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Chapter 63. Emergency Surgery Following Percutaneous Coronary Intervention

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In patients who undergo elective percutaneous coronary intervention (PCI) at hospitals without cardiac surgery on site compared to hospitals that have surgery on site, the incidence of major adverse cardiac events (MACE) is:

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A. Increased

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B. Decreased

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C. Similar

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D. Unknown

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E. Not important

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The correct answer is C

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The issue of safety and efficacy for elective or nonprimary PCI done at centers that do not have surgery on site was a contentious issue in the early 2000s. The equivalence for elective PCI at off-site versus on-site centers has been consistently answered by large registries such the National Cardiovascular Data Registry (NCDR) and the United Kingdom Registry and by meta-analysis. But more importantly, the well-done recent C-PORT-E and MASS-COMM randomized trials have thoroughly resolved that there are no differences in MACE for patients who undergo elective or nonprimary PCI in centers with or without surgery on site. A key point to make, however, is that all these published studies involved high-quality off-site PCI centers that adhered to accepted high standards of practice.

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In the current contemporary era, what is the best estimate for incidence of death in patients who undergo emergency cardiac surgery for failed PCI?

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A. 1%-3%

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B. 4%-6%

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C. 7%-9%

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D. 10%-15%

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E. 20%-25%

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The correct answer is D

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Although the incidence of emergency surgery for failed PCI has consistently dropped over the past 30 years, the mortality rate when emergency surgery does occur has not changed significantly and remains high. The rate 10% to 15% rate appears to be an appropriate estimate. This range was based on reported rates in various key published reports, including those by the Cleveland Clinic, Mayo Clinic, and NCDR.

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All of the following strategies would be appropriate to stabilize a patient with significant acute coronary artery perforation prior to going to emergency cardiac surgery for failed PCI, EXCEPT:

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A. Maintain steering wire access if at all possible

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B. Use inflated dilatation balloon to stanch perforation

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C. Implant a bare metal stent to stabilize the vessel

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D. Implant a polytetrafluoroethylene (PTFE)-covered stent

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E. Perform a pericardiocentesis if severe tamponade ...

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