Percutaneous Coronary Intervention Without On-site Cardiac Surgery

Abstract

Since its introduction almost 40 years ago, the procedural safety of percutaneous coronary intervention (PCI) has improved enormously. In particular, the need for emergency coronary artery bypass grafting (CABG) has strikingly diminished, although it has not been eliminated. In consequence of this remarkable achievement, the requirement that PCI should be conducted only in centers with cardiac surgery available on-site has been gradually relaxed. In parallel with this change, primary PCI (PPCI) as immediate treatment for acute ST-elevation myocardial infarction (STEMI) has been shown to be superior therapy when it can be performed rapidly after infarction onset. These 2 forces together have led to growth in the number of centers with catheterization facilities that perform PCI without on-site cardiac surgery. Many of these centers are smaller hospitals in rural or suburban areas, and part of the justification was that they can be more rapidly and easily accessible to patients with STEMI than the more urban and distant hospitals with on-site surgical availability. Studies show that these smaller centers also are performing PCI for indications other than STEMI, that is, for urgent, nonurgent, and elective indications.For several years researchers have been examining whether PCI performed at centers without on-site cardiac surgery have worse outcomes, usually measured as mortality, compared with centers that have on-site surgery. The results so far have been uniformly negative; that is, it has never been demonstrated that clinical outcomes are any different (worse or better) at centers without on-site cardiac surgery compared with those with it. In this issue of JAMA Cardiology, Goel and colleagues 1 provide additional confirmatory evidence for this lack of difference. Using data from the National Inpatient Sample (NIS) comprising almost 7 million PCI procedures, these investigators again examined the question. The PCI procedures at both types of centers were categorized by clinical indication: STEMI, non-ST-elevation acute coronary syndrome (NSTE-ACS), or elective PCI. Although unadjusted mortality rates were lower at centers with cardiac surgery on-site, after multivariate adjustment there were no differences in mortality between the 2 types for any of the 3 indications. These results echo many other reports. [2][3][4][5] There are 2 findings within these new data that are worth noting. First, the investigators demonstrate quantitatively that the proportion of PCI procedures performed at hospitals without on-site cardiac surgery is increasing. Over the 10 years examined, the proportion of procedures performed at centers without on-site surgery programs

Performing Percutaneous Coronary Intervention Without On-site Cardiac Surgery Is Not a License for Percutaneous Coronary Intervention Instead of Coronary Artery Bypass Grafting

“…The authors point out the potential limitations of using an administrative database that is incomplete with respect to some important outcome measures and lack of follow-up to assess appropriateness. The thoughtful accompanying commentary by Anderson calls for further investigation and validation, warning about the possibility of diluting the PCI experience across too many centers and potentially hurting outcomes. By the same token, ad hoc CS coverage and programs created for the sole purpose of PCI backup are de facto low-volume programs that can struggle to achieve and maintain surgical quality.…”

“…Anderson rightly argues that the success of modern regional cardiac systems of care, which incorporate enhanced communications and expeditious patient transportation to referral centers, challenges the value of PCI at peripheral centers with no CS. Beyond the value of salvage coronary artery bypass grafting (CABG) in treating PCI complications, CS comes with a halo effect in which quality and appropriateness of care are enshrined.…”