Percutaneous coronary intervention without surgery on‐site is here to stay

The need for emergency cardiac bypass surgery due to a complication occurring during a PCI procedure has gone down from an initial 6–10 % in the early 1980s to less than 0.5 % in the present era [1]. Technological advances have made the procedure very safe in the hands of experienced operators working in dedicated centres. In Europe in the last decade, many PCI programs without surgery on-site have been started as a consequence of this rare need for actual surgical backup. In addition, these PCI programs were started in (mostly rural) regions where travel distances to PCI centres with surgery on-site resulted in long delays for STEMI patients undergoing primary PCI. The safety and long-term efficacy outcome of PCI programs in centres without surgery on-site have been shown in registries and large randomised studies. Just recently, the MASS COMM investigators demonstrated in a large randomised trial including 3691 patients that there was no difference in the incidence of MACE at 30 days (9.5 % vs 9.4 %; RR 1.00; P < 0.001 for non-inferiority) and at 12 months (17.3 % vs 17.8 %; RR 0.98; P<0.001 for non-inferiority) [2]. These data confirm and extend the results from the CPORT study published in 2012, which randomised 18,867 patients and showed no difference in 6-week mortality and no difference in MACE at 9 months (12.1 % vs 11.2 %; P=0.05) [3]. Both these studies excluded patients undergoing urgent PCI procedures for STEMI and NSTEMI. Reports using non-randomised data from the NRMI database by Pride et al., which included 58,821 STEMI patients and more than 100,000 NSTEMI patients treated either in centres with or without surgery on-site confirmed that the safety (e.g., as assessed on the basis of short-term mortality and need for emergency surgery) and efficacy (e.g., procedural success and longer-term rate of survival) of such PCI procedures was similar [4, 5]. Following these developments, the Dutch Guidelines for Interventional Cardiology 2004 included recommendations for centres and operators that provide PCI without surgery on-site regarding facilities, staffing, training requirements etc [6]. The minimum number of procedures per centre and per operator are required in order to ensure proficiency, experience and continued quality of care. Moreover, structural relations with a surgical centre and protocols for emergency transfer should be present. In order to provide primary PCI for patients with STEMI, a 24–7 service is required and finally, centres are obliged to prospectively …