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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Outcomes and Institutional Variation in Arterial Access Among Patients With AMI and Cardiogenic Shock Undergoing PCI
Dhruv Mahtta1, Pratik Manandhar2, Zachary K Wegermann3
1Division of Cardiovascular Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.
Insights
Transradial access (TRA) for percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with lower in-hospital bleeding, mortality, and vascular complications compared to transfemoral access (TFA). This benefit was consistent across various institutions and patient support levels.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Access
Background:
- Limited contemporary data exists comparing transradial access (TRA) versus transfemoral access (TFA) in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI).
- Understanding institutional variations in TRA utilization is crucial for optimizing patient care.
Purpose of the Study:
- To examine in-hospital outcomes and institutional variability associated with TRA-PCI compared to TFA-PCI in patients with AMI-CS.
- To assess the impact of access site choice on major bleeding, mortality, vascular complications, and need for new dialysis.
Main Methods:
- Analysis of 35,944 patients with AMI-CS from the NCDR CathPCI registry (April 2018-June 2021).
- Utilized multivariable logistic regression and inverse probability weighting to compare outcomes between TRA-PCI and TFA-PCI.
- Included a falsification analysis for non-access site-related bleeding to validate findings.
Main Results:
- TRA-PCI was performed in 25.6% of AMI-CS cases, with increasing utilization over time and significant institutional variability.
- TRA-PCI was associated with significantly lower adjusted rates of major bleeding (OR 0.71), mortality (OR 0.73), vascular complications (OR 0.67), and new dialysis (OR 0.86).
- No significant difference was found in non-access site-related bleeding (OR 0.93), and benefits persisted regardless of mechanical circulatory support use.
Conclusions:
- Transradial access (TRA) is increasingly used for percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS) across US institutions.
- TRA-PCI is associated with significantly reduced in-hospital major bleeding, mortality, vascular complications, and new dialysis compared to transfemoral access (TFA).
- The observed benefits of TRA-PCI in AMI-CS patients are consistent and not influenced by the use of mechanical circulatory support.
Background:
Contemporary data comparing the outcomes of transradial access (TRA) vs transfemoral access (TFA) among patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI) are limited.
Objectives:
This study examines in-hospital outcomes and institutional variation among patients with AMI-CS undergoing TRA-PCI vs TFA-PCI.
Methods:
Patients admitted with AMI-CS from the NCDR CathPCI registry between April 2018 and June 2021 were included. Multivariable logistic regression and inverse probability weighting models were used to assess the association between access site and in-hospital outcomes. A falsification analysis using non-access site-related bleeding was performed.
Results:
Among 35,944 patients with AMI-CS undergoing PCI, 25.6% were performed with TRA. The proportion of TRA-PCI increased over the study period (22.0% in the second quarter of 2018 vs 29.1% in the second quarter of 2021; P-trend <0.001). Significant institutional-level variability in the use of TRA-PCI was also observed: 20.9% of all sites using TRA in <2% of PCIs (low utilization) vs 1.9% of all sites using TRA in >80% of PCIs (high utilization). Patients undergoing TRA-PCI had a significantly lower adjusted incidence of major bleeding (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.67-0.76), mortality (OR: 0.73; 95% CI: 0.69-0.78), vascular complications (OR: 0.67; 95% CI: 0.54-0.84), and new dialysis (OR: 0.86; 95% CI: 0.77-0.97). There was no difference in non-access site related bleeding (OR: 0.93; 95% CI: 0.84-1.03). Sensitivity analyses revealed similar benefit with TRA-PCI among patients without arterial cross-over. There were no significant interactions observed between TRA-PCI with mechanical circulatory support and in-hospital outcomes.
Conclusions:
In this large nationwide contemporary analysis of patients with AMI-CS, about quarter of PCIs were performed via TRA with wide variability across US institutions. TRA-PCI was associated with significantly lower incidence of in-hospital major bleeding, mortality, vascular complications, and new dialysis. This benefit was observed irrespective of mechanical circulatory support use.
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