LETTER TO THE EDITOR
Pushing the envelope too far?
Derek L. Connolly, BSc (Hons) MB, ChB, PhD, FRCP,
Greg Y.H. Lip, MD, FRCP, FESC, FACC and
Ted S.N. Lo, MRCP (UK)
Sandwell and West Birmingham Hospitals, NHS Trust, Lyndon, Birmingham B71 4HJ, United Kingdom
(Email: Derek.Connolly{at}swbh.nhs.uk).
We read with great interest the report by Lotfi et al. (1) and the accompanying editorial comment by Dehmer et al. (2). We would like to share our experience on percutaneous coronary intervention (PCI) without on-site cardiothoracic cover in our hospital. From January 2003 to December 2003, we performed a total of 856 cases of PCI. Of these, 338 (40%) were elective cases and 518 (60%) were unstable cases. As with practices similar to other hospitals in the United Kingdom, most of our unstable cases were for acute coronary syndrome with or without elevation of troponin levels and post-ST-segment elevation infarct unstable angina. Approximately 10% of our acute cases were primary PCI (n = 18) and rescue PCI (n = 29). Use of abciximab was 70.2%. Overall procedural success was 90%, and partial success occurred in another 5%. Redo PCI for acute and subacute closure was 1.2% (10 cases). Overall major adverse cardiac events were 2.4%, with a 0.6% incidence (5 cases) of urgent coronary artery bypass grafting (UCABG) and a mortality of 0.5% (4 cases). The UCABG and mortality were all from unstable patients. We encountered no delay in surgical transfer as the cardiothoracic center is just a few miles away from our hospital. Our figures were compatible with recent reports and trends (3–5); but more importantly, we have 0% UCABG and mortality in elective patients. We believe that elective PCI without on-site cardiothoracic surgical cover, at least in a high-volume center, does not necessarily convey additional risk of harm to patients (6). Indeed, monopolizing PCI to surgical centers in an era when surgery is on the decline may be reducing access to PCI.
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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. Seshadri N, Whitlow PL, Acharya N, et al. The effects of contemporary use of coronary stents on in-hospital mortality Circulation 2002;106:2346-2350.[Abstract/Free Full Text]
4. Smith Jr SC, Dove JT, Jacobs AK, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)—executive summary 12: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) J Am Coll Cardiol 2001;37:2215-2238.[Free Full Text]
5. Kimmel SE, Localio AR, Krone RJ, et al. The effects of contemporary use of coronary stents on in-hospital mortality J Am Coll Cardiol 2001;37499–51.
6. 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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