Elective PCI Without On-Site Cardiac Surgery: Standard of Care?

T he use of percutaneous coronary intervention (PCI) has grown dramatically during the past 30 years. Several developments have led to the growth of PCI, including improved equipment, new anticoagulant and antiplatelet drugs, and the evolution of coronary artery stents. Simultaneous with these improvements, the indications for PCI have expanded, and the safety and outcomes of the procedure have steadily improved. During the early days of balloon angioplasty, procedure mortality was 1% to 2.5%, and up to 5% of patients required urgent coronary artery bypass graft (CABG) surgery.1,2 In comparison, inlab mortality at high-volume centers is now approximately 0.2%, and <0.5% of patients require urgent CABG surgery.3,4 PCI is now the preferred therapy for patients with STsegment elevation myocardial infarction (STEMI).5,6 However, the superior outcomes of primary PCI are adversely affected by time delays that may accumulate before the patient arrives in the cardiac catheterization laboratory at a PCI-capable facility.7,8 Studies showed that door-to-balloon times for primary PCI were not optimal but could be decreased by 30 to 40 minutes in some settings by offering PCI at facilities without onsite surgery.9-11 To avoid the inherent delays that occur when transferring patients, and to extend this therapy to a larger number of patients, some facilities began to perform primary PCI for STEMI in the absence of onsite surgery and reported excellent outcomes.12 Because the actual number of patients with STEMI at any location is relatively small, many of these facilities also started performing elective PCIs in an effort to maintain proficiency among the support staff and have adequate procedure volumes to justify the operation of such programs.13-15 Although it is accepted in many countries abroad, the performance of PCI without on-site cardiac surgery remains controversial in the US.16