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Percutaneous Coronary Intervention for Chronic Total Occlusions

2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 8 Linguagem: Inglês

10.1161/circinterventions.119.008321

1941-7632

David R. Holmes, Gregory W. Barsness,

Cardiac Imaging and Diagnostics

HomeCirculation: Cardiovascular InterventionsVol. 12, No. 8Percutaneous Coronary Intervention for Chronic Total Occlusions Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBPercutaneous Coronary Intervention for Chronic Total OcclusionsGetting New Operators From There to Here David R. Holmes Jr, MD and Gregory W. Barsness, MD David R. Holmes JrDavid R. Holmes Jr David R. Holmes Jr, MD, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester MN 55905. Email E-mail Address: [email protected] Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN. and Gregory W. BarsnessGregory W. Barsness Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN. Originally published16 Aug 2019https://doi.org/10.1161/CIRCINTERVENTIONS.119.008321Circulation: Cardiovascular Interventions. 2019;12:e008321See Article by Young et alThe National Cardiovascular Data Registry1 was developed and implemented to foster the scientific evaluation of important elements of cardiovascular care as typified by this current article which focuses on Examining the operator learning curve for percutaneous coronary intervention of chronic total occlusions.2This field is of great interest for several reasons includingChronic total occlusion (CTO) at the time of coronary angiography is common being documented in ≈30% to ≈50% of patients.3,4 This anatomic subset has been a major factor for patient referral for coronary artery bypass graft surgery rather than percutaneous coronary intervention (PCI).5In the past, procedural percutaneous revascularization success rates were quite limited and, accordingly, many patients were not even considered as candidates for PCI.When PCI was successful in selected patients, there was improvement in symptoms,6,7 quality of life, and prevention of the need for coronary artery bypass graft surgery. In addition, in subsets of patients, for example, those with successful LAD CTO intervention, there was is an associated survival advantage compared to those with unsuccessful PCI. However, although there is a clear association between successful CTO PCI and improvement in quality of life, the overall lack of proven advantage in reducing major adverse cardiovascular event among patients undergoing CTO PCI highlights the importance of ensuring procedural safety.Procedural complications of CTO PCI are not necessarily benign, including tamponade, myocardial infarction, and, rarely, the need for urgent surgery. There is a proportionality between procedural expertise and procedural experience with access, techniques, and complication management.Substantial new fields of strategic approaches, equipment available, and operator experience have developed, leading to recent reports of 90% success rates in selected patients with CTO in experienced centers.In this current analysis of the learning curve in this well-described national registry of a large number of consecutive patients (n=93 875), we can learn important information on the impact of case experience on learning trajectory. This information is essential for developing strategies to provide care for this large group of patients.The specific goal of this study was to "characterize the emergence of new CTO operators" and to determine whether incremental experience was associated with improved outcomes. Details of operator selection are extremely important in this type of analysis. The authors identified 93 875 procedures treated by 7548 operators. They further narrowed this window of observation to 7251 CTO operators defined as low volume operators with less than 10 procedures during the first year after their initial CTO PCI. This group formed the cohort classified as new CTO operators. A fundamental part of this analysis was to identify those new CTO operators and then study their subsequent experience for evidence of changes in case selection and outcome. For that, the authors identified an even smaller group of rapid adopters who subsequently performed ≥20 CTO procedures within the first 365-day period. A limitation in this regard relates to the availability of cooperators, which is not accounted for. This may confound the analysis, in that the procedure may be attributed to one new operator, but, in actual fact, the team may have included one new operator working with a very experienced second operator.Clinical outcomes included in-patient mortality and major adverse cardiovascular event (death by myocardial infarction, tamponade, or PCI requiring urgent coronary artery bypass graft surgery). Other variables of interest include technical measures such as fluoroscopy time, contrast volume, ability to cross with a guidewire, and procedural success.There are some unusual features of this study; one of which is that only 58.2% of the CTO PCI cases were performed electively while the remainder were presumably performed urgently, despite the fact that the definition of a CTO in the article was a 100% stenosis, presumed to be 100% occluded, for ≥3 months and not related to a clinical event prompting the procedure.2 Why 40% of the cases involving a CTO were performed urgently or emergently is, therefore, unclear given study inclusion criteria, unless this 40 % of cases were performed for a non-CTO lesion.There are several important findings. In the overall group of 70 916 procedures performed by new operators, CTO procedural success occurred in 61.4%. This may relate to the fact that the ability to cross with a guidewire occurred in only 73.0% of cases in the overall cohort. When the analysis was stratified by subsequent case volume, as the number of cases performed increased, so did patient and procedural complexity. A progressive increase in patient baseline adverse characteristics, procedural fluoroscopy time, and contrast volume was associated with increased procedural experience. At the same time, the percent of cases performed electively increased progressively among groups of operators with greater experience, highlighting a presumed shift in case selection and planning that paralleled CTO procedural experience and familiarity. Overall, major adverse cardiovascular event occurred in 4.3% of cases, most commonly major bleeding (4.0%) and myocardial infarction (2.0%). Although the authors suggest that major bleeding, perforation, and tamponade were uncommon, the numbers suggest otherwise, with major procedure-related complications as high or higher among the more complex cases performed by more experienced operators, including bleeding in 7.6%, perforation in 2.3%, and tamponade in 1.2% of cases in the highest volume operator stratum.What have we learned from this large number of CTO cases from a selected group of operators, and how might this help going forward?There is clearly a steep learning curve among new CTO operators. This is reflected in the distinct skill set required for hybrid antegrade and retrograde approaches,8–10 dual access site management, and complication recognition and management. There is even a novel vocabulary and unique toolset that requires initial mastery and ongoing review. Most important, perhaps, is knowing where to start and when to stop. This is reflected in the U-shaped curve identified in case-mix complexity associated with increasing operator experience. Just as early PCI training begins with the question "Can I perform this PCI?" and transitions to "How should I perform this PCI?" CTO operators begin by developing the necessary knowledge, skills, and facility with CTO PCI tools and techniques to become comfortable with the CTO interventional process.This embrace of the hybrid approach, or more generally, the ability to modify approach during a given procedure based on intraprocedural events, leads to improved rates of success and potential for improved outcome.8,11–13 In the current study, greater procedural experience was associated with a decrease in performance of ad hoc cases, reflecting the understanding that CTO intervention requires a dedicated effort. Rather than emboldening a less-restrictive approach to case selection, this reflects the growth in understanding that successful case completion requires careful study of the preprocedural angiogram and, more importantly, a clear understanding of the associated risks and potential outcomes of complex CTO intervention by the patient and proceduralist alike. Similarly, the associated increase in patient complexity and increased comorbidity identified in the case-mix of more experienced operators suggests that over time, the primary challenge for operators transitions from "Can I?" to "How should I?" This makes assessment of learning curves complex. More experienced operators take on more complex patients but in a more studied way—success and complications go up in parallel due to case selection and willingness to persist, but the crucial precept is knowing where to start and when to stop. Patient safety and procedural awareness through optimal informed consent, case preparation, and an increase in best practices is enhanced with increased operator experience, as reflected in this article.What then will it take to cross the "Can't Get There from Here" category off the list and change it to "Made it?" It will take more experience, more skill, focusing on very carefully selected cases in truly expert centers by a team of truly expert physicians, implementation of more modern PCI CTO techniques, and continued technological development. All of these taken together will be essential to improving patient care for this large group of patients. With greater experience, CTO operators develop the strategic awareness to plan for success and the experience to modify the procedural approach to suit specific situations and morphologic subtypes, optimizing individual patient outcome while advancing the entire field.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Guest Editor for this article was Harold L. Dauerman, MD.https://www.ahajournals.org/journal/circinterventionsDavid R. Holmes Jr, MD, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester MN 55905. Email holmes.[email protected]eduReferences1. Moussa I, Hermann A, Messenger JC, Dehmer GJ, Weaver WD, Rumsfeld JS, Masoudi FA. The NCDR CathPCI Registry: a US national perspective on care and outcomes for percutaneous coronary intervention.Heart. 2013; 99:297–303. doi: 10.1136/heartjnl-2012-303379.CrossrefMedlineGoogle Scholar2. 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