CardioExchange Archive

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 meta-analysis, published in JAMA, suggests that 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 and without on-site surgery:

Among 124,074 STEMI patients:

• In-hospital mortality: 4.6% for no surgical backup vs. 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)

Among 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, he writes, “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.”

Kinlay concludes:

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.

Please note that TheHeart.Org and U.S. News & World Report have released the findings of a survey about this topic.