CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

December 15th, 2011

PCI and On-Site CABG: Out of Site, Out of Mind?

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According to a recent meta-analysis of studies in patients undergoing PCI, rates of in-hospital mortality and emergency CABG for primary and non-primary PCI were similar at centers with and without on-site surgery.  At least, that’s the story the press is spreading around.

However, several caveats should be noted . . .

1. The study included patients undergoing primary PCI (for STEMI, n=124,074) and those undergoing non-primary PCI (elective or urgent, n=914,288).

    • After “adjustment for publication bias,” the mortality rates for non-primary PCI were approximately 25% higher at centers without on-site surgery than at centers with on-site surgery.
    • In patients undergoing primary PCI, the emergency CABG rates were lower at sites without on-site surgery than at those with on-site surgery, raising the concern that “borderline” stable patients with suboptimal PCI results may have been kept at their local facility instead of being transported emergently to a surgical center.

2. Few of the studies reported a composite end point of death and emergency CABG surgery; therefore, it is possible that one outcome was exchanged for the other (i.e., failure to transfer precluded emergency CABG and increased death rates in patients undergoing PCI at sites without on-site CABG).

3. The relationship between outcomes and PCI volume of centers or operators was not examined.

Based on what you know, would you be willing to have an elective PCI at a center without on-site CABG capability?

Categories: Cardiac Surgery
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5 Responses to “PCI and On-Site CABG: Out of Site, Out of Mind?”

  1. Xavier Prida, MD says:
    December 15, 2011 at 5:14 pm

    Whatever the statistical shortcomings of such a meta-analysis(a “drowning pool”) can the real world logistics of recreating the experienced human resource components of staff and interventionalists be disseminated throughout the realm of potential or willing centers without on-site surgery to assure comparable outcomes? I think not.
    I would be willing to have elective PCI at center without on-site surgery if the personnel, laboratory physical plant and processes of care were homologous to centers with on-site surgery – the only difference being the geographic location absent a heart OR.
    As I understand the fundamental intent of C-PORT trial was to ascertain the non-necessity of onsite surgery and surgeons so as to not dilute the volume experience upon which outcomes are dependent in CABG patients. So, could we not similarly create a diluent effect on PCI volumes and operators, another volume dependent care process?

  2. David Powell , MD, FACC says:
    December 15, 2011 at 8:38 pm

    The 75 PCI individual annual minimum is strongly enforced, at least around here in New Jersey. Total PCI volume has of course declined over a few years. In our suburban area, availability and less than 20 mile travel times to hospitals are in demand, particularly from hospital systems. Interventionalists with substantial office practices now do 75 to 150 cases a year. But instead of 3 of them, a single interventionalist with a small outpatient practice may be more desirable. This process is accelerated by the exponentially growing alliances between private practice and hospital systems (which are also expanding).

  3. Clark Hinderleider, MD, MS, PhD says:
    December 15, 2011 at 10:46 pm

    I do not think that PCI should be done at any institution without an active cardiac surgery capability.

    Competing interests pertaining specifically to this post, comment, or both:
    None

  4. Xavier Prida, MD says:
    December 16, 2011 at 3:32 pm

    As Dr. Powell points out, focusing volume to one operator may remedy a dilution effect on volume.However, that then exposes the vulnerability of call frequency and availability of a single operator.

  5. Matthew Carr, MD says:
    February 1, 2012 at 11:06 pm

    I have worked in a high volume pci center for many years. We have on site surgery. LONG AGO WE GAVE UP HAVING AN O.R. AT THE READY DURING PCI PROCEDURES SINCE THE EMERGENCY RATE IS UNDER 1%. Now if an emergency surgery is needed, the wait for an OR and surgeon is 45 minues to an hour. Who are we kidding? The impella, iabp and tendem heart are in the lab for support. Try to get a surgeon to spend his day on standby for ptca cases. Our satellite hospital is 30 tp 40 minutes away , quite a bit less than the time it takes to get an OR and surgeon together. I suspect that those arguing against a stand alone site are doing so out of self interest and have no data to back it up. I am also surprised at the recommendations tha a new facility should first do acute MI’s and later consider elective cases. Perhaps teen agers should first learn to drive Grand Prix races and then be allowed on the streets of our cities?

    Competing interests pertaining specifically to this post, comment, or both:
    None