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Dafaalla M, Rashid M, Moledina S, Kinnaird T, Ludman P, Curzen N, Zaman S, Nolan J, Mamas MA. Characteristics and Outcomes of Patients Who Underwent Coronary Atherectomy in Centers With and Without On-Site Cardiac Surgery. Am J Cardiol 2023; 204:242-248. [PMID: 37556893 DOI: 10.1016/j.amjcard.2023.07.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023]
Abstract
We aimed to describe the clinical characteristics and outcomes of patients who underwent atherectomy at the time of percutaneous coronary intervention in centers with on-site surgical centers (SCs) versus nonsurgical centers (NSCs). Patients treated with coronary atherectomy between January 1, 2006, to December 31, 2019, from the British Cardiovascular Society Intervention (BCIS) registry were included. Primary outcomes were in-hospital all-cause mortality and major adverse cardiovascular and cerebrovascular events. A total of 20,833 patients were treated with coronary atherectomy, of which 7,983 (38%) were performed at NSC. The proportion of coronary atherectomies performed in NSC increased from 12.5% in 2006 to 42% in 2019. Compared with patients treated at SC, patients treated in NSC were older (mean age 75.1 ± SD years vs 74.2 ± SD, p <0.001), but had comparable prevalence of hypertension (NSC 73.9% vs SC 72.8%, p = 0.085), diabetes mellitus (NSC 32.2% vs SC 31.6%, p = 0.43) and renal disease (NSC 6.0% vs SC 6.0%, p = 0.99). Intracoronary imaging was used more often in NSC than SC (22.3% vs 19.4%, p <0.001). After adjustment, the odds of in-hospital mortality (odds ratios [OR] 0.76, 95% confidence intervals [CI] 0.50 to 1.16), major adverse cardiovascular and cerebrovascular events (OR 0.80, 95% CI 0.53 to 1.21), emergency coronary artery bypass graft (OR 0.49, 95% CI 0.15 to 1.57), major bleeding (OR 0.67, 95% CI 0.36 to 1.24) and coronary perforation (OR 1.07, 95% CI 0.97 to 1.43) in NSC were comparable with SC. In conclusion, coronary atherectomy in hospitals with off-site surgical cover has become more frequent, with no association with poorer outcomes, compared with hospitals with on-site surgical cover.
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Affiliation(s)
- Mohamed Dafaalla
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Saadiq Moledina
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Tim Kinnaird
- University Hospital of Wales, Cardiff, United Kingdom
| | - Peter Ludman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Trust and Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Sarah Zaman
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Australia
| | - James Nolan
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Effects of cardiac surgical support on long-term outcomes of emergent or complex percutaneous coronary intervention cases: a sub-analysis of the SHINANO 5-year registry. Heart Vessels 2022; 37:1106-1114. [PMID: 34997289 PMCID: PMC9142436 DOI: 10.1007/s00380-021-02015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/17/2021] [Indexed: 11/04/2022]
Abstract
Significant improvements in percutaneous coronary intervention (PCI) technology have enabled cardiovascular procedures to be performed without onsite cardiac surgery facilities. However, little is known about the association between onsite cardiac surgical support and long-term outcomes of PCI, particularly among emergent and complex cases. We investigated whether the presence or absence of cardiovascular surgery affects the long-term prognosis after PCI, emergent and complex elective cases. The SHINANO 5-year registry, a prospective, observational, and multicenter cohort study registry in Nagano, Japan, consecutively included 1665 patients who underwent PCI between August 2012 and July 2013. The procedures were performed at 11 hospitals with onsite cardiac surgery facilities [onsite surgery (+) group; n = 1257] and 8 hospitals without onsite cardiac surgery facilities [onsite surgery (-) group; n = 408]. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac and cerebrovascular events [MACCE: all-cause death, Q-wave myocardial infarction, non-fatal stroke, and target lesion revascularization]. The onsite surgery group (+) had a lower rate of emergent PCI and ST-segment elevation myocardial infarction (40.8% vs. 51.7%, p < 0.01 and 24.9% vs. 39.2%, p < 0.01, respectively), and a higher prevalence of hemodialysis and history of peripheral artery disease (7.6% vs. 2.45%, p < 0.01 and 12.1% vs. 6.9%, p < 0.01, respectively). However, the Kaplan-Meier analysis showed no difference in the 5-year mortality rate (16.4% vs. 15.2%, p = 0.421) and MACCE incidence (31.6% vs. 28.9%, p = 0.354) between the groups. Also, there were no differences in the mortality rate and incidence of MACCE among emergent cases of ST-segment elevation myocardial infarction and complex elective cases who underwent PCI. Long-term outcomes of PCI appear to be comparable between institutions with and without onsite cardiac surgical facilities.
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3
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Grines CL, Mehta S. ST-segment elevation myocardial infarction management: great strides but still room for improvement. Eur Heart J 2021; 42:4550-4552. [PMID: 34529771 DOI: 10.1093/eurheartj/ehab596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA
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4
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Mujtaba SF, Khan MN, Sohail H, Sial JA, Karim M, Saghir T, Abbas K, Ahmed M, Qamar N. Outcome at Six Months After Primary Percutaneous Coronary Interventions Performed at a Rural Satellite Center of Sindh Province of Pakistan. Cureus 2020; 12:e8345. [PMID: 32617219 PMCID: PMC7325348 DOI: 10.7759/cureus.8345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 05/28/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Primary percutaneous coronary intervention (PPCI) is now a well-established treatment of acute ST-elevation myocardial infarction (STEMI). For the first time in Pakistan, various off-site satellite centers are established to perform PPCI 24-hours. Our population mainly resides in the rural area with low literacy rate and poor socioeconomic conditions. The majority of the patients who are presented in the satellite center had either never received any long-term treatment plan or were non-compliant to their medication. The objective of this study was to determine the outcome of patients at six months who underwent primary PCI at a rural satellite center of Sindh, Pakistan. Methods This study was conducted at Larkana satellite center of National Institute of Cardiovascular Diseases, Karachi. Patients who underwent PPCI for STEMI from October 2017 to March 2018 were enrolled in the study. In case of death of the patient, data were obtained from the attendant of the deceased. Patients, on follow-up visits, were interrogated for post-procedure symptoms. Results A total of 271 patients were enrolled in the study. The mean age ± standard deviation of patients was 54.84 ± 10.64 years. The most common culprit artery was left anterior descending (LAD) artery with 161 (59.4%) patients, followed by right coronary artery (RCA) with 98 (36.2%) patients. Only 41 (15%) patients had a three-vessel disease, while 141 (52%) patients had single-vessel disease. On follow-up, 70 (25.8%) patients complained of chest pain grade II, 20 (7.4%) complained of shortness of breath (SOB) grade II, 44 (16.2%) complained of vertigo, and 16 (5.9%) complained of nonspecific weakness. The mortality rate of 6.3% (17) was observed after six months of PPCI. The mortality rate was found to be lower for patients with LAD disease (p = 0.036) and higher among patients with RCA as the culprit artery (p = 0.045). The mortality rate was significantly associated with the number of diseased vessels and the type of stent deployed. Conclusion Primary PCI, at a rural satellite center, has an overall positive outcome. Steps should be taken to provide free medication along with encouragement towards compliance of dual antiplatelet medication. Furthermore, the facility for subsequent procedures should be provided at the same set-up.
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Affiliation(s)
- Syed F Mujtaba
- Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Muhammad N Khan
- Interventional Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Hina Sohail
- Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Jawaid A Sial
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Musa Karim
- Statistics, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Tahir Saghir
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Kiran Abbas
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
- Medicine and Surgery, Sindh Medical College, Karachi, PAK
| | - Moiz Ahmed
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
- Medicine and Surgery, Sindh Medical College, Karachi, PAK
| | - Nadeem Qamar
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
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5
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Hannan EL, Zhong Y, Wu Y, Berger PB, Jacobs AK, Walford G, Venditti FJ, Ling FSK, Tamis-Holland J, King SB. Treatment of Coronary Artery Disease and Acute Myocardial Infarction in Hospitals With and Without On-Site Coronary Artery Bypass Graft Surgery. Circ Cardiovasc Interv 2019; 12:e007097. [PMID: 30616362 DOI: 10.1161/circinterventions.118.007097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many studies have revealed no outcome differences among patients undergoing percutaneous coronary intervention (PCI) in hospitals with and without surgery on-site (SOS), but one earlier study found differences in target vessel PCI rates and in mortality for patients with acute myocardial infarction who did not undergo PCI. It is important to examine outcome differences between SOS and non-SOS hospitals with more contemporary data. METHODS AND RESULTS A total of 21 924 propensity-matched patients who were discharged between January 1, 2013, and November 30, 2015, who were in the New York PCI registry and other hospital databases were used to compare outcomes in hospitals with and without SOS for all patients and for patients with and without ST-segment-elevation myocardial infarction (STEMI) undergoing PCI. Also, 30-day mortality was compared for patients with STEMI regardless of whether they underwent PCI. For all patients with PCI and patients without STEMI, there were no significant differences in in-hospital/30-day mortality, 2-year mortality, or 2-year repeat target lesion PCI. For patients with STEMI, there were no significant mortality differences between patients in SOS and non-SOS hospitals. Patients with STEMI in SOS hospitals had significantly lower 2-year repeat target lesion PCI rates (adjusted hazard ratio, 0.68 [0.49-0.94]). There was no difference in the percentage of patients undergoing PCI in the 2 types of hospitals (75.7% versus 74.6%; P=0.21) or in 30-day mortality of all patients with STEMI (patients who did and did not undergo PCI, 10.86% versus 11.32%; adjusted odds ratio, 1.06 [0.88-1.29]). CONCLUSIONS Short-term and long-term outcomes were not different in SOS and non-SOS hospitals except that 2-year repeat target lesion PCI rates were lower in SOS hospitals for patients with STEMI.
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Affiliation(s)
- Edward L Hannan
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Ye Zhong
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Yifeng Wu
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | | | - Alice K Jacobs
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Gary Walford
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Ferdinand J Venditti
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Frederick S K Ling
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Jacqueline Tamis-Holland
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
| | - Spencer B King
- Cardiac Services Program, University at Albany, State University of New York (E.L.H., Y.Z., Y.W.)
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Koolen KHAJ, Mol KA, Rahel BM, Eerens F, Aydin S, Troquay RPT, Janssen L, Tonino WAL, Meeder JG. Off-site primary percutaneous coronary intervention in a new centre is safe: comparing clinical outcomes with a hospital with surgical backup. Neth Heart J 2016; 24:581-8. [PMID: 27595816 PMCID: PMC5039129 DOI: 10.1007/s12471-016-0872-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVES To evaluate the procedural and clinical outcomes of a new primary percutaneous coronary intervention (PPCI) centre without surgical back-up (off-site PCI) and to investigate whether these results are comparable with a high volume on-site PCI centre in the Netherlands. BACKGROUND Controversy remains about the safety and efficacy of PPCI in off-site PCI centres. METHODS We retrospectively analysed clinical and procedural data as well as 6‑month follow-up of 226 patients diagnosed with ST-elevated myocardial infarction (STEMI) who underwent PPCI at VieCuri Medical Centre Venlo and 115 STEMI patients who underwent PPCI at Catharina Hospital Eindhoven. RESULTS PPCI patients in VieCuri Medical Centre had similar procedural and clinical outcomes to those in Catharina Hospital. Overall there were no significant differences. The occurrence of procedural complications was low in both groups (8.4 % VieCuri vs. 12.3 % Catharina Hospital). In the VieCuri group there was one procedural-related death. No patients in either group needed emergency surgery. At 30 days, 17 (7.9 %) patients in the VieCuri group and 9 (8.1 %) in the Catharina Hospital group had a major adverse cardiac event. CONCLUSION Performing PPCI in an off-site PCI centre is safe and effective. The study results show that the procedural and clinical outcomes of an off-site PPCI centre are comparable with an on-site high-volume PPCI centre.
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Affiliation(s)
- K H A J Koolen
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands.
| | - K A Mol
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - B M Rahel
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - F Eerens
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - S Aydin
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - R P T Troquay
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - L Janssen
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - W A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - J G Meeder
- Department of Cardiology, VieCuri Medical Centre, Venlo, The Netherlands
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7
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Lee JM, Hwang D, Park J, Kim KJ, Ahn C, Koo BK. Percutaneous Coronary Intervention at Centers With and Without On-Site Surgical Backup. Circulation 2015; 132:388-401. [DOI: 10.1161/circulationaha.115.016137] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/03/2015] [Indexed: 01/16/2023]
Abstract
Background—
Emergency coronary artery bypass grafting for unsuccessful percutaneous coronary intervention (PCI) is now rare. We aimed to evaluate the current safety and outcomes of primary PCI and nonprimary PCI at centers with and without on-site surgical backup.
Methods and Results—
We performed an updated systematic review and meta-analysis by using mixed-effects models. We included 23 high-quality studies that compared clinical outcomes and complication rates of 1 101 123 patients after PCI at centers with or without on-site surgery. For primary PCI for ST-segment–elevation myocardial infarction (133 574 patients), all-cause mortality (without on-site surgery versus with on-site surgery: observed rates, 4.8% versus 7.2%; pooled odds ratio [OR], 0.99; 95% confidence interval, 0.91–1.07;
P
=0.729;
I
2
=3.4%) or emergency coronary artery bypass grafting rates (observed rates, 1.5% versus 2.4%; pooled OR, 0.76; 95% confidence interval, 0.56–1.01;
P
=0.062;
I
2
=42.5%) did not differ by presence of on-site surgery. For nonprimary PCI (967 549 patients), all-cause mortality (observed rates, 1.6% versus 2.1%; pooled OR, 1.15; 95% confidence interval, 0.94–1.41;
P
=0.172;
I
2
=67.5%) and emergency coronary artery bypass grafting rates (observed rates, 0.5% versus 0.8%; pooled OR, 1.14; 95% confidence interval, 0.62–2.13;
P
=0.669;
I
2
=81.7%) were not significantly different. PCI complication rates (cardiogenic shock, stroke, aortic dissection, tamponade, recurrent infarction) also did not differ by on-site surgical capability. Cumulative meta-analysis of nonprimary PCI showed a temporal decrease of the effect size (OR) for all-cause mortality after 2007.
Conclusions—
Clinical outcomes and complication rates of PCI at centers without on-site surgery did not differ from those with on-site surgery, for both primary and nonprimary PCI. Temporal trends indicated improving clinical outcomes in nonprimary PCI at centers without on-site surgery.
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Affiliation(s)
- Joo Myung Lee
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
| | - Doyeon Hwang
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
| | - Jonghanne Park
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
| | - Kyung-Jin Kim
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
| | - Chul Ahn
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
| | - Bon-Kwon Koo
- From Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Korea (J.M.L., D.H., J.P., K.-J.K., B.-K.K.); Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.A.); and Institute of Aging, Seoul National University, Korea (B.-K.K.)
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Simard T, Hibbert B, Pourdjabbar A, Ramirez FD, Wilson KR, Hawken S, O'Brien ER. Percutaneous coronary intervention with or without on-site coronary artery bypass surgery: A systematic review and meta-analysis. Int J Cardiol 2013; 167:197-204. [DOI: 10.1016/j.ijcard.2011.12.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 12/11/2011] [Accepted: 12/17/2011] [Indexed: 10/14/2022]
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Oqueli E. Current state of the performance of percutaneous coronary intervention in centres without on-site cardiac surgery. Intern Med J 2012; 42 Suppl 5:58-67. [PMID: 23035684 DOI: 10.1111/j.1445-5994.2012.02898.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Before the routine use of coronary stents, potential complications of percutaneous coronary interventions required the presence of backup cardiac surgery on-site. Advances in pharmacotherapy and interventional techniques, particularly in the last decade, have significantly decreased the rates of complications requiring emergency cardiac surgery, from approximately 4% to 6% in the balloon angioplasty era to as low as 0.3% to 0.6% in the contemporary era of routine intracoronary stent implantation. An early invasive approach has been shown to improve outcomes among patients with non-ST elevation acute coronary syndromes (NSTEACS), particularly in those at the highest risk, emphasising the importance of early access to revascularisation premises in such patients. Patients with ST-segment elevation myocardial infarction require immediate and sustained recanalisation of the culprit vessel to obtain rapid reperfusion of the threatened myocardium, in order to reduce infarct size and improve outcomes. Primary percutaneous coronary intervention at hospitals without on-site cardiac surgery improves clinical outcomes and reduces length of stay when compared with fibrinolytic therapy. It also significantly reduces door-to-balloon times when compared with transfer for percutaneous coronary interventions at hospitals with on-site surgery. It has been published that risk-adjusted mortality rates for patients undergoing percutaneous coronary interventions in centres without on-site surgical backup are comparable with those of percutaneous coronary intervention facilities that have cardiac surgery on-site, regardless of whether percutaneous coronary intervention was performed as primary therapy for ST-segment elevation myocardial infarction or in a non-primary setting. To achieve these results however, an adequate percutaneous coronary intervention programme is required, including proper hospital infrastructure and appropriately trained interventional cardiologists.
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Affiliation(s)
- E Oqueli
- Ballarat Health Services, Ballarat, Victoria, Australia.
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10
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Shahian DM, Meyer GS, Yeh RW, Fifer MA, Torchiana DF. Percutaneous coronary interventions without on-site cardiac surgical backup. N Engl J Med 2012; 366:1814-23. [PMID: 22571203 DOI: 10.1056/nejmra1109616] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David M Shahian
- Center for Quality and Safety and Department of Surgery, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA.
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Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JWM, Oliver-McNeil SM, Popma JJ, Tommaso CL. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol 2012; 59:2221-305. [PMID: 22575325 DOI: 10.1016/j.jacc.2012.02.010] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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12
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Zia MI, Wijeysundera HC, Tu JV, Lee DS, Ko DT. Percutaneous Coronary Intervention With vs Without On-Site Cardiac Surgery Backup: A Systematic Review and Meta-analysis. Can J Cardiol 2011; 27:664.e9-16. [DOI: 10.1016/j.cjca.2010.12.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 03/07/2010] [Indexed: 11/29/2022] Open
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Abstract
Prior to the widespread adoption of intracoronary stent implantation, potential complications of percutaneous coronary intervention (PCI) necessitated the presence of backup cardiac surgery. However, as stent implantation has become the predominant form of PCI, the incidence of emergent cardiac surgery has declined exponentially. Despite this, current guidelines recommend against the performance of elective PCI at hospitals without on-site cardiac surgery and recommend that primary PCI for ST-segment elevation myocardial infarction (STEMI) might be considered at hospitals without backup cardiac surgery. These recommendations are based predominantly on two principles: (1) hospital volume for PCI is strongly associated with clinical outcomes, and (2) results from a large registry study, in which the authors reported a substantial increase in mortality among patients undergoing non-primary/rescue PCI at hospitals without backup cardiac surgery. Since that time, evidence from multiple studies has suggested that performance of PCI at hospitals without backup cardiac surgery is feasible, safe, and both clinically and cost effective. Among STEMI patients, in particular, performance of primary PCI at hospitals without on-site cardiac surgery reduces time to reperfusion and subsequent adverse cardiovascular events as well as likely reducing infarct size. In this review, we will examine the evidence surrounding the performance of PCI for stable and unstable coronary disease at hospitals without on-site backup cardiac surgery.
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14
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Abstract
Background and Aim Primary percutaneous coronary intervention (PCI) is the preferred treatment option for acute myocardial infarction (MI). Off-site PCI reduces time-to-treatment, which could potentially lead to enhanced clinical outcomes. Therefore, we investigated whether off-site PCI improves 5-year clinical outcomes compared with on-site PCI and whether this is related to in-hospital 99mTc-sestamibi single photon emission computed tomography (MIBI SPECT) parameters. Methods We describe the 5-year follow-up for a combined endpoint of death or re-infarction in 128 patients with acute MI who were randomly assigned to undergo primary PCI at the off-site centre (n = 68) or to transferral to an on-site centre (n = 60). Three days after PCI, MIBI SPECT was performed to estimate infarct size. A multivariate Cox regression model was created to study the relation between MIBI SPECT parameters and long-term clinical outcomes. Results After a mean follow-up of 5.8 ± 1.1 years, 25 events occurred. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 ± 54 versus 125 ± 59 min, p = 0.003). However, infarct size (17 ± 15 versus 14 ± 12%, p = 0.34) and 5-year death or infarct rate (21% versus 18%, p = 0.75) were comparable between treatment centres. With multivariate analysis, only Killip class ≥2 and Q wave MI, but not scintigraphic data, predicted long-term clinical outcomes. Conclusion Off-site PCI reduced door-to-balloon time with a comparable 5-year death or infarct rate. Parameters from resting MIBI SPECT on day 3 after MI did not predict long-term clinical outcomes.
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15
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Hannan EL, Zhong Y, Racz M, Jacobs AK, Walford G, Cozzens K, Holmes DR, Jones RH, Hibberd M, Doran D, Whalen D, King SB. Outcomes for Patients With ST-Elevation Myocardial Infarction in Hospitals With and Without Onsite Coronary Artery Bypass Graft Surgery. Circ Cardiovasc Interv 2009; 2:519-27. [DOI: 10.1161/circinterventions.109.894048] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The benefit of primary percutaneous coronary interventions (P-PCI) for patients with ST-elevation myocardial infarction (STEMI) has been well documented. However, controversy still exists as to whether PCI should be expanded to hospitals without coronary artery bypass graft surgery.
Methods and Results—
Patients who were discharged after PCI for STEMI between January 1, 2003, and December 12, 2006, in P-PCI centers (hospitals with no coronary artery bypass graft surgery, and PCI only for patients with STEMI) were propensity matched with patients in full service centers, and mortality and subsequent revascularization rates were compared. For patients undergoing PCI, there were no differences for in-hospital/30-day mortality (2.3% for P-PCI centers versus 1.9% for full service centers [
P
=0.40]), emergency coronary artery bypass graft surgery immediately after PCI (0.06% versus 0.35%,
P
=0.06), 3-year mortality (7.1% versus 5.9%,
P
=0.07), or 3-year subsequent revascularization (23.8% versus 21.5%,
P
=0.52). P-PCI centers had a lower same/next day coronary artery bypass graft rate (0.23% versus 0.69%,
P
=0.046) and higher repeat target vessel PCI rates (12.1% versus 9.0%,
P
=0.003). For patients with STEMI who did not undergo PCI, P-PCI centers had higher in-hospital mortality (28.5% versus 22.3%; adjusted odds ratio, 1.38; 95% CI, 1.10 to 1.75).
Conclusions—
No differences between P-PCI centers and full service centers were found in in-hospital/30-day mortality, the need for emergency surgery, 3-year mortality or subsequent revascularization, but P-PCI centers had higher repeat target vessel PCI rates and higher mortality rates for patients who did not undergo PCI. P-PCI centers should be monitored closely, including the monitoring of patients with STEMI who did not undergo PCI.
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Affiliation(s)
- Edward L. Hannan
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Ye Zhong
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Michael Racz
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Alice K. Jacobs
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Gary Walford
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Kimberly Cozzens
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - David R. Holmes
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Robert H. Jones
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Mary Hibberd
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Donna Doran
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Deborah Whalen
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
| | - Spencer B. King
- From the University at Albany (E.L.H., M.R., Y.Z., K.C.), State University of New York; Albany College of Pharmacy and Health Sciences (M.R.), Albany, NY; New York State Department of Health (M.R., D.D.), Albany, NY; Boston Medical Center (A.K.J., D.W.), Boston, Mass; St Joseph’s Hospital (G.W.), Syracuse, NY; Mayo Clinic (D.R.H.), Rochester, Minn; Duke University Medical Center (R.H.J.), Durham, NC; SUNY Stony Brook (M.H.), Stony Brook, NY; and St Joseph’s Hospital (S.B.K.), Atlanta, Ga
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Singh M, Gersh BJ, Lennon RJ, Ting HH, Holmes DR, Doyle BJ, Rihal CS. Outcomes of a system-wide protocol for elective and nonelective coronary angioplasty at sites without on-site surgery: the Mayo Clinic experience. Mayo Clin Proc 2009; 84:501-8. [PMID: 19483166 PMCID: PMC2688623 DOI: 10.1016/s0025-6196(11)60581-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital). PATIENTS AND METHODS Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site. RESULTS Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge. CONCLUSION Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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17
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Singh M, Gersh BJ, Lennon RJ, Ting HH, Holmes DR, Doyle BJ, Rihal CS. Outcomes of a system-wide protocol for elective and nonelective coronary angioplasty at sites without on-site surgery: the Mayo Clinic experience. Mayo Clin Proc 2009; 84:501-8. [PMID: 19483166 PMCID: PMC2688623 DOI: 10.4065/84.6.501] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital). PATIENTS AND METHODS Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site. RESULTS Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge. CONCLUSION Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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18
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Kutcher MA, Klein LW, Ou FS, Wharton TP, Dehmer GJ, Singh M, Anderson HV, Rumsfeld JS, Weintraub WS, Shaw RE, Sacrinty MT, Woodward A, Peterson ED, Brindis RG. Percutaneous Coronary Interventions in Facilities Without Cardiac Surgery On Site: A Report From the National Cardiovascular Data Registry (NCDR). J Am Coll Cardiol 2009; 54:16-24. [DOI: 10.1016/j.jacc.2009.03.038] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 02/18/2009] [Accepted: 03/10/2009] [Indexed: 11/17/2022]
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Peels J, Hautvast R, de Swart J, Huybregts M, Umans V, Arnold A, Jessurun G, Zijlstra F. Percutaneous coronary intervention without on site surgical back-up; two-years registry of a large Dutch community hospital. Int J Cardiol 2009; 132:59-65. [DOI: 10.1016/j.ijcard.2007.10.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 07/18/2007] [Accepted: 10/27/2007] [Indexed: 10/22/2022]
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20
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Srinivas V, Hailpern SM, Koss E, Monrad ES, Alderman MH. Effect of Physician Volume on the Relationship Between Hospital Volume and Mortality During Primary Angioplasty. J Am Coll Cardiol 2009; 53:574-579. [DOI: 10.1016/j.jacc.2008.09.056] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 09/22/2008] [Accepted: 09/29/2008] [Indexed: 11/28/2022]
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21
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Safety and efficacy of offsite percutaneous coronary interventions in 1,348 consecutive patients in rural Tasmania. Am J Cardiol 2008; 102:1323-7. [PMID: 18993149 DOI: 10.1016/j.amjcard.2008.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 07/08/2008] [Accepted: 07/13/2008] [Indexed: 11/22/2022]
Abstract
Despite controversy, a growing body of data exists suggesting that percutaneous coronary intervention (PCI) with no surgical onsite availability is safe and efficacious. Over a period of 3 years all patients requiring PCI had their intervention performed at the Launceston General Hospital, a regional hospital serving rural Tasmania, Australia. There were no exclusion criteria uniformly adopted. Primary end points included angiographic success and major procedure-related complications. A total cohort of 1,348 consecutive patients underwent PCI during the calendar years of 2005 through 2007, including patients with ST-elevation myocardial infarction. Angiographic success for all patients was >98%. In-hospital mortality was 0.8% overall. Only 1 patient required urgent transfer to a cardiac surgical center. Bleeding rates requiring transfusion were approximately 1%. Excellent clinical outcomes have been achieved in a relatively remote PCI center in rural, northern Tasmania, where there is no emergency cardiac surgical availability. Angiographic success was high and complication rates were low, consistent with worldwide standards. In conclusion, PCI without onsite surgery appears safe and efficacious when well-trained staffing is available.
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Giuliani G, Bonechi F, Vecchio S, Biondi-Zoccai GGL, Nieri M, Vittori G, Spaziani G, Nassi F, Chechi T, Di Mario C, Zipoli A, Margheri M. Comparison of primary angioplasty in rural and metropolitan areas within an integrated network. EUROINTERVENTION 2008; 4:365-72. [PMID: 19110811 DOI: 10.4244/eijv4i3a65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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23
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Knaapen P, de Mulder M, van der Zant FM, Peels HO, Twisk JWR, van Rossum AC, Cornel JH, Umans VAWM. Infarct size in primary angioplasty without on-site cardiac surgical backup versus transferal to a tertiary center: a single photon emission computed tomography study. Eur J Nucl Med Mol Imaging 2008; 36:237-43. [PMID: 18719908 DOI: 10.1007/s00259-008-0917-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/28/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) performed in large community hospitals without cardiac surgery back-up facilities (off-site) reduces door-to-balloon time compared with emergency transferal to tertiary interventional centers (on-site). The present study was performed to explore whether off-site PCI for acute myocardial infarction results in reduced infarct size. METHODS AND RESULTS One hundred twenty-eight patients with acute ST-segment elevation myocardial infarction were randomly assigned to undergo primary PCI at the off-site center (n = 68) or to transferal to an on-site center (n = 60). Three days after PCI, (99m)Tc-sestamibi SPECT was performed to estimate infarct size. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 +/- 54 versus 125 +/- 59 min, respectively, p < 0.01), although symptoms-to-treatment time was only insignificantly reduced (257 +/- 211 versus 286 +/- 146 min, respectively, p = 0.39). Infarct size was comparable between treatment centers (16 +/- 15 versus 14 +/- 12%, respectively p = 0.35). Multivariate analysis revealed that TIMI 0/1 flow grade at initial coronary angiography (OR 3.125, 95% CI 1.17-8.33, p = 0.023), anterior wall localization of the myocardial infarction (OR 3.44, 95% CI 1.38-8.55, p < 0.01), and development of pathological Q-waves (OR 5.07, 95% CI 2.10-12.25, p < 0.01) were independent predictors of an infarct size > 12%. CONCLUSIONS Off-site PCI reduces door-to-balloon time compared with transferal to a remote on-site interventional center but does not reduce infarct size. Instead, pre-PCI TIMI 0/1 flow, anterior wall infarct localization, and development of Q-waves are more important predictors of infarct size.
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Affiliation(s)
- Paul Knaapen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
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Stone GW. Angioplasty strategies in ST-segment-elevation myocardial infarction: part I: primary percutaneous coronary intervention. Circulation 2008; 118:538-51. [PMID: 18663102 DOI: 10.1161/circulationaha.107.756494] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Gregg W Stone
- Columbia University Medical Center, 111 E 59th St, 11th Floor, New York, NY 10022, USA.
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A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction. J Gen Intern Med 2008; 23:1246-56. [PMID: 18459014 PMCID: PMC2517976 DOI: 10.1007/s11606-008-0563-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 07/05/2007] [Accepted: 02/08/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI). DATA SOURCE Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry. INTERVENTIONS We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy. MEASUREMENTS AND MAIN RESULTS We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13-64% for door to balloon. CONCLUSIONS We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.
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Jacobs AK. Primary percutaneous coronary intervention without cardiac surgery on-site: coming to a hospital near you? Am Heart J 2008; 155:585-8. [PMID: 18371462 DOI: 10.1016/j.ahj.2008.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 01/26/2008] [Indexed: 01/22/2023]
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Peels HO, de Swart H, Ploeg TV, Hautvast RW, Cornel JH, Arnold AE, Wharton TP, Umans VA. Percutaneous coronary intervention with off-site cardiac surgery backup for acute myocardial infarction as a strategy to reduce door-to-balloon time. Am J Cardiol 2007; 100:1353-8. [PMID: 17950789 DOI: 10.1016/j.amjcard.2007.06.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 06/13/2007] [Accepted: 06/13/2007] [Indexed: 10/22/2022]
Abstract
We investigated whether primary percutaneous coronary intervention (PCI) for patients admitted with an acute ST-segment elevation myocardial infarction could be performed more rapidly and with comparable outcomes in a community hospital versus a tertiary center with cardiac surgery. We started the first PCI with an off-site surgery program in The Netherlands in 2002 and report the results of 439 consecutive patients. In the safety phase, 199 patients presenting with ST-segment elevation myocardial infarction were randomly assigned to treatment at our off-site center versus a more distant cardiac surgery center. In the confirmation phase, 240 consecutive patients were treated in the off-site hospital. Safety and efficacy end points were the rate of an angiographically successful PCI procedure (diameter stenosis <50% and Thrombolysis In Myocardial Infarction grade 3 flow) in the absence of major adverse cardiac and cerebrovascular events at 30 days. The randomization phase showed a 37-minute decrease in door-to-balloon time (p <0.001) with comparable procedural and clinical successes (91% Thrombolysis In Myocardial Infarction grade 3 flow in the 2 groups). In the confirmation phase, the 30-day rate without major adverse cardiac and cerebrovascular events was 95%. None of the 439 patients in the study required emergency surgery for failed primary PCI. In conclusion, time to treatment with primary PCI can be significantly shortened when treating patients in a community hospital setting with off-site cardiac surgery backup compared with transport for PCI to a referral center with on-site surgery. PCI at hospitals with off-site cardiac surgery backup can be considered a needed strategy to improve access to primary PCI for a larger segment of the population and can be delivered with a very favorable safety profile.
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Affiliation(s)
- Brahmajee K Nallamothu
- Health Services Research and Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, and the Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical School, Ann Arbor, USA
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Ellrodt G, Sadwin LB, Aversano T, Brodie B, O'Brien PK, Gray R, Hiratzka LF, Larson D. Development of Systems of Care for ST-Elevation Myocardial Infarction Patients. Circulation 2007; 116:e49-54. [PMID: 17538040 DOI: 10.1161/circulationaha.107.184048] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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30
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Singh KP, Harrington RA. Primary percutaneous coronary intervention in acute myocardial infarction. Med Clin North Am 2007; 91:639-55; x-xi. [PMID: 17640540 DOI: 10.1016/j.mcna.2007.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Primary percutaneous coronary intervention (PCI) has emerged as the preferred therapy for acute ST-segment elevation myocardial infarction (STEMI), as multiple randomized clinical trials and pooled analyses have shown improved clinical outcomes compared with medical reperfusion. Unfortunately, medical centers with 24-hour PCI capability are concentrated in urban areas, relegating many patients in the United States to inferior medical reperfusion. Ongoing substantial research efforts are directed at optimizing mechanical reperfusion, including refinements in adjuvant medical therapy and the use of drug-eluting stents in the catheterization laboratory. Research efforts are also focusing on the implementation of streamlined transfer systems from community centers to tertiary care centers, akin to systems used in the trauma model. Furthermore, experience with the performance of primary PCI at community centers without onsite surgical backup is growing. This article summarizes data regarding the current state, challenges, and future directions of primary PCI for STEMI, emphasizing adherence to current American College of Cardiology/American Heart Association guidelines.
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Affiliation(s)
- Kanwar P Singh
- Pat and Jim Calhoun Cardiovascular Center, University of Connecticut, Farmington, CT 06030, USA.
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Kent DM, Ruthazer R, Griffith JL, Beshansky JR, Grines CL, Aversano T, Concannon TW, Zalenski RJ, Selker HP. Comparison of mortality benefit of immediate thrombolytic therapy versus delayed primary angioplasty for acute myocardial infarction. Am J Cardiol 2007; 99:1384-8. [PMID: 17493465 DOI: 10.1016/j.amjcard.2006.12.068] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Revised: 12/21/2006] [Accepted: 12/21/2006] [Indexed: 11/25/2022]
Abstract
Primary percutaneous coronary intervention (PPCI) yields superior mortality outcomes compared with thrombolysis in ST-elevation acute myocardial infarction (STEMI) but takes longer to administer. Previous meta-regressions have estimated that a procedure-related delay of 60 minutes would nullify the benefits of PPCI on mortality. Using a combined database from randomized clinical trials and registries (n = 2,781) and an independently developed model of mortality risk in STEMI, we developed logistic regression models predicting 30-day mortality for PPCI and thrombolysis by examining the influence of baseline risk on the treatment effect of PPCI and on the hazard of treatment delay. We used these models to solve mathematically for "time interval to mortality equivalence," defined as the PPCI-related delay that would nullify its expected mortality benefit over thrombolysis, and to explore the influence of baseline risk on this value. As baseline risk increases, the relative benefit of PPCI compared with thrombolytic therapy significantly increases (p = 0.002); patients with STEMI at relatively low risk of mortality accrue little or no incremental mortality benefit from PPCI, but high-risk patients benefit greatly. However, as baseline risk increases, the hazard associated with longer treatment-related delay also increases (p = 0.007). These 2 effects are compensatory and yield a roughly uniform time interval to mortality equivalence of approximately 100 minutes in patients who have at least a moderate degree of mortality risk (> approximately 4%). In conclusion, the mortality benefits of PPCI and the hazard of PPCI-related delay depend on baseline risk. Previous meta-regressions appear to have underestimated the PPCI-related delay that would nullify the incremental benefits of PPCI.
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Affiliation(s)
- David M Kent
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Lemkes J, Peels J, Huybregts R, de Swart H, Hautvast R, Umans V. Emergency cardiac surgery after a failed percutaneous coronary intervention in an interventional centre without on-site cardiac surgery. Neth Heart J 2007; 15:173-7. [PMID: 17612679 PMCID: PMC1877970 DOI: 10.1007/bf03085976] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND.: Based on experience from other countries, the Medical Centre Alkmaar was granted permission to start the first Dutch PCI programme without on-site cardiac surgery. The cardiology group of the Medical Centre Alkmaar started an off-site PCI programme in 2002 with only primary PCI in the first year and a full PCI programme from November 2003 onwards. We report the first Dutch experience with acute cardiac surgery following a failed PCI procedure in an off-site clinic. PATIENTS.: From October 2002 until February 2007, 2500 patients were treated by PCI in the Medical Centre Alkmaar. These patients were treated for an acute myocardial infarction (33%), acute coronary syndromes (37%) or progressive angina (30%). In this first series of off-site PCI in the Netherlands, the incidence of emergency cardiac surgery following failed PCI was 0.2% All five patients who needed emergency surgery underwent elective PCI for progressive stable coronary artery disease. No emergency surgery was needed for primary PCIs in patients with an acute myocardial infarction. All patients survived emergency surgery following failed PCI. CONCLUSION.: Adherence to the Dutch guidelines of interventional cardiology with protocols describing a close collaboration with cardiac surgeons and an immediate availability of rapid ground transportation are mandatory when performing off-site PCI. This series extends the current expertise of emergency surgery after failed PCI to off-site clinics. With appropriate settings, off-site PCI may not be associated with an increase in the risk of adverse events. (Neth Heart J 2007;15:173-7.).
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Affiliation(s)
- J.S. Lemkes
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands
| | - J.O.J. Peels
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands
| | - R. Huybregts
- Department of Cardiac Surgery, VU Medical Centre, Amsterdam, the Netherlands
| | - H. de Swart
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands
| | - R. Hautvast
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands
| | - V.A.W.M. Umans
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, the Netherlands
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Dalby M, Roughton M, Ilsley C. Door-to-balloon time in acute myocardial infarction. N Engl J Med 2007; 356:1475-6; author reply 1478-9. [PMID: 17409334 DOI: 10.1056/nejmc063669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Dehmer GJ, Kutcher MA, Dey SK, Shaw RE, Weintraub WS, Mitchell K, Brindis RG. Frequency of percutaneous coronary interventions at facilities without on-site cardiac surgical backup--a report from the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Am J Cardiol 2007; 99:329-32. [PMID: 17261392 DOI: 10.1016/j.amjcard.2006.08.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Revised: 08/22/2006] [Accepted: 08/22/2006] [Indexed: 10/23/2022]
Abstract
The practice of performing percutaneous coronary intervention (PCI) in centers without on-site cardiac surgical backup is controversial. Using data from facilities that participated in the American College of Cardiology/National Cardiovascular Data Registry, the incidence of PCI without on-site surgical backup was evaluated. From January 1, 2001 through December 31, 2004, 39 of 449 (8.7%) centers were identified as sites that performed PCI without on-site surgical backup. By the end of 2005, 75 of 463 (16%) participating facilities were performing PCI without on-site backup. By using standardized data element definitions, it was possible to differentiate between patients who underwent elective PCI and those who had urgent nonelective PCI for acute ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction. This analysis showed that the number of elective and nonelective PCI procedures with or without on-site surgical backup per quarter had increased significantly (p <0.0001) from 2001 to 2004. The number of PCI procedures performed without on-site surgical backup continued to increase in 2005. In conclusion, the significant increase in elective PCIs performed at facilities without on-site surgical backup occurred despite national guidelines that state elective PCI should not be done in centers without on-site cardiac surgery.
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Affiliation(s)
- Gregory J Dehmer
- Texas A&M University College of Medicine and Cardiology Division, Scott & White Clinic, Temple, Texas, USA.
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Harjai KJ, Stone GW, Grines CL, Cox DA, Garcia E, Tcheng JE, Na Y, Griffin JJ, Guagliumi G, Stuckey T, Turco M, Rutherford BD, Lansky AJ, Mehran R. Usefulness of routine unfractionated heparin infusion following primary percutaneous coronary intervention for acute myocardial infarction in patients not receiving glycoprotein IIb/IIIa inhibitors. Am J Cardiol 2007; 99:202-7. [PMID: 17223419 DOI: 10.1016/j.amjcard.2006.07.084] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Revised: 07/25/2006] [Accepted: 07/25/2006] [Indexed: 11/15/2022]
Abstract
We evaluated the utility of a routine postprocedure course of unfractionated heparin after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in patients not receiving glycoprotein IIb/IIIa inhibitors. In the CADILLAC study, 2,082 patients with AMI who underwent primary PCI were randomized to receive stents versus percutaneous transluminal coronary angioplasty (PTCA), each with or without abciximab. In a subset of 976 patients who did not receive abciximab, we compared outcomes of patients who received postprocedural heparin (n = 758; 78%; median duration 2 days) with those who did not. In 421 patients treated with PTCA, postprocedural heparin use was associated with lower in-hospital major adverse cardiac events (MACEs; 5.3% vs 11.4%, p = 0.069), 1-year MACEs (22% vs 31%, p = 0.08), and decreased in-hospital moderate/severe bleeding (2.3% vs 8.9%, p = 0.01). By multivariate analyses, heparin use correlated with freedom from in-hospital and 1-year MACEs in patients after PTCA. In contrast, in 555 patients who underwent stenting, postprocedural heparin use was associated with increased bleeding and hospitalization costs without a decrease in early or late MACEs. In conclusion, in patients with AMI treated with coronary stenting without glycoprotein IIb/IIIa inhibitors, routine postprocedural heparin was not associated with any significant benefits and may be safely omitted. However, in a subset of patients treated with PTCA, postprocedural heparin use was independently associated with fewer in-hospital and 1-year MACEs.
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Affiliation(s)
- Ellen C Keeley
- Department of Internal Medicine (Cardiology Division), University of Virginia School of Medicine, Charlottesville, USA
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Shiraishi J, Kohno Y, Sawada T, Nishizawa S, Arihara M, Hadase M, Hyogo M, Yagi T, Shima T, Okada T, Matoba S, Yamada H, Tatsumi T, Kitamura M, Furukawa K, Matsubara H. In-Hospital Outcomes of Primary Percutaneous Coronary Interventions Performed at Hospitals With and Without On-Site Coronary Artery Bypass Graft Surgery. Circ J 2007; 71:1208-12. [PMID: 17652882 DOI: 10.1253/circj.71.1208] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is performed in hospitals without on-site coronary artery bypass graft surgery in the ;real world'. However, data on the in-hospital outcomes of primary PCI performed at hospitals with and without on-site cardiac surgery are still lacking in Japan. METHODS AND RESULTS In the present study, 2,230 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Of these, 1,817 patients underwent primary PCI. Excluding patients without adequate data, we retrospectively compared clinical background, coronary risk factors, angiographic findings, acute results of primary PCI and in-hospital prognosis between patients undergoing primary PCI in hospitals without on-site cardiac surgery (without surgery group, n=792) and those in hospitals with (with surgery group, n=993). The without surgery group had higher prevalence of previous myocardial infarction, Killip class>or=3 at admission and multivessels as a culprit lesion than the with surgery group. The without surgery group was more likely to have lower frequency of stent usage and lower thrombolysis in myocardial infarction flow grade just after PCI, whereas it was more likely to have intra-aortic balloon pumping and temporary pacing during procedures. The overall in-hospital mortality did not differ between the 2 groups. On multivariate analysis, in AMI patients undergoing primary PCI, Killip class>or=3 at admission, multivessels or left main trunk (LMT) as culprit lesions, number of diseased vessels>or=2 or diseased LMT, and age were the independent predictors of the in-hospital mortality, but the presence of on-site cardiac surgery was not. CONCLUSIONS These results suggest that in-hospital outcomes in AMI patients undergoing primary PCI at hospitals without on-site cardiac surgery are comparable to those at hospitals with on-site cardiac surgery in Japan.
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Affiliation(s)
- Jun Shiraishi
- Department of Cardiology, Kyoto First Red Cross Hospital, and Department of Cardiology and Vascular Regenerative Medicine, Kyoto Prefectural University School of Medicine, Japan.
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Skelding KA, Klein LW. SCAI membership survey of the 2005 AHA/ACC/SCAI PCI guideline: a summary report from the Interventional Committee. Catheter Cardiovasc Interv 2006; 68:173-80. [PMID: 16789027 DOI: 10.1002/ccd.20854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Singh M. The predicament of offering elective percutaneous coronary intervention at sites without on-site cardiac surgery. Am Heart J 2006; 152:810-1. [PMID: 17070137 DOI: 10.1016/j.ahj.2005.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Accepted: 08/12/2005] [Indexed: 10/24/2022]
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Canabal Berlanga A, Martín Parra C, Sáez Noguero S, Cabestrero Alonso D, Rodríguez Blanco M. [Results of the performance of percutaneous coronary revascularization procedures without the presence of heart surgery]. Med Intensiva 2006; 30:331-6. [PMID: 17067506 DOI: 10.1016/s0210-5691(06)74538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The offer of percutaneous coronary revascularization procedures has extended over a large number of health care sites including those that do not have heart surgery. This phenomenon is related with the favorable results of the coronary angioplasty in the treatment of acute coronary syndrome, reported in the scientific literature, above all after the appearance of the coronary stent and the new antiaggregant drugs. In order to offer the primary angioplasty to the population as a treatment that is more effective than drug revascularization, sites having coronary interventionism without heart surgery and sometimes with low volume of patients per year have proliferated. At present, a review is being made of the convenience of continuing with this tendency and reflection is made on the necessary conditions in the expansion of these percutaneous procedures through the secondary level health care sites. The initial data of this review seem to indicate that the existence of interventionist cardiology laboratories in sites without heart surgery can be defended when a minimum number of procedures per year is guaranteed, the primary angioplasty and rescue one being those that have the best results. However, worse results are obtained in sites not supported by heart surgery when non-primary, non-rescue angioplasties and non-ST elevation acute coronary syndromes are dealt with and above all when there is a small volume of patients per year.
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Harjai KJ, Mehta RH, Stone GW, Boura JA, Grines L, Brodie BR, Cox DA, O'Neill WW, Grines CL. Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction? J Interv Cardiol 2006; 19:285-94. [PMID: 16881971 DOI: 10.1111/j.1540-8183.2006.00146.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.
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Long KH, McMurtry EK, Lennon RJ, Chapman AC, Singh M, Rihal CS, Wood DL, Holmes DR, Ting HH. Elective Percutaneous Coronary Intervention Without On-Site Cardiac Surgery. Med Care 2006; 44:406-13. [PMID: 16641658 DOI: 10.1097/01.mlr.0000207489.13557.cc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Low procedural complication rates, barriers to access, and patient preference have encouraged the development of percutaneous coronary intervention (PCI) programs at centers that are often closer to home but without on-site cardiac surgical capability. OBJECTIVES We compared clinical and economic outcomes associated with performing low-risk elective PCI at a community hospital without on-site cardiac surgery with those obtained at a more remote tertiary care center with on-site cardiac surgery. DESIGN AND MEASURES We matched 257 patients undergoing low-risk, elective PCI at a community hospital (Immanuel St. Joseph's Hospital [ISJ] between January 27, 2000, and July 31, 2002) to 514 PCI patients treated at a tertiary care hospital (Saint Marys Hospital [SMH] between January 27, 2000, and April 30, 2002) based on clinical and lesion criteria. Clinical outcomes (in-hospital procedural success and target vessel failure during long-term follow up) and economic outcomes (direct medical costs, billed charges, and hospital length of stay [LOS]) were compared between groups. The Mayo Clinic PCI Registry (containing clinical, angiographic, and follow-up data) and administrative data were used in matching and outcomes assessment. RESULTS Procedural success was achieved more often among ISJ-treated patients (99% vs. 95%; P = 0.02); however, no difference in target vessel failure rates was observed during a median follow-up time of 3.1 years (estimated 1-year event rate: 15.2% vs. 14.8%; P = 0.46). ISJ-treated patients incurred, on average, $3024 more in estimated total costs ($13,771 vs. $10,746; P < 0.001) and $6084 more in billed charges (P < 0.001), but incurred similar LOS post procedure (1.53 days). CONCLUSIONS Similar clinical outcomes were achieved at a community hospital without on-site cardiac surgery but at significantly increased direct medical cost. Patients, providers, hospitals, payers, and policymakers should consider whether the benefits associated with locally provided specialized cardiovascular services warrant this additional cost.
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Affiliation(s)
- Kirsten Hall Long
- Department of Health Sciences Research, Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Ting HH, Raveendran G, Lennon RJ, Long KH, Singh M, Wood DL, Gersh BJ, Rihal CS, Holmes DR. A Total of 1,007 Percutaneous Coronary Interventions Without Onsite Cardiac Surgery. J Am Coll Cardiol 2006; 47:1713-21. [PMID: 16631012 DOI: 10.1016/j.jacc.2006.02.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 01/31/2006] [Accepted: 02/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We sought to compare clinical outcomes of elective percutaneous coronary intervention (PCI) and primary PCI for ST-segment elevation myocardial infarction (STEMI) at a community hospital without onsite cardiac surgery to those at a tertiary center with onsite cardiac surgery. BACKGROUND Disagreement exists about whether hospitals with cardiac catheterization laboratories, but without onsite cardiac surgery, should develop PCI programs. Primary PCI for STEMI at hospitals without onsite cardiac surgery have achieved satisfactory outcomes; however, elective PCI outcomes are not well defined. METHODS A total of 1,007 elective PCI and primary PCI procedures performed from March 1999 to August 2005 at the Immanuel St. Joseph's Hospital-Mayo Health System (ISJ) in Mankato, Minnesota, were matched one-to-one with those performed at St. Mary's Hospital (SMH) in Rochester, Minnesota. Strict protocols were followed for case selection and PCI program requirements. Clinical outcomes (in-hospital procedural success, death, any myocardial infarction, Q-wave myocardial infarction, and emergency coronary artery bypass surgery) and follow-up survival were compared between groups. RESULTS Among 722 elective PCIs, procedural success was 97% at ISJ compared with 95% at SMH (p = 0.046). Among 285 primary PCIs for STEMI, procedural success was 93% at ISJ and 96% at SMH (p = 0.085). No patients at ISJ undergoing PCI required emergent transfer for cardiac surgery. Survival at two years' follow-up by treatment location was similar for patients with elective PCI and primary PCI. CONCLUSIONS Similar clinical outcomes for elective PCI and primary PCI were achieved at a community hospital without onsite cardiac surgery compared with those at a tertiary center with onsite cardiac surgery using a prospective, rigorous protocol for case selection and PCI program requirements.
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Affiliation(s)
- Henry H Ting
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Nallamothu BK, Bates ER, Wang Y, Bradley EH, Krumholz HM. Driving Times and Distances to Hospitals With Percutaneous Coronary Intervention in the United States. Circulation 2006; 113:1189-95. [PMID: 16520425 DOI: 10.1161/circulationaha.105.596346] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The success of prehospital triage protocols for patients with ST-elevation myocardial infarction (STEMI) will depend, in part, on how patients are geographically distributed around hospitals that perform percutaneous coronary intervention (PCI). Accordingly, we determined the proportion of the adult population in the United States with timely access to PCI hospitals using driving times and distances.
Methods and Results—
We performed a cross-sectional study using hospital-level data from the American Hospital Association Annual Survey and Census tract-level data on adults 18 years of age or older from the 2000 United States Census. Our aims were to determine the proportion of the adult population who (1) lived within 60 minutes of a PCI hospital and (2) had additional transport times within 30 minutes if directly referred to a PCI hospital as opposed to a closer, non-PCI hospital. Median times and distances to the closest PCI hospital were 11.3 (interquartile range [IQR] 5.7 to 28.5) minutes and 7.9 (IQR 3.5 to 22.4) miles, respectively. A total of 79.0% of the adult population lived within 60 minutes of a PCI hospital. Among those with a non-PCI hospital as their closest facility, 74.0% required additional transport times of <30 minutes if directly referred to a PCI hospital as opposed to the non-PCI hospital. These estimates varied substantially across regions and urban, suburban, and rural Census tracts.
Conclusions—
Nearly 80% of the adult population in the United States lived within 60 minutes of a PCI hospital in 2000. Even among those living closer to non-PCI hospitals, almost three fourths would experience <30 minutes of additional delay with direct referral to a PCI hospital, which suggests that such a strategy might be feasible for these individuals.
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Affiliation(s)
- Brahmajee K Nallamothu
- Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
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Wharton TP. Increasing the speed and delivery of primary percutaneous coronary intervention in the community: should the ACC/AHA Guidelines be revisited? Crit Pathw Cardiol 2006; 5:34-43. [PMID: 18340216 DOI: 10.1097/01.hpc.0000164655.08221.3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Thomas P Wharton
- Section of Cardiology, Exeter Hospital, Exeter, New Hampshire, USA.
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Mehta RH, Harjai KJ, Cox DA, Stone GW, Brodie BR, Boura J, Grines L, O'Neill W, Grines CL. Comparison of coronary stenting versus conventional balloon angioplasty on five-year mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol 2005; 96:901-6. [PMID: 16188513 DOI: 10.1016/j.amjcard.2005.05.044] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 05/26/2005] [Accepted: 05/26/2005] [Indexed: 11/28/2022]
Abstract
Little is known about the influence of stenting versus balloon angioplasty on long-term outcomes (particularly mortality) after primary percutaneous coronary intervention (PCI). We evaluated 2,087 patients with ST-elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction (PAMI) trials in the United States, who underwent primary PCI. The main outcome was all-cause mortality at 5 years, obtained through the National Death Index. Of the 2,087 patients, stenting was performed in 692 (33%). The absolute difference in the hospital (2.2% vs 3.3%), 1-year (3.3% vs 5.2%), and 5-year (10% vs 13%) mortality rates favored patients receiving a stent versus conventional balloon therapy, with the difference increasing with time. A multivariate Cox model identified stent use (vs balloon alone) as an independent correlate of lower 5-year mortality (hazard ratio 0.60, 95% confidence interval 0.42 to 0.85). The absolute reduction in mortality was greatest in the highest risk group. In conclusion, compared with balloon angioplasty, stenting during primary PCI not only resulted in better angiographic and short-term outcomes, but also in a sustained beneficial effect on mortality at 5 years. These data support the routine use of coronary stenting in most patients undergoing primary PCI, when feasible.
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Krumholz HM. The Year in Epidemiology, Health Services, and Outcomes Research. J Am Coll Cardiol 2005; 46:1362-70. [PMID: 16198857 DOI: 10.1016/j.jacc.2005.06.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Accepted: 06/14/2005] [Indexed: 01/19/2023]
Affiliation(s)
- Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut 06520-8088, USA.
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 SW First Street, Rochester, MN 55905, USA.
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