Operator volumes and in-hospital outcomes: an analysis of 7,740 rotational atherectomy procedures from the BCIS national database

Objectives: the aims of this study were to use a national percutaneous coronary intervention (PCI) registry to study temporal changes in procedure volumes of PCI using rotational atherectomy (ROTA-PCI), the patient and procedural factors associated with differing quartiles of operator ROTA-PCI volume, and the relationship between operator ROTA-PCI volumes and in-hospital patient outcomes.

Background: whether higher operator volume is associated with improved outcomes after ROTA-PCI is poorly defined.

Methods: data from the British Cardiovascular Intervention Society national PCI database were analyzed for all ROTA-PCI procedures performed in the United Kingdom between 2013 and 2016. Individual logistic regressions were performed to quantify the independent association between annual operator ROTA-PCI volume and in-hospital outcomes.

Results: in total, 7,740 ROTA-PCI procedures were performed, with a negatively skewed distribution and an annualized operator volume median of 2.5 procedures/year (range 0.25 to 55.25). Higher volume operators undertook more complex procedures in patients with greater comorbid burdens than lower volume operators. A significant inverse association was observed between operator ROTA-PCI volume and in-hospital mortality (odds ratio [OR]: 0.986/case; 95% confidence interval [CI]: 0.975 to 0.996; p = 0.007) and major adverse cardiac and cerebral events (OR: 0.983/case; 95% CI: 0.975 to 0.993; p < 0.001). Additionally, lower rates of emergency cardiac surgery (OR: 0.964/case; 95% CI: 0.939 to 0.991; p = 0.008), arterial complications (OR: 0.975/case; 95% CI: 0.975 to 0.982; p < 0.001) and in-hospital major bleeding (OR: 0.985/case; 95% CI: 0.977 to 0.993; p < 0.001) were associated with higher ROTA-PCI operator volume. Sensitivity analyses in several subgroups demonstrated a consistency of improved outcomes as annual ROTA-PCI volume increased. An annual volume of <4 ROTA-PCI procedures/year was observed to be associated with increased major adverse cardiac and cerebral events, with 239 of 432 operators (55%) not exceeding this threshold.

Conclusions: in-hospital adverse outcomes occurred less frequently as ROTA-PCI operator volume increased. These data suggest that operator volume is an important factor determining outcome after ROTA-PCI.

complications, national database, operator volume, outcomes, rotational atherectomy

10.1016/j.jcin.2021.04.034

1936-8798

1423-1430

Kinnaird, Tim

3cfe5aa5-eb28-4a4d-b2e4-6ea0799d85d0

Gallagher, Sean

2c8d69a0-9362-4dd2-b5ae-14ef988e5807

Sharp, Andrew

ee3d8496-53a4-40de-ba16-add24d70b515

Protty, Majd

8e118b3f-0816-4c21-a105-f499ba16a65b

Salim, Tariq

4d593091-37d9-44a4-8988-ff1e38424c7c

Ludman, Peter

28ef305d-e09e-40a7-84b4-6ccedfb37cc8

Copt, Samuel

32842f37-50b6-476a-88bd-cf186e8bb58c

Curzen, Nick

70f3ea49-51b1-418f-8e56-8210aef1abf4

Mamas, Mamas A

41515b72-75ff-4922-bb9f-8f9c63f9f5af

12 July 2021

Kinnaird, Tim

3cfe5aa5-eb28-4a4d-b2e4-6ea0799d85d0

Gallagher, Sean

2c8d69a0-9362-4dd2-b5ae-14ef988e5807

Sharp, Andrew

ee3d8496-53a4-40de-ba16-add24d70b515

Protty, Majd

8e118b3f-0816-4c21-a105-f499ba16a65b

Salim, Tariq

4d593091-37d9-44a4-8988-ff1e38424c7c

Ludman, Peter

28ef305d-e09e-40a7-84b4-6ccedfb37cc8

Copt, Samuel

32842f37-50b6-476a-88bd-cf186e8bb58c

Curzen, Nick

70f3ea49-51b1-418f-8e56-8210aef1abf4

Mamas, Mamas A

41515b72-75ff-4922-bb9f-8f9c63f9f5af

Kinnaird, Tim, Gallagher, Sean, Sharp, Andrew, Protty, Majd, Salim, Tariq, Ludman, Peter, Copt, Samuel, Curzen, Nick and Mamas, Mamas A (2021) Operator volumes and in-hospital outcomes: an analysis of 7,740 rotational atherectomy procedures from the BCIS national database. JACC Cardiovascular Interventions, 14 (13), 1423-1430. (doi:10.1016/j.jcin.2021.04.034).

Record type: Article

Abstract

Background: whether higher operator volume is associated with improved outcomes after ROTA-PCI is poorly defined.

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More information

Accepted/In Press date: 20 April 2021

e-pub ahead of print date: 16 June 2021

Published date: 12 July 2021

Additional Information: Available Under an Elsevier user license Open archive https://www.sciencedirect.com/science/article/pii/S1936879821007883?via%3Dihub Funding Information: As noted in other health care systems, the frequency of ROTA-PCI use in the United Kingdom increased over time, driven presumably a combination of an ageing population (and thus increasingly calcified coronary arteries) and an expansion of PCI indications into more complex anatomic settings (17,18). ROTA-PCI can be technically challenging with even the initial step of distal placement of the rota guidewire in some cases being difficult. Given its unwieldy nature, most operators in contemporary practice use a more standard guidewire first, with subsequent wire exchange using a variety of techniques, including over-the-wire balloons, microcatheters, and trapping balloons. In the calcific milieu in which ROTA-PCI is used, distal guidewire placement requires a certain level of operator skill and a knowledge of the problem-solving algorithms required. Once set up for atherectomy, acute procedural complications are relatively frequent, with coronary perforation, coronary or aortic dissection, and slow flow all more common than during PCI not involving rotational atherectomy (11,12,19). Furthermore, the potentially disastrous stuck rota burr requires a high degree of technical skill to retrieve and rescue the situation (20,21). Thus, ROTA-PCI may represent a particular subset of PCI procedures in which operator volume and experience might influence patient outcomes. The present study supports this hypothesis, observing a relationship between higher annual operator ROTA-PCI volume and in-hospital MACCE (driven mainly by periprocedural MI) and also in-hospital major bleeding and arterial complications. In the current published research, few data are available on ROTA-PCI operator volume, although several studies have reported an association between higher center ROTA-PCI volume and improved patient outcomes (22,23). These previous studies and the present study are therefore consistent in suggesting that procedural ROTA-PCI procedural volume may be an important factor in determining patient outcomes. Publisher Copyright: © 2021 American College of Cardiology Foundation Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

Keywords: complications, national database, operator volume, outcomes, rotational atherectomy