Background: Public reporting of percutaneous coronary intervention (PCI) often uses periprocedural (30 days) mortality as a surrogate for procedural quality, though it is unclear how often death is attributable to the PCI. The cause of death among patients who died within 30 days of PCI in a national healthcare system was thus evaluated. Methods and Results: We identified all patients who died within 30 days of PCI in the Veterans Affairs (VA) Healthcare System from October 2005 to September 2016. Causes of death were classified through a detailed chart review using definitions from the Academic Research Consortium. Of 115 191 patients undergoing PCI during the study period, 1674 patients died within 30 days of PCI (1.5%). A detailed chart review demonstrated that the majority of patients had an undifferentiated death not definitively attributable to a single cause (981, 59%), whereas a minority had a death directly attributable to a cardiovascular cause (467, 28%). The majority of cardiovascular deaths were unrelated to the interventional procedure (335, 72%). Cardiovascular deaths were more likely to occur in the inpatient setting (95%) compared with noncardiac (89%) or undifferentiated deaths (49%, P <0.001). Conclusions: A minority of deaths occurring after percutaneous revascularization were definitively due to cardiac causes, with an even smaller proportion related to the PCI. With such a small proportion of deaths directly attributable to the PCI, these data suggest that 30-day mortality may be an inappropriate metric to assess procedural quality.

IMPORTANCE Anatomical scoring systems for coronary artery disease, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention [PCI] With Taxus and Cardiac Surgery) score, are well established tools for understanding patient risk. However, they are cumbersome to compute manually for large data sets, limiting their use across broad and varied cohorts. OBJECTIVE To adapt an anatomical scoring system for use with registry data, allowing facile and automatic calculation of scores and association with clinical outcomes among patients undergoing percutaneous or surgical revascularization. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional observational cohort study involved procedures performed in all cardiac catheterization laboratories in the largest integrated health care system in the United States, the Veterans Affairs (VA) Healthcare System. Patients undergoing coronary angiography in the VA Healthcare System followed by percutaneous or surgical revascularization within 90 days were observed and data were analyzed from January 1, 2010, through September 30, 2017. MAIN OUTCOMES AND MEASURES An anatomical scoring system for coronary artery disease complexity before revascularization was simplified and adapted to data from the VA Clinical Assessment, Reporting, and Tracking Program. The adjusted association between quantified anatomical complexity and major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and repeat revascularization, was assessed for patients undergoing percutaneous or surgical revascularization. RESULTS A total of 50 226 patients (49 359 men [98.3%]; mean [SD] age, 66 [9] years) underwent revascularization during the study period, with 34 322 undergoing PCI and 15 904 undergoing coronary artery bypass grafting (CABG). After adjustment, the highest tertile of anatomical complexity was associated with increased hazard of MACCEs (adjusted hazard ratio [HR], 2.12; 95% CI, 2.01-2.23). In contrast, the highest tertile of anatomical complexity among patients undergoing CABG was not independently associated with overall MACCEs (adjusted HR, 1.04; 95% CI, 0.92-1.17), and only repeat revascularization was associated with increasing complexity (adjusted HR, 1.34; 95% CI, 1.06-1.70) in this subgroup. CONCLUSIONS AND RELEVANCE These findings suggest that an automatically computed score assessing anatomical complexity can be used to assess longitudinal risk for patients undergoing revascularization. This simplified scoring system appears to be an alternative tool for understanding longitudinal risk across large data sets.

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Background Patients undergoing percutaneous coronary intervention ( PCI ) are older with greater medical comorbidities and anatomical complexity than ever before, resulting in an increased frequency of nonemergent high‐risk PCI ( HR ‐ PCI ). We thus sought to evaluate the temporal trends in performance of HR ‐ PCI and utilization of mechanical circulatory support in the largest integrated healthcare system in the United States. Methods and Results A cohort of high‐risk adult patients that underwent nonemergent PCI in the Veterans Affairs Healthcare System between January 2008 and June 2018 were identified by objective clinical, hemodynamic, and anatomic criteria. Temporal trends in the performance of HR ‐ PCI , utilization of mechanical circulatory support, and site‐level variation were assessed. Of 111 548 patients assessed during the study period, 554 met 3 high‐risk criteria whereas 4414 met at least 2 criteria for HR ‐ PCI . There was a significant linear increase in the proportion of interventions that met 3 ( P <0.001) or at least 2 ( P <0.001) high‐risk criteria over time, with rates approaching 1.9% and 11.2% in the last full calendar year analyzed. A minority of patients who met all high‐risk criteria received PCI with mechanical support (15.7%) without a significant increase over time ( P =0.193). However, there was significant site‐level variation in the probability of performing HR ‐ PCI (4.0‐fold higher likelihood) and utilizing mechanical circulatory support (1.9‐fold higher likelihood) between high and low utilization sites. Conclusions The proportion of cases categorized as HR ‐ PCI has increased over time, with significant site‐level variation in performance. The majority of HR ‐ PCI cases did not utilize mechanical support, highlighting a discrepancy between current recommendations and clinical practice in an integrated healthcare system.

This paper describes the case of a patient who developed refractory heart failure due to a fistula from the left ventricle to the coronary sinus that was unintentionally created after a surgical myectomy and mitral valve replacement. Advanced image guidance with a pre-procedure 3-dimensional physical model and intraprocedure echocardiography fusion facilitated transcatheter plugging of the shunt with symptom resolution. ( Level of Difficulty: Advanced. )