On-site surgical backup for PCI has long been mandated by guidelines, though its necessity in the modern era has been questioned, and the most recent PCI guidelines published last month lack a specific recommendation about surgical backup. Now a large new meta-analysis published in JAMA suggests that the PCI performed without surgical backup may be safe.
Examining data from 40 studies, Mandeep Singh and colleagues found no significant differences in in-hospital mortality or emergency CABG between centers with or without on-site surgery:
124,074 STEMI patients:
- In-hospital mortality: 4.6% for no surgical backup versus 7.2% for surgical backup (OR 0.96, CI 0.88-1.05)
- Emergency bypass: 0.22% vs 1.03% (OR 0.53, CI 0.35-0.79)
914,288 elective and urgent PCI patients:
- in-hospital mortality: 1.4% vs 2.1% (OR 1.15, CI 0.93-1.41)
- Emergency bypass: 0.17% vs 0.29% (OR 1.21, CI 0.52-2.85)
In an accompanying editorial, Scott Kinlay notes that the rate of emergency CABG is now 10 times lower than in the early balloon angioplasty era. The results of the meta-analysis, along with previous studies, “suggest that the current patterns of judicious PCI by operators in hospitals without CABG surgery leads to risks that are similar to those of hospitals with CABG surgery.”
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.
Here is the press release from JAMA:
CHICAGO—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.
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.”
Editorial: The Trials and Tribulations of Percutaneous Coronary Intervention in Hospitals Without On-site CABG Surgery
WIn an accompanying editorial, 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.”