2. Kent KM, Bentivoglio LG, Block PC, Cowley MJ, Dorros G, GosselinAJ, Gruentzig A, Myler RK, Simpson J, Stertzer SH, Williams DO, Fisher L, Gillespie MJ, Mullin SM, Mock MB. Percutaneoustransluminal coronary angioplasty report from the NHLBI Registry. Am J Cardiol 1981;47:201l-2020. 3. Detre K, Holubkov MS, Kelsey S, Cowley M, Kent K, Williams D, Myler R, Faxon D, Holmes D, BourassaM, Block P, GosselinA, Bentivoglio L, Leatherman L, Dorms G, King S, Galichia J, Al-Bassam M, Leon M, Robertson T, PassamaniE, and the Co-investigatorsof the National Heart, Lung, and Blood Institute’s PercutaneousTransluminal Coronary Angioplasty Registry. Percutaneoustransluminal coronary angioplasty in 1985-1986and 1977-1981National Heart, Lung, and Blood Institute Registry. N Engl J Med 1988;3l&265-270.
“Beauty
4. Klinke WP, Hui W. Coronary angioplasty without on-site surgical facilities. Am J Cardiol 1992;70:1520-1525. 5. Detre KM, Holmes DR, Holubkov R, Cowley MJ, BourassaMG, Faxon DP, Dorros GR, BentivoglioLG, Kent KM, Myler RK, and the Co-investigatorsof the National Heart, Lung, and Blood Institute’s PercutaneousTransluminal Coronary Angioplasty Registry. Incidenceand consequences of periproceduralocclusion: the 1985-86 National Heart, Lung, and Blood Institute’s Percutaneous Transluminal Coronary Angioplasty Registry. Circulation 1990;82:739-750. 6. Leon M, Kent K, Satler L, PopmaJ, Cooke R, Stark K, Donovan K, Witt J, Shotts P, Pichard A. A Multi-device lesion-specificapproach for unfavorable coronary anatomy (abstr). J Am Coil Cardiol 1992;19:93A\.
is in the Eye
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Floyd D. Loop, MD, and Patrick L. Whitlow, MD
I
n this issueof The American Journal of Cardiology, Klinke and Hu? report their results of percutaneous transluminal coronary angioplasty (PTCA) performed from 1981 to 1991 in a center without on-site surgery facilities. Ninety-five percent of their 762 patients underwent l-vessel dilatation, and the PTCA successrate was 76%. Surgery was possibleonly by transfer to a regional center located 6 kilometers away; 12 patients (1.6%) were successfully transferred there for “emergency surgery.” Seven patients (0.9%) died during or within 24 hours after PTCA; none of these were successfullytransported to the operating room for emergency bypass grafting. Major complications affected 5 patients (4.6%), including 2.1% with myocardial infarction. At first glance, these results appear acceptablewhen compared with those from centers with on-site surgical facilities, and the low emergency surgery rate of 1.6% for procedures performed from 1981 to 1991 even appears commendable compared with other large series (National Heart, Lung, and Blood Institute Registry, 1985-1986, 3.5%2;Emory University, 4.8%3;and Cleveland Clinic, 2.9%4).However, closer scrutiny of the series produces several points of concern. Of critical importance when considering the results of PTCA without on-site surgical backup is whether patients have timely accessto surgical support. Although there are no controlled data to prove that emergency surgery after unsuccessful PTCA improves survival, prevents myocardial infarction, salvagesischemic myocardium or improves functional capacity over medical therapy, good early and long-term results obtained with emergency bypass surgery have been well-documented.s.5Randomized studies have not been initiated becausethe consensusof clinical opinion is that emergency surgery is effective for ischemia after unsuccessful PTCA. This view is substantiated by the Subcommittee on Coronary Angioplasty of the American College of Cardiology/American Heart Association (ACC/ From the Department of Thoracic and Cardiovascular Surgery, and the Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio. Manuscript received August 7, 1992, and accepted August 8. Address for reprints: Floyd D. Loop, MD, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195.
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AHA), which concluded that an on-site cardiovascular surgical team should be a prerequisite for coronary angioplasty.6 Since several new technologies to treat abrupt closure with PTCA becameavailable (coronary stents,7directional coronary atherectomy,8 laser balloon angioplasty9 and perfusion balloonslo), emergency surgery rates of
“Beauty
4. Klinke WP, Hui W. Coronary angioplasty without on-site surgical facilities. Am J Cardiol 1992;70:1520-1525. 5. Detre KM, Holmes DR, Holubkov R, Cowley MJ, BourassaMG, Faxon DP, Dorros GR, BentivoglioLG, Kent KM, Myler RK, and the Co-investigatorsof the National Heart, Lung, and Blood Institute’s PercutaneousTransluminal Coronary Angioplasty Registry. Incidenceand consequences of periproceduralocclusion: the 1985-86 National Heart, Lung, and Blood Institute’s Percutaneous Transluminal Coronary Angioplasty Registry. Circulation 1990;82:739-750. 6. Leon M, Kent K, Satler L, PopmaJ, Cooke R, Stark K, Donovan K, Witt J, Shotts P, Pichard A. A Multi-device lesion-specificapproach for unfavorable coronary anatomy (abstr). J Am Coil Cardiol 1992;19:93A\.
is in the Eye
n
n
?
Floyd D. Loop, MD, and Patrick L. Whitlow, MD
I
n this issueof The American Journal of Cardiology, Klinke and Hu? report their results of percutaneous transluminal coronary angioplasty (PTCA) performed from 1981 to 1991 in a center without on-site surgery facilities. Ninety-five percent of their 762 patients underwent l-vessel dilatation, and the PTCA successrate was 76%. Surgery was possibleonly by transfer to a regional center located 6 kilometers away; 12 patients (1.6%) were successfully transferred there for “emergency surgery.” Seven patients (0.9%) died during or within 24 hours after PTCA; none of these were successfullytransported to the operating room for emergency bypass grafting. Major complications affected 5 patients (4.6%), including 2.1% with myocardial infarction. At first glance, these results appear acceptablewhen compared with those from centers with on-site surgical facilities, and the low emergency surgery rate of 1.6% for procedures performed from 1981 to 1991 even appears commendable compared with other large series (National Heart, Lung, and Blood Institute Registry, 1985-1986, 3.5%2;Emory University, 4.8%3;and Cleveland Clinic, 2.9%4).However, closer scrutiny of the series produces several points of concern. Of critical importance when considering the results of PTCA without on-site surgical backup is whether patients have timely accessto surgical support. Although there are no controlled data to prove that emergency surgery after unsuccessful PTCA improves survival, prevents myocardial infarction, salvagesischemic myocardium or improves functional capacity over medical therapy, good early and long-term results obtained with emergency bypass surgery have been well-documented.s.5Randomized studies have not been initiated becausethe consensusof clinical opinion is that emergency surgery is effective for ischemia after unsuccessful PTCA. This view is substantiated by the Subcommittee on Coronary Angioplasty of the American College of Cardiology/American Heart Association (ACC/ From the Department of Thoracic and Cardiovascular Surgery, and the Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio. Manuscript received August 7, 1992, and accepted August 8. Address for reprints: Floyd D. Loop, MD, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195.
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THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
AHA), which concluded that an on-site cardiovascular surgical team should be a prerequisite for coronary angioplasty.6 Since several new technologies to treat abrupt closure with PTCA becameavailable (coronary stents,7directional coronary atherectomy,8 laser balloon angioplasty9 and perfusion balloonslo), emergency surgery rates of
