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Multicenter Study
. 2014 Dec 23;130(25):2295-301.
doi: 10.1161/CIRCULATIONAHA.114.011541. Epub 2014 Nov 12.

Surgical Ineligibility and Mortality Among Patients With Unprotected Left Main or Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

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Free PMC article
Multicenter Study

Surgical Ineligibility and Mortality Among Patients With Unprotected Left Main or Multivessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Stephen W Waldo et al. Circulation. .
Free PMC article

Abstract

Background: Decisions to proceed with surgical versus percutaneous revascularization for multivessel coronary artery disease are often based on subtle clinical information that may not be captured in contemporary registries. The present study sought to evaluate the association between surgical ineligibility documented in the medical record and long-term mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention.

Methods and results: All subjects undergoing nonemergent percutaneous coronary intervention for unprotected left main or multivessel coronary artery disease were identified at 2 academic medical centers from 2009 to 2012. Documentation of surgical ineligibility was assessed through review of electronic medical records. Cox proportional hazard models adjusted for known mortality risk factors were created to assess long-term mortality in patients with and without documentation of surgical ineligibility. Among 1013 subjects with multivessel coronary artery disease, 218 (22%) were deemed ineligible for coronary artery bypass graft surgery. The most common explicitly cited reasons for surgical ineligibility in the medical record were poor surgical targets (24%), advanced age (16%), and renal insufficiency (16%). After adjustment for known risk factors, documentation of surgical ineligibility remained independently associated with an increased risk of in-hospital (odds ratio, 6.26; 95% confidence interval, 2.16-18.15; P<0.001) and long-term mortality (hazard ratio, 2.98; 95% confidence interval, 1.88-4.72, P<0.001) after percutaneous coronary intervention.

Conclusions: Documented surgical ineligibility is common and associated with significantly increased long-term mortality among patients undergoing percutaneous coronary intervention with unprotected left main or multivessel coronary disease, even after adjustment for known risk factors for adverse events during percutaneous revascularization.

Keywords: eligibility determination; percutaneous coronary intervention; risk adjustment; surgery.

Figures

Figure 1
Figure 1
Study Population. Flow-diagram depicting inclusion and exclusion criteria for analysis.
Figure 2
Figure 2
Mortality. Kaplan-Meier estimates comparing long-term mortality among those with surgical anatomy undergoing percutaneous revascularization stratified by documentation of surgical ineligibility. Surgical inelibility (Inelig) was associated with a significant increase in mortality when compared to those that were surgically eligible (Elig, Log-Rank < 0.001).

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