Percutaneous Coronary Intervention Program Research Articles

Evidence of Systematic Duplication by New Percutaneous Coronary Intervention Programs

Evidence suggests that recent and projected future investments in percutaneous coronary intervention (PCI) programs at US hospitals fail to increase access to timely reperfusion for patients with ST-segment elevation myocardial infarction. We set out to estimate the annual number and costs of new PCI programs in US hospitals from 2004 to 2008 and identify the characteristics of hospitals, neighborhoods, and states where new PCI programs have been introduced. We estimated a discrete-time hazard model to measure the influence of these characteristics on the decision of a hospital to introduce a new PCI program. In 2008, 1739 US hospitals were capable of performing PCI, a relative increase of 16.5% (251 hospitals) over 2004. The percentage of the US population with projected access to timely PCI grew by 1.8%. New PCI programs were more likely to be introduced in areas that already had a PCI program with more competition for market share, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac catheterization laboratories, and in wealthier and larger hospitals. Our data show that new PCI programs were systematically duplicative of existing programs and did not help patients gain access to timely PCI. The total cost of recent US investments in new PCI programs is large and of questionable value for patients.

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.

Commencement of a Percutaneous Coronary Intervention Program in a Private Rural Setting with Low Volume PCI Without Onsite Cardiac Surgery

Commencement of a Percutaneous Coronary Intervention Program in a Private Rural Setting with Low Volume PCI Without Onsite Cardiac Surgery

Quality assessment and improvement in interventional cardiology: A position statement of the Society of Cardiovascular Angiography and Interventions, part 1: Standards for quality assessment and improvement in interventional cardiology

Percutaneous coronary intervention (PCI) improves quality of life and survival in certain clinical settings [1]. These benefits are counterbalanced by the procedural risks. To encourage quality patient care, each PCI program must evaluate its performance through a meaningful continuous quality improvement (CQI) process. The ACC/AHA/SCAI 2005 PCI guideline update, as well as the newly implemented SCAI/ACC catheterization laboratory accreditation program, Accreditation for Cardiovascular Excellence (ACE), requires a CQI program for every health care facility in which PCI is performed [2]. CQI is an iterative method to evaluate operational approaches and remedy deficiencies [3]. The primary emphasis in CQI is on evaluating the overall program structure, processes, and outcomes of care; however, specific operator performance assessed by peer review is highly desirable. The Federal Health Care Improvement Act of 1986 recognized the importance of these programs by protecting participants and their deliberations. The Society for Cardiovascular Angiography and Intervention (SCAI) has previously published guidelines to develop a framework for these activities in the catheterization laboratory [4,5]. This statement is Rush Medical College, Chicago, Illinois Central Arkansas Veterans Health System and University of Arkansas for Medical Sciences, Little Rock, Arkansas Pennsylvania State University College of Medicine, MS Hershey Medical Center, Hershey, Pennsylvania University of Texas Health Science Center, Houston, Texas University of Alabama at Birmingham, Birmingham, Alabama Mayo Clinic School of Medicine, Rochester, Minnesota Beth Israel Deaconess Medical Center, Boston, Massachusetts Duke University Medical Center, Durham, North Carolina Ochsner Medical Center, New Orleans, Louisiana St. Vincent Hospital, Worcester, Massachusetts University of California, Irvine Medical Center, Irvine, California University of Texas Health Sciences Center at San Antonio, San Antonio, Texas

Modelo de intervención coronaria percutánea primaria en la Comunidad de Castilla-La Mancha

A B S T R A C T Coronary heart disease, and acute myocardial infarction in particular, is the primary cause of death in Spain, resulting in more deaths than cancer. Where available, primary percutaneous coronary intervention is the treatment of choice in the first 12 hours after an acute myocardial infarction. The universalization of percutaneous revascularization to all patients with myocardial infarctions necessitates the creation of wellorganized networks. The participation of health-care professionals and coordination with local health-care authorities are essential. This article describes the CORECAM protocol of the primary percutaneous coronary intervention program in Castile-La Mancha, Spain, thereby providing a summary of the treatment initiative for patients with acute myocardial infarction.

Trends During 1993-2004 in the Availability and Use of Revascularization After Acute Myocardial Infarction in Markets Affected by Certificate of Need Regulations

This study examines trends in the diffusion of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) during 1993-2004 for patients with acute myocardial infarction in markets with and without Certificate of Need (CON) regulations for open-heart surgery or cardiac catheterization and in markets that repealed CON for either of these procedures. In contrast to prior studies, this study accounts for regional hospital markets that cross state boundaries-often with different CON activities in each state. The overall use of CABG increased modestly throughout the 1990s and subsequently decreased, corresponding to a dramatic increase in PCI. There was a greater rise in the number of CABG programs in markets with significant reduction in CON regulations during 1993-2004 compared with other markets, but CON reduction was not related to growth of PCI programs. Reimbursement, ease of use, clinician endorsement, and technological advances in PCI may outweigh effects of CON.

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

Provision of Percutaneous Coronary Intervention on Patients Admitted with Acute Coronary Syndrome in a Regional Centre without a PCI Program: The Bendigo Experience

253 Provision of Percutaneous Coronary Intervention on Patients Admitted with Acute Coronary Syndrome in a Regional Centre without a PCI Program: The Bendigo Experience Karl Poon2,∗, Voltaire Nadurata 1 1 Bendigo Health Care Group, Victoria, Australia; 2 Royal Hobart Hospital, Tasmania, Australia Description/methodology: This is a 12-month retrospective study of patients admitted to a regional centre with a coronary angiography suite but without a percutaneous coronary intervention (PCI) program. All patients who underwent inpatient coronary angiography from 1 September 2006 till 31 August 2007 and subsequently underwent PCI were included in the study. All patients were analysed in relation to lesion characteristics (AHA/ACC and SCAI classification), the waiting time and the cost of transfer toMelbourne hospitals for subsequent PCI. Patients with low to moderate risk and moderate to high success were reported. Results: Eighty-two patients were included in the study. Seventy-two (87%) were classified as either ACC/AHA Type A (n− 31) and B (n− 41) lesions. There were seventyfour (90%) patients meeting the SCAI criteria for SCAI-I (n− 44) and SCAI-II (n− 30) classification. Analysis of cost of transfer was done on 47 patients. Total Table 1. STEMI, MPOMFI Elective PCI, MPOMFI p

Outcomes of 1,090 Consecutive, Elective, Nonselected Percutaneous Coronary Interventions at a Community Hospital Without Onsite Cardiac Surgery

We evaluated the efficacy and safety of elective percutaneous coronary intervention (PCI) at a hospital without onsite cardiac surgery. A growing number of hospitals without onsite cardiac surgery perform elective PCI. Few hospitals have reported outcomes, despite controversy surrounding this practice. From August 2003 to December 2005, 1,090 elective PCI were performed at Saint Luke's South Hospital (SLS), a hospital without onsite cardiac surgery, for which the referral center is the Mid America Heart Institute (MAHI). The elective PCI program used experienced interventionalists, technicians, and nurses; a tested helicopter transport protocol; a well-equipped catheterization laboratory; and a quality assurance process. Baseline characteristics, procedural success, and adverse clinical outcomes were compared. Observed frequencies of in-hospital death, a combined end point of Q-wave myocardial infarction (MI)/emergency coronary artery bypass grafting (CABG) surgery, and vascular complications were compared with prediction models. SLS, with lower risk characteristics than MAHI, had unadjusted frequencies of procedural success (93% vs 94%, p = NS), Q-wave MI (0.3% vs 0.3%, p = NS), emergency CABG surgery (0.2% vs 0.03%, p = 0.09), vascular complications (0.6% vs 0.6%, p = NS), and in-hospital death (0.1% vs 0.8%, p = 0.002) that compared favorably with MAHI. Two patients transferred from SLS to MAHI for emergency CABG surgery without adverse effects. Fewer in-hospital deaths and vascular complications were observed at SLS than predicted by models. In conclusion, favorable clinical outcomes were achieved for elective PCI at a hospital without onsite cardiac surgery that used strict program requirements.

The Case for Outpatient Coronary Intervention

Over the past 30 years, dramatic improvements have been achieved in the safety of percutaneous coronary intervention (PCI) procedures, despite the increasing complexity of clinical and anatomic conditions treated. The need for emergent bypass surgery has declined from 8% in 1990 to far less than 1% in the current era, and the rate of vascular complications has declined dramatically as techniques have improved and procedural experience has increased. Given the remarkable current periprocedural safety profile of elective coronary intervention, has the time come for us to consider whether outpatient PCI can be safely performed? In this issue of Circulation , investigators from the Academic Medical Center of the University of Amsterdam investigated this question as part of the Elective PCI in Outpatient Study (EPOS).1 Article p 2299 The study by Heyde and colleagues randomly assigned 800 consecutive, elective, outpatient, planned PCI patients to a strategy of either same-day discharge or routine care that included an overnight observation in the hospital. The patients and providers were blinded to the assignment until after evaluation according to predefined criteria for those patients who required additional observation or treatment. All patients eligible for same-day discharge, regardless of assignment, were then strictly observed for 4 hours and then underwent a rigorous triage evaluation to determine if same-day discharge would be appropriate. At that time, those patients who were randomized to the same-day discharge group were discharged, whereas the patients randomized to the overnight hospitalization group were kept in-hospital for observation. The investigators found that 20% of patients in both disposition arms developed one of the predefined exclusions for same-day discharge. Of the ≈80% of patients suitable for same-day discharge, none suffered a cardiac event within 24 hours after PCI, and only 3 patients suffered a vascular complication, with no differences observed in the 2 …

PCI without on‐site surgical backup

PCI without on‐site surgical backup

A Total of 1,007 Percutaneous Coronary Interventions Without Onsite Cardiac Surgery: Acute and Long-Term Outcomes

We sought to compare clinical outcomes of elective percutaneous coronary intervention (PCI) and primary PCI for ST-segment elevation myocardial infarction (STEMI) at a community hospital without onsite cardiac surgery to those at a tertiary center with onsite cardiac surgery. Disagreement exists about whether hospitals with cardiac catheterization laboratories, but without onsite cardiac surgery, should develop PCI programs. Primary PCI for STEMI at hospitals without onsite cardiac surgery have achieved satisfactory outcomes; however, elective PCI outcomes are not well defined. A total of 1,007 elective PCI and primary PCI procedures performed from March 1999 to August 2005 at the Immanuel St. Joseph's Hospital-Mayo Health System (ISJ) in Mankato, Minnesota, were matched one-to-one with those performed at St. Mary's Hospital (SMH) in Rochester, Minnesota. Strict protocols were followed for case selection and PCI program requirements. Clinical outcomes (in-hospital procedural success, death, any myocardial infarction, Q-wave myocardial infarction, and emergency coronary artery bypass surgery) and follow-up survival were compared between groups. Among 722 elective PCIs, procedural success was 97% at ISJ compared with 95% at SMH (p = 0.046). Among 285 primary PCIs for STEMI, procedural success was 93% at ISJ and 96% at SMH (p = 0.085). No patients at ISJ undergoing PCI required emergent transfer for cardiac surgery. Survival at two years' follow-up by treatment location was similar for patients with elective PCI and primary PCI. Similar clinical outcomes for elective PCI and primary PCI were achieved at a community hospital without onsite cardiac surgery compared with those at a tertiary center with onsite cardiac surgery using a prospective, rigorous protocol for case selection and PCI program requirements.

Low-risk percutaneous coronary interventions without on-site cardiac surgery: Two years' observational experience and follow-up

Background We studied the safety and efficacy of performing low-risk elective and acute infarct percutaneous coronary interventions at a community hospital without cardiac surgical capability. Methods Immanuel St Joseph's Hospital is located 85 miles from St Mary's Hospital, which is the nearest center with on-site cardiac surgery. All components of the Mayo Clinic percutaneous coronary intervention program were replicated at Immanuel St Joseph's Hospital, including a telemedicine system to enable real-time consultation with interventional and cardiac surgical colleagues during procedures. Results From March 1999 to June 2001, 196 patients underwent elective percutaneous coronary intervention at Immanuel St Joseph's Hospital. Procedural success was achieved in 195 (99.5%) patients, with 1 (0.5%) inhospital death. At mean follow-up of 8.2 months, 2 (1.0%) additional patients died of noncardiac causes and 15 (7.7%) patients required target vessel revascularization. From March 2000 to June 2001, 89 patients underwent primary percutaneous coronary intervention for acute myocardial infarction. Procedural success was achieved in 83 (93.3%) patients, with 3 (3.4%) inhospital deaths. At 30-day follow up, no additional patients died, had recurrent myocardial infarction, or required target vessel revascularization. No patients required transfer to another facility for emergent cardiac surgery for a procedure-related complication. Conclusions Low-risk elective and acute infarct percutaneous coronary interventions can be performed with safety and efficacy at a community hospital without cardiac surgical capability by following rigorous standards. (Am Heart J 2003;145:278-84.)

Preliminary results and description of a formal same day percutaneous coronary intervention programme

Preliminary results and description of a formal same day percutaneous coronary intervention programme