Percutaneous coronary intervention with or without on-site coronary artery bypass surgery: a systematic review and meta-analysis.

BACKGROUND

Current American Heart Association guidelines recommend against the performance of elective or primary percutaneous coronary intervention (PCI) without on-site surgical backup (i.e. a class III and IIb recommendation respectively). Despite this, numerous centers have already implemented PCI programs with no on-site surgery backup (NSOS).

METHODS

To evaluate the necessity for on-site surgical backup (SOS) when performing PCI we performed a systematic review and meta-analysis. English-language articles published from 1966 through December 2010 were retrieved using keyword searches of Medline and Scopus, supplemented by letters to authors and reviews of all bibliographies. Article inclusion and data extraction was performed by two independent reviewers. We identified 18 articles published between 1992 and 2009 which contained reported events on 1,150,200 patients.

RESULTS

The combined odds ratio calculated using a random effects model for death with NSOS was 0.93 (95% CI, 0.80-1.09). In studies with data reported for primary PCI and elective PCI the OR for death was 0.91 (95% CI, 0.84-1.00) and 1.04 (95% CI, 0.67-1.63). A lack of effect of SOS was maintained when analysis was performed by study type or by either primary or elective PCI. No differences in rates of emergency coronary artery bypass grafting, post procedural myocardial infarction, target vessel revascularization, or cerebrovascular accidents were observed between SOS and NSOS centers.

CONCLUSION

Both primary and elective PCI can safely be performed at NSOS centers without an increase in mortality or PCI related complications. AHA/ACC guidelines should reflect the lack of benefit conferred by on-site surgical backup. In establishing PCI programs, adequate operator/center volumes, patient selection, and geographic/population considerations should take precedence rather than the availability of on-site surgical backup during PCI.