1. Data on Top 10 Volume Centers in NY State 30-Day RAMR
NYS-DOH Report of PCI
Data on Top 10 Volume Centers in NY State 30-Day RAMR
PCI Statistics
# 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 ,
* Risk-Adjusted Mortality Rate (RAMR) significantly higher than NY statewide rate
**Risk Adjusted Mortality Rate (RAMR) significantly lower than NY statewide rate

2. 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 ,

3. 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** / / / / /
**Risk Adjusted Mortality Rate (RAMR) significantly lower than NY statewide rate

4. 21yrs+ MSH Cath Lab or
Its Interventionalist have
Received ** designation
‘an impossible record to beat’!

5. 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 , ,
**Risk-adjusted readmission rate significantly lower than NY Statewide rate based on 95% CI

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

7. 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

8. 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

9. 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

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

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

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

13. 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

14. 6/28/2019

15. 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

16. 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

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

18. 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

19. 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

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

21. 6/28/2019

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

23. 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

24. 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

25. 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

27. 6/28/2019

28. 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

29. 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

30. 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 ( )
0.85 ( )
0.40
TR band (n=100)
0.82 ( )
0.89 ( )
0.98
Discharge (n=52)
0.88 ( )
0.92 ( )
0.06
van Leeuwen et al.,Circ Cardiovasc Interv 2019;12:e007641

31. 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

32. 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

33. 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

35. 6/28/2019

36. 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

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

38. 6/28/2019

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

41. 6/28/2019

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

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

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

46. 6/28/2019

47. 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

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

49. 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

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

52. 6/28/2019

53. 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 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 days 8.00%
Cumulative readmission between days 24.83%
Kwok et al., J Am Coll Cardiol Intv 2019;12:734

54. 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

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

56. 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

57. 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

58. 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

60. 6/28/2019

61. 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

62. 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.

63. 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

64. 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

65. 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