Risk score for percutaneous coronary intervention: forewarned is forearmed**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology

The use of a modified EuroSCORE to evaluate mortality risk in percutaneous coronary intervention

OBJECTIVE

The goals of this study were to establish a new model for predicting in-hospital mortality of percutaneous coronary intervention (PCI), and to compare the predictive accuracy of the new model with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model.

METHODS

We retrospectively analyzed 18206 Chinese patients undergoing PCI in our hospital between January 2002 and December 2008. Univariate and multivariate logistic regression analysis were performed to determine the preoperative risk factors that predicted in-hospital mortality. The EuroSCORE model was used to predict in-hospital mortality. To improve the predictive value of the EuroSCORE, we proposed a modified EuroSCORE that included some PCI-specific factors.

RESULTS

Multivariate logistic regression analysis indicated that left main trunk lesions, type C lesions, preoperative high-risk state, emergency PCI, and severe reduction of ejection fraction (<30%) were independent predictors of PCI mortality. Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve for the modified EuroSCORE was larger than that for the EuroSCORE, however, there was no significant difference between the actual mortality rate and the mortality rate predicted by the two models. The modified EuroSCORE more accurately predicted the mortality rate in patients with a EuroSCORE score of 7-9 points, whereas it was no better than the standard EuroSCORE in patients with EuroSCORE scores of 1-3 or 4-6 points.

CONCLUSION

The modified EuroSCORE improves acute risk assessment in PCI patients compared with the EuroSCORE, and the mortality rate predicted by the modified EuroSCORE in high-risk patients was close to the actual mortality rate.

Assisted circulation using the TandemHeart during very high-risk PCI of the unprotected left main coronary artery in patients declined for CABG

OBJECTIVES

In a single center experience, we retrospectively evaluated the short-term safety and efficacy of the TandemHeart percutaneous transseptal left ventricular assist (PTVA) system to deliver extracorporeal circulatory support during catheter based treatment of the unprotected left main coronary artery (ULMCA).

BACKGROUND

Percutaneous Coronary Intervention (PCI) of the ULMCA usually has been restricted to patients who are hemodynamically unstable or ineligible for coronary artery bypass grafting (CABG). High-risk patients for CABG should be considered at increased risk for PCI as well. In these patients the TandemHeart PTVA System (p-LVAD) may provide a valuable safeguard to reduce procedural risks.

METHODS AND RESULTS

Between July 2002 and May 2008 the TandemHeart was used in 9 very high risk patients (Logistic Euro score: 13.64 (7.46-29.67); Syntax score:43 (41-50); Mayo Clinic Risk score (MCRS) 7 (6-8); age: median 65 (range 55-71) undergoing elective PCI for the novo lesions on the ULMCA. All patients were declined for CABG by a heart team. A ''true'' percutaneous insertion technique was used in all patients, technical success rate was 100%. The median (range) time for implementation of circulatory support was 27 min (24-30). A median (range) pump flow up to 4.36 (3.40-5.54) L/min was achieved with significant reduction of left ventricular filling pressures, pulmonary capillary wedge pressure and a small increase of systemic arterial pressures. Median (range) duration of support was 93 min (50.4-102). Successful weaning was achieved in all patients. There was no in hospital death, survival at 6 months was (89%), whereas vascular access site complications were seen in 4 patients (44.4%).

CONCLUSIONS

In very high risk PCI, assisted circulation using the TandemHeart-PTVA provides effective, total left ventricular support and may contribute to a reduced procedural risk and improved survival. The rate of device related cardiac and vascular complications was acceptable.

Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score

OBJECTIVES

We sought to develop a simple risk score for predicting mortality after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

BACKGROUND

Accurate risk stratification after primary PCI is important. Previous risk scores after reperfusion therapy have incorporated clinical +/- angiographic variables but have not considered baseline left ventricular function. Moreover, prior studies have not been validated against independent databases or studies.

METHODS

The databases from the two largest multicenter, randomized AMI trials of primary PCI were utilized for score derivation (the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications [CADILLAC] trial, n = 2,082) and subsequent validation (the Stent-Primary Angioplasty in Myocardial Infarction [Stent-PAMI] trial, n = 900). Logistic regression and the jackknife procedure were used to select correlates of one-year mortality that were subsequently weighted and integrated into an integer scoring system.

RESULTS

Seven variables selected from the initial multivariate model were weighted proportionally to their respective odds ratio for one-year mortality (age >65 years [2 points], Killip class 2/3 [3 points], baseline left ventricular ejection fraction <40% [4 points], anemia [2 points], renal insufficiency [3 points], triple-vessel disease [2 points], and post-procedural Thrombolysis In Myocardial Infarction flow grade [2 points]). Three strata of risk were defined (low risk, score 0 to 2; intermediate risk, score 3 to 5; and high risk, score >/=6) with excellent prognostic accuracy for survival in the derivation and validation sets (c statistics = 0.83 and 0.81 for 30-day mortality and 0.79 and 0.78 for 1-year mortality, respectively).

CONCLUSIONS

In AMI patients treated with primary PCI, seven risk factors readily available at the time of intervention accurately predict short- and long-term mortality. Of note, measurement of baseline left ventricular function is the single most powerful predictor of survival and should be incorporated into risk score models.