The Requirement for Emergent Coronary Artery Bypass Surgery Following Percutaneous Coronary Interven

1
The Requirement for Emergent Coronary Artery
Bypass Surgery Following Percutaneous Coronary
Intervention in the Stent Era

• Probal Roy, Axel de Labriolle, Nicholas Hanna,
  Laurent Bonello,
• Teruo Okabe, Tina Pinto-Slottow, Daniel
  Steinberg, Kimberly Smith, Zhenyi Xue, Lowell
  Satler, Kenneth M. Kent, William O. Suddath,
• Augusto D. Pichard and Ron Waksman.
• Division of Cardiology, Washington Hospital
  Center, Washington DC

2
Background

• The performance of percutaneous coronary
  intervention (PCI) at centers without
  cardiothoracic surgery remains a contentious
  issue.
• Though this practice allows greater access to
  care there continues to be safety concerns.
• This study aimed to assess the requirement for
  emergent coronary artery bypass graft (CABG)
  surgery following PCI and to establish a risk
  score based on the predictors identified.

3
Methods - Study Population

• Single-center observational study.
• The study population consisted of 21,957 patients
  who underwent PCI between August 1994 (FDA stent
  approval) till present.
• Patients requiring emergent CABG surgery (defined
  as within 24 hours of the index procedure) were
  identified. CABG and No CABG groups were
  compared.
• Logistic regression analysis was performed to
  assess for independent correlates of emergent
  CABG surgery and a risk score was formulated.

4
Patient Characteristics
5
Patient Characteristics
6
Results

• Emergent CABG surgery was required in 90 patients
  (incidence-0.41).
• Indications for CABG surgery were triple vessel
  disease (40.3), dissection (27.4), acute
  closure (16.1), perforation (8.1) and failure
  to cross (8.1).
• These patients had significantly higher
  in-hospital cardiac death (7.8 vs. 0.7, plt0.01)
  along with higher rates of Q-wave MI,
  neurological events and renal insufficiency.

7
Predictive factors of emergent CABG
8
Results

• Independent correlates of emergent CABG surgery
  post PCI were acute ST segment elevation MI
  presentation, cardiogenic shock, triple vessel
  disease and type C lesion.
• Risk stratification using these predictors
  identified 0.3 of the patient population to have
  a substantial risk (9.3) of requiring emergent
  CABG surgery.
• Conversely, 97.9 of the study cohort had a lt0.9
  incidence of needing urgent surgery.

9
Rates of emergent CABG surgery per number of
predictors per patient
Emergent CABG,
Number of Predictors
10
Distribution of indications for CABG
11
Inhospital outcomes in patients requiring
emergent CABG
incidence
12
Conclusions

• In keeping with previous reports, the need for
  emergent CABG in a large patient population
  undergoing PCI in the stent era was low and
  associated with poor in-hospital outcomes.
• The patient subset identified to be at
  substantial risk for needing emergency surgery
  was small (0.3).
• These findings support the practice of PCI
  without on-site surgery.

13
Limitations

• This was a single center observational study with
  the limitations inherent to this type of
  analysis.
• The definition of emergent CABG, as surgery
  required within 24 hours of PCI, may have been
  over-inclusive.
• Clinical outcome was limited to in-hospital
  events.
• Correlates of emergent CABG were not weighted
  when assessing contribution to risk.

14
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