Lack of a Heart Team in Stand-alone Interventional Cardiology Units Impacts the Revascularization Strategy and the Results in Patients with Multi-vessel Disease

Background: The regional needs and consolidation of cardiac surgery services result in an increased number of stand-alone interventional cardiology units. The lack of on-site cardiac surgery may result in less patient-oriented heart teams, and potentially higher rates of percutaneous coronary intervention (PCI). We aimed to explore the impact of a heart team in stand-alone interventional cardiology units on the decision making and results of patients with multi-vessel coronary disease referred for coronary revascularization.

Methods: This prospective study included 1063 consecutive patients with multi-vessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and PCI (with or without on-site cardiac surgery units).

Results: Of the 1063 patients, 476 (45%) underwent coronary artery bypass graft (CABG) and 587 (55%) PCI. Mean Syntax score was 28.3±17.9 and 18.1±8.4 in the CABG and PCI groups respectively. A higher proportion of patients underwent PCI in hospitals without on-site cardiac surgery (65%), compared to those with (46%) (p<0.001) (Figure). 5-year mortality rate was higher among patients who were admitted in hospitals lacking cardiac surgery (19% vs. 14%, log-rank p=0.047). A subset analysis demonstrated that while in hospitals with an on-site surgery unit, CABG provides 5-year survival advantage compared to PCI (90% vs. 82%, log-rank p=0.004), in centers lacking a surgery unit there was no difference between the revascularization strategies (82% vs. 81%, log-rank p=0.911).

Conclusions: Our study demonstrates the potential for significant bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team. This real-life phenomenon could imply that regional needs and financial considerations associated with the consolidation of cardiac surgery services may not be beneficial for the patient. A heart-team approach should be mandatory even in centers without on-site cardiac surgery services.