[Controversies regarding distribution, instrumentation, and competence of hemodynamics laboratories]

In the last few years we have witnessed a substantial growth in the number of catheterization laboratories, especially in the northern regions of Italy, a phenomenon which has met some controversy and has been discussed in a Symposium at the ANMCO National Conference (Florence, May 20-23, 2000). The controversy is essentially between those who believe in the implementation of catheterization laboratories in all cardiology units equipped with a cardiological intensive care unit (and the creation of a functional network with the tutorial centers) and those who refer to the existing guidelines, standards and VRQ which envisage a geographical distribution of laboratories on the basis of a balance between needs of the population and the minimum quantity of procedures performed by each center in order to guarantee the best quality and cost-effectiveness. The aim of the Symposium was to clarify whether the two "innovations" of these last few years, namely the introduction of new portable radiological equipment on the one hand and the effectiveness of primary angioplasty in the treatment of acute myocardial infarction on the other, may influence the redefinition of criteria regarding the distribution of laboratories, taking into account as well the expansion of indications for coronary angioplasty and coronary angiography. After a lively discussion, the proceedings can be summed up as follows: no agreement was reached regarding the role of portable radiological equipment in the decisional process regarding the setting up of a new catheterization laboratory; primary angioplasty should be carried out in centers with an adequate volume of activity and a functioning inter-hospital organizational structure for this demanding activity; otherwise it does not offer any advantages over fibrinolytic therapy; the proposal of a new organizational model is based on the creation of transverse inter-hospital cardiology departments, the size of which is based on the overall size of the user population, with interventional laboratories distributed in the reference hospitals and diagnostic laboratories in hospitals equipped with a cardiologic intensive care unit (where there is a sufficiently large user population to guarantee at least the minimum number of procedures envisaged by the standards); both parts should work in close cooperation. On this last point there was a contrasting opinion and it was not possible to reach a consensus. The Scientific Societies should formally express their views on this controversial topic, so that guidelines, standards and VRQ can be updated rapidly. The latter should constitute the reference for the procedures of accreditation to which all laboratories and cardiology departments are subjected to, and it is likely that this will be the best way to overcome the present controversy.