Perspective:

This paper is an Expert Consensus Document on percutaneous coronary intervention (PCI) without on-site surgery sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI), American College of Cardiology, and American Heart Association. It updates a prior document on this topic by the SCAI from 2007, using data from multiple sources including recent clinical trials, meta-analyses, and consensus statements. It is extremely well-written and authoritative, and should be considered required reading for interventional cardiologists. The following are five key points to remember:

1. PCI without on-site surgery is here to stay. Only one state now does not allow either primary or elective PCI without on-site surgery. Data also suggest its growing use of PCI and that approximately one third of PCI hospitals now fit into this category.

2. The best available evidence suggests that PCI without on-site surgery is safe with key procedures and policies in place. Two recent and large randomized controlled trials (MASS-COMM and CPORT-E) provide the bulk of this contemporary evidence, which has been taken into consideration in recent guidelines and consensus statements. Primary PCI at PCI hospitals without on-site surgery is a Class IIa recommendation (‘reasonable’) in the 2011 PCI guidelines and elective PCI is a Class IIb recommendation (‘might be considered’).

3. Evidence suggests that, for the most part, the growth of PCI hospitals has not increased geographic access. This raises two concerns. First, it raises the question of dilution of experience among operators due to drops in PCI overall. The authors of this document make these implications in the context of the volume-outcome relationship. Second, it raises issues about costs and resource utilization from duplication of services in light of health care reform.

4. This paper is extremely important if a program for PCI without on-site surgery is being developed in a state. There is valuable information about how to consider its implementation with numerous source documents referenced. In summary, it emphasizes the need for programs to focus on quality metrics and reporting using national registries for benchmarking as well as ensuring certain structural measures are in place (i.e., volume, protocols for transfer).

5. The conclusions of the paper reinforce the dangers of a program built on ‘desires for personal or institutional financial gain, prestige, market share or other similar motives.’ It also points out, however, that ‘without central planning on the state or federal level,’ addressing such issues will be tough. Thus, although it is clear that PCI without on-site surgery is here to stay, there remains much that is uncertain about its optimal role in the future.