Urgent Coronary Bypass Surgery for Failed Percutaneous Coronary Intervention in the Stent Era

Abstract

The authors of this retrospective study reviewed their database of 5,655 consecutive patients undergoing percutaneous coronary intervention (PCI) at Beth Israel Deaconess Medical Center between August 1, 1992, and December 31, 1997, divided into four intervals reflecting changes in PCI technology and decision-making. Their goal was to track trends in indications for urgent CABG and to evaluate whether the practice of performing PCI with on-site surgical standby is still defensible. In the most recent interval (January 1, 1997 to December 3, 1997) the majority of patients (72%) received planned intracoronary stenting by experienced operators. Angiographic and clinical features were analyzed to determine their predictive value in presaging the need for urgent CABG.

The frequency of urgent CABG declined from 2.2% to 0.6% during the study period. The mean time from “recognition of need” for urgent CABG to arrival in the OR was 51 minutes, although these data are not well characterized. Urgent CABG mortality was 6% overall, without significant change over time. The incidence of urgent CABG or death (due to either PCI or CABG) remained unchanged through the study period for the entire population. Patients requiring urgent CABG had a higher incidence of unstable angina and acute MI and had more angiographically complex lesions. These factors were also prevelant in patients having successful PCI, precluding preintervention discrimination to further reduce the need for urgent CABG.

Comment

This study affirms the effectiveness of coronary stenting in a more recent era and serves as a reminder that the concept of PCI with surgical standby is still evolving. Surgical backup has evolved from preintervention consultation with dedicated OR resources in reserve to “next available room with surgeon on call” at most centers.

The authors interpret their data to be consistent with the American College of Cardiology’s mandate that PCI be performed with on-site surgical standby. Their conclusion, however, is not supported by the data presented.

The authors fail to consider the advantages of dispersal of PCI technology and expertise that pertain for patients with acute myocardial infarction and for complications that develop during diagnostic cardiac catheterization. The principal weakness of the present study is its failure to consider the impact of delay in PCI that occurs when patients have to be transferred to hospitals with cardiac surgery capability. As long as the outcome of any single patient is optimized over the outcome of all potential patients, regionalization of high-level expertise in PCI will be perpetuated.

Whether or not this position, which is based at least in part on self-preservation, is the correct one is not accurately addressed in this study.

Am Heart J 2001;142:190-6
Shubrooks SJ Jr, Nesto RW, Leeman D, et al.