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Interventional Cardiology
Table 2: Large Registry Reports of Percutaneous Coronary Interventions without On-Site Cardiac Surgery
Study (Reference) Total number of Number of PCIs Proportion of Sites Emergency Mortality
PCIs Performed without without On-site CABG Needed
On-site Surgery Cardiac Surgery (%)
With On-site Without On-site With On-site Without On-site
Surgery (%) Surgery (%) Surgery (%) Surgery (%)
BCIS
27
73,692 15,539 42 0.1 0.05 0.73
Not separated by site
SCAAR
28
34,363 8,838 58 0.2 0.1 2.2 1.4
†
NCDR
29
308,161 8,736 14.8 0.4 0.3 No difference in
risk-adjusted mortality
BCIS = British Cardiovascular Interventional Society; NCDR = National Cardiovascular Data Registry; SCAAR = Swedish Coronary Angiography and Angioplasty Registry;
PCIs = percutaneous coronary interventions; CABG = coronary artery bypass graft surgery;
†
30-day unadjusted mortality.
Table 3: Selected Contemporary Studies of Percutaneous Coronary Interventions without On-Site Cardiac Surgery
Study (Reference) Total Number of Number of PCIs Proportion of Sites Emergency Mortality
PCIs Performed without without On-site CABG Needed
On-site Surgery Cardiac Surgery (%)
With On-site Without On-site With On-site Without On-site
Surgery (%) Surgery (%) Surgery (%) Surgery
Mayo
11
1,007 1,007 50* 0 0.1 0.5 1.2
Mid-America 1,090 1,090 50* 0.03 0.2 0.8 0.1
Heart
26
VA study
31
401 401 No comparison – 0 – 0
group
Norway
32
609 305 50* 0 0 0 0
Tasmania
33
1,348 1,348 No comparison – 0.07 – 0.8
group
PCIs = percutaneous coronary interventions; VA = Veterans Administration; CABG = coronary artery bypass graft surgery.
*Only two sites reported, one with and one without on-site cardiac surgery.
Reports from Abroad actual impact of opening more PCI centers at facilities without on-site
Many of the early studies related to PCI without on-site surgical back-up surgery is questionable. Using census data from 2000, it was estimated
were from Europe, where this practice has been adopted more widely that nearly 80% of the adult population live within 60 minutes of a PCI-
than in the US (see Table 3). A contemporary study from Norway showed capable hospital and among those living closer to non-PCI hospitals,
excellent safety and in-hospital outcomes at a facility without on-site almost three-quarters would experience <30 minutes of additional delay
cardiac surgery compared with a regional facility that has surgery on- by direct referral to a PCI hospital.
36
Furthermore, a recent study
site.
32
Likewise, excellent safety and outcomes were reported in a series examining data from Michigan estimated that providing PCI without on-
of 1,348 patients at a remote facility without on-site surgery in site surgery improved access to <5% of the population.
37
Tasmania.
33
In this series, no patients were excluded and 18% of the
patients presented with a STEMI (mortality 3.7%). Only one patient Currently, there are three models for the delivery of PCI care in patients
required transfer for urgent CABG because of an ascending aortic with STEMI. One model is to develop PCI programs at community
dissection caused by the guiding catheter. hospitals without on-site surgery in an attempt to provide rapid primary
PCI to patients in their local community.
9,14
Although several reports
Unanswered Questions Related to document that this can be performed safely, it requires a high level of
Percutaneous Coronary Intervention physician and facility support and a commitment to maintain high
without On-site Surgical Back-up standards of quality. Most would argue that it is inappropriate to open
Although the use of PCI without on-site surgery in the US is expanding, more low-volume PCI centers if they are not firmly based on the health
it remains a controversial matter both within and external to the needs of the community. Opening a low-volume PCI program in close
interventional community. Data from the Global Registry of Acute proximity to a high-volume program, thereby degrading the high-volume
Coronary Events (GRACE) shows an increase in the use of reperfusion program, is not necessarily in the best interests of patients or the
therapy among patients with STEMI, but only 44% of patients receive community. However, many factors besides distance can define a
primary PCI.
34
Despite the benefits of primary PCI, timely access to this geographical area, including the level and availability of emergency
service in the US remains a challenge. Only 25% of the acute care transport services, response times of emergency medical transport,
hospitals in the US are capable of providing PCI.
35
One interpretation of immediate availability of qualified cath lab personnel, and coverage by
these facts would be that more PCI centers are needed. However, the interventional cardiologists.
72 US CARDIOLOGY
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