Despite current guidelines discouraging percutaneous coronary interventions (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries) being performed at centers without on-site cardiac surgery capability, an analysis of previous studies finds that PCIs at these centers are not associated with a higher incidence of in-hospital death or emergency coronary artery bypass surgery compared to PCIs at centers with on-site surgery, according to an article in the December 14 issue of JAMA. 1
Studies comparing the outcomes of PCI procedures at centers with and without on-site surgery have had conflicting findings, according to background information in the article.
Mandeep Singh, M.D., M.P.H., of the Mayo Clinic, Rochester, Minn., and colleagues conducted a meta-analysis of studies to compare the outcomes of PCI at centers with and without on-site surgery. A search of the medical literature identified 15 articles that met criteria for inclusion in the analysis, which included data on in-hospital mortality and emergency coronary artery bypass grafting (CABG) surgery after PCI.
Analyses of primary PCI for ST-segment elevation myocardial infarction (a certain pattern on an electrocardiogram following a heart attack) of 124,074 patients demonstrated no increase in the risk of in-hospital death (no on-site surgery vs. on-site surgery: observed risk, 4.6 percent vs. 7.2 percent) or emergency bypass (observed risk, 0.22 percent vs. 1.03 percent) at centers without on-site surgery. “For nonprimary percutaneous coronary interventions (elective and urgent, n = 914,288), the rates of in-hospital mortality (observed risk, 1.4 percent vs. 2.1 percent) and emergency bypass (observed risk, 0.17 percent vs. 0.29 percent) were not significantly different at centers without or with on-site surgery,” the authors write.
“In conclusion, this meta-analysis provides evidence that rates of in-hospital mortality and emergency CABG surgery for primary and nonprimary PCI are similar at centers with and without on-site surgery. Additional outcome data are still needed, including rates and indications for urgent or emergency transfers, especially in patients undergoing nonprimary PCI at centers without on-site surgery.”
In an accompanying editorial2, Scott Kinlay, M.B.B.S., Ph.D., of the VA Boston Healthcare System, Boston, writes that “performance of PCI in hospitals without CABG surgery requires a structured program with several key features.”
“These include experienced operators, experienced nursing staff, and clear plans and agreements for rapid transport of patients to a facility with CABG surgery. Quality assurance for all hospitals providing PCI is an important objective, and participation in national clinical registries, and arguably public reporting will help evaluate and perhaps modulate PCI practice in order to keep adverse events low.”
“The prevention of adverse events is arguably less dependent on the presence of on-site CABG surgery and more dependent on an operator's skill to select appropriate patients, their technical skill to complete PCI, and their commitment to maintain skills through continued education and participation in quality assurance programs.”
1. (JAMA. 2011;306:2487-2494.
2. (JAMA. 2011;306:2507-2509.