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Percutaneous coronary intervention at centers with and without on-site surgery: a meta-analysis
Mandeep Singh1, David R Holmes, Gregory J Dehmer
1Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. singh.mandeep@mayo.edu
Insights
Percutaneous coronary interventions (PCI) at centers without onsite surgery show no increased risk of in-hospital mortality or emergency bypass surgery. This systematic review suggests PCI can be safely performed at hospitals without on-site surgical capabilities.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Current guidelines recommend against performing percutaneous coronary interventions (PCI) at centers lacking on-site surgical facilities.
- Despite recommendations, PCI procedures are increasingly performed at hospitals without on-site surgery.
Purpose of the Study:
- To systematically review and compare in-hospital mortality and emergency coronary artery bypass grafting (CABG) surgery rates.
- To assess outcomes of PCI performed at centers with versus without on-site surgical capabilities.
Main Methods:
- A systematic literature search was conducted across MEDLINE, EMBASE, and Cochrane Review databases (January 1990 - May 2010).
- Included were English-language studies reporting in-hospital mortality and emergency bypass rates for PCI at centers with and without on-site surgery.
- Data from 40 selected studies, representing over 1 million patients, were analyzed using random-effects models.
Main Results:
- For primary PCI in ST-segment elevation myocardial infarction (124,074 patients), no significant differences in in-hospital mortality (4.6% vs 7.2%) or emergency bypass (0.22% vs 1.03%) were observed between centers with and without on-site surgery.
- For non-primary PCI (914,288 patients), in-hospital mortality (1.4% vs 2.1%) and emergency bypass rates (0.17% vs 0.29%) were also not significantly different between the two types of centers.
- Quality assessment using the STROBE checklist ensured the inclusion of high-quality observational studies.
Conclusions:
- Percutaneous coronary interventions performed at centers without on-site surgery are not associated with increased in-hospital mortality.
- The incidence of emergency coronary artery bypass grafting surgery is not significantly higher in centers without on-site surgical facilities compared to those with them.
- Findings suggest that PCI can be safely provided at centers without on-site surgical backup.
Context:
Percutaneous coronary interventions are performed at centers without onsite surgery, despite current guidelines discouraging this.
Objective:
To assess literature comparing rates of in-hospital mortality and emergency coronary artery bypass grafting surgery at centers with and without on-site surgery.
Data Sources:
A systematic search of studies published between January 1990 and May 2010 was conducted using MEDLINE, EMBASE, and Cochrane Review databases.
Study Selection:
English-language studies of percutaneous coronary intervention performed at centers with and without on-site surgery providing data on in-hospital mortality and emergency bypass were identified. Two study authors independently reviewed the 1029 articles originally identified and selected 40 for analysis.
Data Extraction:
Study title, time period, indication for angioplasty, and outcomes were extracted manually from all selected studies, and quality of each study was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.
Data Synthesis:
High-quality studies of percutaneous coronary interventions performed at centers with and without on-site surgery were included. Pooled-effect estimates were calculated with random-effects models. Analyses of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction of 124,074 patients demonstrated no increase in in-hospital mortality (no on-site surgery vs on-site surgery: observed risk, 4.6% vs 7.2%; odds ratio [OR], 0.96; 95% CI, 0.88-1.05; I(2) = 0%) or emergency bypass (observed risk, 0.22% vs 1.03%; OR, 0.53; 95% CI, 0.35-0.79; I(2) = 20%) at centers without on-site surgery. For nonprimary percutaneous coronary interventions (elective and urgent, n = 914,288), the rates of in-hospital mortality (observed risk, 1.4% vs 2.1%; OR, 1.15; 95% CI, 0.93-1.41; I(2) = 46%) and emergency bypass (observed risk, 0.17% vs 0.29%; OR, 1.21; 95% CI, 0.52-2.85; I(2) = 5%) were not significantly different at centers without or with on-site surgery.
Conclusion:
Percutaneous coronary interventions performed at centers without on-site surgery, compared with centers with on-site surgery, were not associated with a higher incidence of in-hospital mortality or emergency bypass surgery.
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