No Excess Mortality When PCI Performed at Centers Without On-site Surgery
Mortality rates are similar regardless of whether patients undergo PCI at centers with or without on-site surgical support, according to observational data from Wales and England published in the July 28, 2015, issue of the Journal of the American College of Cardiology.
However, it remains to be seen whether PCI with on-site surgery may be superior for certain patient subsets, lead author Scot Garg, MBCHB, PhD, of East Lancashire Hospitals NHS Trust (Blackburn, England), told TCTMD in a telephone interview.
For the retrospective analysis, researchers looked at data on 384,013 patients (mean age 64.7 years; 73.2% men) who underwent an index PCI between 2006 and 2012 and were enrolled in the British Cardiovascular Intervention Society database.
The cohort was divided into patients who were treated at centers with (n = 264,917) or without on-site cardiothoracic surgery available (n = 119,096).
Compared with patients at centers with on-site surgery, those at centers without such backup were older; more likely to be women or smokers; and more commonly had a prior MI, PCI, or CABG. This group was also more likely to present with stable angina or NSTEMI, while patients treated at on-site surgical centers more commonly presented with STEMI.
In addition, centers without on-site surgery favored the radial approach, while centers with backup favored femoral access (both P < .001). Hospitals without on-site surgery were less likely to perform CABG or refer patients to emergency CABG. They also less commonly used intra-aortic balloon pumps or performed multivessel PCI (all P < .001).
On-site Surgery Offers No Survival Advantage
Over a median follow-up of 3.4 years, all-cause mortality at 30 days (primary endpoint) occurred in 2.0% of patients treated at centers with off-site surgery vs 2.2% of those treated at institutions with on-site backup (P < .001). However, after multivariable adjustment, there were no mortality differences between the groups at 30 days, 1 year, or 5 years (table 1).
Multivariate analysis also showed no between-group differences based on procedural indication for any time period, and the overall results were confirmed in a propensity-matched analysis involving 74,001 patients.
According to the authors, these patterns held steady over the 6-year study period.
Off-site Surgery Gaining Traction
Given the proliferation of centers without surgical backup and the dwindling use of emergency CABG post-PCI, the authors note, the reassuring results are relevant to today’s practice.
In an accompanying editorial, Ashvin N. Pande, MD, and Alice K. Jacobs, MD, both of Boston University Medical Center (Boston, MA), observe that the “advent of stents and improvements in device technology, procedural technique, and adjunctive pharmacotherapy, as well as increased operator experience, have reduced the incidence of emergency CABG after PCI” to less than 1%.
Gregory Dehmer, MD, of Baylor Scott & White Health, Central Texas (Temple, TX), told TCTMD in a telephone interview that while the growth in PCI centers lacking on-site surgery is relatively recent in the United States, “a number of the countries overseas have been doing PCI without on-site surgery for years. The European guidelines for PCI haven’t even addressed it as being important, because it is so well accepted.
“Even the American guidelines, which for many years classified PCI without on-site surgery for elective patients as Class III, have loosened up in the latest version making this Class IIb,” he added. “Cardiologists have become more comfortable with it.”
However, Drs. Pande and Jacobs caution, the study did not look at recurrent MI, stroke, or bleeding, which “are of interest when one considers the effectiveness and safety of a new practice pattern.”
They add that while “gathering evidence has leaned opinion in the cardiovascular community toward expansion of PCI to facilities without on-site cardiac surgery, … we must take steps to ensure that this occurs in the context of appropriate standards and program development to best serve and protect our patients.”
1. Garg S, Anderson SG, Oldroyd K, et al. Outcomes of percutaneous coronary intervention performed at offsite versus onsite surgical centers in the United Kingdom. J Am Coll Cardiol. 2015;66:363-372.
2. Pande AN, Jacobs AK. Percutaneous cornary intervention without onsite cardiac surgery: ready for take-off [editorial]? J Am Coll Cardiol. 2015;66:373-375.
- Drs. Garg, Pande, Jacobs, and Dehmer report no relevant conflicts of interest.
- Meta-analysis Confirms Safety of PCI without Surgical Backup
- No Impact on Safety Seen at Hospitals Performing PCI with No Surgical Backup
- SCAI/ACC/AHA Statement: PCI Without Surgical Backup Safe When Done According to Protocol
*Nicole Lou is the 2015 Recipient of the Jason Kahn Fellowship in Medical Journalism