|Mühlberger V et al.|
Herzkathetereingriffe in Österreich im Jahr 2017 (mit Audit 2018) // Cardiac Catheterization, Coronary Angiography (CA) and Percutaneous Coronary Interventions (PCI) in Austria during the Year 2017 (Registry Data including Audit 2018)
Journal für Kardiologie - Austrian Journal of Cardiology 2019; 26 (1-2): 10-26
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Keywords: ANCALAR, Kardiologie, Koronarangiographie, PCI, perkutane Koronarintervention, Statistik, Stent, Österreich
Introduction: Our independent, purely academic activity is located in the area of health services research, and has also the option to generate benchmarks for individual centres. Participation in our surveys is voluntary, but no centre is missing. Since 1992, every year, without interruption 90–100 parameters are applicable. The questionnaire will be optimized and adapted to current conditions. This is done in coopercomparability we make only minimal and absolutely most necessary modifications. The data are collected and summarized at the end of the year by each centre itself. During the year the centres are visited or contacted to perform audits and to keep personal feedback with all of them.
Results and Discussion: Concerning international comparison for the year 2016/2017, Austria (A/AU/AUT) is situated with 6468/6422 Diagnostic Coronary Angiographies (CA), 2603/2705 Percutaneous Coronary Interventions (PCI), 397/414 Electrophysiologic Ablations, 95/115 Transarterial Aortic Valve Implantations (TAVI) per one million inhabitants under the top nations in Europe, concerning TAVI in the middle range. The absolute numbers concerning coronary diagnoses (CA) and coronary therapy (PCI) are constant, the relation PCI/CA is 42.1%.
In elective non-acute PCI, the number of cases in 2017 (n = 14,255) remained almost identical to 10 years ago (n = 14,254 cases in 2006). However, the number of patients interrupting the routine program is increasing year by year. An increase of complex and acute interventions is evidenced by the increase in STSegment- elevation myocardial-infarction PCI (STEMI -PCI) to 20.0% of all PCI. The number of Ad-hoc multivessel PCI increased to 20.8% of all PCI. There is also an increase of PCI in bifurcation of large side branches from 6.7% (2011) to 12.4% (2017) and for left main stents from 2.0% (2011) to 3.3% (2017).
Non-femoral (mostly radial) puncture techniques increased from n = 18,441 (2013) to n = 34,627 (2017) in diagnostic coronary angiography (CA). During diagnostic CA 6.4% required a switch from radial to femoral during the procedure (switch/conversion/crossover to femoral). All over, 40.7% of all PCI cases are initiated femoral. However, 30.9% of acute PCI cases are started via the femoral route, but additional 5.2% of those acute radial cases required a switch from radial to femoral during the procedure. While the number of “ad-hoc” PCIs continues to decline (84.4% two years ago to 75.0% currently) it suggests the suspicion that in turn in a re-puncture another „switch to femoral“ takes place.
Complications due to radial puncture techniques were first documented in 2017. In a feedback from reporting centres, 0.55% of complications were during diagnostic CA, 0.9% during elective non acute PCI and 1.1% during acute PCI cases. A prolongation of „catheterdoor – balloon-time“ in acute cases due to radial puncture techniques and/or switch to femoral was observes only by single centres. Silent closures of radial arteries, higher technical and x-ray load or a different learning curve in radial puncture techniques are not analysed by our registry. But data are available in the special Austrian (http://ptca.i-med.ac.at) registry which observes STEMI patients. As part of the autumn conference of the ÖKG working group on december 1st 2017, it was decided that every physician in Austria performing acute PCI should master the radial and femoral techniques as well.
Major bleedings in relation to the total number of bleeding complications is declining, especially in acute PCI (from 34.0% in 2010 to 15.8% in 2017). Glycoprotein IIb/IIIa (5.0%) or Thrombin (0.83%) inhibitors are barely used any more. The unanswered question is the link (causation/association, or hidden confounders) between decreasing major peripheral bleeding complications, decreasing application of GPI and TI, documented increasing radial puncture on the one hand and decreasing „ad-hoc” PCI or secondary change to femoral with all the disadvantages on the other hand in 2016 and 2017.
Re-interventions for chronic stent restenosis (REDO) remain constant at 4.4% (in 2017 n = 782, in 2010: 4.6%) of PCI in reporting centres. However, the proportion of very late stent thrombosis as the cause of the reintervention is decreasing to 9.6% (2017, in 2016: 11.0%, in 2015: 15.4%) of all REDOs. Maybe the application of dual antiplatelet therapy (DAPT even in all-comers) will finally be effective?
A phenomenon are n = 2,148 cases with intracoronary (i. c) devices but without following therapeutic intervention (11.9 % of PCI during 2017). This results in a rate of 42.4% (2,148/5,061) without following therapeutic intervention out of all i.c.-devices, like pressure wire with or without adenosine (FFR; n = 3,668), i.c.-ultrasound (IVUS; n = 755), or optical coherence tomography (OCT; n = 638) in reporting centres in 2017, the year before the percentage was 49.2% (2,532/5,146).
Currently, 21 centres fulfil the criterion of more than 36 STEMI PCI cases per year and centre. In earlier years there were up to 24 labora tories throughout Austria, which fulfilled this criterion. The definition of the „emergency surgery to help PCI“ has become more complex. This is due to the fact that surgeons consider the application of extracorporeal oxygenation as a procedure, which is also understandable, because even here, fatal complications can occur. All-over in n = 35 cases Mortality was n = 4 (11.4%).
This is not the only reason why statistical analysis of mortality is quite complex in such cases. For example the subsequent classification of „PCI in cardiogenic shock (ICD10: R57.0)“ leaves a lot of room for manoeuvre. 34.7% in 2017 at n = 20 critical reporting centers. PCI complications are generally underreported, but some centres in Austria – as well as in Switzerland – independently publish their complication rates themselves. Myocardial infarction as a complication due to PCI in reporting centres is 0.73% (122/16,778) in 2017. However, this is still under-documented within our survey, but the documented number of parameters increases from year to year.
Innovations within cathlabs, using the drug eluting balloon (DEB) as an example for intracoronary innovations, have seen an increase in use from n = 370 (2010) to n = 1,090 (2016), but have become rarely given in comparison to the peak of n = 1,169. One could say that the time of innovation is few and far between today. The classic biostent (biodegradable vascular scaffolds „BVS“) is meanwhile used disappearing seldom, the number dropped from n = 1693 (2014) to n = 112 (2017). A similar reduced use can be seen with clot catchers (n = 891) and intra- aortic balloon pumps (n = 53). In 2017 n = 30 innovative interventions took place, whereas in the past a maximum of n = 241 (2009) interventions took place. In contrast therefore left atrial appendage closures (n = 76, LAA closures) show a slight renaissance in Austria in 2017. The earlier use of percutaneous renal denervation was no longer evaluated in 2017.
Electrophysiology continues to increase in 2017 in all 21 performing centres. Ablations (n = 3,640, total) are increasing and well established, of which n = 1,514 for atrial fibrillation (AF), n = 396 for ventricular arrhythmia (VT) and n = 2,143 for device implantations within the cath labs. The „Leadless Pacemaker“ (n = 157) is a real innovation coming through from 2014 in a pioneer center in Austria, which spreads it worldwide.
Increases are also found in percutaneous valve Implantations or valve Replacements, e. g. Transarterial Aortic Valve procedures (TAVI/ TAVR, n = 1,016) in all 10 Austrian performing centres in 2017, or MitraClip (n = 139). The number of procedures on peripheral vessels, e. g. kidney and legs remained constant, while the number of carotid procedures within the cardiac catheterization labs has decreased. Data are presented in Vienna (November 16th, 2018) at the autumn meeting of the working group “Interventional Cardiology of the Austrian Society of Cardiology” (ÖKG) as a basis for discussion. The presentation 2017/2018 is also available at http://iik.i-med.ac.at.
Kurzfassung: Im internationalen Vergleich mit dem Vorjahr liegt Österreich (A/AU/AUT) im Jahr 2016/2017 mit 6468/6422 diagnostischen Koronarangiographien (CA), 2603/2705 perkutanen Koronaren Interventionen (PCI), 397/414 elektrophysiologischen Ablationen und 95/115 transarteriellen Aortenklappenimplantationen (TAVI) bezogen auf eine Million Einwohner weiterhin im Europäischen Spitzenfeld, bzw. bei TAVI im Mittelfeld. Die Ausbeute PCI/CA ist von 40,2 auf 42,1 % gestiegen.