LETTER TO THE EDITOR
Reply
Gregory J. Dehmer, MD, FACC and
D. Scott Gantt, DO, FACC
Division of Cardiology, Scott & White Clinic, 2401 South 31st Street, Temple, TX 76508
(Email: gdehmer{at}swmail.sw.org).
We thank Dr. Connolly and colleagues for their interest in our editorial comment (1). They provide a snapshot of their experience performing percutaneous coronary intervention (PCI) at a hospital without cardiac surgery backup. Approximately 40% of their cases were elective, 60% were in "unstable" patients, and about 10% were primary PCIs. They report five cases (0.6%) requiring urgent coronary artery bypass surgery (UCABG) and four mortalities (0.5%). These all occurred in the unstable cohort, with no deaths or UCABG in elective patients. It is not stated whether any of the deaths occurred in the five cases that required UCABG, but we know mortality is increased if UCABG is necessary (2). We understand that full disclosure about complications is difficult given the constraints of a Letter to the Editor, but the question could be asked: has their experience led them to change their practice pattern? Because all of their mortalities and UCABG occurred in unstable patients, are unstable patients now being referred to the surgical center just a few miles away?
In addition, if one accepts the report of Lotfi et al. (3), one out of four patients requiring UCABG would be placed at increased risk of harm if delays to surgery were encountered, and about 70% would require stabilization with a balloon pump. Dr. Connolly and colleagues state there was "no delay in surgical transfer," but the actual, time required for transfer is not provided. Perhaps these same patients would have died or needed UCABG even if they had PCI at the surgical center. Because the risk of a severe complication from PCI is now very low, even centers with on-site cardiac surgery rarely hold a surgical suite in a state of immediate readiness, but rather depend on the fact that an operating room (OR) and surgeon will be available on short notice should a complication arise. Perhaps in their setting this would result in a similar time delay; however, there is still the issue of moving an unstable patient, often with a balloon pump, from the catheterization laboratory to an ambulance, traveling to another hospital, unloading the patient and transporting him or her to the OR. We acknowledge this can be done, but is this truly in the best interest of the patient when a hospital with on-site surgery is just a few miles away?
Perhaps in the future, PCI will be perfected to the point that the need for UCABG will be zero. Unfortunately, even in the best PCI centers in the world, we are not yet at that point. Should that time come, however, it would be appropriate to perform PCI at centers without on-site surgery. Until then, this argument is not about monopolizing care to surgical centers, but performing PCI under the safest possible conditions one can provide for patients.
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References
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1. 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]
2. Borkon AM, Failing TL, Piehler JM, et al. Risk analysis of operative intervention for failed coronary angioplasty Ann Thorac Surg 1992;54:884-891.[Abstract]
3. 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]
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