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Moady G, Ovdat T, Rubinshtein R, Eitan A, Daud E, Arow Z, Atar S. The impact of on-site cardiac surgical backup on clinical outcomes of acute coronary syndrome-analysis of the ACSIS national registry. Front Cardiovasc Med 2023; 10:1207473. [PMID: 37727307 PMCID: PMC10505675 DOI: 10.3389/fcvm.2023.1207473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023] Open
Abstract
Background The availability of advanced technologies for mechanical support in hospitals with on-site cardiac surgery (CS), along with the ability to perform urgent coronary artery bypass graft (CABG) surgery, may result in improved clinical outcomes in patients with acute coronary syndrome (ACS). Methods We conducted a retrospective analysis of the bi-annually Acute Coronary Syndrome Israeli Survey (ACSIS) registry from the year 2000 to 2020, performed in hospitals with and without CS. Mortality rates and major adverse cardiac and cerebrovascular events (MACCE) rates are reported. We evaluated two periods of the study-early (2000-2010) vs. late (2011-2020). Propensity score matching was performed to reduce bias between the two groups. Results The study included 16,979 patients (52.3% in the on-site CS group). Patients in the on-site CS group were more likely to undergo percutaneous coronary intervention (PCI), (odds ratio [OR], 1.26 [95% CI, 1.18-1.35]; p < 0.001) and CABG [OR, 1.91 (95%CI, 1.63-2.24); P < 0.001], and patients in hospitals without on-site CS had higher 30-day MACCE [OR, 1.17 (95% CI, 1.07-1.27); p < 0.0005]. Overall, there was no difference in 1-year mortality (hazard ratio [HR], 0.98 [95% CI, 0.89-1.08]; p = 0.71) between the groups. During the late period of the study, patients in the group without on-site CS had lower 30-day mortality [OR, 0.69 (95% CI, 0.49-0.97); P = 0.04], yet with no difference in 1-year mortality [HR, 0.81 (95% CI, 0.65-1.01); p = 0.07]. Conclusions The availability of on-site CS resulted in variations in treatment modality, yet it did not affect the clinical outcomes of ACS. A trend to a better short-term outcomes was noted in hospitals without CS during the late period of the study, which warrants further investigation.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tal Ovdat
- The Israeli Center of Cardiovascular Research, Tel Hashomer, Israel
| | - Ronen Rubinshtein
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Heart Institute, Edith Wolfson Medical Center, Holon, Israel
| | - Amnon Eitan
- Department of Cardiology, Carmel Medical Center, Haifa, Israel
| | - Elias Daud
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Ziad Arow
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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2
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Nguyen TC, Keegan P, Nguyen S, Loyalka P, Kaneko T, Shah PB, Grubb KJ, Babaliaros VC. Balloon-expandable transcatheter aortic valve replacement outcomes by procedure location: Catheterization laboratory versus operating room. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:149-154. [PMID: 31178348 DOI: 10.1016/j.carrev.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/20/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The impact of procedure location on clinical outcomes after TAVR remains unclear. We aimed to compare short-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) in the catheterization laboratory (CATH) versus surgical operating room (OR). METHODS A retrospective review of 63,581 trans-femoral TAVR patients using balloon-expandable valves from 2015 to 2018 were captured utilizing the TVT Registry. Propensity score matching was performed using 24 covariates resulting in 2 risk-adjusted groups. Patients were further stratified by STS Risk Score with outcomes compared. RESULTS Propensity score matching resulted in 24,160 risk-matched CATH and OR patient pairs. Short-term clinical outcomes including all-cause mortality, stroke, major vascular complications, life-threatening bleeding, and new dialysis were similar between CATH and OR (p = all ns). There was no difference in conversion to open heart surgery between CATH and OR with both occurring at a very low rate (0.4% vs. 0.5%, p = 0.07). Moreover, the 30-day survival post-conversion was similar whether TAVR was performed in CATH versus OR (43.3% and 49.7%, p = 0.28). When stratified by STS Risk Score, there was no difference in conversion to surgery or 30-day mortality in low and intermediate risk patients between CATH and OR. For high risk patients, however, conversion to surgery was lower in CATH vs. OR (0.2% vs. 0.4%, p = 0.04) with no difference in 30-day survival (46% vs. 43%, p = 0.94). CONCLUSIONS Procedure location has minimal impact on TAVR procedural and 30-day outcomes with a very low conversion to open surgery rate between CATH versus OR for low, intermediate, and high-risk patients.
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Affiliation(s)
- Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, TX, USA.
| | - Patricia Keegan
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie Nguyen
- Department of Cardiothoracic and Vascular Surgery, Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, TX, USA
| | - Pranav Loyalka
- Department of Cardiothoracic and Vascular Surgery, Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, TX, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Vasilis C Babaliaros
- Emory Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, GA, USA
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3
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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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4
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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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5
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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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Dehmer GJ, Blankenship JC, Cilingiroglu M, Dwyer JG, Feldman DN, Gardner TJ, Grines CL, Singh M. SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup. Catheter Cardiovasc Interv 2015; 84:169-87. [PMID: 25045090 DOI: 10.1002/ccd.25371] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/21/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Gregory J Dehmer
- Baylor Scott & White Health, Central Texas, Temple, TX. SCAI Writing Committee Member and Chair
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7
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Percutaneous Coronary Intervention and the Various Coronary Artery Disease Syndromes. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Akasaka T, Hokimoto S, Oshima S, Nakao K, Fujimoto K, Miyao Y, Shimomura H, Tsunoda R, Hirose T, Kajiwara I, Matsumura T, Nakamura N, Yamamoto N, Koide S, Oka H, Morikami Y, Sakaino N, Kaikita K, Nakamura S, Matsui K, Ogawa H. Clinical outcomes of percutaneous coronary intervention (PCI) at hospital with or without onsite cardiac surgery backup. Int J Cardiol 2014; 176:1385-7. [PMID: 25156861 DOI: 10.1016/j.ijcard.2014.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/02/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Tomonori Akasaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Shuichi Oshima
- Division of Cardiology, Kumamoto Central Hospital, Kumamoto, Japan
| | - Koichi Nakao
- Cardiovascular Center, Kumamoto Saiseikai Hospital, Kumamoto, Japan
| | - Kazuteru Fujimoto
- National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Yuji Miyao
- National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Hideki Shimomura
- Division of Cardiology, Fukuoka Tokushukai Hospital, Fukuoka, Japan
| | | | - Toyoki Hirose
- Division of Cardiology, Minamata City Hospital and Medical Center, Minamata, Japan
| | | | | | | | - Nobuyasu Yamamoto
- Division of Cardiology, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Shunichi Koide
- Division of Cardiology, Health Insurance Yatsushiro General Hospital, Yatsushiro, Japan
| | - Hideki Oka
- Division of Cardiology, Health Insurance Hitoyoshi General Hospital, Hitoyoshi, Japan
| | | | - Naritsugu Sakaino
- Division of Cardiology, Amakusa Regional Medical Center, Amakusa, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sunao Nakamura
- Cardiovascular Center, New Tokyo Hospital, Matsudo, Japan
| | - Kunihiko Matsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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9
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Dehmer GJ, Blankenship JC, Cilingiroglu M, Dwyer JG, Feldman DN, Gardner TJ, Grines CL, Singh M. SCAI/ACC/AHA Expert Consensus Document: 2014 update on percutaneous coronary intervention without on-site surgical backup. J Am Coll Cardiol 2014; 63:2624-2641. [PMID: 24651052 DOI: 10.1016/j.jacc.2014.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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10
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Stolker JM, Allen DS, Cohen DJ, Kennedy KF, Laster SB, Frutkin AD, Mehta SK, O'Neal KR, Marso SP. Comparison of procedural complications with versus without interventional cardiology fellows-in-training during contemporary percutaneous coronary intervention. Am J Cardiol 2014; 113:44-8. [PMID: 24169010 DOI: 10.1016/j.amjcard.2013.08.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
Despite increasing complexity of contemporary procedures at tertiary care hospitals, the relationship between interventional cardiology fellows-in-training (ICFITs) and complications of percutaneous coronary intervention (PCI) has not been reported. We compiled logbooks of 6 ICFITs at an academic hospital and evaluated patient and procedural characteristics of PCIs performed with and without presence of an ICFIT. The primary end point was the composite of all in-hospital PCI complications defined by the American College of Cardiology's National Cardiovascular Data Registry: (1) catheterization laboratory events such as no-reflow and dissection/perforation, (2) general clinical events such as stroke or cardiogenic shock, (3) vascular and bleeding complications, and (4) miscellaneous complications such as peak troponin or creatinine levels. Logistic regression adjusted for differences in measured confounders between patients treated with and without presence of an ICFIT. All analyses were repeated after excluding PCI for ST-elevation myocardial infarction. Of 2,605 PCI procedures at the academic hospital between July 2007 and April 2010, an ICFIT was present for 1,638 procedures (63%). Despite having worse clinical and procedural characteristics, patients in the ICFIT group experienced similar rates of the composite end point (12.9% vs 14.5% without ICFIT, p = 0.27). Longer mean fluoroscopy times and greater number of stents were noted in the ICFIT group; however, hospital length of stay was shorter and no individual adverse events were increased in the ICFIT procedures. Presence of an ICFIT remained unrelated to the composite end point after multivariable adjustment (odds ratio 0.92, 95% confidence interval 0.71 to 1.20; p = 0.53), and findings were similar after excluding PCI for ST-elevation myocardial infarction. In conclusion, in contemporary practice at a large academic medical center, PCI complication rates were not adversely affected by the presence of an ICFIT.
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11
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Hannan EL, Zhong Y, Walford G, Jacobs AK, Venditti FJ, Stamato NJ, Holmes DR, Sharma S, Gesten F, King SB. Underutilization of percutaneous coronary intervention for ST-elevation myocardial infarction in medicaid patients relative to private insurance patients. J Interv Cardiol 2013; 26:470-81. [PMID: 23962131 DOI: 10.1111/joic.12059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine whether disparities in access to invasive cardiac procedures still exist for Medicaid patients, given how old earlier studies are and given changes in the interim in appropriateness guidelines. PATIENTS AND METHODS A total of 5,022 Medicaid and private insurance patients in New York from January 1, 2008 through December 31, 2009 under age 65 with ST-elevation myocardial infarction (STEMI) were compared with regard to their access to percutaneous coronary interventions (PCI) before and after controlling for numerous patient characteristics and other important factors. RESULTS Medicaid patients were significantly less likely to be admitted initially to a hospital certified to perform PCI (90.4% vs. 94.3%, P < 0.001). Also, Medicaid patients were found to be significantly less likely to undergo PCI than other patients (adjusted odds ratio [AOR] = 0.81, 95% CI 0.66, 0.98, P = 0.03). When the probability of each hospital performing PCI for STEMI patients was controlled for, Medicaid patients were still less likely to undergo PCI after controlling for other risk factors (AOR = 0.80, 95% CI 0.65, 0.99, P = 0.04). CONCLUSIONS Medicaid STEMI patients are significantly less likely to undergo PCI within the same day of admission as private pay patients even after adjusting for patient characteristics related to receiving PCI, and the strength of this relationship is not diminished when controlling for whether the admitting hospital has approval to perform PCI or controlling for the tendency of the admitting hospital to treat STEMI with PCI.
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Affiliation(s)
- Edward L Hannan
- School of Public Health, University at Albany, Albany, New York
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12
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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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13
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Jacobs AK, Normand SLT, Massaro JM, Cutlip DE, Carrozza JP, Marks AD, Murphy N, Romm IK, Biondolillo M, Mauri L. Nonemergency PCI at hospitals with or without on-site cardiac surgery. N Engl J Med 2013; 368:1498-508. [PMID: 23477625 DOI: 10.1056/nejmoa1300610] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency surgery has become a rare event after percutaneous coronary intervention (PCI). Whether having cardiac-surgery services available on-site is essential for ensuring the best possible outcomes during and after PCI remains uncertain. METHODS We enrolled patients with indications for nonemergency PCI who presented at hospitals in Massachusetts without on-site cardiac surgery and randomly assigned these patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that had cardiac surgery services available. A total of 10 hospitals without on-site cardiac surgery and 7 with on-site cardiac surgery participated. The coprimary end points were the rates of major adverse cardiac events--a composite of death, myocardial infarction, repeat revascularization, or stroke--at 30 days (safety end point) and at 12 months (effectiveness end point). The primary end points were analyzed according to the intention-to-treat principle and were tested with the use of multiplicative noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness). RESULTS A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point. CONCLUSIONS Nonemergency PCI procedures performed at hospitals in Massachusetts without on-site surgical services were noninferior to procedures performed at hospitals with on-site surgical services with respect to the 30-day and 1-year rates of clinical events. (Funded by the participating hospitals without on-site cardiac surgery; MASS COM ClinicalTrials.gov number, NCT01116882.).
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Affiliation(s)
- Alice K Jacobs
- Boston University School of Medicine, Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston, MA 02118, USA.
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Effect of volume of percutaneous coronary intervention on clinical outcomes in patients with acute myocardial infarctions in hospitals with and without onsite cardiac surgery backup. Int J Cardiol 2013; 163:216-7. [PMID: 22795707 DOI: 10.1016/j.ijcard.2012.06.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 06/24/2012] [Indexed: 11/20/2022]
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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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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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Most Important Papers in ST-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2011. [DOI: 10.1161/circinterventions.111.966846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The following are highlights from the series,
Circulation: Cardiovascular Interventions
Topic Review. This series summarizes the most important manuscripts, as selected by the editors, that have published in the
Circulation
portfolio. The studies included in this article represent the most noteworthy research in the area of ST-elevation myocardial infarction. (
Circ Cardiovasc Interv.
2011;4:e55–e66.)
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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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Transcatheter Valve Therapy: A Professional Society Overview from the American College of Cardiology Foundation and The Society of Thoracic Surgeons. Ann Thorac Surg 2011; 92:380-9. [DOI: 10.1016/j.athoracsur.2011.05.067] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 05/13/2011] [Accepted: 05/13/2011] [Indexed: 11/23/2022]
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Dehmer GJ, Kutcher MA. ST-Segment-Elevation Myocardial Infarction Treated at Hospitals With and Without On-Site Cardiac Surgery. Circ Cardiovasc Interv 2009; 2:497-9. [DOI: 10.1161/circinterventions.109.921346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory J. Dehmer
- From the Department of Medicine (G.J.D.), Texas A&M University Health Science Center College of Medicine; Cardiology Division (G.J.D.), Scott & White Healthcare, Temple, Tex; and Wake Forest University School of Medicine (M.A.K.), Cardiology Division, Winston-Salem, NC
| | - Michael A. Kutcher
- From the Department of Medicine (G.J.D.), Texas A&M University Health Science Center College of Medicine; Cardiology Division (G.J.D.), Scott & White Healthcare, Temple, Tex; and Wake Forest University School of Medicine (M.A.K.), Cardiology Division, Winston-Salem, NC
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