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Comment & Response
August 2017

Performing Percutaneous Coronary Intervention Without On-Site Cardiac Surgery Is Not a License for Percutaneous Coronary Intervention Instead of Coronary Artery Bypass Grafting—Reply

Author Affiliations
  • 1Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
  • 2Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
JAMA Cardiol. 2017;2(8):926-927. doi:10.1001/jamacardio.2017.0532

In Reply We thank Bakaeen et al for their interest in our study.1 They raise a very important point about the potential for indication creep for percutaneous coronary intervention (PCI) at centers without on-site cardiac surgical programs. Our data and analytic approach did not allow for a comprehensive assessment of decision making for revascularization decisions, but the potential certainly exists. Previous studies have shown that the proportion of inappropriate nonacute PCIs has gone down significantly from 26% to 13% at the national level,2 since most hospitals that perform PCI participate in national registries and there are penalties for performance of inappropriate PCI. Interestingly, the proportion of multivessel PCI was actually higher at centers with on-site cardiac surgery in our data, which most likely reflects the higher-risk population.1 Indications for and selection of revascularization modes should follow standard clinical and angiographic criteria. Stable patients with severe epicardial disease, particularly left main and 3-vessel disease, have a long-term mortality benefit with coronary artery bypass grafting and should be referred accordingly. Patients with acute coronary syndromes, particularly ST-elevation myocardial infarctions, and those with lesser degrees of coronary artery disease should in most circumstances undergo PCI.