On-site Cardiac Surgery Research Articles

121 A District General Hospital Experience of Rotational Atherectomy in the United Kingdom

Aims Rotational atherectomy/rotablation (RA) has been traditionally considered a high risk procedure and performed in tertiary centres with on-site surgical backup. Our aim was to analyse RA with regards to procedural success and safety in the setting of a cardiac centre without on-site cardiac surgery. Methods A retrospective analysis of all RA pts between Jan 2010 and April 2013 was undertaken. Demographic data and procedural details were collected from medical case notes, cathlab records, BCIS and radiographer’s database. Hospital, GP records and national mortality registry were used for follow-up information. F/u data was analysed at 30 days and 1 yr post procedure. Results 184 pts underwent 206 PCI’s with RA in the study period of 40 months. This represents 5% of our total 3884 PCI work load. In comparison to non-RA group, RA group was older (74 vs. 67 yr) and had higher risk profile: HTN (72 vs. 68%), DM (35 vs. 21%). Procedures were elective in 153 (74%), ACS-41 (20%) and STEMI-12 (6%). 3-vessel CAD was present in 61 (30%), LMS disease in 26 pts (14%). Intervention was performed on LMS 20 (10%), LAD 111 (54%), LCx 30 (15%) and RCA 66 (32%), with 18 (9%) pts having multivessel RA. There were 9 (4%) ostial lesions, 35 (17%) bifurcation lesions, and 2 (1%) CTOs. There was previous failed PCI in 21 (10%) pts, with ad-hoc RA in 24 (12%) and the rest having upfront RA (161, 78%). Radial access was 38% and femoral in 62% with 6 and 7F catheters used equally. A single burr was used in 175 (85%). Burr sizes were: 1.25 mm (55%), 1.5 mm (39%). IVUS use in 45 (22%); prophylactic temporary PPM in 14 (10%) and prophylactic IABP in 9 (4%). Procedural success was achieved in 198 (96%) with 5 requiring balloon only dilation. Mean total radiation time was 43.8 min, with a mean DAP of 16793 cGy with >50% reduction after first 2 yrs and mean contrast load 270 ml with a 17% reduction after 2 yrs. No procedural comp were seen in 184 (89%) cases, major comp in 6% (12: vascular comp requiring surgery/transfusion-5; tamponade-3; temporary PPM related-2 and PCI wire related in 1; contrast nephropathy-2; coronary perforation due PCI wire-1; transfusion with no source of bleeding-1), and minor comp in 6% (13: hypotension requiring IABP-3; bradycardia requiring temporary PPM-1; coronary slow/no flow-2; coronary dissection-1; other coronary comp-2; other – hypotension, bradyarrhythmia, tachyarrhythmia treated medically-4). In hospital mortality was 1%(2: both ACS) and at 1 yr 5.8%(12) with 2% cardiac mortality. MACE rate (i.e. cardiac mortality, MI, TLR and CABG) at 1 month was 1.5% and at 1 yr 8.7% driven mainly by TLR due to ISR. Event free survival at 1 yr was 178 (86%). Conclusions RA in the setting of off-site surgical backup is a safe and effective with an overall high procedural success rate. Ours is one of the largest series of RA pts in the DES era and support RA use in calcified coronary lesions. Event rate during 1 yr follow-up was mainly driven by TLR due to ISR.

Safety of transcatheter aortic valve implantation in a hospital with visiting on-site cardiac surgery.

To describe the feasibility and safety of transcatheter aortic valve implantation (TAVI) with a visiting on-site cardiac surgery program for surgical back-up. Both European and American guidelines recommend institutional cardiac surgery back-up for TAVI. However, the conversion to cardiac surgery is very rare, many complications of TAVI can be managed by catheter techniques and a visiting team can also provide surgical stand-by. Therefore, the need for institutional cardiac surgery (by a surgeon who routinely performs conventional surgical valve replacement at the institution performing TAVI) has been questioned. A retrospective review of consecutive TAVI cases with visiting on-site cardiac surgery was performed. Key demographic, echocardiographic, and procedural data were collected prospectively. A total of 97 patients (81.9 ± 6.3 years) with high-risk criteria (log Euroscore 21.6 ± 14.4, chronic renal failure 39.2%, severe systolic dysfunction 24.7%) underwent TAVI with visiting on-site cardiac surgery at our institution. Local anesthesia with or without conscious sedation was used in 94.8% of patients. Procedural technical success was 100%, with 2 episodes of tamponade (both treated with pericardiocentesis) and a 16.5% vascular complication rate (all treated conservatively or percutaneously). Thirty-day mortality was 3.1%, with 5.2% rate of stroke and 8.2% rate of major bleeding. There were no conversions to surgery. TAVI can be done safely in the setting of a hospital with visiting on-site cardiac surgery. This requires careful patient selection, experienced operators and surgeons in experienced centers with well-established criteria and processes of care. In this setting, it may be an option for hospitals without institutional cardiac surgery.

Thirty years of standalone percutaneous coronary interventions: A 23,261 case experience from a Canadian tertiary referral centre

Background: When percutaneous coronary intervention (PCI) was first performed >35 years ago, on-site cardiac surgery backup for PCI failure was deemed essential. As techniques improved and primary PCI became the preferred reperfusion strategy for acute myocardial infarction, many standalone PCI programs originally established to facilitate access to primary PCI started to perform elective PCI, which remains a Class IIb recommendation in American College of Cardiology Foundation/American Heart Association/Society for Cardiac Angiography and Interventions guidelines. Two recent United States studies showed that outcomes of elective PCI in standalone centres were noninferior to those with on-site cardiac surgery. The Royal Alexandra Hospital in Edmonton (Alberta) performed the first standalone PCI in Canada in 1981. Objectives: The authors describe their first 30 years’ experience with PCI – the largest single-centre standalone experience reported to date. Methods: Patient and procedural data have been collected since the first standalone PCI in 1981, evolving from paper records to a computer database and, in 1995, a provincial database. Quality assurance and peer review in collaboration with the regional cardiac surgery program was established from the outset. Results: The success, emergency coronary bypass and death rates for 23,261 standalone PCIs performed between 1981 and 2011 were 96.0%, 0.2% and 0.5%, respectively. For 9068 PCIs performed between 2007 and 2011 (a period that most reflects contemporary practice), the rates were 96.5%, 0.04% and 0.6%, respectively. These results compare favourably with PCI results reported in literature, irrespective of the presence or absence of on-site cardiac surgery. Conclusions: With high volumes and an experienced team, standalone PCIs can be performed safely with excellent success and low complication rates.

The safety of rotational atherectomy at a PCI capable centre with no on-site cardiac surgery

Background and Aims: Percutaneous transluminal coronary rotational atherectomy (PTCRA) caries a small but significant risk of mechanical complications (most notably coronary artery perforation) potentially requiring urgent cardiac surgical intervention. The aim of this study is to assess the safety and efficacy of PTCRA facilitated procedures in a non-cardiac surgical centre. Methods: A retrospective analysis of the charts of 115 consecutive patients between January 2000 and December 2014 was undertaken. Patients had calcified lesions requiring PTCRA prior to stent implantation. Thirty-day mortality was the major endpoint. Results: 115 patients underwent PTCRA. Mean age 72.47 years (SD 9.62). Male (63.5%). Thirty-day survival 98.5% (95% CI 92.75% to 99.5%). 97.2% of cases were completed successfully. Artery treated: Left Anterior Descending artery (36.5%); Right Coronary Artery (31.4%). Average number of burrs 1.5; average maximum diameter 1.63mm. Temporary pacing wires utilisation 34.3% . Drug Eluting Stents (DES) was utilised in 84.4% of cases. Two patients had coronary artery perforations (Ellis Classification (EC) system); One Type 1 perforation (no clinical sequalae); one Type 3 (frank) perforation only evident post-stenting during aggressive balloon postdilatation. This patient died before surgical salvage could occur. Another death occurred in a patient with multiorgan failure– the death was unrelated to PTCRA. One patient suffered a large periprocedural myocardial infarct related to iatrogenic coronary dissection occurring during post stenting phase of procedure. Conclusion: In a hospital without on-site cardiac surgical capabilities, PTCRA was performed safely with acceptable survival outcomes at thirty days. No deaths or large MI's occurred that were directly attributable to PTCRA.

Abstract 14873: Is There Difference in Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS) between Hospitals With and Without Onsite Cardiac Surgery Backup?

Background: Based on 2011 ACCF/AHA/SCAI PCI guideline, it is recommended that PCI should be performed at hospital with onsite cardiac surgery. But, recent data suggests that there is no significant difference in clinical outcomes following primary or elective PCI between hospitals with and without onsite cardiac surgery. The proportion of PCI centers without onsite cardiac surgery comprises approximately more than half of all PCI centers in Japan. We examined the impact of with or without onsite cardiac surgery on clinical outcomes following PCI to ACS. Methods: From Aug 2008 to March 2011, subjects (n=2288) were enrolled from the Kumamoto Intervention Conference Study (KICS), which is a multicenter registry, and enrolling consecutive patients undergoing PCI in 15 centers in Japan. Patients were assigned to two groups treated in hospitals with (n=1954) or without (n=334) onsite cardiac surgery. Clinical events were followed up for 12 months. Primary endpoint was in-hospital death, cardiovascular death, myocardial infarction, and stroke. And we monitored other events those were non-cardiovascular deaths, bleeding complications, revascularizations, and emergent CABG. Results: There was no overall significant difference in primary endpoint between hospitals with and without onsite cardiac surgery (9.6%vs9.5%; P=0.737). There was also no significant difference when events in primary endpoint were considered separately. In other events, only revascularization was more frequently seen in hospitals with onsite cardiac surgery (22.1%vs12.9%; P<0.001). Kaplan-Meier analysis for primary endpoint showed that there was no significant difference between two groups (Log Rank P=0.943). By cox proportional hazards model analysis for primary endpoint, without onsite cardiac surgery was not a predictive factor for primary endpoint (HR 0.969, 95%CI 0.704-1.333; P=0.845). We performed propensity score matching analysis to correct for the disparate patient numbers between two groups, and there was also no significant difference for primary endpoint (6.9% vs 8.0%; P=0.544). Conclusions: There is no significant difference in clinical outcomes following PCI for ACS between hospitals with and without onsite cardiac surgery backup in Japan.

The role of the heart team in complicated transcatheter aortic valve implantation: a 7-year single-centre experience

European guidelines recommend to perform transcatheter aortic valve implantation (TAVI) within a multidisciplinary heart team. However, there is a strong drive--despite existing guidelines--to perform TAVI outside of specialized centres. The aim of this study was to clarify the necessity of on-site cardiac surgery by providing a clear insight into the complications during/after TAVI that needed surgical management. A total of 2287 (1523 transfemoral, 752 transapical and 12 transaortic) patients, with a mean age of 84.5 ± 5.3 years, and a mean log EuroSCORE of 21.7 ± 16.3, of which 205 were female (84%), underwent TAVI since February 2006 at our institution. All procedure-related complications that required surgical interventions, whether immediate or delayed but within the initial hospital stay, were recorded and retrospectively analysed. Out of this cohort, 245 (10.7%) patients required surgical treatment due to major complications. A total of 42 patients (1.8%) underwent conversion to full sternotomy and 27 (1.2%) were dependent on the short-term use of the heart-lung machine. Vascular complications with surgical intervention were seen in 85 patients (3.7%), 54 patients (2.4%) had to have a rethoracotomy within their initial stay and 15 (0.7%) required a cardiac reoperation. Severe complications during TAVI that can only be resolved surgically will continue to occur. Therefore, each TAVI procedure should be conducted or accompanied by a cardiac surgeon and an experienced team within a specialized centre.

THIRTY-YEARS OF STANDALONE PCI: EXPERIENCE FROM A HIGH VOLUME CANADIAN CENTRE

The safety of PCI without on-site cardiac surgery has been an ongoing debate since the early 1980’s. However, success rate has improved and acute reocclusion rate reduced since the introduction of stents and new antiplatelet therapy in the 1990s. PCI is now the predominant revascularization modality for coronary disease(CAD) worldwide and where available, primary PCI has become the standard of care for STEMI. In Ontario, 5 new standalone PCI centres have been established in the past 14 years. However, elective standalone PCI remained a Class IIb indication in the 2011 ACCF/AHA/SCAI guidelines. Nonetheless, the recent C-PORT and MASS COM trials in the US concluded that in non-emergency patients, standalone PCI is non-inferior to that performed in centres with on-site cardiac surgery. The Royal Alexandra Hospital performed the first standalone PCI in Canada in 1981 and has provided PCI services to a full spectrum of CAD patients ranging from elective, in-hospital to emergency cases with STEMI and cardiogenic shock. Surgical backup is located at the University of Alberta Hospital 6 km away. Joint case conference is conducted weekly with the cardiac surgery program. In the first 30 years, 23,261 PCIs were performed. We report our 30-year standalone experience, which we believe is the largest single centre experience in literature to date. PCI volumes, clinical and procedural characteristics, lesion success, emergency coronary bypass and mortality rates were collected and reported for the 30-year period. Results for 2006-2011, a period most relevant to current practice were compared with the most recent US PCI data. PCI volumes, CCS Class 4 patients, ad hoc, rescue and primary PCIs all increased significantly over the 30-year period. Success and emergency coronary bypass rates also improved (see Table). For 2006-11, our success, emergency CABG and 30-day mortality rates (96.5, 0.04, 1.1%) compared favorably with National Cardiovascular Data Registry (93-94, 0.3-0.4, 1.2-1.7 %*), C-PORT (93.4-94.1, 0.2, 0.8-0.9 %**) & MASS COM(95.6-97.1, 0.1-0.3, 0.3-0.7 %). PCIs can be performed safely in an experienced, high volume standalone centre with excellent success and very low complication rates. These results support the safety of establishing new standalone PCI centres to meet the growing population demand for percutaneous revascularization for coronary disease.

A PROVINCIAL APPROACH TO IMPROVING STEMI CARE IN ONTARIO

The Cardiac Care Network of Ontario (CCN) is dedicated to improving the quality, efficiency, access and equity in the delivery of adult cardiovascular services in Ontario. CCN works to plan, coordinate, implement and evaluate adult cardiovascular care in the province of Ontario, and is responsible for the CCN Cardiac Registry, a clinical data registry that includes all cardiac procedures in Ontario. CCN established a STEMI Working Group (membership comprised of representatives from PCI and Non PCI hospitals, Emergency Medical Services and Base Hospitals) to conduct a current state assessment and standardize care for ST elevation myocardial infarctions (STEMI) in Ontario. Seventeen hospitals in Ontario provide Percutaneous Coronary Intervention (PCI) of which 6 are Stand Alone PCI programs (without on-site cardiac surgery). Data from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) suggest that the incidence of STEMI in Ontario is approximately 68 per 100,000 adult residents, providing an estimate of 7,000 STEMIs per year. STEMIs are treated through the restoration of blood flow in the coronary artery through one of two treatment options or “reperfusion” modalities:-Primary PCI-Fibrinolysis Therapy-Pharmaco-invasive Therapy. In order to determine the current state of care for STEMI patients, the CCN STEMI WG conducted a survey of emergency services, PCI hospitals and non PCI hospitals. The results of the environmental scan, combined with analysis of administrative data, review of best practice guidelines and published literature, provided the foundation for 16 recommendations to optimize STEMI care in Ontario, of which five were identified as priority recommendations. In December 2013 the Auditor General of Ontario reviewed the Land Ambulance service in Ontario, and included CCN STEMI WG’s recommendations in its report to the Ontario government. CCN has expanded its Cardiac Registy to include metrics related to quality indicators for STEMI care to monitor performance of the STEMI system in Ontario. CCN’s recommendations for a province-wide, standardized and coordinated approach to STEMI care will help to decrease the variation in the use of pre-hospital care resources, improve coordination of care and access to PCI, and as a result, improve patient outcomes (e.g., reduced morbidity and mortality) as patients receive the right care (reperfused) in the right place (PCI Centre) at the right time (within the recommended timelines).

TRENDS IN PCI FOR PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION AT ONTARIO CARDIAC CENTRES WITH AND WITHOUT ON-SITE CARDIAC SURGERY

In order to increase the accessibility of Percutaneous Coronary Interventions (PCI) for patients in Ontario, there has been an increase in the number of PCI capable centres without on-site cardiac surgery across the Province in recent years. The objective of this analysis was to describe the volumes, characteristics and treatment times of patients undergoing ST-Segment Elevation Myocardial Infarction (STEMI) related procedures at PCI capable hospitals with (OSS) and without (no-OSS) on-site surgery. The Cardiac Care Network of Ontario maintains a provincial registry of all PCI procedures across Ontario. Data on all procedures performed on patients with a diagnosis of STEMI and undergoing cardiac catheterization within 24 hours of diagnosis were captured on a standardized PCI/STEMI case report form. Patients for this analysis were categorized as Primary PCI, Rescue PCI (emergency PCI for failed fibrinolysis) or Pharmaco-invasive PCI (routine PCI within 24 hours of fibrinolysis). Between April 1 2011 and March 31 2014, 14681 STEMI PCI procedures were performed at 16 PCI sites (OSS=11; no-OSS=5) (see Table 1). The number and proportion of Ontario STEMI cases performed at no-OSS centres over three years were (2011-2012: n=481(13.2%), 2012-2013: n=711(17.0%), 2013-2014: n=1100(24%). During the same period, the number of STEMI cases at OSS centres remained stable. Baseline variables and overall crude treatment times (door to balloon for Primary PCI) were comparable between OSS and no-OSS sites (84 min vs 83 min). These data suggest broader access to emergency PCI for STEMI patients across Ontario over the time period of interest. The greater provision of STEMI PCI has been driven by over a 2-fold increase in the number of cases performed at no-OHS centers, which now provide approximately one-quarter of all STEMI PCI in the Province.

Clinical outcomes of percutaneous coronary intervention (PCI) at hospital with or without onsite cardiac surgery backup

Based on 2011 ACCF/AHA/SCAI PCI guidelines, it is recommended that PCI should be performed at a hospital with onsite cardiac surgery [1]. But, recent data suggests that there is no difference in clinical outcomes following primary [2,3] or elective PCI [4,5] between hospitals with or without onsite cardiac surgery [6]. However, this has not been determined for Japan. We examined the impact of onsite cardiac surgery on clinical outcomes following PCI in Japan.

PW152 Initial Experience With The Pre-Hospital Assessment For Primary Angiogram (PAPA) Program For ST Elevation Myocardial Infarction Based On The Glasgow Algorithm At A Regional New South Wales Hospital Without Onsite Cardiac Surgery

PW152 Initial Experience With The Pre-Hospital Assessment For Primary Angiogram (PAPA) Program For ST Elevation Myocardial Infarction Based On The Glasgow Algorithm At A Regional New South Wales Hospital Without Onsite Cardiac Surgery

PT197 Outcomes of PCI in Hospital with and without On-site Cardiac Surgery. An Australian experience

PT197 Outcomes of PCI in Hospital with and without On-site Cardiac Surgery. An Australian experience

PM210 Comparing Outcomes of Primary Percutaneous Coronary Interventions For ST Elevation Myocardial Infarcts Assessed Via The Pre-Hospital Assessment For Primary Angiogram (PAPA) Program and In The Emergency Department At A Regional New South Wales Hospital Without Onsite Cardiac Surgery

PM210 Comparing Outcomes of Primary Percutaneous Coronary Interventions For ST Elevation Myocardial Infarcts Assessed Via The Pre-Hospital Assessment For Primary Angiogram (PAPA) Program and In The Emergency Department At A Regional New South Wales Hospital Without Onsite Cardiac Surgery

Pre-procedural fasting for coronary interventions: is it time to change practice?

IntroductionTraditionally, patients are kept nil-per-os/nil-by-mouth (NPO/NBM) prior to invasive cardiac procedures, yet there exists neither evidence nor clear guidance about the benefits of this practice.ObjectivesTo demonstrate that percutaneous cardiac catheterisation...

Elective percutaneous coronary intervention without on-site cardiac surgery: an Iranian survey

Elective percutaneous coronary intervention without on-site cardiac surgery: an Iranian survey

Position statement on transcatheter aortic valve implantation in Portugal

ObjectiveTo evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal. Methods and ResultsThe working group analyzed the epidemiology of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal.The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams.TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency.The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe.From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used. ConclusionTAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk.Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes.

Posição de consenso sobre válvulas aórticas percutâneas transcatéter em Portugal

ObjectiveTo evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal. Methods and ResultsThe working group analyzed the epidemiology of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal.The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams.TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency.The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe.From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used. ConclusionTAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk.Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes.

Outcome of patients after emergency conversion from transcatheter aortic valve implantation to surgery

To evaluate: 1) the causes of emergency conversion from transcatheter aortic valve implantation (TAVI) to surgery, 2) procedural settings, and 3) short-term outcome of converted patients. The prospective German TAVI registry was used to identify patients who underwent bail-out surgery during TAVI. Additionally, standardised questionnaires were developed and used to assess more detailed periprocedural and postprocedural data. Emergency conversion from TAVI to open cardiac surgery was required in 24 of 1,975 patients (1.2%). Primary conversion causes were aorto-valvular complications (i.e., aortic annulus rupture, aortic perforation, or thoracic aortic dissection). This was followed by prosthesis embolisation, myocardial perforation, severe aortic regurgitation, and coronary obstructions. The mean time interval between abortions of TAVI to surgery was 19 minutes (SD ± 17 min, range 5-80 min). Four of 24 patients (16.7%) died during the initial surgery, seven of 24 (29.2%) within the first 72 hours and the 30-day mortality was 45.8%. The highest mortality was observed in patients with aortic perforation or dissection (4/5, 80%). Mortality rates for other entities were: prosthesis embolisation 40% (2/5), myocardial perforation 50% (2/4), annulus rupture 67% (2/3), severe aortic regurgitation 33% (1/3), and coronary impairment 0% (0/3). Emergency conversion from TAVI to surgery is a rare event carrying a mortality of around 45% after 30 days. Outcome of converted patients with prior injury of aortic, aorto-valvular, or myocardial tissue during TAVI was poor, whereas patients with severe aortic regurgitation and those with coronary complications had a more favourable outcome after 30 days. Collected procedural and outcome data demand on-site cardiac surgery as a prerequisite for TAVI and constant process optimisation efforts regarding such emergency scenarios.

Nonemergency PCI without onsite cardiac surgery was noninferior to PCI with onsite services for MACE

Source Citation Jacobs AK, Normand SL, Massaro JM, et al; MASS COMM Investigators. Nonemergency PCI at hospitals with or without on-site cardiac surgery. N Engl J Med. 2013;368:1498-508. 23477625

Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling.