VANCOUVER, B.C. – It makes little difference if percutaneous coronary interventions are done in a facility with on-site bypass rescue or not; safety outcomes are statistically the same, according to a prospective observational study of more than 100,000 PCI cases in California.
Adjusted for lesion, patient, and other risk factors, the composite rate of in-hospital death or emergent coronary artery bypass grafting (CABG) was 2.11% for 99,332 PCIs – about 18% of them ST-elevation myocardial infarctions – at 116 facilities offering on-site cardiac surgery and 1.58% for 2,601 procedures – about a third of them STEMIs – at six facilities where patients had to be transferred elsewhere, if needed, for emergency bypass.
The on-site hospitals had 1.16% of their non–ST-elevation MI (NSTEMI) cases end in death or emergent CABG; 1.15% of NSTEMI cases ended that way in the six sites that did not offer cardiac surgery, a nonsignificant difference.
"Off-site hospitals can do just as well as on-site hospitals for the overall composite of mortality and emergent CABG. The overall success rates are the same," said lead investigator Dr. William Bommer, president of California’s American College of Cardiology chapter.
The goal of the ongoing project is to see if it would be safe to end California’s requirement that PCIs, for the most part, be done only in hospitals that offer on-site cardiovascular surgery, a question other states are struggling with as well. The California provision dates to the 1980s, when the procedure was more risky than it is now. Prompted by Dr. Bommer and his chapter’s suggestion, the state legislature allowed the six pilot sites to offer PCI.
Part of the problem with the restriction is that it limits PCI access for rural STEMI patients in Northern California. Many people there and elsewhere are more than an hour away from STEMI centers, even by airlift. As indicated by the higher proportion of STEMI patients in the six demonstration sites, "the population we are bringing in by opening [this] up tends to be sicker," said Dr. Bommer, also professor of cardiovascular medicine at the University of California, Davis.
There’s also the issue of hospitals keeping expensive CABG programs going mostly so that they can qualify to offer PCI. A handful of hospitals in the state do less than one CABG per week; almost half do less than two. "That’s not good medicine," Dr. Bommer said at the 18th World Congress on Heart Disease.
"Once this [change] goes through and you no longer, in selected cases, need heart surgery to do PCI, the biggest change will not be a flurry of new PCI labs; the biggest change will be an attenuation of [low-volume] cardiac surgery" programs, he said in an interview.
Dr. Bommer said he has no financial interests in nonsurgical PCI centers.