Safety of elective--including "high risk"--percutaneous coronary interventions without on-site cardiac surgery

Abstract

Background: Current guidelines (American College of Cardiology/American Heart Association) for percutaneous coronary intervention (PCI) limit the performance of elective cases to hospitals with the capability for cardiac surgery. The number of hospitals in the United States with this capability is limited, which restricts availability of this proven technology.

Objective: To determine the safety of performing elective, nonselected PCI in hospitals without cardiac surgery capability.

Design, setting, and patients: A single-center retrospective analysis of the first 1000 patients undergoing elective, including "high-risk," PCI in the county hospital in Phoenix, Arizona.

Main outcome measures: A database (Access Microsoft Windows) was established to follow patient characteristics, indications for the procedure, technical aspects of the procedure, outcomes and complications. The Quality Improvement Committee followed each case closely to independently assess the adequacy of indications and patient management, with a monthly case review of every patient who had a periprocedural or postprocedural complication.

Results: Failure to complete target vessel revascularization occurred in 68 of the total 1756 vessels (3.8%). Seven patients (0.7%), required elective referral for coronary artery bypass graft surgery after failed PCI. Coronary perforations occurred in 9 patients (0.9%); all resolved with percutaneous techniques. Postprocedure myocardial infarction was diagnosed in 21 patients (2.1%). Two patients (0.2%) developed a stroke. Periprocedural death (within 48 hours of the procedure) occurred in 2 patients (0.2%). Out of the 1000 interventions performed, none required emergency coronary artery bypass graft surgery.

Conclusions: Technical advances in interventional cardiology allow for safe performance of PCI in hospitals without on-site cardiac surgery facilities if proposed conditions are met. Our results together with the vast experience in other countries supports a paradigm change that would increase the number of hospitals that can offer interventional cardiology procedures with a corresponding increase in the number of patients that would benefit.