CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Mandeep Singh, MD*,
Eric Yang, MD,
Richard Gumina, MD,
Ryan J. Lennon, MS,
Charanjit S. Rihal, MD and
David R. Holmes, Jr, MD
* Division of Cardiovascular Disease and Internal Medicine, Mayo College of Medicine, 200 First Street SW, Rochester, Minnesota 55905 (Email: singh.mandeep{at}mayo.edu).
Dr. Wharton’s letter resonates with our practice at two regional sites with no on-site surgery (1). None of us is immune from hubris, but by the same token, none of us is either above or below it (as the case may be), selecting only specific data points on a curve that agree with what we hold to be the "truth." A single publication or a trial rarely reveals the entire truth, and more data are needed to discover concordance in the findings. When the results of multiple datasets are similar in directionality, degree, and extent, we can be increasingly confident that we know the answer to the specific question posed. We need to remember that the questions evolve as do the answers.
Thus, we agree wholeheartedly with Dr. Wharton about "growing evidence supporting the current safety of percutaneous coronary intervention [PCI] ... with off-site surgical backup." The challenge is to increase safe access to this important part of our therapeutic armamentarium. Programs that have been performing off-site PCIs have found that success depends on: 1) careful patient and lesion selection; 2) a protocol to rapidly transport patients with PCI complications to centers with on-site surgery; 3) skilled operators and catheterization laboratory staff who are able to perform these procedures with a high success rate; and 4) processes of the patient’s care that will improve the outcomes following PCI. It will be prudent to establish guidelines for elective PCIs similar to those proposed by Dr. Wharton for the conduct of primary PCIs (2).
Until further studies evaluating the safety of off-site PCI can be performed, we ask all cardiologists to practice another Greek word, anochi, which means "tolerance." In other words, cardiologists should keep an open mind regarding the performance of PCI without surgical backup until further data are available.
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References
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1. Yang EH, Gumina RJ, Lennon RJ, Holmes Jr. DR, Rihal CS, Singh M. Emergency coronary artery bypass surgery for percutaneous coronary interventionschanges in the incidence, clinical characteristics, and indications from 1979 to 2003. J Am Coll Cardiol 2005;46:2004-2009.[Abstract/Free Full Text]2. Wharton Jr. TP, McNamara NS, Fedele FA, Jacobs MI, Gladstone AR, Funk EJ. Primary angioplasty for the treatment of acute myocardial infarctionexperience at two community hospitals without cardiac surgery. J Am Coll Cardiol 1999;33:1257-1265.[Abstract/Free Full Text]
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