Root Cause Analysis of Deaths in ST-Segment Elevation Myocardial Infarctions Treated With Primary PCI: What Can We Do Better?

OBJECTIVE: Recent data demonstrate that mortality of patients with ST-elevation myocardial infarction (STEMI) has not changed despite dramatic reduction in door-to-balloon times. Identifying potential areas in care that can be further optimized to decrease mortality remains a priority. METHODS: We performed a root cause analysis of all patients who died following primary percutaneous coronary intervention (PCI) during index hospitalization from 2008 to 2013 at the University of Michigan. Using a standardized data collection form, two interventional cardiologists and one non-invasive cardiologist reviewed patient care prior to arrival to the catheterization lab, while in the catheterization lab, and after primary PCI to determine cause of death and to rate potential preventability of death on a Likert scale (0 unpreventable - 4 mostly preventable). RESULTS: Of the 25 deaths over the 5-year period, 8 were deemed at least mildly preventable by one or more reviewer. No death was deemed totally preventable. Interreviewer agreement was moderate for both cause of death (nominal Krippendorff's alpha = .58) and preventability of death (nominal alpha = .233). In spite of this overall lack of agreement, in all 8 preventable cases at least one reviewer cited ischemia to balloon time as a potentially addressable factor associated with the death. CONCLUSION: Mortality following primary PCI was deemed mostly unpreventable. However, improvement in total ischemic time, and in particular symptom-onset to medical care, was identified as one potential target that might be of value in further reducing the mortality associated with STEMI.

Transradial Szabo technique for intervention of ostial lesions.

OBJECTIVES: The aim of our study is to assess the feasibility and safety of transradial intervention (TRI) of coronary ostial lesions using the Szabo technique. BACKGROUND: When performing TRI of coronary ostial lesions, precise stent positioning is of paramount importance. TRI has experienced increasing popularity in the U.S.; however, utilization of the Szabo technique has not been systematically evaluated in this setting. We report the results of ostial stent deployment using the Szabo technique for 2 experienced TRI operators and centers. METHODS: This was a retrospective analysis of 40 consecutive patients who underwent PCI from April 2009 to September 2011. All patients who underwent PCI via the transradial route with the Szabo technique for ostial lesions performed by experienced transradial operators (>200 cases/yr) were included. RESULTS: In our study of 40 patients with 41 coronary ostial lesions, overall procedural success rate was 100%. Stent dislodgement was seen in 1 patient. Clinical follow up was 100%, with a mean duration of 292.7±200 days. Target lesion revascularization (TLR) was seen in 2 patients (5%). One patient had an episode of transient ischemic attack (TIA) at 33 days after PCI; another experienced subacute stent thrombosis at 81 days while on dual antiplatelet therapy. MACE was 7.5% overall. CONCLUSION: In our study, treatment of coronary ostial lesions with the Szabo technique via TRI is associated with a high procedural success rate and a low MACE of 7.5%.

Drug-eluting stents versus bare-metal stents for treatment of bare-metal in-stent restenosis.

OBJECTIVES: We compared the long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) for treatment of bare-metal in-stent restenosis (ISR). BACKGROUND: There are no randomized trials or observational studies directly comparing the safety and efficacy of DES versus BMS for treatment of bare-metal ISR. METHODS: We examined data on all patients who underwent percutaneous coronary intervention (PCI) for ISR at Cleveland Clinic between 05/1999 and 06/2007. We compared the efficacy and safety of DES to BMS for treating bare-metal ISR. The primary end point was a composite of death, myocardial infarction (MI), or target lesion revascularization (TLR). The secondary endpoints were individual components of the primary endpoint. RESULTS: Of the 931 patients identified over 8 years, 706 had bare-metal ISR and met our study criteria. Of the 706 patients with bare-metal ISR, 362 were treated with DES and 344 with BMS. There were 230 cumulative events for a median follow-up of 3.2 years. After adjusting for 27 variables, DES were associated with lower primary endpoint compared to BMS for treatment of bare-metal ISR (21% vs. 45%, adjusted hazard ratio [HR] 0.63; 95% confidence interval [CI], 0.42-0.95; P = 0.03). The individual secondary endpoint of death (8% vs. 24%, P = 0.005) favored DES, but MI (3% vs. 8%, P = 0.31), and TLR (13% vs. 20%, P = 0.23) failed to reach statistical significance. CONCLUSIONS: In our multivariate analysis of patients with bare-metal ISR, DES use was associated with significantly lower death, MI, or TLR when compared to BMS.