Primary PCI Without On-site Surgery and Without On-site
Cath Lab

Modern treatment of acute myocardial infarction is based on early and complete reperfusion. The time between the onset of myocardial infarction and reperfusion determines the mortality benefit and is influenced by various factors including a large delay in seeking medical attention by the patients.¹ The best strategy for reperfusion has been an area of ongoing research. Emergency primary percutanoeus intervention (PCI) is superior to thrombolysis in selected cases.² To make early primary PCI available to a wider population, various strategies, including PCI in catheterization laboratories without on-site cardiac surgery, have been proposed.^3,4 New ACC/AHA guidelines designate this strategy as a class IIb indication with restrictions.⁵ The paper by Akdemir et al. in this issue of the Journal6 explores another dimension in this issue: Is it feasible to provide primary PCI to a wider population by establishing “mobile” catheterization laboratories in remote areas? It is important to note that this “mobile” catheterization laboratory is still within a hospital with an intensive care unit and trained personnel to care for these high-risk patients. It is different from the stand-alone “mobile” catheterization laboratory, which is a standard angiography unit installed in a tractor-trailer and is used for routine angiography in the field. “Mobile” x-ray units are smaller and less expensive and can be incorporated into existing hospitals with a smaller capital investment. According to Akdemir et al.,⁶ experienced operators can perform PCI with acceptable success rates using “mobile” x-ray units, although there are questions about image quality and technical handicaps such as image loss for several minutes at a time as a result of equipment overheating. These problems may cause the loss of valuable time. Other questions also remain to be answered. For example, how spread out in the community should these “mobile” catheterization units be to maximize the benefit, if there is any? This will be determined by the restraints on the medical and financial resources. It must be decided whether these resources are better used to improve the population’s awareness of the importance of seeking and receiving medical attention sooner. If patients can be seen within the first 2 to 3 hours, thrombolysis may be a better choice.⁷ Would the “mobile” strategy still improve myocardial infarction outcomes as compared to immediate thrombolysis with or without transfer to a center with an established catheterization laboratory? Even if primary PCI is brought physically closer to patients, more effort is needed to achieve shorter symptom onset-to-balloon times. Protocols for transferring critical patients from remote catheterization units to surgical centers should be more realistically established and tested.

1. National Heart Attack Alert Program Coordinating Committee Working Group on Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Educational strategies to prevent prehospital delay in patients at high risk for acute myocardial: A report by the National Heart Attack Alert Program. J Thromb Thrombol 1998;6:47–61. 2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: A quantitative review of 23 randomised trials. Lancet 2003;361:13–20. 3. Wharton TP, McNamara NS, Fedele FA, et al. Primary angioplasty for the treatment of acute myocardial infarction: Experience at two community hospitals without cardiac surgery. J Am Coll Cardiol 1999;33:1257–1265. 4. Primary Angioplasty in Acute Myocardial Infarction at Hospitals With No Surgery On-Site (the PAMI-No SOS study) versus transfer to surgical centers for primary angioplasty. J Am Coll Cardiol 2004;43:1943–1950. 5. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004. Available at www.acc.org/clinical/guidelines/stemi/index.pdf. 6. Akdemir R, Ozhan H, Erbilen E, et al. Primary angioplasty without on-site surgical back-up: The first experience with mobile catherization facility. J Invas Cardiol 2004;16:645–648. 7. Bonnefoy E, Lapostolle F, Leizorovicz A, et al. for the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction Study Group. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: A randomised study. Lancet 2002;360:825–829.