The Learning Curve for Transradial Percutaneous Coronary Intervention Among Operators in the United States: A Study From the National Cardiovascular Data Registry®

Study Questions:

What is the learning curve for transradial percutaneous coronary intervention (TRI)?

Methods:

The study used CathPCI Registry® data from July 2009 to December 2012, to identify new radial operators. New radial operators were defined by a femoral-only PCI approach for 6 months after their first PCI in the database and ≥15 total TRIs thereafter. Primary outcomes for this study were fluoroscopy time, contrast volume, and procedure success. Secondary outcomes included in-hospital mortality, bleeding, and vascular complications. Adjusted outcomes were analyzed using operator TRI experience as a continuous variable with generalized linear mixed models.

Results:

This study included 54,561 TRI procedures performed at 704 sites. Of the entire cohort, 942 operators performed 1-10 cases; 942 operators performed 11-50 cases; 375 operators performed 51-100 cases; and 148 operators performed 101-200 cases. While initially the procedure was used in lower-risk patients, as radial caseload increased, more TRIs were performed in women, and in ST-segment elevation myocardial infarction patients. There was a decrease in fluoroscopy time and contrast use with greater operator TRI experience. Procedure success was high, and mortality, bleeding, and vascular complications remained low across TRI volumes.

Conclusions:

As operator TRI volume increases, higher-risk patients are chosen for TRI. There is an increase in operator proficiency, with the threshold to overcome the learning curve being approximately 30-50 cases.

Perspective:

This study confirms prior data that there is a learning curve for TRI, with a threshold of around 50 cases. There has been a significant increase in the use of the radial approach nationally, and many training institutions have switched to a radial first approach. The learning curve in this study reflects the experience of operators who are switching from a nearly 100% femoral approach, and suggests that this switch can be safely accomplished.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Learning Curve, United States, Percutaneous Coronary Intervention


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