Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention.
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.


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.
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Stephen W
SW
Waldo
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Eric A
EA
Secemsky
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Cashel
C
O'Brien
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Kevin F
KF
Kennedy
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Eugene
E
Pomerantsev
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Thoralf M
TM
Sundt
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Edward J
EJ
McNulty
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
Benjamin M
BM
Scirica
From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.). ryeh@partners.org.
Robert W
RW
Yeh
D000368:Aged; D006348:Cardiac Surgical Procedures; D000075202:Contraindications; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy*; D003661:Decision Support Techniques; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D016016:Proportional Hazards Models; D012307:Risk Factors
eligibility determination; percutaneous coronary intervention; risk adjustment; surgery