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

Abstract

T he need for emergency cardiac surgery has decreased dramatically from 6% to 10%, 1 during the era of balloon angioplasty, to 0.1% to 0.4% in the current era of stents because of the many advances in technology, techniques, adjunctive pharmacotherapy, and operator experience. [2][3][4] Despite this progress, concerns remain about performing percutaneous coronary intervention (PCI) at centers without on-site surgical backup, especially regarding nonprimary PCI for conditions other than ST-segment-elevation myocardial infarction (STEMI). Because primary PCI confers longer survival and timely reperfusion, increased access to primary PCI was encouraged. Subsequently, numerous studies showed that safety and efficacy of primary PCI are similar in centers with and without on-site surgical capability. 4,5 Current American College of Cardiology Foundation/ American Heart Association/Society for Cardiovascular Angiography and Interventions guidelines recommend that primary PCI for STEMI be performed at centers without on-site surgical backup (class IIa, level of evidence: B). 1,5 Editorial see p 365 Clinical Perspective on p 401Conversely, nonprimary PCI has been a major issue in this debate; no survival benefit supports allowing nonprimary PCI at centers without on-site surgical backup. Nonprimary Background-Emergency coronary artery bypass grafting for unsuccessful percutaneous coronary intervention (PCI) is now rare. We aimed to evaluate the current safety and outcomes of primary PCI and nonprimary PCI at centers with and without on-site surgical backup. Methods and Results-We performed an updated systematic review and meta-analysis by using mixed-effects models. We included 23 high-quality studies that compared clinical outcomes and complication rates of 1 101 123 patients after PCI at centers with or without on-site surgery. For primary PCI for ST-segment-elevation myocardial infarction (133 574 patients), all-cause mortality (without on-site surgery versus with on-site surgery: observed rates, 4.8% versus 7.2%; pooled odds ratio [OR], 0.99; 95% confidence interval, 0.91-1.07; P=0.729; I 2 =3.4%) or emergency coronary artery bypass grafting rates (observed rates, 1.5% versus 2.4%; pooled OR, 0.76; 95% confidence interval, 0.56-1.01; P=0.062; I 2 =42.5%) did not differ by presence of on-site surgery. For nonprimary PCI (967 549 patients), all-cause mortality (observed rates, 1.6% versus 2.1%; pooled OR, 1.15; 95% confidence interval, 0.94-1.41; P=0.172; I 2 =67.5%) and emergency coronary artery bypass grafting rates (observed rates, 0.5% versus 0.8%; pooled OR, 1.14; 95% confidence interval, 0.62-2.13; P=0.669; I 2 =81.7%) were not significantly different. PCI complication rates (cardiogenic shock, stroke, aortic dissection, tamponade, recurrent infarction) also did not differ by on-site surgical capability. Cumulative meta-analysis of nonprimary PCI showed a temporal decrease of the effect size (OR) for all-cause mortality after 2007. Conclusions-Clinical outcomes and complication rates of PCI at centers without on-...

Is cardiac surgery backup required for left main stenting?

“…Overall, the results reported by Lee et al 3 are promising; however, heterogeneity of LMS disease makes it difficult to generalize the results of this study. Larger, multicenter, or randomized trials are needed to firmly establish the role of PCI in this field.…”

“…One of the recent meta‐analysis showed that the safety (including in‐hospital mortality and emergent surgery), procedural success and long‐term outcomes of primary PCI performed in centers without on‐site cardiothoracic surgery was similar to that performed with on‐site surgery. Perhaps the fast demise of LMS complications may not be ameliorated by emergency (albeit with many delays due to resource mobilization and transfer) cardiac surgery 3 …”

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites

“…The place of PCI without on-site, but readily accessible, coronary surgery is largely established [4]. Importantly, outcomes from selected sites performing remote and rural PCI within Australia have been previously reported, though details regarding patient selection in these cohorts are less well established [5,6].…”

Outcome of Percutaneous Coronary Intervention in Relation to the Institutional Volume of Coronary Artery Bypass Surgery

“…The reported need for emergency cardiac surgery in the contemporary era of intracoronary stent implantation has lowered to the range of 0.3-0.6% [17,18]. More recent meta-analysis suggested that clinical outcomes and complications after PCI are similar between hospitals with and without on-site surgical backup regardless of the indications for PCI [3]. In addition, a recently published study on this topic pointed out that the volume-outcome relationship might no longer be inverse in the era of radial access and technical iteration of equipment made available to PCI operators.…”

“…Percutaneous coronary intervention (PCI) is performed in a wide range of institutions [1,2]. Current evidence suggests that PCI can be safely performed in hospitals with low surgical volume and facilities without on-site cardiac surgery units [3,4]. In the 2011 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) guideline, elective PCI was upgraded to Class IIb and primary PCI to Class IIa at facilities without on-site surgery [5].…”