LETTER TO THE EDITOR
Reply
Mat Lotfi, MD and
Peter H. Seidelin, MD
Cardiac Intensive Care Unit, University Health Network, Toronto General Hospital, 200 Elizabeth Street, EN 12-238, Toronto, Ontario, Canada M5G 2C4
(Email: peter.seidelin{at}uhn.on.ca).
Drs. Gubner and Rowe express concern about the conclusions and implications of our study (1) and the accompanying editorial comment (2). In regards to transfer delays, data from experienced centers have consistently shown that patients who require urgent coronary artery bypass grafting (UCABG) after failed percutaneous coronary intervention (PCI) have dramatically longer times to surgery in hospitals without versus with on-site surgical availability (359 ± 406 min vs. 170 ± 205 min; p = 0.0001) (3). In this large series, even though the number of patients with three-vessel disease was significantly less in the group without on-site surgery (9% vs. 22%; p < 0.05), the mortality rate was not lower—thus raising concerns that delays to surgery may have been a detrimental factor. Although all of the UCABG patients in our cohort who had at least one of the prespecified criteria were rushed to surgery within 2 h, we did not suggest that this time frame should be mandated as the "standard of excellence." However, it would be reasonable to suggest that rapid treatment of these unstable UCABG patients is important and more likely to be accomplished at centers with on-site surgical availability. Also, there are other incentives (i.e., financial, access) to establishing new elective angioplasty programs without on-site cardiac surgery, and our study's main objective was to add information on the potential risk of doing so. We believe it is in the best interest of patients and the cardiology community to have well-delineated strategies to monitor the expansion and performance of such centers in a carefully transparent fashion.
We appreciate the comments of Dr. Connolly and colleagues detailing their experience with angioplasty without surgical backup. The 0.6% UCABG rate is similar to the rate in our report, but with only 338 elective cases in their cohort, it is difficult to make any generalizable statements about the safety of elective angioplasty without surgical backup. In our report, 15 (0.5%) of the 3,039 patients who had elective angioplasty required UCABG. One-third of these elective patients who required UCABG met our prespecified criteria for increased harm attributable to delays of surgery.
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References
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1. Lotfi M, Mackie K, Dzavik V, Seidelin PH. Impact of delays to cardiac surgery after failed angioplasty and stenting J Am Coll Cardiol 2004;43:337-342.[Abstract/Free Full Text]
2. Dehmer GJ, Gantt DS. Coronary intervention at hospitals without on-site cardiac surgery: are we pushing the envelope too far? J Am Coll Cardiol 2004;43:343-345.[Free Full Text]
3. Loubeyre C, Morice MC, Berzin B, et al. Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a French multicenter registry Cathet Cardiovasc Interv 1999;47:441-448.[CrossRef][Medline]
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