|Mühlberger V et al.|
Herzkathetereingriffe in Österreich im Jahr 2018 (mit Audit 2019) //Cardiac Catheterization, Coronary Angiography (CA) and Percutaneous Coronary Interventions (PCI) in Austria during the Year 2018 (Registry Data including AUDIT 2019)
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Keywords: ANCALAR, Koronarangiographie, PCI, perkutane Koronarintervention
Background: The dynamic nature of cardiac catheterization and increasing number of complex cases has implications for cardiac registries. Cardiac registers and the interpretation of their data need to continue and adapt. Methods: The Austrian National Catheterization Laboratory Registry ANCALAR is an observational registry that collects data on cardiac catheterization in Austria, annually, generating benchmarks for PCI capable health centres, data has been collected yearly since 1992. With new data from 2018 now available, trends in cardiac catheterization in Austria are described using international comparisons with Germany and Switzerland. ANCALAR is an independent registry, the data represents all PCI capable clinics in Austria. Detailed information on data collection tools and indicator definitions are available on the ANCALAR study homepage: https://iik.i-med.ac.at/. International comparisons are made using pooled data from PCIclinics in each respective country per 1 million population, in line with conventional methodology. Data for benchmark parameters including CA, PCI, ablations, TAVI and numbers of other parameters have been reported by 100% of clinics in Austria. For a few specific parameters, particularly indicators of negative outcomes such as severe bleeding during CA or PCI, not all clinics report data. Where applicable, a description of missingness notes the exact number of clinics (out of the 33 possible) from which only complete data were pooled to calculate the respective indicator from subsets of clinics where data are complete to give a more accurate picture of what is happening in Austrian Cath Labs. Results: All 33 PCI-clinics with a total of 53 Cath Lab tables between them in 2018 reported n = 55,909 diagnostic Coronary Angiographies (CA) and n = 24,462 PCI.
International Context: In Austria and Switzerland, the absolute numbers of CA are comparable and more or less constant between 2016 and 2018; Germany has consistently higher rates of CA and PCI. In Austria there is a slight increase in the PCI/CA ratio from 40.2% in 2016 to 43.8% in 2018; this ratio (PCI/CA) is almost the same as Germany, Switzerland have a higher ratio. Overall, Austria place just under the top nations in Europe for CA and PCI. Austria began reducing the use of GP blockers and catheter thrombectomies years before guidelines reacted to new evidence and at the same time that Switzerland has stopped counting these GP blockers cases in their regis try. In addition, reduction in the use of balloon pumps and catheter thrombectomies in Austria has then been protracted compared to guidelines. Electrophysiology in Austria with n = 397 ablations per million inhabitants in 2016 shows better numbers than the European mean of n = 288/mio. Switzerland (n = 784/mio) or Germany (n = 999/mio) having higher numbers in 2016, but Austria coming up to 444/mio in 2018. For TAVI Austria place just under the middle range nations in Europe, is increasing year on year in Austria per 1 million inhabitants, and was 130 per million in 2018.
Concerning defect closure procedures like PFO, PDA, ASD, VSD during the year 2016 Switzerland was in front with n = 767 cases compared to Austria with n = 218 interventions. Austria coming up in 2018 with n = 311 procedures. Trends in acute and non-acute PCI use in Austria: In elective non-acute PCI, the number of cases in 2018 (n = 14,439) remained almost identical to 10 years ago (n = 14,254 cases in 2006). However, the number of patients undergoing non-routine and/or acute PCI (which interrupt daily planned PCI) is increasing year on year. Currently 21 centres fulfil the criterion of more than 36 STEMI PCI cases per year and centre and STEMI-PCI cases accounted for 18.5% of all PCIs in reporting centres in 2018. Furthermore, an increase of complex interventions is evidenced. The number of “ad hoc” multivessel PCI increased from 19.1 (2015) to 22.1% of all PCI in 2018. There is also an increase of PCI for left main stents from 2.0% (2011) to 3.9% (2018) and in bifurcation of large side branches from 6.7% (2012) to 12.4% (2017) declining to 10.5% in 2018 with more “ad hoc” multivessel PCI in 2018 at the same time.
The incidence of major bleedings relative to the total number of bleeding complications is declining, especially in non-acute PCI (from 21.9% in 2017 to 17.3% in 2018). Glycoprotein IIb/ IIIa (4.3%) or Thrombin Inhibitors (TI, 0.37%) are barely used any more.
Trends in Puncture Techniques: Non-femoral (mostly radial) puncture techniques in diagnostic CA increased in absolute terms to n = 35,939 (2018). In total, 58.7% of all therapeutic PCI cases are initiated using a non-femoral approach (59.3% during 2017). But at the same time the number of “ad hoc” PCIs during diagnostic CA continues to decline (84.4 % in 2015 to 72.6% in 2018) and with additional 8.3% of those radial PCI cases requiring a switch from radial to femo ral during the procedure in 2017 and in 2018. So both puncture techniques, radial and femoral, still are of importance. Local complications due to radial puncture techniques occurred in 0.9 (2017) and 0.65 % (2018) during all PCI cases.
Use of new intracoronary interventional devices or special techniques: The time of new devices and techniques (“innovations”) within Cath Labs seems few and far between today. For example, the decline in use of biodegradable vascular scaffolds (BVS) accelerated since 2014 and these are now very seldom used (n = 37 in 2018). A similar reduction in use can be seen with catheter thrombectomies (n = 662) and intra-aortic balloon pumps (n = 48).
A visible phenomenon in 2018 are n = 2,056 cases with intracoronary (IC) devices but without following therapeutic intervention (10.6 % of PCI during 2018) such as pressure wire with or without adenosine (FFR), IC ultrasound (IVUS), or optical coherence tomography (OCT) but without following therapeutic intervention. The number of IC devices without following therapeutic intervention is declining (13.1% during 2015 and 10.6 % of PCI during 2018) and for the first time since introduction FFR is declining from the maximum of n = 3,631 (15.9% of PCI) in 2016 to n = 3,497 (14.3%) in 2018.
Extracoronary interventions: The use of percutaneous renal denervation was no longer evaluated in 2017. The number of procedures on peripheral vessels, e.g. kidney and legs and the number of carotid procedures within the cardiac catheterization laboratories remained constant on a low level.
Electrophysiology: Electrophysiology continued to increase in 2018 in all 21 performing centres. Electrophysiological ablations (n = 3,903, total) are increasing and well established, of which n = 1,783 were for atrial fibrillation (AF) and n = 289 for ventricular arrhythmia (VT, n = 396 in 2017). Of the n = 2,300 pacemaker implantations within the Cath Labs (the „Leadless Pacemaker“ [n = 157 in 2017 an n = 125 in 2018]) is a real innovation pioneered in 2014 at an Austrian centre, now spreading worldwide. Percutaneous Valve Implantations: Increases are also found in percutaneous valve implantations or valve replacements, e.g. transarterial aortic valve procedures (TAVI/TAVR) in all 10 Austrian performing centres in 2018 (n = 1,142), as well as in the MitraClip™ (n = 181) Conclusions: The most recent results from ANCALAR highlight that interventional cardiology in Austria is, in the main, in line with the top countries in Europe with some idiosyncrasies in its response to new evidence and guidelines, where Austria is often both ahead of the curve, adapting daily practice before new guidelines are released and at same time facing obstacles in timely adoption of others.
In conclusion our registry data show that Austria is another example of the difficulties of real life and science meeting in the world of Interventional Cardiology; with registry data careful interpretation is needed to identify artefacts and understand real differences in the practice of interventional cardiology.
Data are presented in Linz (November 19th, 2019) at the autumn meeting of the working group “Interventional Cardiology of the Austrian Society of Cardiology” (ÖKG) as a basis for discussion. The presentation 2018/2019 is also available at http://iik.i-med.ac.at.
Kurzfassung: Hintergrund: Die dynamische Natur des Herzkatheterismus und die zunehmende Zahl komplexer Eingriffe wirken sich auf kardiologische Registraturen aus. Kardiologische Register und die Interpretation der resultierenden Daten müssen in Anbetracht dieser Veränderungen aufrechterhalten und laufend adaptiert werden. Methode: Das nationale österreichische Herzkatheterregister „ANCALAR” dient seit 1992 jährlichen Beobachtungsstudien zur Versorgungsforschung. Die Herzkatheterdaten aller österreichischer Zentren werden einerseits zu Vergleichszwecken („benchmarks“) innerhalb des Landes und andererseits international auf der Basis üblicher Verfahren zum Vergleich gepoolter Daten pro Million Einwohner vor allem mit der Schweiz und Deutschland verwendet. Für Österreich liegen die aktuellen Daten aus dem Jahr 2018 vor. ANCALAR ist unabhängig und flächendeckend, die Homepage: https://iik.i-med.ac.at/ gibt Auskunft über die methodischen Details. In jährlichen Publikationen seit 1992 ist die Methode optimiert, aber nie grundlegend geändert worden. Falls Daten von einzelnen Zentren nicht vollständig gemeldet werden, erfolgte in den letzten Jahren eine zusätzliche Berechnung der Prozentwerte auf der Basis nur der vollständig gemeldeten Parameter für den longitudinalen innerösterreichischen Vergleich.