The practice of percutaneous coronary interventions in hospitals without on-site cardiac surgery : review of guidelines and analysis of Québec data, 1999-2004

11-06-2007 | Cardiologie et maladies neurovasculaires

Percutaneous coronary intervention (PCI) is a technique for opening up or dilating coronary arteries narrowed or occluded by atherothrombotic lesions. It is generally performed in catheterization laboratories in facilities that have on-site cardiac surgery to deal with certain serious, albeit rare, complications that can occur. However, over the past several years, there have been pressures worldwide to perform PCI at facilities without on-site cardiac surgical support. Québec already has five such centres (more than in the rest of Canada combined), but the Ministère de la Santé et des Services sociaux continues to receive requests for opening new catheterization laboratories in hospitals without on-site cardiac surgery. Despite the advantages of this practice in terms of patient access, its advisability and safety are still debated.

The present assessment is based on a review of the most recent guidelines that exist in other countries and jurisdictions, and on an analysis of Québec medico-administrative data for PCIs performed from 1999 to 2004.

A review of the available evidence indicates that clinical outcomes are slightly but significantly less favourable in patients who undergo PCI at centres without on-site cardiac surgery, even in highly controlled conditions with the rigorous selection of low-risk patients. The same observation emerges from the analysis of PCI outcomes in Québec, using a first PCI as the reference event. Although these results should be considered preliminary because of the limitations of the analysis, the 1-year overall mortality risk appears to be significantly higher at centres without on-site cardiac surgery. The relative and absolute increases in this risk are estimated at 29% and 1.4%, respectively, compared to the risk observed in centres with on-site cardiac surgery.

This report highlights the persistent uncertainty regarding the real advantages of the practice of PCI in centres without on-site surgery and leads AETMIS to advise caution in response to the continuing demand for the expansion of such centres. In all cases, given the considerable resources required to perform PCI and achieve its benefits, and the risks inherent in this intervention, this assessment emphasizes the importance of interhospital collaboration, the establishment of clear protocols, and the attainment of essential quality-of-care criteria. The report also stresses the need to institute a high-quality clinical data registry for monitoring performance to ensure the most favourable outcomes for patients and the optimal allocation of resources.

 

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