Percutaneous Coronary Intervention at Centers With and Without On-Site Surgery: A Meta-Analysis

Study Questions:

What are the rates of in-hospital mortality and emergency coronary artery bypass grafting (CABG) surgery at centers with and without on-site surgery?

Methods:

A systematic search of studies published between January 1990 and May 2010 was conducted using MEDLINE, EMBASE, and Cochrane Review databases. English-language studies of percutaneous coronary intervention (PCI) performed at centers with and without on-site surgery providing data on in-hospital mortality and emergency bypass were identified. Two study authors independently reviewed the 1,029 articles originally identified, and selected 40 for analysis. Study title, time period, indication for angioplasty, and outcomes were extracted manually from all selected studies, and quality of each study was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.

Results:

High-quality studies of PCIs performed at centers with and without on-site surgery were included. Pooled-effect estimates were calculated with random-effects models. Analyses of primary PCI for ST-segment elevation myocardial infarction (STEMI) of 124,074 patients demonstrated no increase in in-hospital mortality (no on-site surgery vs. on-site surgery: observed risk, 4.6% vs. 7.2%; odds ratio [OR], 0.96; 95% confidence interval [CI], 0.88-1.05; I2 = 0%) or emergency bypass (observed risk, 0.22% vs. 1.03%; OR, 0.53; 95% CI, 0.35-0.79; I2 = 20%) at centers without on-site surgery. For nonprimary PCIs (elective and urgent; n = 914,288), the rates of in-hospital mortality (observed risk, 1.4% vs. 2.1%; OR, 1.15; 95% CI, 0.93-1.41; I2 = 46%) and emergency bypass (observed risk, 0.17% vs. 0.29%; OR, 1.21; 95% CI, 0.52-2.85; I2 = 5%) were not significantly different at centers without or with on-site surgery.

Conclusions:

The authors concluded that PCI performed at centers without on-site surgery, compared with centers with on-site surgery, were not associated with a higher incidence of in-hospital mortality or emergency bypass surgery.

Perspective:

This study suggests that mortality and the need for emergency CABG surgery after primary PCI for STEMI were similar at centers with and without on-site surgical backup. The narrow funnel plot and consistent individual and combined effect estimates for mortality support the safety of performing primary PCI at these centers. The results of this meta-analysis are relevant to patient care and support recent American College of Cardiology Foundation/American Heart Association guidelines that give a Class IIb indication for PCI for elective indications, and give a Class IIa indication for primary PCI at centers without on-site surgery, provided that appropriate planning for program development has been accomplished. However, additional data are needed, including rates and indications for urgent or emergency transfers, especially in patients undergoing nonprimary PCI at centers without on-site surgery with continued monitoring of outcomes.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Myocardial Infarction, Coronary Artery Bypass, Percutaneous Coronary Intervention, Checklist, MEDLINE


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