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Although Lotfi et al. (1) have contributed extremely useful data concerning the risks of percutaneous coronary intervention (PCI), I am afraid their final conclusion and particularly the implications of Dehmer and Gantt's (2) editorial comment are potentially misguided and misleading. What the data demonstrate is that in this excellent facility there is a 0.0017 probability (11 of 6,582) of having a condition develop during PCI, which has a “high likelihood of harm with additional delay to surgery.” Rapid surgical intervention was defined as being under 2 h from the event, and was successful in all the patients in this cohort.
Although the data support the conclusions about the incidence of complications, it does not support the conclusion, particularly of the editorial comment, that PCI should not be performed at hospitals without on-site surgical backup. Surgical backup needs to be available in a timely fashion, with coordination between cardiologists and cardiac surgeons regardless of where the intervention is performed. The fact that a hospital has a cardiac surgery program does not provide sufficient safety if there is not an operating room (OR) or surgeon available for emergencies (as is the case in many institutions). Likewise, the fact that a hospital does not have an on-site surgery program does not prevent it from having an integrated, efficient, and coordinated transfer system capable of getting a critical patient to an OR within 2 h. The point is not that on-site surgery is necessary. It is that timely surgery results in good outcomes.
Restricting elective angioplasty to select institutions because of a very small risk ignores the substantial benefit offered by community-based interventions. The availability of skilled interventional cardiologists in community hospitals confers important benefits over and above those measured in acute outcome studies such as this one. This includes managing delayed complications such as acute or subacute stent occlusion postdischarge, continuity of long-term patient care, physician and patient education, acute infarct and acute coronary syndrome intervention, and, very importantly, increasing the awareness of need for the coordination of care with tertiary cardiac surgery programs. All of these tend to raise the standard of care for all cardiac patients in our communities, not just those who make it to a “center of excellence.” Policymakers must consider not only risk but also benefit for the entire community.
Finally, identifying 2 h to OR for emergency surgery as a standard of excellence is laudable. Providing a single solution for all communities is presumptuous.
- American College of Cardiology Foundation
- Lotfi M.,
- Mackie K.,
- Dzavik V.,
- Seidelin P.H.
- Dehmer G.J.,
- Gantt D.S.