TCT-658 Complex High and Indicated Percutaneous Coronary Indication: Does Operator Volume Influence Patient Outcome?

Kinnaird, Tim; Gallagher, Sean; Spratt, James; Ludman, Peter; de Belder, Mark; de Belder, Mark; Anderson, Richard; Hanratty, Colm; Hanratty, Colm; Walsh, Simon; Curzen, Nick; Mamas, Mamas

Abstract

Background
Complex high-risk and indicated revascularisation using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. Using the British Intervention Society (BCIS) PCI database, we examined temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes.

Methods
Data were analysed on all CHIP-PCI procedures in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by either patient characteristics (age >80years, left ventricular ejection fraction <30%, previous coronary artery bypass surgery, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, use of rotational atherectomy or use of laser atherectomy). Individual operator volume was totalled for the 2012 to 2014 period and operators divided into four quartiles of volume (Q1-Q4). We then performed individual logistic regressions on the imputed data set for each of the MACE events according to quantify the independent association between operator quartile and outcomes. To correct for potential baseline imbalances regarding the volume quartiles and their association with clinical outcomes, we used a propensity score estimation for multiple treatments using generalized boosted models.

Results
CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (p<0.001 for trend). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were also associated with a greater degree of comorbidity with significant trends for hypertension, peripheral vascular disease, previous MI and diabetes mellitus across the four quartiles. Higher quartiles of volume were associated with greater baseline disease burden with a greater number of diseased vessel, and a higher frequency of two and three vessel disease. Additionally, higher operator volume was associated with more complex disease with left main disease increasing from 11.2% in Q1 to 16.7% in Q4 (p<0.001). In a similar fashion the presence of a CTO was also associated with operator volume, increasing from 40.5% in Q1 to 46.7% in Q4 (p<0.001). Higher volume CHIP-PCI operators undertook increasingly complex procedures and were more likely to be perform the procedures in with use of devices to support complex PCI including rotational and laser atherectomy, intravascular imaging, micro-catheters and left ventricular support all associated with increased CHIP-PCI volumes. Higher volume CHIP-PCI operators tackled more vessels and more lesions, and as a result implanted more stents. Increasing CHIP-PCI operator quartile was associated with a greater number of successful vessels, a greater number of successful lesions and a higher likelihood of two and three vessel PCI success. Despite higher baseline disease burden, post-PCI disease burden was similar across operator quartile, with lower degrees of post-PCI disease associated with higher operator quartiles when indexed to baseline disease severity. After adjustment for baseline difference, in-hospital major bleeding (p<0.001 for trend), access site complications (p=0.018) and coronary perforation (p=0.017) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (p=0.167), in-hospital major adverse cardiovascular events (p=0.269), and 12-month mortality (p=0.784) were similar across the volume quartiles. After adjustment there was no increase in 12-month mortality with higher operator volume quartile. Using logistic regression, there was no relationship between operator quartile or operator volume/case and 12-month mortality.

Conclusion
CHIP-PCI cases represent a large population in contemporary PCI practice. Higher CHIP-PCI operator volumes were associated with more complex patients and procedures and with increased procedural complications. However there was no relationship between CHIP-PCI operator volume and in-hospital or 12-month mortality.

Citation

Kinnaird, T., Gallagher, S., Spratt, J., Ludman, P., de Belder, M., de Belder, M., …Mamas, M. (2018). TCT-658 Complex High and Indicated Percutaneous Coronary Indication: Does Operator Volume Influence Patient Outcome?. Journal of the American College of Cardiology, 72(13), B263. https://doi.org/10.1016/j.jacc.2018.08.1867

• Journal Article Type: Conference Paper
• Conference Name: Thirtieth Annual Symposium Transcatheter Cardiovascular Therapeutics (TCT)
• Conference Location: San Diego, CA, USA
• Publication Date: 2018-09
• Deposit Date: Jun 21, 2023
• Journal: Journal of the American College of Cardiology
• Print ISSN: 0735-1097
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 72
• Issue: 13
• Pages: B263
• DOI: https://doi.org/10.1016/j.jacc.2018.08.1867
• Keywords: Cardiology and Cardiovascular Medicine
• Additional Information: This article is maintained by: Elsevier; Article Title: TCT-658 Complex High and Indicated Percutaneous Coronary Indication: Does Operator Volume Influence Patient Outcome?; Journal Title: Journal of the American College of Cardiology; CrossRef DOI link to publisher maintained version: https://doi.org/10.1016/j.jacc.2018.08.1867; Content Type: simple-article; Copyright: Copyright © 2018 Published by Elsevier Inc.