc Interv 2017;May 16:[Epub ahead of print].

JACC in a Flash
Novel DES Safe, Effective For Coronary Lesions With Very Small Vessels

The first drug-eluting stent (DES) dedicated for the treatment of coronary lesions with very small reference vessel diameter may be associated with a low rate of target lesion failure and late lumen loss without a signal for stent thrombosis, according to research published May 17 in JACC: Cardiovascular Interventions and presented at EuroPCR in Paris.

Matthew J. Price, MD, FACC, et al., enrolled a total of 101 patients with 104 lesions. The mean lesion length was 12.6 ± 6.3 mm and mean reference vessel diameter was 1.91 ± 0.26 mm; the majority of lesions were anatomically complex.

At discharge, the rate of target lesion failure was 2.0 percent, driven by target vessel myocardial infarction. The rate of 12-month target lesion failure was 5.0 percent, fulfilling the pre-specified performance goal. Target lesion revascularization occurred in 2.0 percent, target vessel myocardial infarction in 3.0 percent, target vessel failure in 5.0 percent and major adverse cardiac events in 5.0 percent of patients. There were no deaths or episodes of stent thrombosis.

In an angiographic sub-study of 26 patients with 27 lesions, in-stent late lumen loss was 0.2 6 ± 0.48 mm, in-stent percent diameter stenosis was 22.5 ± 26.9 percent, and in-stent binary restenosis occurred in 12.0 percent.

“The use of this novel-sized DES appears to be a feasible approach for the treatment of coronary lesions in extremely small vessels,” the authors conclude.

Price MJ, Saito S, Shlofmitz RA, et al. JACC Cardiovasc Interv 2017;May 17:[Epub ahead of print].

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Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Arrhythmias, Interventions and ACS

Keywords: Cardiology Interventions, Acute Coronary Syndrome, Acute Kidney Injury, Aspirin, Mitral Valve, Registries, Surgeons, Thoracic Surgery, Thoracic Surgical Procedures, Transcatheter Aortic Valve Replacement

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