Ad Hoc Percutaneous Coronary Intervention in Stable Patients With Multivessel or Unprotected Left Main Disease
Edward L Hannan1, Ye Zhong1, Kimberly Cozzens1
1University at Albany, State University of New York, Albany, New York, USA.
Insights
Ad hoc percutaneous coronary intervention (PCI) is frequently used in multivessel (MV) or left main (LM) disease patients. Wide hospital variation exists, suggesting a need for standardized heart team approaches.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Health Services Research
Background:
- Limited data exists on ad hoc percutaneous coronary intervention (PCI) use in stable multivessel (MV) or unprotected left main (LM) disease.
- A heart team approach is recommended for these complex patient groups.
Purpose of the Study:
- To determine the utilization rates of ad hoc PCI in patients with MV or LM disease.
- To investigate inter-hospital variations in ad hoc PCI practices for these patient populations.
Main Methods:
- Utilized New York State cardiac registries data from 2018-2019.
- Analyzed ad hoc PCI as a percentage of all PCI and revascularizations for MV/LM disease.
Main Results:
- Ad hoc PCI was performed in 78.4% of eligible patients, with rates varying by disease complexity (58.7% for unprotected LM to 85.4% for 2-vessel proximal LAD disease).
- Ad hoc PCIs represented 35.1% of all revascularizations, showing significant hospital-level variation (15% to 46% for 3-vessel disease).
- Utilization was higher in hospitals without on-site surgery and in specific patient subgroups.
Conclusions:
- Ad hoc PCI is common in MV/LM disease, particularly in 2-vessel proximal LAD disease.
- Significant variation in ad hoc PCI use among hospitals and patient factors (diabetes, low ejection fraction) warrants attention.
- A systems approach to standardize heart team consultation and shared decision-making is recommended for all hospitals.
Background:
There is very little information about the use of ad hoc percutaneous coronary intervention (PCI) in stable patients with multivessel (MV) disease or unprotected left main (LM) disease patients for whom a heart team approach is recommended.
Objective:
To identify the extent of ad hoc PCI utilization for patients with multivessel disease or left main disease, and to explore the inter-hospital variation in ad hoc PCI utilization for those patients.
Methods:
New York State's cardiac registries were used to examine the use and variation in use of ad hoc PCI for MV/LM disease as a percentage of all MV/LM PCIs and revascularizations (PCIs plus coronary artery bypass graft procedures) during 2018 to 2019 in New York.
Results:
After exclusions, 6,425 of the 8,196 stable PCI patients with MV/LM disease (78.4%) underwent ad hoc PCI, ranging from 58.7% for patients with unprotected LM disease to 85.4% for patients with 2-vessel proximal left anterior descending (PLAD) disease. Ad hoc PCIs comprised 35.1% of all revascularizations, ranging from 11.5% for patients with unprotected LM disease to 63.9% for patients with 2-vessel PLAD disease. The risk-adjusted utilization of ad hoc PCI as a percentage of all revascularizations varied widely among hospitals (eg, from 15% in the first quartile to 46% in the last quartile for 3-vessel disease).
Conclusions:
Ad hoc PCIs occur frequently even among patients with MV/LM disease. This is particularly true among patients with 2-vessel PLAD disease. The frequency of ad hoc PCIs is lower but still high among patients with diabetes and low ejection fraction and higher in hospitals without surgery on-site (SOS). Given the magnitude of hospital- and physician-level variation in the use of ad hoc PCIs for such patients, consideration should be given to a systems approach to achieving heart team consultation and shared decision making that is consistent for SOS and non-SOS hospitals.
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