Perspective:

The following are 10 points to remember about this clinical competence statement update on coronary artery interventional procedures:

1. The writing committee recommends a minimum institutional volume threshold of 200 percutaneous coronary interventions (PCIs) per year. Full service laboratories (both primary and elective PCI, with and without onsite cardiac surgery) performing <200 cases annually must have stringent systems and process protocols with close monitoring of clinical outcomes and additional strategies that promote adequate operator and catheterization laboratory staff experience through collaborative relationships with larger volume facilities.

2. To provide quality PCI services, the institution must ensure that its catheterization facility is properly equipped and managed, and that all of its necessary support services, including data collection, are of high quality and are readily available.

3. Interventional cardiologists should perform a minimum of 50 coronary interventional procedures per year (averaged over a 2-year period) to maintain competency. The writing committee believes operators performing <50 PCIs/year should not be denied privileges or excluded from performing coronary interventions based solely on their procedural volume. In instances where operators are performing <50 PCIs annually, the writing committee strongly encourages both institutions and operators to carefully assess whether their performance is adequate to maintain competence.

4. The writing committee endorses the 2011 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) PCI guideline recommendation that primary PCI (PPCI) for ST-segment elevation myocardial infarction (STEMI) be performed by experienced operators who perform more than 11 PPCI procedures per year and ideally these procedures should be performed at facilities that perform >36 PPCI procedures annually. Low-volume centers that only perform PPCI (typically without onsite surgery) and exist to meet critical access needs must demonstrate acceptable outcomes.

5. The writing committee recommends that operators performing PCI without onsite surgery should perform >50 total PCIs per year, including >11 primary PCIs per year. Operators who cannot maintain these case volume recommendations at their primary practice site should maintain privileges and continue to perform PCI procedures at a high-volume institution with onsite surgical backup to meet these annual volume requirements.

6. It was the opinion of the writing committee that the public, policy makers, and payors should not overemphasize specific volume recommendations, recognizing that this is just one of many factors that may be related to clinical outcomes.

7. The writing committee strongly encourages the participation in a local or national registry, such as the NCDR^® CathPCI Registry, which can help measure performance, assess appropriateness of procedures, and promote continuous quality improvement.

8. The writing committee supports the recommendation of the 2011 ACCF/AHA/SCAI PCI guideline that every PCI program should operate a quality improvement program that routinely reviews quality and outcomes of the entire program, reviews results of individual operators, includes risk adjustment, provides peer review of difficult or complicated cases, and performs random case reviews.

9. Given that coronary interventions in patients with hypertrophic cardiomyopathy, ventricular tachycardia, and coronary fistulae are rare, a team approach including coronary interventionalists, cardiothoracic surgeons, and cardiothoracic anesthesiologists is important for optimal results. Dedicated personnel should be identified, and a regular review of program activity and results should be documented.

10. The committee feels strongly that alcohol ablation for hypertrophic obstructive cardiomyopathy (HOCM) should be performed only with a multidisciplinary team, and that volume is just one of many factors that should be considered in assessing an operator competency. After each operator has developed the needed skillset in a proctored environment, then, given the rarity of the procedure, five alcohol ablations for HOCM per year should be considered a reasonable volume to maintain that skillset.