PCI without surgical backup: shall we do it?

PCI done without on-site cardiac surgery backup was shown to be as safe as procedures done with on-site backup in several registries. Yes, it is safe and efficacious, but many still raise a question “does any patient prefer to have angioplasty done at a center without surgical backup?"

Then shall we open a cath-lab where there is no surgical backup? In 2011, CMS-TH, Bharatpur established a cath-lab without any surgery backup. Should it be done? I personally agree that there is a desperate need for PCI with no matter surgery backup in remote areas where transit to regional centers is unreliable and awkward. If a patient with acute STEMI collapses in our ER, then can we take a risk to refer him to a surgical backup center that is approximately 6 hours far? So, I believe primary PCI facility should be available in a timely manner irrespective of surgical backup.

What if the patient needed an emergency CABG? I argue, emergency CABG is required in only 0.2% of cases. In one study, the rate of emergency coronary bypass surgery, which was needed by 0.3% of patients treated at centers without surgical backup, and by 0.4% of those treated with on-site backup.

In an effort to evaluate the introduction of PCI care at hospitals without onsite cardiac surgery, the state of California instituted a pilot program comparing PCI results in six pilot and 120 non-pilot facilities. The results of the study were recently released on March 29, 2014—ACC 14.

The study concluded that while pilot without onsite cardiac surgery hospitals performed proportionately more primary PCIs than onsite hospitals and showed a significantly better PCI composite safety endpoint, the pilot without onsite cardiac surgery hospitals had worse composite efficacy endpoints than non-pilot hospitals. Offsite hospitals perform more primary and fewer elective PCIs than Onsite hospitals. Moreover, emergency CABG rates were low in both Offsite and Onsite hospitals reducing the need for Onsite Cardiac Surgery. [PCI-CAMPOS study]

We recently published a paper in JNMA.

Dubey L, et al. Percutaneous coronary intervention without onsite cardiac surgery backup. J Nepal Med Assoc 2013;52(189):267-71

We concluded that despite having no cardiac surgery backup, in-hospital mortality and other complications following PCI were acceptable in our cardiac catheterization laboratory.

Q wave in lead V1-V2

A 60-year old male presented with acute dyspnea and chest pain. He was tachypnic and ill looking. Here is the ECG:

Sinus rhythm @100bpm. Incomplete RBBB. Q wave in lead V1 

What is the likely diagnosis? Septal MI (old)? But the patient has acute onset dyspnea and chest pain.

What is the significance of Q wave in lead V1-V2?

QS pattern in V1-2 usually is associated with a septal infarct, but it can occur with anatomic changes (vertical axis) due to lung disease or LVH and with intraventricular conduction defects such as LAFB, LBBB, and WPW or with hypertrophic cardiomyopathy.

In one study (http://www.ncbi.nlm.nih.gov/pubmed/14731215), 99 cases having QS deflections in both leads V1 and V2 but no other ECG abnormality were studied and reported that prior MI, or presence of clinical CAD was present in only about 20% of the cases. Authors further concluded that QS deflections in leads V1-V2 appeared most often to be an artifact of precordial lead placement.

Patient in the present case had large mobile thrombus in the right heart chamber leading to Acute Pulmonary Embolism. Patient was managed by intravenous tPA and improved rapidly.  (ECG courtesy: Dr Stephen W Smith)

Final note

If the history does not suggest a MI or another explanation, the ECG should be repeated with anatomically correct electrode placement. If the patient has pulmonary disease as an explanation, other ECG findings of lung disease should be present. The diagnosis of septal infarction should not be made if LAFB, LBBB or WPW are present.

Shepherd's Crook Right Coronary Artery

Shepherd’s Crook configuration of right coronary artery (RCA) (a dramatic upturn with a near-180º switchback turn) represents a challenge for the interventional cardiologists. Because there is less support provided by the guiding catheters, angioplasty of such artery is associated with a lower primary success rate. 

Judkins Right (JR) catheter is particularly inadequate for this type of RCA anatomy. AL1, Hockey stick, SCR, IM, Voda right, MP catheters are best suited for this anatomy. I have an experience of doing angioplasty in such RCA using X-tra Backup (XB) catheter successfully (in two cases so far). 

A Shepherds Crook RCA (dotted line)

A Shepherd’s Crook is a very useful tool for shepherds who are navigating fields of varying height or uneven terrain. Its curved head designed to help catch a sheep by the neck or leg. The symbol is a stick with a C-curve at the top.

Shepherd Crook Stick

Spontaneous coronary artery dissection (SCAD)

Spontaneous coronary artery dissection (SCAD) is a rare disease with a female preponderance and tendency to occur in pregnancy, making a hormonal influence likely. 
 

According to a study (J Invasive Cardiol 2008; 20:553–9), only 500 cases of SCAD have been documented in the medical literature till no, and it may be due to a significant number of SCAD patients dying suddenly. 

In a recent issue of ARYA Atherosclerosis, I have reported a case of SCAD in an aged male who presented with SCAD and was managed successfully by PCI and stenting. 

http://www.arya.mui.ac.ir/index.php/arya/article/view/650

This is a very nice paper, not only because this is the first reported case from Nepal, but also because SCAD was detected in a 69-year old male who presented with unstable angina. SCAD has been reported most commonly in young women of whom approx 30% of cases occur in peripartum period. It may be secondary to decreased collagen production or enhanced degradation in intima and media of vessel wall, increased shear stress on arterial wall due to augmented cardiac output, inherent hypercoagulability in peripartum state, and hemorrhagic disruption of vasa vasorum. 

[Full text article can be downloaded soon from the Journal website]

Since there are no guidelines regarding optimal treatment of this condition, management of SCAD remains controversial.

Our patient was managed with PCI and stenting and he is doing well with no angina at 6-month follow-up.

SCAD (Radiolucent dissection (arrows)) in LCX. Circ 2012;126:579-588 

SCAD in RCA. Dubey L. ARYA Atheroscler 2014 Vol 10 No 2 

Note:

Incidence of SCAD is very low. SCAD occurs most often in young women (age <40 years). It occurs frequently in the peripartum period. However, there are a few reports (including my case report) SCAD can be seen in the middle or older aged males with risk factor for CAD.