Carere, Ronald G

Gao, Min

Humphries, Karin H

Izadnegahdar, Mona

Kiely, Michael

Pate, Gordon E

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1040-75 Population rates of invasive cardiac procedures in British Columbia, 1995–2001 

JACC March 3, 2004 ABSTRACTS - Special Topics  403A
Special Topics
procedures that use DES.
Figure 1: Predicted contribution margin reduction at a case study hospital (in 000s)
1040-75 Population Rates of Invasive Cardiac Procedures in 
British Columbia, 1995-2001
Gordon E. Pate, Karin H. Humphries, Mona Izadnegahdar, Min Gao, Michael Kiely, 
Ronald G. Carere, Saint Paul's Hospital, Vancouver, BC, Canada, Centre for Health 
Evaluation and Outcomes Sciences, Vancouver, BC, Canada
Background: This audit examined the age-sex standardized population rates of coronary
angiography (CA), percutaneous intervention (PCI) and coronary artery bypass surgery
(CABG) in British Columbia (BC) between 1995 and 2001.
Methods: Data sources were as follows: CABG-BC Cardiac Registry, CA and PCI- BC
Medical Services Plan, Acute Coronary Syndromes (ACS, ICD9 codes 410,411,413)-
Hospital Separation database,population data-BC Statistics. All rates are age and sex
standardized per 100,000 BC resident adults over 20 years.
Results: The rates of diagnostic CA and PCI have increased from 352 and 101 per
100,000 in 1995 to 400 and 154 per 100,000 respectively in 2001 (p<0.01). Single stage
‘ad hoc’ PCI increased from 38% in 1995 to 68% in 2001. The stenting rate increased
dramatically from 25% of PCI procedures in 1995 to 90% in 2001 (p<0.01). The rate of
CABG remained stable at between 70-79 per 100,000. There was a downward trend in
the annual hospitalized incidence of ACS (477 to 430, p=0.04). The incidence of ACS
and the rates of CA, PCI and CABG were higher for men in all age groups. PCI was more
common than CABG in all groups.
Conclusion: The incidence of ACS in British Columbia is falling. The rates of SCA and
PCI are increasing. This may reflect an appropriate evidence-based response to data
supporting greater application of coronary angiography following acute coronary syn-
dromes after publication of several studies supporting a routine invasive approach.
Table:
1040-76 30-Day Mortality Trends Following Acute Myocardial 
Infarction in the Elderly
Judith H. Lichtman, Yun Wang, Sharon-Lise Normand, Rhuna Shen, Lawrence M. Brass, 
Harlan M. Krumholz, Yale University School of Medicine, New Haven, CT
Background. Despite numerous innovations in prevention, diagnosis and treatment of
acute myocardial infarction (AMI), relatively little is known about how these changes have
modified short-term mortality outcomes over time, especially for elderly patients. Current
estimates have generally been derived from small geographic areas, or voluntary regis-
tries that may not be generalizable beyond participating locations or institutions. We
sought to examine national 30- day mortality trends following an AMI among elderly
Medicare beneficiaries (benes).
Methods. All fee-for-service (FFS) Medicare benes 65 years of age or older, discharged
with an AMI (ICD-9 410.xx) from 1993-1999 were included in the study. AMI patients dis-
charged from non-acute facilities, transfers, repeat admissions within 8 weeks, or those
with less than 12 months of continuous FFS status were excluded. Risk adjustment vari-
ables included demographics, and comorbidities and cardiac procedures identified from
hospitalizations within the prior year. Observed and expected 30-day mortality rates were
calculated for age (65-74, 75-84, 85+) and gender subgroups. Logistic regression models
compared annual mortality rates relative to 1993, with adjustment for demographic and
clinical factors.
Results. There were a total of 1,814,196 AMI discharges from 1993-1999. Annual unad-
justed mortality rates remained stable over time (range of 19-20%), despite trends of
increasing comorbidities, cardiac procedures, and advancing mean age of the AMI benes
over the time period. Women had a modest decline in mortality within all age groups, but
rates for men remained relatively stable, with a slight increase for men 85+ years of age.
Risk adjusted annual mortality rates remained essentially unchanged over time (OR
1.01, 95% CI 1.00-1.03; 1.03, 1.01-1.04; 1.01, 0.99-1.02; 0.99, 0.97-1.00; 0.98, 0.97-
1.00; and 1.01; 1.00-1.03).
Conclusions. Despite minor decreases in mortality for women within all age groups, the
absolute decreases in mortality rates are negligible. It is unclear whether the static rates
signal limitations of current therapeutic options, the increasing complexity of AMI
patients, or a combination of these factors.
POSTER SESSION
1058 Medical Simulation: Tools for Learning on 
the Horizon
Sunday, March 07, 2004, 3:00 p.m.-5:00 p.m.
Morial Convention Center, Hall G
Presentation Hour: 4:00 p.m.-5:00 p.m.
1058-67 Durability of Bioprosthetic Aortic Valves: What Is the 
Re-Operation Risk for My Patients?
John Puvimanasinghe, Johanna Takkenberg, Marinus Eijkemans, Ewout Steyerberg, Lex 
van Herwerden, Eric Jamieson, Gary Grunkemeier, Dik Habbema, Ad Bogers, Erasmus 
Medical Center, Rotterdam, The Netherlands, Providence Health System, Portland, OR
Background: A drawback to the choice of bioprostheses for aortic valve replacement
(AVR) is their limited durability and resultant need for re-operation. The purpose of this
study was to quantify and compare structural valvular deterioration (SVD), re-operation-
free life expectancy and the lifetime risk of re-operation after aortic valve replacement
with three widely used bioprostheses respectively.
Methods: We used long-term follow-up data on Carpentier-Edwards standard porcine
(CE-S), Carpentier-Edwards bovine pericardial (CE-P) and Carpentier-Edwards supra-
annular porcine (CE-SA) bioprostheses to generate age-dependent Weibull curves to
describe SVD. These curves were used to calculate the median time to SVD at different
patient ages of implantation. We also conducted a meta-analysis of the literature (CE-S –
3,161 patients and 22,326 patient-years; CE-P – 2,685 patients and 12,250 patient-
years; CE-SA – 3,796 patients and 20,127 patient-years) to estimate the hazards of other
valve-related events. The results of the Weibull analysis and meta-analysis were used to
parameterize a micro-simulation model, which calculated the re-operation-free life
expectancy and lifetime risk of SVD in these patients.
Results: For example, for a 65-year-old male, median time to SVD was 15.3, 20.1 and
22.2 years for the CE-S, CE-P and CE-SA valves. Re-operation-free life expectancy was
9.3, 9.9 and 10.1 years and the lifetime risk of re-operation due to SVD was 31%, 17%
and 14% respectively. For a 70-year-old male, this lifetime risk of re-operation due to
SVD was 20%, 10% and 8% respectively.
Conclusions: Estimates of SVD in the second-generation pericardial and supra-annular
bioprostheses are comparable and provide an advantage over the first-generation stan-
dard valve. Both second-generation bioprostheses offer a low lifetime risk of re-operation
for elderly patients requiring aortic valve replacement. Microsimulation provides detailed
insight into the prognosis after AVR and assists in the choice of a valve for a given
patient.
1058-68 A Virtual Heart Model for Image Orientation and 
Teaching Three-Dimensional Echocardiography
Nico Bruining, Gernoth Grunst, Thomas Berlage, Bernhard Mumm, Johannes Waldinger, 
Jos R. Roelandt, Erasmus MC, Rotterdam, The Netherlands, GMD, Sankt_Augustin, 
Germany
The interest and clinical applications of three-dimensional echocardiography (3DE) is
rapidly growing. While initially used as a research tool, real-time 3DE is currently imple-
mented in state-of-the-art ultrasound consoles. However, most echocardiographers are
familiar with two-dimensional imaging and real-time 3D volume rendered images of car-
diac pathologies often pose difficulties in understanding both the origin and orientation of
the reconstructed tomographic views used for analysis. This phenomenon is referred to
as “lost in space”. We developed a virtual reality heart (VR) model and a demonstrator,
which can be linked to 3DE data sets, using three specific anatomical landmarks, provid-
ing spatial information and the geometric position of the heart within the 3DE data. The
demonstrator, which consists out of a dummy thorax, a space locator system and a data-
base that can be filled with 3DE data sets of cardiac pathologies, is used for virtual
echocardiographic patient examinations (fig.).We examined the usefulness of the VR
heart model integrated in commercially available 3D reconstruction and analytic software
(TomTec, Munich, Germany) in 61 3DE data sets obtained in 58 patients (24 transesoph-
ageal and 37 transthoracic examinations). In 70.3% of the cases the VR heart model was
linked to the 3DE data sets and successfully implemented in 3D reconstruction software
Age-sex standardized rates per 100,000 BC residents
1995 1996 1997 1998 1999 2000 2001
Acute Coronary Syndromes 477 484 434 442 440 430
Coronary Angiography 352 354 352 356 368 393 400
Percutaneous Coronary 
Intervention
101 108 113 122 131 144 154
Coronary Artery Bypass 
Grafting
73 75 76 79 77 75 70


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1040-75 Population rates of invasive cardiac procedures in British Columbia, 1995–2001

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