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The authors used the BCIS (British Cardiovascular Intervention Society) database to define the factors associated with percutaneous coronary intervention (PCI) procedural complexity.Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly defined.The BCIS (British Cardiovascular Intervention Society) database was used to study all PCI procedures in the United Kingdom 2006-2016. A multiple logistic regression model was developed to identify variables associated with in-hospital major adverse cardiac or cerebrovascular events (MACCE) and to construct a CHIP score. The cumulative effect of this score on patient outcomes was examined.A total of 313,054 patients were included. Seven patient factors (age ≥80 years, female sex, previous stroke, previous myocardial infarction, peripheral vascular disease, ejection fraction 30%, and chronic renal disease) and 6 procedural factors (rotational atherectomy, left main PCI, 3-vessel PCI, dual arterial access, left ventricular mechanical support, and total lesion length60 mm) were associated with increased in-hospital MACCE and defined as CHIP factors. The mean CHIP score/case for all PCIs increased significantly from 1.06 ± 1.32 in 2006 to 1.49 ± 1.58 in 2016 (P 0.001 for trend). A CHIP score of 5 or more was present in 2.5% of procedures in 2006 increasing to 5.3% in 2016 (P 0.001 for trend). Overall in-hospital MACCE was 0.6% when the CHIP score was 0 compared with 1.2% with any CHIP factor present (P 0.001). As the CHIP score increased, an exponential increase in-hospital MACCE was observed. The cumulative MACCE for procedures associated with a CHIP score 4+ or above was 3.2%, and for a CHIP score 5+ was 4.4%. All other adverse clinical outcomes were more likely as the CHIP score increased.Seven patient factors and 6 procedural factors were associated with adverse in-hospital MACCE and defined as CHIP factors. Use of a CHIP score might be a future target for risk modification.

The authors used the British Cardiovascular Intervention Society (BCIS) national percutaneous coronary intervention (PCI) database to explore temporal changes in the use of intravascular imaging for unprotected left main stem PCI (uLMS PCI), defined the associates of imaging use, and correlate clinical outcomes including survival with imaging use.Limited registry data support the use of intravascular imaging during uLMS PCI to improve outcomes.Data were analyzed from 11,264 uLMS PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify associates of imaging use. Propensity matching created 5,056 pairs of subjects with and without imaging and logistic regression was performed to quantify the association between imaging and outcomes. Multivariate logistic regression to identify the independent predictors of 12-month mortality was performed.Imaging use increased from 30.2% in 2007 to 50.2% in 2014 (p for trend 0.001). The factors associated with imaging use included stable angina presentation (odds ratio [OR]: 1.200; 95% confidence interval [CI]: 1.147 to 1.246; p 0.001), bifurcation LMS disease (OR: 1.220; 95% CI: 1.140 to 1.300; p 0.001), previous PCI (OR: 1.320; 95% CI: 1.200 to 1.440; p 0.001), and radial access (OR: 1.266; 95% CI: 1.217 to 1.317; p 0.001). A lower rate of coronary complications, lower in-hospital major adverse cardiac events (OR: 0.470; 95% CI: 0.37 to 0.590; p 0.001), and improved 30-day (OR: 0.540; 95% CI: 0.430 to 0.680; p 0.001) and 12-month (OR: 0.660; 95% CI: 0.570 to 0.770; p 0.001) mortality were observed with imaging use compared with no imaging use. Greater mortality reductions were observed with higher operator LMS PCI volume. In logistic regression modeling, imaging use was associated with improved 12-month survival.The observed lower mortality with use of intravascular imaging to guide uLMS PCI justifies the undertaking of a large-scale randomized trial.

Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, temporal trends, predictors, and outcomes of radial access (RA) versus femoral access (FA) for unprotected left main stem percutaneous coronary intervention (LMS-PCI) were studied.Data on arterial access site for LMS-PCI are poorly defined.Data were analyzed from 19,482 LMS-PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.The frequency of FA use fell from 77.7% in 2007 to 31.7% in 2014 (p 0.001 for trend). In the most contemporary study years (2012 to 2014), the strongest associates of FA use for unprotected LMS-PCI were renal disease, PCI for restenosis, chronic total occlusion intervention, and female sex. Use of intravascular imaging and chronic anticoagulation were associated with a higher likelihood of RA use. Complexity of the PCI procedure in the RA cohort increased significantly during the study period. Length of stay was shorter (2.6 ± 9.2 vs. 3.6 ± 9.0; p 0.001) and same day discharge greater (43.0% vs. 26.6%; p 0.001) with RA use. After propensity matching, RA use was associated with significant reductions in in-hospital events including access site arterial complications, major bleeding, and major adverse cardiovascular events. Conversion to RA for LMS-PCI was associated with similar reductions in the whole patient cohort. RA use was not associated with lower 12-month mortality.In contemporary practice, the radial artery is the predominant access site for unprotected LMS-PCI, and its use is associated with shorter length of stay, less vascular complications, and less major bleeding than femoral access.

Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, access site choice and outcomes of patients undergoing PCI with previous coronary artery bypass grafting (CABG) were studied.Given the influence of access site on outcomes, use of radial access in PCI-CABG warrants further investigation.Data were analyzed from 58,870 PCI-CABG procedures performed between 2005 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.The number of PCI-CABG cases and the percentage of total PCI increased significantly during the study period. Femoral artery (FA) utilization fell from 90.8% in 2005 to 57.6% in 2014 (p 0.001), with no differences in the rate of change of left versus right radial use. In contemporary study years (2012 to 2014), female sex, acute coronary syndrome presentation, chronic total occlusion intervention, and lower operator volume were independently associated with FA access. Length of stay was shortened in the radial cohort. Unadjusted outcomes including an access site complication (1.10% vs. 0.30%; p 0.001), blood transfusion (0.20% vs. 0.04%; p 0.001), major bleeding (1.30% vs. 0.40%; p 0.001), and in-hospital death (1.10% vs. 0.60%; p = 0.001) were more likely to occur with FA access compared with radial access. After adjustment, although arterial complications, transfusion, and major bleeding remained more common with FA use, short- and longer-term mortality and major adverse cardiac event rates were similar.In contemporary practice, FA access remains predominant during PCI-CABG with case complexity associated with it use. FA use was associated with longer length of stay, and higher rates of vascular complications, major bleeding, and transfusion.

The authors sought to determine the relationships between left radial access (LRA) or right radial access (RRA) and clinical outcomes using the British Cardiovascular Intervention Society (BCIS) database.LRA has been shown to offer procedural advantages over RRA in percutaneous coronary intervention (PCI) although few data exist from a national perspective around its use and association with clinical outcomes.The authors investigated the relationship between use of LRA or RRA and clinical outcomes of in-hospital or 30-day mortality, major adverse cardiovascular events (MACE), in-hospital stroke, and major bleeding complications in patients undergoing PCI between 2007 and 2014.Of 342,806 cases identified, 328,495 (96%) were RRA and 14,311 (4%) were LRA. Use of LRA increased from 3.2% to 4.6% from 2007 to 2014. In patients undergoing a repeat PCI procedure, the use of RRA dropped to 72% at the second procedure and was even lower in females (65%) and patients75 years of age (70%). Use of LRA (compared with RRA) was not associated with significant differences in in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.90 to 1.57; p = 0.20), 30-day mortality (OR: 1.17, 95% CI: 0.93 to 1.74; p = 0.16), MACE (OR: 1.06, 95% CI: 0.86 to 1.32; p = 0.56), or major bleeding (OR: 1.22, 95% CI: 0.87 to 1.77; p = 0.24). In propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke (OR: 0.52, 95% CI: 0.37 to 0.82; p = 0.005).In this large PCI database, use of LRA is limited compared with RRA but conveys no increased risk of adverse outcomes, but may be associated with a reduction in PCI-related stroke complications.

This study sought to determine the risk factors for post-transcatheter aortic valve replacement (TAVR) dialysis and to determine the impact of pre-TAVR or post-TAVR dialysis on mortality.TAVR is now established as an alternative treatment to surgical aortic valve replacement. Data examining the impact of dialysis on outcomes after TAVR are lacking.The UK TAVI (Transcatheter Aortic Valve Implantation) Registry was established to report outcomes on all TAVR procedures performed within the United Kingdom (2007 to 2014). Data were collected prospectively on 6,464 patients with a median follow-up of 625 days.The proportion of patients on dialysis before TAVR has remained constant at 1.8%. After TAVR, the proportion of patients newly needing dialysis after TAVR has fallen from 6.1% (2007 to 2008) to 2.3% (2013 to 2014). The risk of new dialysis requirement after TAVR was independently associated with lower baseline renal function, year of procedure, impaired left ventricular function, diabetes, use of an Edwards valve, a nontransfemoral approach, need for open surgery, and moderate-to-severe aortic regurgitation after the procedure. Requirement for new dialysis after TAVR was associated with higher mortality at 30 days (hazard ratio: 6.44; 95% confidence interval: 4.87 to 8.53) and at 4 years (hazard ratio: 3.54; 95% confidence interval: 2.99 to 4.19; p 0.001 for all) compared with patients without dialysis requirement.The proportion of patients needing dialysis after TAVR has decreased over time. Post-TAVR dialysis is associated with increased mortality. Factors identified with dialysis requirement after TAVR require further investigation.

This study used a large national cohort to examine patterns of thrombectomy use in ST-segment elevation myocardial infarction (STEMI) and the relationship to mortality.The impact of coronary thrombectomy on mortality in STEMI has not been definitively established. Published trial data have been insufficiently powered to address this.The U.K. national registry was used to study 98,176 patients treated with primary percutaneous coronary intervention (PCI), between January 1, 2006, and December 31, 2013. Patients were grouped on the basis of whether they received thrombectomy or not; subgroups of simple (manual aspiration) and complex (mechanical) thrombectomy were also evaluated. The primary endpoint was 30-day mortality. The principal adjusted analysis used propensity score matching (PSM). A sensitivity analysis was performed using logistic regression controlled for the propensity score.Thrombectomy use markedly increased in the United Kingdom between 2008 and 2010 but plateaued thereafter at slightly below 50% of all primary PCI cases. No significant mortality difference was seen, in adjusted analyses, between the overall thrombectomy group and the no thrombectomy group, at 30 days or 1 year (at 30 days, PSM average treatment effect [ATE] coefficient 0.0028, 95% confidence interval: -0.0048 to 0.0104; p = 0.47). Likewise, no difference was seen between the simple (manual) thrombectomy versus no thrombectomy, at either time point (at 30 days, PSM ATE coefficient 0.0007, 95% confidence interval: -0.0049 to 0.0063; p = 0.80). By contrast, the complex (mechanical) thrombectomy group demonstrated a significantly higher mortality than the no thrombectomy group at 1-year follow-up (PSM ATE coefficient 0.0434, 95% confidence interval: 0.0081 to 0.0786; p = 0.017).Coronary thrombectomy was not associated with lower mortality in primary PCI for STEMI when used in our large all-comer cohort in a selective manner on the basis of physician judgment. These findings are consistent with other negative clinical outcomes in recent large randomized controlled trials studying routine manual thrombectomy in primary PCI.

The U.K. Transcatheter Aortic Valve Implantation Registry reported 30-day and 1-year mortality rates of 7.1% and 21.4%, respectively, for patients who underwent transcatheter aortic valve replacement (TAVR) in the United Kingdom between 2007 and 2009. The study aim was to report long-term outcomes in this same cohort of patients.There are few data on outcomes beyond 3 years after TAVR in any notable number of patients.Data from all TAVR procedures performed in the United Kingdom between January 2007 and December 2009 were prospectively collected. All-cause mortality status was reported in March 2014. Mortality tracking was achieved in 97.7% patients.The minimal time from replacement to census was 4.1 years, and the maximal time was 7.0 years. The 3- and 5-year survival rates were 61.2% and 45.5%, respectively. Independent predictors of 3-year mortality were renal dysfunction (hazard ratio [HR]: 1.65), atrial fibrillation (HR: 1.36), logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥18.5 (HR: 1.33), respiratory dysfunction (HR: 1.28), and ventricular dysfunction (left ventricular ejection fraction 30%) (HR: 1.53). Coronary artery disease (HR: 1.28) and age (HR: 1.03) were additional independent predictors of mortality at 5 years. Stroke within 30 days of TAVR was the only independent procedural predictor of mortality at 3 and 5 years (HR: 2.17 at 3 years). Device type, access route, and paravalvular leak did not independently predict long-term outcome.In the large U.K. Transcatheter Aortic Valve Implantation Registry, long-term outcomes after TAVR are favorable with 3- and 5-year survival rates of 61.2% and 45.5%, respectively. Long-term survival after TAVR is largely determined by intrinsic patient factors. Other than stroke, procedural variables, including paravalvular aortic leak, did not appear to be independent predictors of long-term survival.

This study sought to evaluate in-hospital outcomes and 3-year mortality of patients presenting with unprotected left main stem occlusion (ULMSO) treated with primary percutaneous coronary intervention (PPCI).Limited data exists about management and outcome following presentation with ULMSO.From January 1, 2007 to December 21, 2012, 446,257 PCI cases were recorded in the British Cardiovascular Intervention Society database of all PCI cases in England and Wales. Of those, 568 were patients having emergency PCI for ST-segment elevation infarction (0.6% of all PPCI) who presented with ULMSO (TIMI [Thrombolysis In Myocardial Infarction] flow grade 0/1 and stenosis75%), and they were compared with 1,045 emergency patients treated with nonocclusive LMS disease. Follow-up was obtained through linkage with the Office of National Statistics.Presentation with ULMSO, compared with nonocclusive LMS disease, was associated with a doubling in the likelihood of periprocedural shock (57.9% vs. 27.9%; p 0.001) and/or intra-aortic balloon pump support (52.5% vs. 27.2%; p 0.001). In-hospital (43.3% vs. 20.6%; p 0.001), 1-year (52.8% vs. 32.4%; p 0.001), and 3-year mortality (73.9% vs 52.3%, p 0.001) rates were higher in patients with ULMSO, compared with patients presenting with a patent LMS, and were significantly influenced by the presence of cardiogenic shock. ULMSO and cardiogenic shock were independent predictors of 30-day (hazard ratio [HR]: 1.61 [95% confidence interval (CI): 1.07 to 2.41], p = 0.02, and HR: 5.43 [95% CI: 3.23 to 9.12], p0.001, respectively) and 3-year all-cause mortality (HR: 1.52 [95% CI: 1.06 to 2.17], p = 0.02, and HR: 2.98 [95% CI: 1.99 to 4.49], p 0.001, respectively).In patients undergoing PPCI for ULMSO, acute outcomes are poor and additional therapies are required to improve outcome. However, long-term outcomes for survivors of ULMSO are encouraging.

This study sought to determine mortality rates among cardiogenic shock (CGS) patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome in the contemporary treatment era and to determine predictors of mortality.It is unclear whether recent advances in pharmacological and interventional strategies have resulted in further improvements in short- and long-term mortality and which factors are associated with adverse outcomes in patients presenting with CGS and undergoing PCI in the setting of acute coronary syndrome.This study analyzed prospectively collected data for patients undergoing PCI in the setting of CGS as recorded in the BCIS (British Cardiovascular Intervention Society) PCI database.In England and Wales, 6,489 patients underwent PCI for acute coronary syndrome in the setting of CGS. The mortality rates at 30 days, 90 days, and 1 year were 37.3%, 40.0%, and 44.3%, respectively. On multiple logistic regression analysis, age (for each 10-year increment of age: odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.51 to 1.68; p0.0001), diabetes mellitus (OR: 1.47, 95% CI: 1.28 to 1.70; p0.0001), history of renal disease (OR: 2.03, 95% CI: 1.63 to 2.53; p0.0001), need for artificial mechanical ventilation (OR: 2.56, 95% CI: 2.23 to 2.94; p0.0001), intra-aortic balloon pump use (OR: 1.57, 95% CI: 1.40 to 1.76; p0.0001), and need for left main stem PCI (OR: 1.90, 95% CI: 1.62 to 2.23; p0.0001) were associated with higher mortality at 1 year.In this large U.K. cohort of patients undergoing PCI in the context of CGS, mortality remains high in spite of the use of contemporary PCI strategies. The highest mortality occurs early, and this time period may be a particular target of therapeutic intervention.