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