California Cardiac Surgery Intervention Project

Summary of California-wide Trends in Cardiac Procedures - MACCE after Cardiac Surgery / Intervention

The Multiple Adverse Cardiac and Cerebrovascular Events (MACCE) outcome is based on death, post-operative stroke, post-operative acute myocardial infarction or non-elective re-intervention during the index admission or during acute care admissions following transfer after the index surgery/intervention that were connected to the index admission.

The MACCE % after Transcatheter AVR (TAVR) was added to the summary table below, however, as approriate risk-adjustment for outcomes after TAVR has yet to be determined, risk-adjusted hospital-level outcomes after TAVR are not currently available.

MACCE after Cardiac Procedures, California, 2014-2015

Cardiac ProcedureNumber of ProceduresNumber of Events% MACCE
Isolated CABG 24,476 1,304 5.33
CABG/Valve 5,378 445 8.27
Isolated Valve 12,502 639 5.11
PCI with ACS 52,536 5,37210.22
PCI without ACS 43,656 2,417 5.54
TAVR 4,452 261 5.86

Looking at Multiple Adverse Cardiac and Cerebrovascular Events after Isolated CABG surgery, CABG/Valve surgery and Isolated Valve surgery, MACCEs mostly decreased from 1999 to 2015. The MACCE % after PCI with ACS was similar throughout the study period. For the PCI without ACS, the MACCE % increased from a low of 4.3% in 2006 to a high of 5.6% in 2015

Using the level of Multiple Adverse Cardiac and Cerebrovascular Events observed in 2014-2015 as a standard, MACCE after isolated CABG surgery has decreased from 1999 to 2010 with similar mortality levels thereafter. A breakdown of the type of adverse event indicates that mortality is the largest contributor to the MACCE for almost every year.

MACCE after isolated valve surgery steadily decreased from 1999 to 2011 with similar levels thereafter. The contribution of mortality to the MACCE decreased from 57% in 1999 to 43% in 2015. The share of post-op strokes among adverse events after isolated valve surgery increased from 16.6% in 2000 to a peak of 33.6% in 2012. In 2013 and 2014, the share of post-op strokes among adverse events has dropped slightly, however this trend did not continue in 2015.

The trend in MACCE after CABG/Valve surgery is similar to the trend observed for isolated CABGs in that MACCE rates decreased through 2008, then continued at similar levels. For CABG/Valve surgeries, re-interventions during the index surgery or immediately following admissions were rare. The mortality component drove 48% of adverse events measured through the MACCE in 2015.

The incidence of MACCE in PCIs with ACS increased slightly from 1999 to 2005, then went down sharply in 2006; the MACCE % was similar for the next 5 years with another sharp decline in 2012. MACCE levels in 2013 through 2015 were similar to those in 2012. The MACCE for PCIs with ACS was driven primarily by non-elective re-interventions followed by mortality. Acute MIs and Post-Op Strokes were relatively rare.

After a sharp decline in the incidence of MACCE in PCIs without ACS from 1999 to 2000, MACCE levels stagnated around 2000 levels through 2005. In 2006, MACCE levels decreased, then hovered at a slightly higher level from 2007 to 2015. The MACCE for PCIs without ACS was driven primarily by non-elective re-interventions followed by acute MIs. Post-Op Strokes were relatively rare. For PCIs without ACS, multiple adverse events occurred in about 13% of patients.

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