The learning curve for transradial percutaneous coronary intervention among operators in the United States: a study from the National Cardiovascular Data Registry

Connie N Hess, Eric D Peterson, Megan L Neely, David Dai, William B Hillegass, Mitchell W Krucoff, Michael A Kutcher, John C Messenger, Samir Pancholy, Robert N Piana, Sunil V Rao, Connie N Hess, Eric D Peterson, Megan L Neely, David Dai, William B Hillegass, Mitchell W Krucoff, Michael A Kutcher, John C Messenger, Samir Pancholy, Robert N Piana, Sunil V Rao

Abstract

Background: Adoption of transradial percutaneous coronary intervention (TRI) in the United States is low and may be related to challenges learning the technique. We examined the relationships between operator TRI volume and procedural metrics and outcomes.

Methods and results: We used CathPCI Registry data from July 2009 to December 2012 to identify new radial operators, defined by an exclusively femoral percutaneous coronary intervention approach for 6 months after their first percutaneous coronary intervention in the database and ≥15 total TRIs thereafter. Primary outcomes of fluoroscopy time, contrast volume, and procedure success were chosen as markers of technical proficiency. Secondary outcomes included in-hospital mortality, bleeding, and vascular complications. Adjusted outcomes were analyzed by using operator TRI experience as a continuous variable with generalized linear mixed models. Among 54 561 TRI procedures performed at 704 sites, 942 operators performed 1 to 10 procedures, 942 operators performed 11 to 50 procedures, 375 operators performed 51 to 100 procedures, and 148 operators performed 101 to 200 procedures. As radial caseload increased, more TRIs were performed in women, in patients presenting with ST-segment elevation myocardial infarction, and for emergency indications. Decreased fluoroscopy time and contrast use were nonlinearly associated with greater operator TRI experience, with faster reductions observed for newer (<30-50 cases) compared with more experienced (>30-50 cases) operators. Procedure success was high, whereas mortality, bleeding, and vascular complications remained low across TRI volumes.

Conclusions: As operator TRI volume increases, higher-risk patients are chosen for TRI. Despite this, operator proficiency improves with greater TRI experience, and safety is maintained. The threshold to overcome the learning curve appears to be approximately 30 to 50 cases.

Keywords: learning curve; percutaneous coronary intervention.

Conflict of interest statement

Conflict of Interest Disclosures: None.

© 2014 American Heart Association, Inc.

Figures

Figure 1
Figure 1
Selection of TRI Procedures and Radial Operators. Shown is the flow diagram of TRI procedure and operator selection resulting in the final analysis population. PCI indicates percutaneous coronary intervention; TRI, transradial percutaneous coronary intervention.
Figure 2
Figure 2
Definition of New Radial Operator. Depicted is the definition of a new radial operator used for inclusion in the analysis. Starting with the first TFI in version 4 CathPCI Registry, operators are required to have a “blanking period” of 6 months without a TRI, but at least 1 TFI per reporting quarter. Operators A and B have different start dates for their blanking period but both meet inclusion criteria. Operator C is excluded, as there is no TFI in the second reporting quarter. TFI indicates transfemoral percutaneous coronary intervention; TRI, transradial percutaneous coronary intervention.
Figure 3
Figure 3
Distribution of TRI Volume among Operators. Shown is the distribution of total TRI procedures performed by operators included in our analysis. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.
Figure 4
Figure 4
Relationship between Operator TRI Volume and Procedural Outcomes. Shown are curves depicting the unadjusted and adjusted relationships between TRI volume and fluoroscopy times (A and B, respectively); unadjusted relationships between TRI volume and contrast volume (C and D, respectively), and unadjusted and adjusted relationships between TRI volume and procedure success (E and F, respectively). Dotted lines represent 95% confidence intervals. TRI indicates transradial percutaneous coronary intervention.

Source: PubMed

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