PCI With or Without On-Site Surgery

Study Questions:

What are the current safety and outcomes of primary percutaneous coronary intervention (PCI) and nonprimary PCI at centers with and without on-site surgical backup?

Methods:

The investigators 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 and performed an updated systematic review and meta-analysis using mixed-effects models. All patients and outcomes were analyzed separately by type of PCI (primary PCI or nonprimary PCI) according to the originally assigned group. Statistical heterogeneity was quantified using the I2 statistics.

Results:

For primary PCI for ST-segment elevation myocardial infarction (133,574 patients), all-cause mortality (without on-site surgery vs. with on-site surgery: observed rates, 4.8% vs. 7.2%; pooled odds ratio [OR], 0.99; 95% confidence interval [CI], 0.91-1.07; p = 0.729; I2 = 3.4%) or emergency coronary artery bypass grafting (CABG) rates (observed rates, 1.5% vs. 2.4%; pooled OR, 0.76; 95% CI, 0.56-1.01; p = 0.062; I2 = 42.5%) did not differ by presence of on-site surgery. For nonprimary PCI (967,549 patients), all-cause mortality (observed rates, 1.6% vs. 2.1%; pooled OR, 1.15; 95% CI, 0.94-1.41; p = 0.172; I2 = 67.5%) and emergency CABG rates (observed rates, 0.5% vs. 0.8%; pooled OR, 1.14; 95% CI, 0.62-2.13; p = 0.669; I2 = 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:

The authors concluded that 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.

Perspective:

This study reports that clinical outcomes and complication rates of patients treated with PCI at centers without onsite surgery did not differ from centers with on-site surgery, for both primary and nonprimary PCI. Furthermore, temporal trends of improving clinical outcomes for nonprimary PCI at centers without onsite surgery were observed. Additional studies are warranted, to compare rates of repeat revascularization, medical costs, and quality of life, especially after nonprimary PCI between centers with and without on-site surgery.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Myocardial Infarction, Percutaneous Coronary Intervention, Shock, Cardiogenic, Stroke


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