Hybrid Coronary Revascularization has Improved Short-term Outcomes but Worse Mid-term Reintervention Rates Compared to CABG: A Propensity Matched Analysis.

OBJECTIVE: We evaluated short-term outcomes and mid-term survival and reintervention of hybrid coronary revascularization versus conventional coronary artery bypass grafting using a propensity score matched cohort. METHODS: We conducted a retrospective review of patients undergoing surgery for multivessel coronary artery disease from 2007 to 2015 at a single institution. Patients were propensity matched 1:1 to receiving hybrid coronary revascularization or conventional bypass grafting by multivariate logistic regression on preoperative characteristics. Short-term outcomes were compared. Freedom from reintervention and death were assessed by Kaplan-Meier analysis, log-rank test, and Cox proportional hazards regression. RESULTS: Propensity score matching selected 91 patients per group from 91 hybrid and 2601 conventionally revascularized patients. Hybrid revascularization occurred with surgery first in 56 (62%), percutaneous intervention first in 32 (35%), and simultaneously in 3 (3%) patients. Median intervals between interventions were 3 and 36 days for surgery first and percutaneous intervention first, respectively. Preoperative characteristics were similar. Patients undergoing hybrid revascularization had shorter postoperative length of stay (median = 4 vs 5 days, P < 0.001), less postoperative transfusion (13.2% vs 34.1%, P = 0.001), and respiratory failure (0% vs 6.6%, P = 0.03). They were more likely to be discharged home (93.4% vs 71.4%, P < 0.001), with no difference in 30-day mortality (P = 0.99), readmission (P = 0.23), or mid-term survival (P = 0.79). Hybrid revascularization was associated with earlier reintervention (P = 0.02). Hazard ratios for reintervention and patient mortality of hybrid coronary revascularization versus conventional revascularization were 3.60 (95% confidence interval = 1.16-11.20) and 1.17 (95% confidence interval = 0.37-3.72), respectively. CONCLUSIONS: Despite having favorable short-term outcomes and similar survival, hybrid coronary revascularization may be associated with earlier reintervention compared with conventional techniques.

Comparison of Index Hospitalization Costs Between Robotic CABG and Conventional CABG: Implications for Hybrid Coronary Revascularization.

OBJECTIVES: To compare the direct costs of the index hospitalization and 30-day morbidity and mortality incurred during robotic and conventional coronary artery bypass grafting at a single institution based on hospital clinical and financial records. DESIGN: Retrospective study, propensity-matched groups with one-to-one nearest neighbor matching. SETTING: University hospital, a tertiary care center. PARTICIPANTS: Two thousand eighty-eight consecutive patients who underwent primary coronary artery bypass grafting (CABG) from January 2007 to March 2012. INTERVENTIONS: One hundred forty-one matched pairs were created and analyzed. MEASUREMENTS AND MAIN RESULTS: Robotic CABG was associated with a decrease in operative time (5.61±1.1 v 6.6±1.15 hours, p<0.001), a lower need for blood transfusion (12.8% v 22.6%, p = 0.04), a shorter length of stay (6 [4-9]) v 7 [5-11] days, p = 0.001), a shorter ICU stay (31 [24-49] hours v 52 [32-96.5] hours, p<0.001) and lower NY state complications composite rate (4.26% v 13.48%, p = 0.01). In spite of that, the cost of robotic procedures was not significantly different from matched conventional cases ($18,717.35 [11,316.1-34,550.6] versus $18,601 [13,137-50,194.75], p = 0.13), except 26 hybrid coronary revascularizations in which angioplasty was performed on the same admission (hybrid 25,311.1 [18,537.1-41,167.85] versus conventional 18,966.13 [13,337.75-56,021.75], p = 0.02). CONCLUSION: Robotically assisted CABG does not increase the cost of the index hospitalization when compared to conventional CABG unless hybrid revascularization is performed on the same admission.

Caring for the adult with congenital heart disease in an adult catheterization laboratory by pediatric interventionalists--safety and efficacy.

OBJECTIVE: The purpose of this study is to describe the outcomes of cardiac catheterizations performed by pediatric interventional cardiologists in an adult catheterization laboratory on adult patients with congenital heart disease (CHD). BACKGROUND: With improved survival rates, the number of adults with CHD increases by ∼5%/year; this population often requires cardiac catheterization. METHODS: From January 2005 to December 2009, two groups of patients were identified, an adult group (>21 years) and an adolescent group (13-21 years), who had catheterizations performed by pediatric interventional staff. RESULTS: Fifty-seven catheterizations were performed in 53 adults, while 59 were performed in 47 adolescents. The male to female ratio differed significantly between groups; only 15/53 (28%) of adults were male vs. 26/47 (55%) of adolescents (P =.006). Among adults, 27 had previously corrected CHD, 16 with atrial septal defect (ASD), and six with patent foramen ovale (PFO). This differed significantly from the adolescents, where only 30 had previously corrected CHD, seven with ASD, and one with PFO (P =.012). Among adults who were catheterized, interventions were performed on 28/53 (53%). All interventions were successful and included ASD/PFO closure, patent ductus arteriosus occlusion, coarctation dilation, pulmonary artery dilations, and one saphenous vein graft aneurysm closure. Nineteen adults had coronary angiography performed by adult interventionalists in consult with pediatric interventionalists. Two complications occurred among adults (3.8%) vs. one complication (2%; P = 1) among adolescents. No femoral vessel complications or catheterization-associated mortality occurred. CONCLUSIONS: Cardiac catheterizations can be performed effectively and safely in adults with CHD by pediatric interventional cardiologists in an adult catheterization laboratory.

Improving primary percutaneous coronary intervention performance in an urban minority population using a quality improvement approach.

It has been well established that there are racial and ethnic disparities in cardiovascular care. Quality improvement initiatives have been recommended to proactively address these disparities. An initiative was implemented to improve timeliness of and access to primary percutaneous coronary intervention (PCI) procedures among myocardial infarction patients at an academic medical center serving a predominantly minority population. The effort was part of a national quality improvement collaborative focused on improving cardiovascular care for Hispanic/Latino and African American/ black populations. The proportion of primary PCI procedures performed within 90 minutes improved significantly from 17% in the first quarter of 2006 to 93% in the fourth quarter of 2008 (P < .001). There were no significant differences in the frequency with which Hispanic/Latino or African American/black patients received primary PCI therapy in comparison to nonmembers of these groups. Quality improvement techniques can improve the quality of and access to acute cardiovascular care for minority populations.

Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states. METHODS: We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states. RESULTS: New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non-New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non-New York patients (P < .001) taken for CABG within 3 days of shock onset. CONCLUSIONS: In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.