Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California 94115, USA.
JACC Cardiovasc Interv. 2011 Sep;4(9):1020-7. doi: 10.1016/j.jcin.2011.06.010.
This study sought to characterize reasons for surgical ineligibility in patients undergoing nonemergent unprotected left main (ULM) percutaneous coronary intervention (PCI) and to assess the potential for these reasons to confound comparative effectiveness studies of coronary revascularization.
Although both PCI and coronary artery bypass graft surgery are treatments for ULM disease, some patients are not eligible for both treatments, which may result in treatment selection biases.
In 101 consecutive patients undergoing nonemergent ULM PCI, mixed methods were used to determine the prevalence of treatment selection dictated by surgical ineligibility and to identify the reasons cited for avoiding coronary artery bypass graft surgery. We then determined whether these reasons were captured by the ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) Cath-PCI dataset to assess the ability of this registry to account for biases in treatment selection. Finally, the association of surgical eligibility with long-term outcomes after ULM PCI was assessed.
Treatment selection was dictated by surgical ineligibility in over half the ULM PCI cohort with the majority having reasons for ineligibility not captured by the ACC-NCDR. Surgical ineligibility was a significant predictor of mortality after adjustment for Society of Thoracic Surgeons (hazard ratio [HR]: 5.4, 95% confidence interval [CI]: 1.2 to 25), EuroSCORE (European System for Cardiac Operative Risk Evaluation) (HR: 5.9, 95% CI: 1.3 to 27), or NCDR mortality scores (HR: 6.2, 95% CI: 1.4 to 27).
Surgical ineligibility dictating treatment selection is common in patients undergoing nonemergent ULM PCI, occurs on the basis of risk factors not captured by the ACC-NCDR, and is independently associated with worse long-term outcomes after adjusting for standard risk scores.
本研究旨在描述非紧急情况下接受非保护左主干（ULM）经皮冠状动脉介入治疗（PCI）的患者手术不合格的原因，并评估这些原因对冠状动脉血运重建的疗效比较研究产生混淆的可能性。
虽然 PCI 和冠状动脉旁路移植术都是 ULM 疾病的治疗方法，但有些患者不适合这两种治疗方法，这可能导致治疗选择偏倚。
在 101 例连续接受非紧急 ULM PCI 的患者中，采用混合方法确定由手术不合格导致的治疗选择的流行程度，并确定避免冠状动脉旁路移植术的原因。然后，我们确定这些原因是否被 ACC-NCDR（美国心脏病学院-国家心血管数据注册中心） Cath-PCI 数据集所捕获，以评估该注册中心对治疗选择偏差的解释能力。最后，评估 ULM PCI 后手术合格与长期结局的关系。
超过一半的 ULM PCI 患者因手术不合格而决定治疗方案，其中大多数不合格的原因未被 ACC-NCDR 捕获。在调整了胸外科医师协会（Surgery Society of Thoracic Surgeons，STS）评分（风险比[HR]：5.4，95%置信区间[CI]：1.2 至 25）、欧洲心脏手术风险评估系统（European System for Cardiac Operative Risk Evaluation，EuroSCORE）（HR：5.9，95% CI：1.3 至 27）或 NCDR 死亡率评分（HR：6.2，95% CI：1.4 至 27）后，手术不合格是死亡率的一个显著预测因素。
在接受非紧急 ULM PCI 的患者中，手术不合格导致治疗选择的情况很常见，而且这些选择是基于 ACC-NCDR 未捕获的风险因素，并且在调整标准风险评分后与长期结局不良独立相关。
