Data on Top 10 Volume Centers in NY State 30-Day RAMR NYS-DOH Report of PCI 2014-16 Data on Top 10 Volume Centers in NY State 30-Day RAMR PCI Statistics 2014-16 # cases All cases Non-Emergency cases Emergency cases 1. Mount Sinai Hospital 10,888 0.90** 0.58** 2.84 2. St. Francis Hospital 8,035 1.13 0.72 3.29 3. Columbia Presbyterian Hospital 6,978 1.02 0.70 2.40 4. North Shore University Hospital 6,780 1.03 0.77 2.16 5. St. Josephs Hospital 5,777 1.22 0.91 2.76 6. Lenox Hill Hospital 5,042 1.25 0.81 3.18 7. Beth Israel Medical Center 4,993 0.98 0.54 3.20 8. NYU Hospitals Center 4,985 1.35 0.96 3.25 9. Rochester General Hospital 4,668 1.36 0.86 3.69 10. Buffalo General Medical Center 4,571 1.60* 1.04 4.01 NYS Total 146,568 1.18 0.77 3.10 http:// www.nyhealth.gov * Risk-Adjusted Mortality Rate (RAMR) significantly higher than NY statewide rate **Risk Adjusted Mortality Rate (RAMR) significantly lower than NY statewide rate

Data on Top 10 Volume Centers in NY State 30-Day RAMR NYS-DOH Report of PCI 2016 Data on Top 10 Volume Centers in NY State 30-Day RAMR PCI Statistics 2016 # cases All cases Non-Emergency cases 1. Mount Sinai Hospital 3,479 1.39 1.07 2. St. Francis Hospital 2,731 1.15 0.71 3. North Shore University Hospital 2,411 1.21 0.92 4. Columbia-Presbyterian Hospital 2,164 0.86 0.58 5. St. Josephs Hospital 1,933 1.36 0.98 6. NYU Hospitals Center 1,882 1.50 1.23 7. Lenox Hill Hospital 1,689 1.16 0.87 8. Beth Israel Medical Center 1,643 0.99 0.40 9. Buffalo General Hospital 1,545 1.45 1.00 10. Rochester General Hospital 1,500 1.32 0.72 NYS Total 50,337 1.24 0.84

NYS-DOH 30-day RAMR for PCI at MSH for last 5 Reports **Star Interventionalists Years/ # cases All cases RAMR % Non-Emergency cases RAMR % **Interventionalist 3249 2555 725 0.72** 0.64** 0.21** 0.50 0.34** 0.00** Dr. Sharma Dr. Kini Dr. Moreno 3356 2693 0.66** 0.65 0.41** 0.27** 3566 2714 0.62** 0.55** 0.36** 0.19** 3925 2883 439 0.56** 0.60 0.29** 0.38** 0.31** 0.16 Dr. Dangas 4052 2874 0.51** 0.35** 2014-2016/ 2013-2015/ 2012-2014/ 2011-2013/ 2010-2012/ **Risk Adjusted Mortality Rate (RAMR) significantly lower than NY statewide rate

21yrs+ MSH Cath Lab or Its Interventionalist have Received ** designation ‘an impossible record to beat’!

Hospital Observed, Expected and Risk-Adjusted Readmission Rates for All PCI in New York State 2016 Hospital # Cases Readmissions All cases RARR % 95% CI for RARR Mount Sinai Hospital 2,865 204 7.21** (6.25,8.26) NYS Total 45,273 4,133 9.13 http:// www.nyhealth.gov **Risk-adjusted readmission rate significantly lower than NY Statewide rate based on 95% CI

Complex Coronary Cases Supported by: Abbott Vascular Inc Boston Scientific Corp Terumo Vascular Corp Cardiovascular Science Inc Abiomed Inc Chiesi Inc

Disclosures Samin K. Sharma, MD, FSCAI, FACC Speaker’s Bureau – Boston Scientific Co Abbott Vascular Inc, ABIOMED, CSI Annapoorna S. Kini, MD, MRCP, FACC Nothing to disclose Sameer Mehta, MD, FACC

May 21th 2019 Case #119: DR 61yrs M Presentation: Pt presented with CCS class I angina and intermediate risk positive SPECT MPI for inferior and lateral ischemia done as the part of pre-op evaluation for shoulder surgery. A cardiac cath on May 7, 2019 revealed severe II vessel CAD: 90% mid RCA DES ISR, 80% distal RCA, CTO of small dLCx, 80% calcific Ramus Intermedius with Syntax score 20 & LVEF 60%. Patent ostial RCA stent is protruding 5-6mm outside the ostium. Pt underwent successful PCI of Ramus using rotablator and Promus Premier DES and did well. Prior History: Hypertension, Hyperlipidemia, Smoking, SAQ 88 Medications: Once daily dosage Aspirin 81mg, Clopidogrel 75mg, Atorvastatin 40mg, ISMN 30mg Metoprolol XL 50mg, Amlodipine 5mg 8

Case# 119: cont… Plan Today: SYNTAX Score: 20 Cardiac Cath 5/7/2019: Right Dominance II V CAD and LVEF 60% LM: No obstruction LAD: No obstruction LCx: 1005 CTO dLCx%-moderate size RCA: 90% mRCA DES ISR, 90% calcified dRCA Pt underwent RotaDES of Ramus (Promus Premier 3/38 mm) to RCA and did well Plan Today: Planned for staged PCI of complex RCA (due to stent protrusion) using rotablator and DES 9

AUC 2017: Two-Vessel Disease Patel et al., J Am Coll Cardiol 2017;69:2212

Issues Involving The Case Hand dysfunction after Trans-radial intervention Incidence, causes & implications of Readmission post PCI

Issues Involving The Case Hand dysfunction after Trans-radial intervention Incidence, causes & implications of Readmission post PCI

Trans Radial Intervention (PCI) Advantage Mortality in ACS Vascular complications Major bleeding-access Comfort to patient Early ambulation Overall PCI cost No Effect MI MACE ST Stroke Non-access site bleeding AKI-CIN Disadvantage Crossover (6%) Radiation exposure Femoral complication Radial; artery occlusion (4-10%) Learning curve Hand dysfunction

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Primary Endpoint: Positive* Binary Source of Upper Extremity Function ARCUS Trial Primary Endpoint: Positive* Binary Source of Upper Extremity Function 6/28/2019 Ijsselmuiden et al., TCT 2017

Upper Extremity Function Physiological Parameters Range of Motion Anatomic integrity Strength Absence of pain Coordination Sensibility Zwaan et al., Catheter Cardiovasc Interv 2016;88:1036

Flowchart Study Schedule 6/28/2019 Zwaan et al., Catheter Cardiovasc Interv 2016;88:1036

Frequent Variations of the Take-Off of the Radial Artery 6/28/2019 Radial artery arising from Brachial artery Independent radial artery arising from Axillary artery Radial artery arising from the Axillary artery with a contribution from the Brachial artery Slender artery arising from the Axillary artery continuing as the radial artery. The major blood supply to the Radial artery is supplied by the Brachial artery. This type is highly susceptible to perforation. Zwaan et al., Catheter Cardiovasc Interv 2016;88:1036

ARCUS Trial: Complications After TR-PCI 6/28/2019 % N=183 N=142 N=26 N=10 p=0.04 p=0.61 16 (5.1%) patients had RA recanalization at 6 months 44 (14%) patients post TR-PCI were referred to a hand rehabilitation at 6 months Ijsselmuiden et al., J Am Coll Cardiol 2017;70:B282

ARCUS Trial: Complications After TR-PCI 6/28/2019 % N=22 N=8 N=4 N=2 Ijsselmuiden et al., TCT 2017

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Enrollment Flowchart of the Study Population 6/28/2019 van Leeuwen et al., J Am Coll Cardiol Intv 2015;8:515

Effect of Catheterization on Upper Limb Function and Cold Intolerance Stratified by Access Site 6/28/2019 Upper Limb Function Assessed with the QuickDASH Score Upper Extremity Cold Intolerance Assessed with the CISS Score CISS – Cold Intolerance System Severity van Leeuwen et al., J Am Coll Cardiol Intv 2015;8:515

N=388 Transradial Transfemoral Change of Upper Limb Function Stratified for Minimal Clinically Important Difference and Access Type 6/28/2019 N=388 Transradial Transfemoral van Leeuwen et al., J Am Coll Cardiol Intv 2015;8:515

Duration and Type of Upper Extremity Complaints After TR Access 6/28/2019 van Leeuwen et al., J Am Coll Cardiol Intv 2015;8:515

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ACRA Perfusion Study: Laser Doppler Perfusion Imaging (LDPI) 6/28/2019 Methods of LDPI of Both Thumbs and Homolateral Digits 2, 3, and 4 LDPI Images with Incomplete Superficial Palmer Arch A and B how both were positioned during LDPI with introducer sheath in Situ (red arrow) C and D Infrared LDPI images high LDPI (red); intermediate LDPI (green); low (yellow) E and F Region of interest used for LDPI quantification (yellow) van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

ACRA Perfusion Study: Enrollment Flow Diagram 6/28/2019 Elective coronary procedures n=611 Eligible study participants n=120 Study participants n=100 Perfusion imaging of the hand Hand function n=83 Enrollment Analyses Follow-up Excluded (n=20): Exclusion criteria (n=18) Declined to participate (n=2) No follow-up (n=17): Loss to follow-up (n=12) Refused further f-up (n=1) Death (n=3) Cognitive dysfunction (n=1) van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

ACRA Perfusion Study: Perfusion Index of Both Thumbs in Patients Undergoing TRI 6/28/2019 Perfusion Index *; Homolateral Thumb Perfusion Index*; Contralateral Thumb p Value Radial access (n=100) 0.82 (0.48-1.26) 0.85 (0.46-1.17) 0.40 TR band (n=100) 0.82 (0.51-1.23) 0.89 (0.53-1.13) 0.98 Discharge (n=52) 0.88 (0.58-1.36) 0.92 (0.55-1.32) 0.06 van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

ACRA Perfusion Study: The Change of Digital Hand Perfusion in Patients Undergoing Transradial Intervention 6/28/2019 Percentage change from baseline van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

ACRA Perfusion Study: Digital Perfusion of the Access Site Hand and Contralateral Hand in Patients Undergoing Transradial Intervention 6/28/2019 van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

ACRA Perfusion Study: The Change of Digital Hand Perfusion in Patients Undergoing Transradial Intervention 6/28/2019 p=0.35 % p=0.54 van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

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Clinical Results of Hand Sensory and Motor Dysfunction at 30 Days After Transradial Access Nerve damage Sensory loss/ Pain Hand dysfunction Radial artery tingling/numbness occlusion % Hand dysfunction (disability, grip strength change, power loss or any other hand complications) Ul Haq et al., World J Cardiol 2017;9:609

Issues Involving The Case Hand dysfunction after Trans-radial intervention Incidence, causes & implications of Readmission post PCI

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Causes of Readmission in Order of Decreasing Frequency Wasfy et al., Cir Cardiovasc Interv 2014;7:97

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Outcomes for Readmitted Patients According to Age Group 6/28/2019 Kwok et al., Am J Cardiol 2018;122:220

Key Factors Associated with Readmission Within Age Groups Kwok et al., Am J Cardiol 2018;122:220

Cardiac and Non-Cardiac Causes of Readmissions by Age Group Years % PCI Cases Kwok et al., Am J Cardiol 2018;122:220

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Flow Diagram of Readmissions and Outcomes Total patients with PCI between 2013 and 2014 (n=862,649) Died after first PCI 2.4% (n=21,116) Survived to be discharged 97.6% (n=841,533) Planned readmission with 30 days 1.0% (n=8,189) Not readmitted with 30 days 89.8% (n=755,362) Unplanned readmissions within 30 days 9.3% (n=77,982) Non-cardiac readmissions within 30 days 56.1% (n=43,758) and 3.1% died during readmissions Cardiac readmissions within 30 days 43.9% (n=34,225) and 2.8% died during readmissions Kwok et al., J Am Coll Cardiol Intv 2018;11:665

Cost of Index PCI and Total Cost 6/28/2019 Kwok et al., J Am Coll Cardiol Intv 2018;11:665

Causes of Non-Cardiac Readmissions Causes of Readmission Causes of Non-Cardiac Readmissions Causes of Cardiac Readmissions Kwok et al., J Am Coll Cardiol Intv 2018;11:665

Independent Predictors of 30-Day Non-Cardiac and Cardiac Readmissions After PCI Kwok et al., J Am Coll Cardiol Intv 2018;11:665

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Flow Diagram of Patient Inclusion Patients with percutaneous coronary Intervention in the Nationwide Readmission Database (2,576,141) Patients excluded because of: In-hospital death (n=54,549) Elective readmission (n=109,578) Sample for further analysis (n=2,412,014) Patients admitted between January to November each calendar year used in the analysis of 7-day and 30-day unplanned readmissions (n=2,215,638) Readmission between 0-7 days 2.45% and 8-30 days 7.63% Cumulative readmission between 0-7 days 2.45% and 0-30 days 9.89% Patients admitted between January to September each calendar year used in the analysis of 90-day unplanned readmissions (n=1,834,767) Readmission between 31-90 days 8.92% Cumulative readmission between 0-90 days 18.02% Patients admitted between January to June each calendar year used in the analysis of 180-day unplanned readmissions (n=1,252,454) Readmission between 91-180 days 8.00% Cumulative readmission between 0-180 days 24.83% Kwok et al., J Am Coll Cardiol Intv 2019;12:734

Rates of Unplanned Readmission Rates of Unplanned Readmission within Time Groups Cumulative Rates of Unplanned Readmission Over Time Kwok et al., J Am Coll Cardiol Intv 2019;12:734

Histogram and Temporal Trends According to Time to Unplanned Readmission Kwok et al., J Am Coll Cardiol Intv 2019;12:734

Rate of Non-cardiac Unplanned Readmissions at Different Time Points Rate of non-cardiac readmissions (%) Time to readmission (days) Kwok et al., J Am Coll Cardiol Intv 2019;12:734

Non-Cardiac and Cardiac Causes of Readmissions at Different Time Periods After Index Discharge for PCI Kwok et al., J Am Coll Cardiol Intv 2019;12:734

Causes of Unplanned Readmissions at Different Time Points Rate of Non-Cardiac Readmissions Rate of Cardiac Readmissions Kwok et al., J Am Coll Cardiol Intv 2019;12:734

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Can We Reduce Readmission After PCI: First 30 Days Intense and careful scrutiny of discharge instructions Follow-up visit early after discharge ( 1-2 weeks post) Care coordination for follow-up phone call (1-2 days post) and medicine reconciliation Risk stratify patients tagged for high risk for readmission due to multiple comorbidities Address issues of vascular access, potential revascularization of non-culprit significant lesion, CHF management, bleeding, renal failure and respiratory care Good Intervention will certainly reduce readmission at 30-Day

Take Home Message: Hand dysfunction after TRI and Incidence of readmission post PCI Recently numerous studies have reported hand dysfunction after TRI and persistent dysfunction is associated with RAO. Hand dysfunction parameters usually improves at long-term. Various studies of hand perfusion and objective parameters have reassured safety of TRI Readmission after PCI is a frequent occurrence peaking at 7 days and significantly declining after 30-days. Most common cause is nonspecific chest pain early after discharge. After 30-days non-cardiac causes predominates for the readmission. Careful follow-up of high risk PCI for readmission has potential to decrease the readmission.

Question # 1 The correct answer is D Following statement is true regarding recent hand dysfunction after TRI except; It occurs in <10% of cases It is higher with pts with RAO It usually improves at follow-up Hand perfusion studies have shown significant changes during TRI E. It is associated with higher cold sensitivity The correct answer is D

Question # 2 The correct answer is B Following are the true statements about readmission after PCI except; It occurs in about 10% cases in 30 days and 25% in 6 months It is highest between 30days-6months Many of the readmissions are preventable It occurs due to both cardiac and non cardiac causes It is associated with higher follow-up cost The correct answer is B

Question # 3 The correct answer is E Following is most common cause of readmission after PCI: A. Bleeding B. Renal failure C. Pneumonia D. MI E. Atypical/nonspecific chest pain The correct answer is E