Nonemergency PCI at Hospitals With or Without On-Site Cardiac Surgery
What is the safety and efficacy of percutaneous coronary intervention (PCI) provided at institutions without on-site cardiac surgery?
In the MASS COMM (Randomized Trial to Compare Percutaneous Coronary Intervention Between Massachusetts Hospitals With Cardiac Surgery On-Site and Community Hospitals Without Cardiac Surgery On-Site) study, patients presenting for nonemergent PCI at hospitals without on-site cardiac surgery were randomized to PCI at that hospital or PCI at a hospital with on-site cardiac surgery. The coprimary endpoints were a composite of death, myocardial infarction (MI), and repeat revascularization or stroke at 30 days (safety endpoint) or 1 year (efficacy endpoint).
The study involved seven hospitals with on-site cardiac surgery and seven without cardiac surgery. A total of 3,691 patients were randomized, with 2,774 patients undergoing the procedure at hospitals without cardiac surgery and 917 at hospitals with cardiac surgery. There was no difference in the primary endpoint at 30 days (9.5% vs. 9.4%; relative risk, 1.00) or at 12 months (17.3% vs. 17.8%). There was no difference in the individual endpoints of death, MI, repeat revascularization, or stroke at either of the time points.
The authors concluded that nonemergency PCI performed at institutions without on-site cardiac surgery is noninferior to that performed at institutions with cardiac surgery.
This trial adds to the growing body of data supporting the safety of PCI at institutions without surgical backup. This is not surprising since the need for emergency cardiac surgery is so infrequent in contemporary PCI, and because the operators in these studies are often the same people working across two different hospitals. With a decline in the total number of coronary revascularizations performed nationally, the policy implications of this study are complex. This study bolsters the evidence for PCI without surgical backup in areas where there is lack of PCI availability, although I suspect that most institutions that start performing PCI without cardiac surgery on-site in the near future will be in close proximity to institutions that offer both PCI and cardiac surgery.
Keywords: Risk, Myocardial Infarction, Stroke, Thoracic Surgery, Cardiac Surgical Procedures, Angioplasty, Balloon, Coronary, Massachusetts, Percutaneous Coronary Intervention
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