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REVIEW ARTICLE

Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal

^* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA

Manuscript received September 27, 2001; revised manuscript received March 19, 2002, accepted April 1, 2002.

^* Reprint requests and correspondence: Dr. Bernard J. Gersh, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.

Since the early 1990s, with significant improvement in the procedural success of percutaneous coronary interventions (PCIs), there has been a concomitant reduction in the need for emergency coronary artery bypass graft surgery. This review article focuses on the need for on-site cardiac surgery in patients with acute myocardial infarction undergoing primary angioplasty at centers without on-site cardiac surgical backup. It gives an overview of the need for emergency bypass surgery in both the large trial setting and the community hospital setting. Special consideration is also given to the risks and benefits of primary angioplasty compared with thrombolytic therapy, transfer to an institution with an on-site cardiac surgical facility compared with primary PCI, the frequency and indications for emergency cardiac surgery related and unrelated to primary angioplasty and the requirements for primary angioplasty that must be met in hospitals without the capability of on-site cardiac surgery.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   AMI = acute myocardial infarction   CABG = coronary artery bypass graft surgery   CI = confidence interval   GUSTO = Global Use of Strategies To Open occluded arteries trial   MITI = Myocardial Infarction Triage and Intervention registry   MITRA = Maximal Individual TheRapy in Acute myocardial infarction registry   NRMI = National Registry of Myocardial Infarction   PAMI-2 = Primary Angioplasty in Myocardial Infarction-2 trial   PCI = percutaneous coronary intervention   RR = relative risk   TIMI = Thrombolysis In Myocardial Infarction trial

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