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Objective: Existing clinical prediction models (CPM) for short-term mortality after transcatheter aortic valve implantation (TAVI) have limited applicability in the UK due to moderate predictive performance and inconsistent recording practices across registries. The aim of this study was to derive a UK-TAVI CPM to predict 30-day mortality risk for benchmarking purposes.Methods: A two-step modelling strategy was undertaken: first, data from the UK-TAVI Registry between 2009 and 2014 were used to develop a multivariable logistic regression CPM using backwards stepwise regression. Second, model-updating techniques were applied using the 2013-2014 data, thereby leveraging new approaches to include frailty and to ensure the model was reflective of contemporary practice. Internal validation was performed by bootstrapping to estimate in-sample optimism-corrected performance.Results: Between 2009 and 2014, up to 6339 patients were included across 34 centres in the UK-TAVI Registry (mean age, 81.3; 2927 female (46.2%)). The observed 30-day mortality rate was 5.14%. The final UK-TAVI CPM included 15 risk factors, which included two variables associated with frailty. After correction for in-sample optimism, the model was well calibrated, with a calibration intercept of 0.02 (95% CI -0.17 to 0.20) and calibration slope of 0.79 (95% CI 0.55 to 1.03). The area under the receiver operating characteristic curve, after adjustment for in-sample optimism, was 0.66.Conclusion: The UK-TAVI CPM demonstrated strong calibration and moderate discrimination in UK-TAVI patients. This model shows potential for benchmarking, but even the inclusion of frailty did not overcome the need for more wide-ranging data and other outcomes might usefully be explored. [ABSTRACT FROM AUTHOR]

Objectives 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. Background 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. Methods 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. Results 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 patients >75 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). Conclusions 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. [ABSTRACT FROM AUTHOR]

Aims: Access site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the British Cardiovascular Intervention Society PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied.Methods and Results: Data were analysed from 11,444 PCI-ROTA 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.Results: For PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], P = .008), CTO intervention (OR 1.95, [1.209-3.314], P = .006), and history of previous CABG (OR 1.68, [1.124-2.515], P = .010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, P < .001). After adjustment for baseline differences, arterial complications (OR 15.6, P < .001), transfusion (OR 12.5, P = .023) and major bleeding OR 6.0, P < .001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups.Conclusions: In contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion. [ABSTRACT FROM AUTHOR]

Background--Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or can occur spontaneously. This study aims to evaluate temporal changes in RH, its predictors, and clinical outcomes in a national cohort of patients undergoing percutaneous coronary intervention in the United Kingdom. Methods and Results--We analyzed RH events in patients who underwent percutaneous coronary intervention between 2007 and 2014. Multiple logistic regression models were used to identify factors associated with RH and to quantify the association between RH and 30-day mortality and major adverse cardiovascular events. A total of 511 106 participants were included, and 291 in hospital RH events were recorded (0.06%). Overall, rates of RH declined from 0.09% to 0.03% between 2007 and 2014. The strongest independent predictors of RH events were femoral access (odds ratio [OR], 19.66; 95% confidence interval [CI], 11.22-34.43), glycoprotein IIb/IIIa inhibitor (OR, 2.63; 95% CI, 1.99-3.47), and warfarin use (OR, 2.53; 95% CI, 1.07-5.99). RH was associated with a significant increase in 30-day mortality (OR, 3.59; 95% CI, 2.19-5.90) and in-hospital major adverse cardiovascular events (OR, 5.76; 95% CI, 3.71-8.95). A legacy effect was not observed; patients with RH who survived 30 days did not have higher 1-year mortality compared with those without this complication (hazard ratio, 0.97; 95% CI, 0.49-1.91). Conclusions--Our results suggest that RH is a rare event that is declining in the United Kingdom, related to transition to transradial access site utilization, but remains a clinically important event associated with increased 30-day mortality but no long-term legacy effect. [ABSTRACT FROM AUTHOR]

Objectives This study sought to examine the relationship between access site practice and clinical outcomes in patients requiring percutaneous coronary intervention (PCI) following thrombolysis for ST-segment elevation myocardial infarction (STEMI). Background Transradial access (TRA) is associated with better outcomes in patients requiring PCI for STEMI. A significant proportion of STEMI patients may receive thrombolysis before undergoing PCI in many countries across the world. There are limited data around access site practice and its associated outcomes in this cohort of patients. Methods The author used the British Cardiovascular Intervention Society dataset to investigate the outcomes of patients undergoing PCI following thrombolysis between 2007 and 2014. Patients were divided into TRA and transfemoral access groups depending on the access site used. Multiple logistic regression and propensity score matching were used to study the association of access site with in-hospital and long-term mortality, major bleeding, and access site–related complications. Results A total of 10,209 patients received thrombolysis and PCI during the study time. TRA was used in 48% (n = 4,959) of patients; 3.3% (n = 336) patients died in hospital, 1.6% (n = 165) of patients experienced major bleeding, 4.2% (n = 437) experienced major adverse cardiac events (MACE), and 4.6% (n = 468) experienced 30-day mortality. After multivariate adjustment, TRA was associated with significantly reduced odds of in-hospital mortality (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.42 to 0.83; p = 0.002), major bleeding (OR: 0.45; 95% CI: 0.31 to 0.66; p < 0.001), MACE (OR: 0.72; 95% CI: 0.55 to 0.94; p = 0.01), and 30-day mortality (OR: 0.72; 95% CI: 0.55 to 0.94; p = 0.01). Conclusions TRA is associated with decreased odds of bleeding complications, mortality, and MACE in patients undergoing PCI following thrombolysis and should be preferred access site choice in this cohort of patients. [ABSTRACT FROM AUTHOR]

Objectives 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. Background 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. Methods 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. Results 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. Conclusions 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. [ABSTRACT FROM AUTHOR]

Background--The evidence base for coronary perforation (CP) occurring during percutaneous coronary intervention in patients with a history of coronary artery bypass surgery (PCI-CABG) is limited and the long-term effects unclear. Using a national PCI database, the incidence, predictors, and outcomes of CP during PCI-CABG were defined. Methods and Results--Data were analyzed on all PCI-CABG procedures performed in England and Wales between 2005 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. During the study period, 309 CPs were recorded during 59 644 PCI-CABG procedures with the incidence rising from 0.32% in 2005 to 0.68% in 2013 (P<0.001 for trend). Independent associates of perforation in native vessels included age, chronic occlusive disease intervention, rotational atherectomy use, number of stents, hypertension, and female sex. In graft PCI, predictors of perforation were history of stroke, New York Heart Association class, and number of stents used. In-hospital clinical complications including Q-wave myocardial infarction (2.9% versus 0.2%; P<0.001), major bleeding (14.0% versus 0.9%; P<0.001), blood transfusion (3.7% versus 0.2%; P<0.001), and death (10.0% versus 1.1%; P<0.001) were more frequent in patients with CP. A continued excess mortality occurred after perforation, with an odds ratio for 12-month mortality of 1.35 for perforation survivors compared with matched nonperforation survivors without a CP (P<0.0001). Conclusions--CP is an infrequent event during PCI-CABG but is closely associated with adverse clinical outcomes. A legacy effect of perforation on 12-month mortality was observed. [ABSTRACT FROM AUTHOR]

Objectives The aims of this study were to examine the relationship between body mass index (BMI) and clinical outcomes following percutaneous coronary intervention (PCI) and to determine the relevance of different clinical presentations requiring PCI to this relationship. Background Obesity is a growing problem, and studies have reported a protective effect from obesity compared with normal BMI for adverse outcomes after PCI. Methods Between 2005 and 2013, 345,192 participants were included. Data were obtained from the British Cardiovascular Intervention Society registry, and mortality data were obtained through the U.K. Office of National Statistics. Multiple logistic regression was performed to determine the association between BMI group (<18.5, 18.5 to 24.9, 25 to 30 and >30 kg/m 2 ) and adverse in-hospital outcomes and mortality. Results At 30 days post-PCI, significantly lower mortality was seen in patients with elevated BMIs (odds ratio [OR]: 0.86 [95% confidence interval (CI): 0.80 to 0.93] 0.90 [95% CI: 0.82 to 0.98] for BMI 25 to 30 and >30 kg/m 2 , respectively). At 1 year post-PCI, and up to 5 years post-PCI, elevated BMI (either overweight or obese) was an independent predictor of greater survival compared with normal weight (OR: 0.70 [95% CI: 0.67 to 0.73] and 0.73 [95% CI: 0.69 to 0.77], respectively, for 1 year; OR: 0.78 [95% CI: 0.75 to 0.81] and 0.88 [95% CI: 0.84 to 0.92], respectively, for 5 years). Similar reductions in mortality were observed for the analysis according to clinical presentation (stable angina, unstable angina or non–ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction). Conclusions A paradox regarding the independent association of elevated BMI with reduced mortality after PCI is still evident in contemporary U.K. practice. This is seen in both stable and more acute clinical settings. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to assess, using a national percutaneous coronary intervention (PCI) database, access-site choice and outcomes after chronic total occlusion (CTO) PCI. Background Given the influence of access site on outcomes, the use of radial access in CTO PCI warrants further investigation. Methods Data were analyzed from the British Cardiovascular Intervention Society dataset of 26,807 elective CTO PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regression was used to identify predictors of access-site choice and its association with outcomes. Results There was a significant decrease in femoral artery (FA) access from 84.6% in 2006 to 57.9% in 2013. Procedural factors associated with FA access included dual access (odds ratio [OR]: 3.89; 95% confidence interval [CI]: 3.45 to 4.32), CrossBoss/Stingray (OR: 1.87; 95% CI: 1.43 to 2.12), intravascular ultrasound (OR: 1.32; 95% CI: 1.21 to 1.53), and microcatheter use (OR: 1.18; 95% CI: 1.03 to 1.39). There was an association between FA access and the number of CTO devices used (p = 0.001 for trend). Access-site complications (1.5% vs. 0.5%; p < 0.001), periprocedural myocardial infarction (0.5% vs. 0.2%; p = 0.037), major bleeding (0.8% vs. 0.2%, p < 0.001), transfusion (0.4% vs. 0%; p < 0.001), and 30-day death (0.6% vs. 0.1%; p = 0.002) were more frequent in patients undergoing CTO PCI using FA access. An access-site complication during CTO PCI was associated with significant increases in transfusion (8.0% vs. 0.1%; p < 0.001), procedural coronary complication (17.3% vs. 5.8%; p < 0.0001), major bleeding (8.4% vs. 0.3%; p < 0.001), and mortality at all time points. Conclusions FA access remains predominant during CTO PCI, with case complexity and device size associated with its use. Access-site complications were more frequent with FA use and strongly correlated with adverse outcomes. [ABSTRACT FROM AUTHOR]