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

For PCIs, the Multiple Adverse Cardiac and Cerebrovascular Events within 90 Days (MACCE-90) outcome is based on multiple adverse events after the intervention: 1. Death; 2. Post-Op Stroke; 3. Post-Op Acute MI; 4. Unplanned Re-Intervention. The MACCE-90 outcome for PCIs shown in this summary is based on adverse events a patient experienced during the intervention admission/encounter, subsequent through-a-transfer connected acute care admissions or acute care inpatient re-admissions within 90 days of the index intervention. Re-Interventions during the index admission and within 30 days of the index PCI or re-interventions during elective re-admissions are not included.

For the surgery groups, the Multiple Adverse Cardiac and Cerebrovascular Events within 90 Days (MACCE-90) outcome is based on multiple adverse events after the cardiac procedure: 1. Death; 2. Post-Op Stroke; 3. Post-Op Acute MI; 4. Re-Intervention. The MACCE-90 outcome shown in this summary is based on adverse events a patient experienced in the surgery admission, subsequent through-a-transfer connected acute care admissions or acute care inpatient re-admissions within 90 days of the index surgery.

MACCE-90 after Cardiac Procedures, California, 2017-2018

Cardiac ProcedureNumber of ProceduresNumber of Events% MACCE-90
Isolated CABG 22,237 1,754 7.89
Isolated SAVR, MVR, MV Repair 8,597 586 6.81
TAVR 8,452 628 7.43
Isolated SAVR, MVR, MV Repair with CABG 3,809 39710.42
PCI with ACS 51,810 5,18210.00
PCI without ACS 41,116 3,150 7.66
CABG: Coronary Artery Bypass Graft
SAVR: Surgical Aortic Valve Replacement
MVR: Mitral Valve Replacement
MV Repair: Mitral Valve Repair
TAVR: Transcatheter Aortic Valve Replacement
PCI: Percutaneous Coronary Intervention
ACS: Acute Coronary Syndrome

Looking at the unadjusted rate Multiple Adverse Cardiac and Cerebrovascular Events within 90 Days after isolated CABG surgery, the MACCE-90 decreased from a high of 10.2% in 2004 to a low of 7.7% in 2018. For isolated SAVR, MVR or MV Repair with or without CABG surgery the MACCE-90 decreased from 1999 to 2018. The MACCE-90 after Transcatheter AVR procedures decreased dramatically from 2011 to 2016 and stayed at 2016 levels in 2017 and 2018. The MACCE-90 after PCI with and without ACS was at similar levels throughout the study period.

Using the level of Multiple Adverse Cardiac and Cerebrovascular Events within 90 days of the cardiac procedure observed in 2017-2018 as the standard, the case mix adjusted MACCE-90 after isolated CABG surgery decreased from 1999 to 2018. A breakdown of the type of adverse event indicates that mortality contributed 30%, post-op stroke 23.5% and re-interventions 20.3% to the MACCE-90 in 2018. Note that for all the charts below the number of adverse events for 2018 is affected by the truncated follow-up period as the MACCE-90 has to be calculated based on surgeries that were performed through October 2, 2018.

The casemix adjusted MACCE-90 after isolated SAVR, MVR or MV Repair steadily decreased from 1999 to 2011. The most important components of the MACCE-90 were mortality and post-op stroke.

The casemix adjusted MACCE-90 after Transcatheter AVR declined steadily from 2011 to 2016, holding steady for 2017 and 2018. Mortality and post-op stroke events were the biggest driver of the MACCE-90.

The casemix adjusted MACCE-90 after isolated SAVR, MVR or MV Repair with CABG surgery decreased from 1999 to 2015, and stayed at similar levels for subsequent years. The mortality and stroke components drove over close to 75% of adverse events captured by the MACCE-90 in 2018.

The casemix adjusted MACCE-90 in PCIs with ACS decreased from 1999 to 2013, then held steady for 2014 through 2018. As for the MACCE, the casemix adjusted MACCE-90 for PCIs with ACS was driven primarily by mortality (54.8% of MACCE-90 events). Un-planned re-interventions however, do play a larger role for this longer follow-up period (27.4% of MACCE-90 events).

The casemix adjusted MACCE-90 in PCIs without ACS decreased from 1999 to 2018. The MACCE-90 for PCIs without ACS was driven primarily by post-op acute MIs. Post-Op Strokes were relatively rare.