On-site Surgery Research Articles

Predicting emergency coronary artery bypass graft following PCI: application of a computational model to refer patients to hospitals with and without onsite surgical backup

BackgroundClinical tools to stratify patients for emergency coronary artery bypass graft (ECABG) after percutaneous coronary intervention (PCI) create the opportunity to selectively assign patients undergoing procedures to hospitals with and...

Endovascular repair of pseudoaneurysms after open surgery for aortic coarctation.

To analyse early and long-term results of thoracic endovascular aortic repair (TEVAR) in patients with pseudoaneurysms after open aortic coarctation (CoA) repair. A total of 11 patients of 418 patients who had been treated with TEVAR during the period from January 1998 to April 2015 (8 males; median age 53 years) were retrospectively analysed. Dacron patch aortoplasty was primarily performed in 9 patients and subclavian flap aortoplasty in 2 patients. Seven of the 11 patients had asymptomatic pseudoaneurysms (median diameter 56 mm, range 20-65 mm) diagnosed by routine screening. Symptomatic patients presented with haemoptysis, lower limb ischaemia, haemodynamic collapse and back pain and underwent emergency repair (4/11). Adjunctive procedures at the proximal landing zone were required in 7/11 patients. The median number of implanted endoprostheses per patient was 1 (range: 1-5). The median follow-up was 60 months (range 6-161 months). Technical success was achieved in 91% (10/11; 1 secondary elective open conversion). The 30-day mortality was 0%. The stroke rate was 18% (2 non-disabling strokes). In 2 patients (20%), stent-graft displacement during deployment was observed. The reintervention rate was 33% (Type Ib endoleak, left arm claudication, partial coverage of the left common carotid artery). Clinical success during follow-up was achieved in 10/11 patients. In 9/10 patients, aneurysm sac shrinkage was observed. The Type II endoleak rate was 10% (1/10; intercostal artery). The overall mortality rate was 9% (1 patient died of amyotrophic lateral sclerosis). Endovascular treatment of post-coarctation pseudoaneurysms is feasible in elective and emergency cases, yielding durable results in the long term. Due to anatomical specifics, implantation may be challenging and requires careful procedural planning. On-site cardiothoracic surgery backup is essential in case open conversion is required.

Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®

Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive. A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed. A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %). This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.

Frequency of mitogen-activated protein kinase and phosphoinositide 3-kinase signaling pathway pathogenic alterations in EUS-FNA sampled malignant lymph nodes in rectal cancer with theranostic potential

Targeted next-generation sequencing has the potential to stratify a tumor by molecular subtype and aid the development of a biomarker profile for prognostic risk stratification and theranostic potential. To assess the frequency and distribution of pathogenic alterations in malignant lymph node cytology specimens. Multigene molecular profiling of archived malignant EUS-FNA lymph node cytology specimens using the Ion Ampliseq Cancer Hotspot Panel v2, which targets at least 2855 possible mutations within 50 cancer-associated genes. Single tertiary referral center. Sporadic, treatment naive, locally advanced primary rectal cancer by EUS-FNA (n= 76) who subsequently completed neoadjuvant therapy with on-site oncologic surgery. The frequency and distribution of pathogenic alterations in malignant lymph node cytology specimens by the mitogen-activated protein kinase (MAPK) or phosphoinositide 3-kinase (PI3K) signaling pathways, by KRAS or NRAS wild-type lymph node status, by extramesenteric lymph node status, and by a complete pathologic response status. Eleven patients (14.5%) were 50-gene panel wild-type. Sixty-five patients had 139 pathogenic alterations (2 [1-3] per patient) in 13 of 50 evaluated genes. The following represent a spectrum of identified alterations: TP53 (n= 52; 68.4%), APC (n= 36; 47.4%), KRAS (n= 22; 28.9%), FBXW7 (n= 8; 10.5%), NRAS (n= 6; 7.9%), PIK3CA (n= 4; 5.3%), SMAD4 (n= 3; 3.9%), and BRAF (n= 3; 3.9%). Pathogenic alterations were identified in the MAPK and PI3K signaling pathways in 41% and 5% of patients, respectively. Findings were limited to a 50 cancer-associated gene analysis. Molecular EUS lymph node assessments using cancer "hotspot" panels can identify pathogenic alteration frequency and distribution and have theranostic potential for individualized patient care.

Unprotected Left-Main Coronary Angioplasty in the Elderly in a High Volume Catheterization Centre without On-Site Surgery Facilities: Immediate and Medium Term Outcome—The Old-Placet Registry

We aim to assess clinical feasibility and efficacy of unprotected left main (ULM) percutaneous coronary intervention (PCI) in patients older than 75 years over a 6-year period and with 2-year follow-up demonstrating that PCI is a feasible revascularization strategy even in absence of on-site cardiothoracic support. Nevertheless, the outcome of these high-risk patients is still hampered by a sensible in-hospital mortality rate. Older patients have a higher mortality at follow-up (10.0 versus 0.8%, P = 0.014), while younger patients have a low mortality after the acute phase (15.7 versus 8.4%, P = 0.15).

Patient access and 1-year outcomes of percutaneous coronary intervention facilities with and without on-site cardiothoracic surgery: insights from the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) program.

The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real-world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has used this strategy, with strict quality oversight, since 2005, and can provide insight into this question. Among 24,387 patients receiving PCI at VA facilities between October 2007 and September 2010, 6616 (27.1%) patients underwent PCI at facilities (n=18) without on-site CT surgery. Patient drive time (as a proxy for access), procedural complications, 1-year mortality, myocardial infarction, and rates of subsequent revascularization procedures were compared by facility. Results were stratified by procedural indication (ST-segment-elevation myocardial infarction versus non-ST-segment-elevation myocardial infarction/unstable angina versus elective) and PCI volume. With the inclusion of PCI facilities without on-site CT surgery, median drive time for patients treated at those facilities decreased by 90.8 minutes (P<0.001). Procedural need for emergent coronary artery bypass graft and mortality rates were low and similar between facilities. Adjusted 1-year mortality and myocardial infarction rates were similar between facilities (hazard ratio in PCI facilities without relative to those with on-site CT surgery, 1.02; 95% confidence interval, 0.87-1.2), and not modified by either PCI indication or PCI volume. Subsequent revascularization rates were higher at sites without on-site CT surgery facilities (hazard ratio, 1.21; 95% confidence interval, 1.03-1.42). This study suggests that providing PCI facilities without on-site CT surgery in an integrated health care system with quality oversight improves patient access without compromising procedural or 1-year outcomes.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Results of a Stand-Alone PCI Program at Schneider Regional Medical Center

Percutaneous coronary intervention (PCI) is a class I recommended therapy for both ST segment elevation myocardial infarction (STEMI) and unstable angina. Traditionally, PCI has been performed in large tertiary centers with on-site coronary bypass surgery programs. Over the past 10 to 15 years, “stand-alone” PCI programs have become more prevalent, particularly in the United States. Geographic, cultural, and financial challenges prohibit routine transfer to tertiary centers in a timely fashion. This article discusses the PCI program at Schneider Regional Medical Center.

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.

SCAI/ACC/AHA Expert Consensus Document: 2014 Update on Percutaneous Coronary Intervention Without On-Site Surgical Backup

In 2007, the Society for Cardiovascular Angiography and Interventions (SCAI) published an Expert Consensus Document titled “The Current Status and Future Direction of Percutaneous Coronary Intervention without On-Site Surgical Backup.”1 This document summarized the available data on the performance of percutaneous coronary intervention (PCI) without on-site surgery in the United States (US), reviewed the existing literature, examined the recommendations for the performance of PCI in this setting from several professional organizations abroad and from experienced programs in the US, defined the best practices for facilities engaged in PCI without on-site surgery and made recommendations for the future role of PCI without on-site surgery. Since publication of that document, new studies, meta-analyses, and randomized trials have been published comparing PCI with and without on-site surgery. In addition, the total number of PCIs performed annually has decreased, reports about the overuse of PCI have emerged, and appropriate use criteria for coronary revascularization have been published. A noteworthy change occurred in the 2011 PCI guideline in which elective PCI was upgraded to Class IIb and primary PCI was upgraded to Class IIa at facilities without on-site surgery.2 Several tables on the structure and operation of programs without on-site surgery from the 2007 SCAI Expert Consensus Document were used in the 2011 PCI guideline recommendations. Finally, new updates of the ACCF/SCAI Expert Consensus Document on Cardiac Catheterization Laboratory Standards and the ACCF/AHA/SCAI Clinical Competence in Coronary Artery Interventional Procedures have been published.3,4 Although many of the concerns about the safety of PCI without on-site surgery have been resolved, there are new issues to consider as the delivery of PCI continues to evolve in the US. Accordingly, the SCAI, ACCF, and AHA have engaged in this effort to reevaluate the current status of PCI without on-site surgery in the US. …

Outcomes of structuralinterventions in a hospital without onsite cardiothoracic surgery

Outcomes of structuralinterventions in a hospital without onsite cardiothoracic surgery

PW153 The Safety of Remote PCI in 1,543 Patients in Rural New South Wales without Cardiac Surgery Onsite

PW153 The Safety of Remote PCI in 1,543 Patients in Rural New South Wales without Cardiac Surgery Onsite

PCI without surgical backup—evidence-based, but wise?

The results of MASS COMM support the safety of performing percutaneous coronary intervention at centres without on-site cardiothoracic surgery services. To translate these findings into clinical practice, robust quality oversight programmes, with direct measurement of procedural outcomes and complications, are needed. The VA CART programme provides a model for such a strategy.

Reducing severe intraprocedural complications during transcatheter aortic valve implantation with an interdisciplinary heart team approach

provide any comparison of patients in whom TAVI was performed with and without a heart team approach to support their conclusion. As TAVI continues to evolve, refinements in patient selection, technology and operator experience are likely to reduce many complications and the need for ECS. We concur with the authors that the heart team approach is key for good outcomes and the successful further development of TAVI as a valuable treatment alternative for select high-risk patients with symptomatic aortic stenosis. However, we would like to caution against the authors’ use of the heart team approach as synonymous with an on-site cardiac surgical programme (authors stress on the ‘prerequisite of institutionalized departments of cardiology and cardiac surgery at sites performing TAVI’). Some centres have adopted a similar ‘heart team’ approach by collaborating with an off-site cardiac surgery team that participates not only in the procedure, but also in patient selection. Preliminary data on the small number of patients enrolled in the German TAVI registry have suggested comparable mortality among patients undergoing TAVI at sites without on-site surgery, but which used this approach compared with sites with the on-site surgical programme (3.8 vs 8.8%, P= 0.12) [6]. We submit that more data are needed on this issue, but until the time that such information is available on larger numbers of patients, we caution against the implicit use of the phrase ‘an interdisciplinary heart team approach’ as synonymous with the on-site cardiac surgery programme.

Abstract 162: Procedural and 1-Year Outcomes between PCI Centers with and without On-Site CT Surgery: Insights from the VA CART Program

Background: Clinical trials demonstrate that percutaneous coronary intervention (PCI) can be safely performed at medical centers without on-site cardiothoracic (CT) surgery, and current PCI guidelines support this practice with effective quality oversight. Translation of these trial findings and guideline recommendations into clinical practice has not been described. In 2005, the VA initiated a policy to expand PCI access by performing procedures at centers without on-site CT surgery under strict quality standards. The impact of this policy on procedural and longer-term patient outcomes has not been evaluated. Methods: We studied all PCIs conducted in the VA health care system between 2007-2010. We used data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program, a national clinical quality program that collects real-time data on coronary procedures, procedural complications, and outcomes. Procedural complications (need for emergent CABG and in-lab death), 1-year all-cause mortality, myocardial infarction (MI), and rates of repeat revascularization procedures were compared by presence of on-site CT surgery. We used multivariate survival analysis to assess the association between the presence of on-site CT surgery and 1-year outcomes. The analyses were further stratified by procedural indication (ACS vs. elective) and cath lab PCI volume (≥ vs. &lt;165 PCIs/year). Results: 24,387 patients received a PCI at 59 centers in the VA health care system between 2007-2010. 6,900 (28.3%) patients underwent PCI at 19 centers without on-site CT surgery. Rates of procedural complications were similar for PCI centers with and without on-site CT surgery (emergent CABG: 13 (0.1%) at PCI centers with on-site CT surgery vs. 2 (&lt;0.05%) at PCI centers without on-site CT surgery, p-value 0.26; deaths: 15 (0.1%) at PCI centers with on-site CT surgery vs. 5 (0.1%) at PCI centers without on-site CT surgery, p-value 0.74). Adjusted 1-year combined all-cause mortality and MI rates were similar between centers (HR 0.995, 95% CI 0.84, 1.17), but revascularization rates were higher at sites without on-site CT surgery centers (HR 1.20, 95% CI 1.05, 1.33). Neither PCI indication nor cath lab volume significantly modified these results. Conclusions: Our findings demonstrate that procedural and 1-year patient outcomes are similar between PCI centers with and without on-site CT surgery. These results indicate that the clinical trial evidence of PCI safety without on-site CT surgery can be effectively translated to clinical practice. The VA’s policy allowing for PCI centers without on-site CT surgery in the setting of a quality oversight program may serve as a potential model for improving PCI access in large, integrated health care systems.

MASS COM Trial: Nonemergency PCI Safe without on-Site Surgery Capability

MASS COM Trial: Nonemergency PCI Safe without on-Site Surgery Capability

The Year in Cardiology 2012: coronary intervention

I am delighted to provide readers of the European Heart Journal with an overview of scientific data relating to Coronary Intervention in 2012. This article aims to summarize the important publications and presentations; it includes a summary of the main interventional meetings (ACC, EuroPCR, ESC, TCT, and AHA) together with a selection of important publications from the major general and specialist journals. Throughout Europe there has been a move towards percutaneous coronary intervention (PCI) being performed in units without on-site cardiac surgery. In the UK, over 60% of units do not have on-site surgery and these units generally perform a lower volume of PCI than those with on-site surgery (median of 435 compared with 1454 procedures, respectively). The need for emergency surgery is now a very uncommon complication. The Atlantic CPORT Investigators randomized, in a non-inferiority design, nearly 19 000 patients undergoing PCI to a hospital with or without on-site surgery in a ratio of 1–3. Six-week mortality was virtually identical (1.0 vs. 0.9%) and 9-month major adverse cardiac events (MACE) were also similar (11.2 vs. 12.1%); however, target vessel revascularization (TVR) was higher without on-site surgery (6.5 vs. 5.4%, P = 0.01). This difference was seen regardless of the definition of TVR and regardless of stent type and may reflect a more conservative approach or a lower initial success rate without on-site surgery. In the USA, a very small proportion of total PCI was performed without on-site surgery and it remains to be seen whether this study will alter that proportion.1 Public reporting of patient outcomes following PCI is an important tool to monitor the quality of care; however, it may lead some operators to become ‘risk-averse’. Joynt et al . reported a retrospective observational study of patients admitted with an acute coronary syndrome to US hospitals in …

Ligation of patent ductus arteriosus in low birth weight premature infants: timing for intervention and effectiveness of bed-side surgery

BackgroundPatent ductus arteriosus is a common congenital cardiac condition. Its importance is mostly underestimated and accepted as an “easy” heart disease. Physiological consequences of pulmonary overflow may cause severe mortality in premature neonates. Accurate timing of surgical intervention is essential to decrease the mortality in very low birth weight premature infants. On-site surgery in the intensive care units (ICUs) results excellent surgical quality without jeopardizing the safety of the patients.MethodsWe have summarized the clinical and operative data of 26 premature neonates (<37 weeks of gestational age), which were operated for the diagnosis of PDA in the ICUs of Dokuz Eylül University. Thirteen low birth weight infants (<1000 gr) have been compared with remaining 13 neonates (>1000 gr).ResultsThere was no surgical mortality in both groups. Co-existing problems were observed in both groups, which did not affect surgical mortality and morbidity.ConclusionsSurgery in the ICU is a safe method for premature neonates with physiologically significant PDA. This technique should be the method of choice in experienced centers.

Percutaneous Coronary Intervention at Centers With and Without On-Site Surgery

Context Percutaneous coronary interventions are performed at centers without onsite surgery, despite current guidelines discouraging this. Objective To assess literature comparing rates of in-hospital mortality and emergency coronary artery bypass grafting surgery at centers with and without on-site surgery. Data Sources A systematic search of studies published between January 1990 and May 2010 was conducted using MEDLINE, EMBASE, and Cochrane Review databases. Study Selection English-language studies of percutaneous coronary intervention performed at centers with and without on-site surgery providing data on in-hospital mortality and emergency bypass were identified. Two study authors independently reviewed the 1029 articles originally identified and selected 40 for analysis. Data Extraction Study title, time period, indication for angioplasty, and outcomes were extracted manually from all selected studies, and quality of each study was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. Data Synthesis High-quality studies of percutaneous coronary interventions performed at centers with and without on-site surgery were included. Pooled-effect estimates were calculated with random-effects models. Analyses of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction of 124 074 patients demonstrated no increase in in-hospital mortality (no on-site surgery vs on-site surgery: observed risk, 4.6% vs 7.2%; odds ratio [OR], 0.96; 95% CI, 0.88-1.05; I 2 = 0%) or emergency bypass (observed risk, 0.22% vs 1.03%; OR, 0.53; 95% CI, 0.35-0.79; I 2 = 20%) at centers without on-site surgery. For nonprimary percutaneous coronary interventions (elective and urgent, n = 914 288), the rates of in-hospital mortality (observed risk, 1.4% vs 2.1%; OR, 1.15; 95% CI, 0.93-1.41; I 2 = 46%) and emergency bypass (observed risk, 0.17% vs 0.29%; OR, 1.21; 95% CI, 0.52-2.85; I 2 = 5%) were not significantly different at centers without or with on-site surgery. Conclusion Percutaneous coronary interventions performed at centers without on-site surgery, compared with centers with on-site surgery, were not associated with a higher incidence of in-hospital mortality or emergency bypass surgery.

Current state of the performance of percutaneous coronary intervention in centres without on‐site cardiac surgery

Before the routine use of coronary stents, potential complications of percutaneous coronary interventions required the presence of backup cardiac surgery on-site. Advances in pharmacotherapy and interventional techniques, particularly in the last decade, have significantly decreased the rates of complications requiring emergency cardiac surgery, from approximately 4% to 6% in the balloon angioplasty era to as low as 0.3% to 0.6% in the contemporary era of routine intracoronary stent implantation. An early invasive approach has been shown to improve outcomes among patients with non-ST elevation acute coronary syndromes (NSTEACS), particularly in those at the highest risk, emphasising the importance of early access to revascularisation premises in such patients. Patients with ST-segment elevation myocardial infarction require immediate and sustained recanalisation of the culprit vessel to obtain rapid reperfusion of the threatened myocardium, in order to reduce infarct size and improve outcomes. Primary percutaneous coronary intervention at hospitals without on-site cardiac surgery improves clinical outcomes and reduces length of stay when compared with fibrinolytic therapy. It also significantly reduces door-to-balloon times when compared with transfer for percutaneous coronary interventions at hospitals with on-site surgery. It has been published that risk-adjusted mortality rates for patients undergoing percutaneous coronary interventions in centres without on-site surgical backup are comparable with those of percutaneous coronary intervention facilities that have cardiac surgery on-site, regardless of whether percutaneous coronary intervention was performed as primary therapy for ST-segment elevation myocardial infarction or in a non-primary setting. To achieve these results however, an adequate percutaneous coronary intervention programme is required, including proper hospital infrastructure and appropriately trained interventional cardiologists.