Wednesday, December 14, 2011


This has been a question since the advent of angioplasty in 1977. In 1977 when the late Andreas Greuntzig first dilated the proximal LAD lesion. he had cardio-surgical backup. In fact the early work by the Americans in San Francisco, was in the operation theatre with a patient undergoing bypass surgery, trying to see if dilating the plaque will cause important distal embolisation of the plaque. So the early work of angioplasty was done, very much with the cooperation of the cardiac surgeons. When angioplasty first started in Malaysia in October 1998 e had cardio=surgical backup, with an open OT ready, just in case. I had to use it a few times, asking my cardiac surgeon to bale me out.
Then in 1992, we received our stents ( the first generation Palmaz Shatz SDS ), and then we almost never had to summon for cardio-surgical help. It has been almost a decade since we last call for cardio-surgical help. The last time I remembered was when I had to do a left main stem and I asked the cardiac surgeon, if he would take it on, and he declined.
Anyway, with the event of the coronary stents ( and they are so good, slick, easy to deliver and can almost go anywhere ), cardiologist can always bale themselves out well, at the earliest hint of trouble. However, there was still resistance from those in authority to allow PCI in centers without cardio-surgical backup. I know that in Malaysia, some of my colleagues in some private hospitals had to accompany their patient from the other centers to their main KL centers, to do the angioplasty. This is also not good, if you consider the cost to the cardiologist and also the patient and relatives. I believe that if an interventionist does not know how to implant a stent to bale out, he should not be doing angioplasty. And of course, as always, we want all centers to keep their registry, hopefully by a senior nurse, so that all records and experience can be tracked. It is all for patient safety. In fact, all cardiac centers ( including those with cardio-surgical back-up ) should also keep their PCI / cardio-surgical registry. All specialist who do interventions and surgeries should also keep their own registry. It makes us aware of our outcome data.
In the Journal of the American Medical Association 306:2487, 2011, there is an article by Dr Mandeep Singh of the Mayo Clinic, addressing this issue. The article is entitled "PCI in cardiac centers with and without on-site cardiac surgery ". He and his colleagues did a meta-analysis of all controlled trials for the last 20 years, a total of 15 large controlled studies involving PCI in cardiac centers with and with-out cardio-surgical backup. They reviewed 124,074 PCIs in patients undergoing primary angioplasty for STEMI and 914, 288 patients undergoing elective PCIs for nonprimary AMI angioplasty. These are very large numbers and must certainly hold some truth. They found no difference in in-hospital mortality, and emergency CABG. There was absolutely no difference in outcomes between the two groups. They have therefore, rightly I think, call for a review of the AHA / ACC / SCAI clinical guidelines. The guidelines currently states that "PCI maybe considered in centers without on-site cardiac surgery", when initially, it states "not useful/effective and may be harmful". Of course we would rather that it would allow PCI in centers with adequate facilities to do PCI, to their degree of competence.
I can see the reluctance in the US system to allow licence to all PCI centers to do PCI ( even without cardio-surgical back-up ), because of the fear of abuse and insurance payments. Once they open up, there will be a mushrooming of PCI centers in the community hospitals, then the system can pose track, and there may not be enough patient load for the large teaching centers. And of course the third party payers will not be so happy, as they have to pay out more. with more centers doing.
Personally, I think it is about time to allow good people to do PCI in centers without cardio-surgical back-up. How to control is another issue. I have heard of cardiac surgeons telling cardiologist they cannot PCI 2 vessel disease, because the angioplasty list is vetted by the cardiac surgeons. That is ridiculous.
Which is the greater evil. To allow PCI in centers without on-site cardiac surgery or not?
As always it is the professional that is important. You cannot legislate morality and ehical standards, either the cardiologist have it or he does not. In some ways, it reflects how we bring them up. It does look like many have been brought up different from us.

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