Percutaneous Coronary Intervention at Centers With and Without On-Site Surgery

CURRENT GUIDELINES RECOMmendagainstperformingelectivepercutaneouscoronaryintervention(PCI)at institutions without on-site cardiac surgery capability(AmericanHeartAssociation/American CardiologyclassIII indication). It isconsideredacceptabletoperformPCIatsuch facilities (class IIb) for patients with STsegmentelevationmyocardial infarction (STEMI), but additional requirements must be present at the facility to ensure patientsafety. Theneedforon-sitecoronary artery bypass grafting (CABG) surgerytobackupPCIwasconsideredmandatoryduringtheprioreraofangioplasty, when up to 5% of patients required urgent or emergency CABG surgery after failed angioplasty. Despite the marked decline in the need for emergency CABG surgery after PCI and satisfactory outcomes at selected centers, several concerns remain regarding PCI programs without on-site surgical backup. First, favorable results reported from such centers were largely derived from small, single-center observational registries. Second, 1 large study using administrative data demonstrated worse outcomes for elective PCIs at sites without on-site surgery, especially at centers with low annual angioplasty volumes. Third, since publication of the guidelines, additional studies at institutions without on-site surgery have reported favorable results. This unresolved clinical issue has implications for the delivery of clinical care For editorial comment see p 2507. Author Affiliations: Division of Cardiovascular Diseases (Drs Singh, Holmes, and Rihal) and Division of Biomedical Statistics and Informatics (Mr Lennon), Mayo Clinic, Rochester, Minnesota; Division of Cardiology, Scott & White Healthcare, Temple, Texas (Dr Dehmer); Cardiovascular Medicine, Exeter Hospital, Exeter, New Hampshire (Dr Wharton); Department of Cardiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina (Dr Kutcher); and Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland (Dr Aversano). Corresponding Author: Mandeep Singh, MD, MPH, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (singh.mandeep @mayo.edu). Context Percutaneous coronary interventions are performed at centers without onsite surgery, despite current guidelines discouraging this.