PCI in centres without surgical backup

As percutaneous coronary intervention (PCI) has advanced, improved technology and increased collective experience have led to a marked reduction in the need for emergency coronary artery bypass surgery (CABG), with only 0.15% of patients requiring emergency surgical intervention in 2002.  In fact, PCI is now commonly practiced in hospitals without on-site cardiothoracic back-up, something that was almost unheard of even a decade ago.  Despite this expansion, the evidence for this approach – patient outcomes in the absence of immediate surgical intervention – remains undefined.

In this prospective noninferiority trial a total of 18,867 patients requiring urgent (excluding primary) or elective PCI were randomly assigned in a 3:1 ratio to undergo PCI at a hospital with (4718 patients) or without (14,149 patients) on-site cardiac surgery. The study had two primary end points: 6-week mortality and 9-month incidence of major adverse cardiac events (the composite of death, Q-wave myocardial infarction, or target-vessel revascularization).  The 6-week mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at those with on-site surgery (95% CI, -0.31 to 0.23; P=0.004 for noninferiority).  Similarly, the 9-month rates of major adverse cardiac events were 12.1% and 11.2% at hospitals without and those with on-site surgery, respectively (95% CI, 0.04 to 1.80; P=0.05 for noninferiority).  Of note, the secondary end-point of target-vessel revascularization was significantly higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01).

 Conclusion:

PCI performed at hospitals without on-site cardiac surgery is noninferior to PCI performed at hospitals with on-site cardiac surgery with respect to mortality at 6 weeks and major adverse cardiac events at 9 months.  These data support the expansion of PCI facilities to non-cardiothoracic centres that has emerged in recent years.

  •  Aversano T, Lemmon CC, Liu L; Atlantic CPORT Investigators. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med. 2012;366:1792-802.