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, 2020-2021

Cardiac ProcedureNumber of ProceduresNumber of Events% MACCE-90
Isolated CABG 19,451 1,444 7.42
Isolated SAV-Replacement, SMV-Replacement, SMV-Repair 6,304 439 6.96
TAVR 13,170 783 5.94
Isolated SAV-Replacement, SMV-Replacement, SMV-Repair with CABG 2,855 34312.02
PCI with ACS 47,504 4,92910.38
PCI without ACS 35,108 2,779 7.91
CABG: Coronary Artery Bypass Graft
SAV: Surgical Aortic Valve
SMV: Surgical Mitral Valve
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 7.2% in 2021. For isolated Surgical AV-Replacement, MV-Replacement or MV-Repair, the MACCE-90 decreased from 1999 to 2019, but increased in 2020 and 2021. For Surgical AV-Replacement, MV-Replacement or MV-Repair with CABG surgery, the MACCE-90 decreased from 1999 to 2019, but was higher than in 2019 in 2020 and 2021.

The MACCE-90 after Transcatheter AV-Replacement decreased dramatically from 2011 to 2013, continued to decrease at a slower rate through 2020 with a very slight increase in 2021. 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 2020-2021 as the standard, the case mix adjusted MACCE-90 after isolated CABG surgery decreased from 1999 to 2021. A breakdown of the type of adverse event indicates that mortality contributed 32.9%, post-op stroke 23.5% and re-interventions 19.5% to the MACCE-90 in 2021. Note that for all the charts below the number of adverse events for 2021 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, 2021.

The casemix-adjusted MACCE-90 after isolated Surgical AV-Replacement, MV-Replacement or MV-Repair steadily decreased from 1999 to 2020 with an increase in 2021. The most important components of the MACCE-90 were mortality and post-op stroke.

The casemix-adjusted MACCE-90 after Transcatheter AV-Replacement declined steadily from 2011 to 2020 with a slight uptick in 2021. Mortality and post-op stroke events were the biggest drivers of the MACCE-90.

The casemix-adjusted MACCE-90 after isolated Surgical AV-Replacement, MV-Replacement 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 81% of adverse events captured by the MACCE-90 in 2021.

The casemix-adjusted MACCE-90 in PCIs with ACS decreased from 1999 to 2019, increasing slightly in 2020 and 2021. As for the MACCE, the casemix-adjusted MACCE-90 for PCIs with ACS was driven primarily by mortality (59% of MACCE-90 events). Un-planned re-interventions however, do play a larger role for this longer follow-up period (22.7% of MACCE-90 events).

The casemix-adjusted MACCE-90 in PCIs without ACS decreased from 1999 to 2021. The MACCE-90 for PCIs without ACS was driven primarily by post-op acute MIs. Post-Op Strokes were relatively rare.