Does Operator Volume Affect PCI Outcomes?

Patients undergoing left-main percutaneous coronary intervention (PCI) had better outcomes when the operator had performed a higher volume of procedures, even though these patients tended to have more complex and extensive cardiovascular disease, according to a study published Oct. 17 in JACC: Cardiovascular Interventions. This is the first study to conclusively demonstrate that operator experience impacts the prognosis of patients who undergo high-risk PCI.

Researchers in Beijing led by Bo Xu, MBBS, examined the records of 1,948 patients who underwent left-main PCI between January 2004 and December 2011, with 25 operators performing the procedure. Of those patients, 1,422 (73 percent) were treated by seven experienced, high-volume operators and 526 (27 percent) patients were treated by 18 less experienced, low-volume operators. High-volume operators performed a mean of 25 left-main PCIs per year, while low-volume operators performed a mean of four left-main PCIs per year. 

Results showed that patients treated by high-volume operators had better short- and long-term outcomes. Death within 30 days was 0.6 percent with high-volume operators and 2.1 percent with low-volume operators. Patients of high-volume operators also had lower risks of cardiac death and all-cause mortality, as well as a trend toward a decreased risk of stent thrombosis. After three years, patients treated by experienced, high-volume operators experienced a significantly lower risk of cardiac death.

These outcomes were observed even though patients who underwent left-main PCI with a high-volume operator had more extensive coronary artery disease and underwent more technically complex procedures. High-volume operators were also more likely to use first-generation, rather than second-generation, drug-eluting stents.

In an editorial comment accompanying the study, Ralph G. Brindis, MD, MPH, MACC, and Gregory J. Dehmer, MD, MACC, looked at data from ACC’s CathPCI Registry to determine the amount of left-main PCIs performed by high- and low-volume operators in the U.S. They found that for left-main PCIs performed between April 2015 and March 2016, only 1 percent of operators would be considered high-volume based on the study’s criteria of having performed at least 15 left-main PCIs per year for at least three consecutive years. Additionally, these operators performed only 8.4 percent of these annual procedures in the U.S. 

“These numbers are a stark contrast compared with the results of the study by Yang and colleagues and perhaps should be a wake-up call to the interventional community,” Brindis and Dehmer said. “The concept of a ‘Center of Excellence’ has been widely promoted and, frankly, overused to the point it now has little meaning. The study findings show that a ‘Center of Excellence’ for left-main PCI should be one with experienced, high-volume operators that can demonstrate good outcomes.” 

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Drug-Eluting Stents, Percutaneous Coronary Intervention, Prognosis, Registries, Research Personnel, Thrombosis, United States

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