SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup

Dehmer, Gregory J.; Blankenship, James C.; Çilingiroğlu, Mehmet; Dwyer, James G.; Feldman, Dmitriy N.; Gardner, Timothy J.; Grines, Cindy L.; Singh, Mandeep

doi:10.1161/cir.0000000000000037

Cited by 47 publications

(34 citation statements)

References 68 publications

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“…For institutions without on-site cardiac surgery, oversight to ensure the quality of procedures is paramount [2,7]. For such sites, operators should perform at least 50 PCIs/year, including 11 primary PCIs, and the institution should ideally recruit more experienced operators.…”

Section: Institutional and Operator Qualifications And Components Of mentioning

confidence: 99%

SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiology–Association canadienne de cardiologie d'intervention)*

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Cathet Cardio Intervent

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Section: Institutional and Operator Qualifications And Components Of mentioning

confidence: 99%

SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory: (Endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista; Affirmation of value by the Canadian Association of interventional cardiology–Association canadienne de cardiologie d'intervention)*

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“…First, despite the 2007 American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline containing a class III recommendation for nonprimary PCI without on-site surgical backup, many studies continue to report nonsignificant differences of outcomes, including reports about nonprimary PCI during 2006 to 2007, [16][17][18] and the number of PCIs performed without onsite surgery has increased since 2007 across the United States. 1 Second, the expanded use of DES since 2006 to 2007, especially secondgeneration DES with improved flexibility, deliverability, technical success rates, and safety profile (ie, significantly reduced fatal stent thrombosis rates), might explain this trend. 33 Nonetheless, this finding should be regarded as hypothesis generating.…”

Section: Nonprimary or Elective Pci Without On-site Surgerymentioning

confidence: 99%

“…The pooled OR and 95% confidence intervals were calculated with the restricted maximum likelihood (REML) method for mixed-effects as well as the Mantel-Haenszel method for fixed-effects. 1 Because of progressive changes in primary study designs and clinical practice patterns, especially revascularization method (balloon angioplasty, bare metal stent, 1 st or 2 nd generation DES), we evaluated the impact of publication date on the overall effect of pooled…”

Section: Data Synthesis and Analysismentioning

confidence: 99%

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

et al. 2015

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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-...

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“…2013; Dehmer et al. 2014). Hospitals reporting volume to any database can be ranked from highest to lowest and an appropriate cutpoint can be selected for designation.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of regionalized systems for stroke and myocardial infarction

et al. 2015

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BackgroundAcute ischemic stroke (AIS) and ST‐segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI.MethodsLiterature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non‐ or pre‐regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking “regionalization” and “myocardial infarction” or citation as a model system by any American Heart Association statement.ResultsFor AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre‐ or nonregionalized state. The final yield was nine papers from six systems.ConclusionAlthough regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.

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SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup

Abstract: . Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the "Policies and Development" link.

Cited by 47 publications

References 68 publications

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

Effectiveness of regionalized systems for stroke and myocardial infarction

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