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The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Er

The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Era Probal Roy, Axel de Labriolle, Nicholas Hanna, Laurent Bonello ,

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The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Er

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  1. The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Intervention in the Stent Era Probal Roy, Axel de Labriolle, Nicholas Hanna, Laurent Bonello, Teruo Okabe, Tina Pinto-Slottow, Daniel Steinberg, Kimberly Smith, Zhenyi Xue, Lowell Satler, Kenneth M. Kent, William O. Suddath, Augusto D. Pichard and Ron Waksman. Division of Cardiology, Washington Hospital Center, Washington DC

  2. Background • The performance of percutaneous coronary intervention (PCI) at centers without cardiothoracic surgery remains a contentious issue. • Though this practice allows greater access to care there continues to be safety concerns. • This study aimed to assess the requirement for emergent coronary artery bypass graft (CABG) surgery following PCI and to establish a risk score based on the predictors identified.

  3. Methods - Study Population • Single-center observational study. • The study population consisted of 21,957 patients who underwent PCI between August 1994 (FDA stent approval) till present. • Patients requiring emergent CABG surgery (defined as within 24 hours of the index procedure) were identified. CABG and No CABG groups were compared. • Logistic regression analysis was performed to assess for independent correlates of emergent CABG surgery and a risk score was formulated.

  4. Patient Characteristics

  5. Patient Characteristics

  6. Results • Emergent CABG surgery was required in 90 patients (incidence-0.41%). • Indications for CABG surgery were: triple vessel disease (40.3%), dissection (27.4%), acute closure (16.1%), perforation (8.1%) and failure to cross (8.1%). • These patients had significantly higher in-hospital cardiac death (7.8% vs. 0.7%, p<0.01) along with higher rates of Q-wave MI, neurological events and renal insufficiency.

  7. Predictive factors of emergent CABG

  8. Results • Independent correlates of emergent CABG surgery post PCI were acute ST segment elevation MI presentation, cardiogenic shock, triple vessel disease and type C lesion. • Risk stratification using these predictors identified 0.3% of the patient population to have a substantial risk (9.3%) of requiring emergent CABG surgery. • Conversely, 97.9% of the study cohort had a <0.9% incidence of needing urgent surgery.

  9. Rates of emergent CABG surgery per number of predictors per patient Emergent CABG, % Number of Predictors

  10. Distribution of indications for CABG

  11. In–hospital outcomes in patients requiring emergent CABG % incidence

  12. Conclusions • In keeping with previous reports, the need for emergent CABG in a large patient population undergoing PCI in the stent era was low and associated with poor in-hospital outcomes. • The patient subset identified to be at substantial risk for needing emergency surgery was small (0.3%). • These findings support the practice of PCI without on-site surgery.

  13. Limitations • This was a single center observational study with the limitations inherent to this type of analysis. • The definition of emergent CABG, as surgery required within 24 hours of PCI, may have been over-inclusive. • Clinical outcome was limited to in-hospital events. • Correlates of emergent CABG were not weighted when assessing contribution to risk.

  14. References 1. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB 3rd, Morrison DA, O'Neil WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006; 113(7):e166-286. 2.. Ting HH, Raveendran G, Lennon RJ, Long KH, Singh M, Wood DL, Gersh BJ, Rihal CS, Holmes DR Jr. A total of 1,007 percutaneous coronary interventions without onsite cardiac surgery: acute and long-term outcomes. J Am Coll Cardiol. 2006; 47(8):1713-21. 3.Zavala-Alarcon E, Cecena F, Ashar R, Patel R, Van Poppel S, Carlson R. Safety of elective--including "high risk"--percutaneous coronary interventions without on-site cardiac surgery. Am Heart J. 2004; 148(4):676-83. 4. Ting HH, Garratt KN, Singh M, Kjelsberg MA, Timimi FK, Cragun KT, Houlihan RJ, Boutchee KL, Crocker CH, Cusma JT, Wood DL, Holmes DR. Low-risk percutaneous coronary interventions without on-site cardiac surgery: two years' observational experience and follow-up. Am Heart J. 2003; 145(2):278-84

  15. References 5. Peels JO, Hautvast RW, de Swart JB, Huybregts MA, Umans VA, Arnold AE, Jessurun A, Zijlstra F.Percutaneous coronary intervention without on site surgical back-up; two-years registry of a large dutch community hospital. Int J Cardiol. 2008 Jan 30. 6. Frutkin AD, Mehta SK, Patel T, Menon P, Safley DM, House J, Barth CW 3rd, Grantham JA, Marso SP. Outcomes of 1,090 consecutive, elective, nonselected percutaneous coronary interventions at a community hospital without onsite cardiac surgery. Am J Cardiol. 2008; 101(1):53-7. 7. Paraschos A, Callwood D, Wightman MB, Tcheng JE, Phillips HR, Stiles GL, Daniel JM, Sketch MH Jr. Outcomes following elective percutaneous coronary intervention without on-site surgical backup in a community hospital. Am J Cardiol. 2005; 95(9):1091-3. 8. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation. 2002; 106(18):2346-50.

  16. References 9. Yang EH, Gumina RJ, Lennon RJ, Holmes DR Jr, Rihal CS, Singh M. Emergency coronary artery bypass surgery for percutaneous coronary interventions: changes in the incidence, clinical characteristics, and indications from 1979 to 2003. J Am Coll Cardiol. 2005; 46(11):2004-9. 10. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361(9351):13-20. 11. Peels HO, de Swart H, Ploeg TV, Hautvast RW, Cornel JH, Arnold AE, Wharton TP, Umans VA. Percutaneous coronary intervention with off-site cardiac surgery backup for acute myocardial infarction as a strategy to reduce door-to-balloon time. Am J Cardiol. 2007; 100(9):1353-8. 12. Kutcher MA.Percutaneous Coronary Interventions at Facilities Without On-Site Cardiac Surgery (National Cardiovascular Data Registry). ACC 2008. 13. Wennberg DE, Lucas FL, Siewers AE, Kellett MA, Malenka DJ. Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery. JAMA. 2004; 292(16):1961-8.

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