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PCI Without On-Site Cardiac Surgery

Both elective and primary procedures were feasible and safe at an institution with rigorous protocols, despite lack of on-site surgery.

Advances in stent design and adjunctive pharmacotherapies have reduced complications and the need for emergency bypass surgery in patients undergoing percutaneous coronary intervention (PCI). Nonetheless, ACC/AHA guidelines recommend against elective PCI without on-site surgery capability and make only a class IIb recommendation for primary PCI in ST-segment-elevation MI (Journal Watch Cardiology Jan 12 2006). Now, researchers have compared 1007 STEMI patients undergoing PCI (722 elective, 285 primary) at a community hospital without on-site surgery backup to a matched cohort undergoing PCI at a tertiary-care facility with on-site surgery. Both institutions are affiliated with Mayo Clinic.

A rigorous case-selection protocol ensured enrollment of only low- to moderate-risk cases; among the exclusion criteria were planned rotablation and poor LV function (for elective PCI) and cardiogenic shock (for primary PCI). All operators had maintained guideline-recommended procedural volumes. A real-time telemedicine consultation link to the tertiary center and a tested transport protocol (including access to helicopters) were in place.

Glycoprotein IIb/IIIa inhibitor use was similar between facilities for primary PCI, but significantly higher at the community hospital for elective PCI, as intended by the protocol. For both primary and elective PCI, the two facilities had similarly high rates of procedural and angiographic success (93%–97%) and similarly low rates of in-hospital complications. In elective PCI at the community hospital, no emergency transfers for cardiac surgery were needed, and two patients died in the hospital unrelated to PCI. One elective-PCI patient at the tertiary center required emergency surgery due to a coronary perforation. No primary-PCI patients at either hospital needed emergency surgery.

Comment: This study confirms that the need for emergency bypass with contemporary PCI is rare and documents the feasibility and safety of both elective and primary PCI in a community hospital without on-site cardiac surgery. However, rigorous case selection, operator training and credentialing, a tested transfer protocol, informed consent, and formal quality assurance undoubtedly contributed to the program’s success. The authors caution that their results should not be used to justify proliferation of low-volume PCI programs without cardiac surgery capability and rigorous program requirements.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology May 25, 2006

Citation(s):

Ting HH et al. A total of 1,007 percutaneous coronary interventions without onsite cardiac surgery: Acute and long-term outcomes. J Am Coll Cardiol 2006 Apr 18; 47:1713-21.

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