Outcomes of a System-Wide Protocol for Elective and Nonelective Coronary Angioplasty at Sites Without On-site Surgery: The Mayo Clinic Experience

Abstract

OBJECTIVE:To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital). PATIENTS AND METHODS:Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site.RESULTS: Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge. CONCLUSION:Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.Mayo Clin Proc. 2009;84(6):501-508 ACC = American College of Cardiology; AHA = American Heart Association; CABG = coronary artery bypass grafting; CI = confidence interval; MACE = major adverse cardiovascular event; MCRS = Mayo Clinic risk score; MHS = Mayo Health System; MI = myocardial infarction; OR = odds ratio; PCI = percutaneous coronary intervention From the Division of Cardiovascular Diseases (M.S., B

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…Риск смерти, связанный с этой проце-дурой при СИБС, составляет <0,5% [380][381][382]. Эффективность ЧКВ при СИБС, по сравнению с медикаментозной терапией и КШ, была всесто-ронне изучена.…”

Percutaneous Coronary Intervention at Centers With and Without On-Site Surgical Backup

“…13,14,17,18,22,24,27,28 All 9 studies reported group size and clinical outcomes according to PCI type. The proportion with 3-vessel disease was relatively higher in 7 studies than in other studies, 7,13,15,17,21,22,27 ranging from 33.6% to 61.5% across these studies. The proportion with left main vessel PCI was reported by only 8 studies and was very low, ranging from 0.4% to 3.8% across these studies.…”

“…Among these citations, 39 articles were retrieved for full review; 23 met inclusion criteria ( Figure 1). 2,3,7,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] …”

SCAI/ACC/AHA Expert Consensus Document

“…Recommendations for case selection at facilities without on-site surgery are shown in Table V, and criteria for identifying high-risk lesions and patients are contained in Table VI. There are statistical models for identifying PCI patients at higher risk for mortality or emergency CABG that could be helpful for identifying patients who should not undergo PCI at facilities without on-site surgery [18,71]. However, these models have not been tested or applied on a large scale to determine the advisability of performing a PCI at facilities without on-site surgery.…”

“…Since 2006, 11 original studies and 3 meta-analyses on the topic of PCI without on-site surgery have been identified by a computerized systematic literature search using Medline (PubMed and Ovid) and Cochrane Databases [9,[11][12][13][14][15][16][17][18][19][20][21][22][23].…”