Impact of Operator Experience andVolume on Outcomes After LeftMainCoronary Artery PercutaneousCoronary Intervention.

Abstract

The aim of this study was to assess the impact of operator experience on prognosis after left main coronary artery (LM) percutaneous coronary intervention (PCI). LM PCI can be technically challenging and potentially risky considering the amount of supplied myocardium. Consecutive patients who underwent unprotected LM PCI at a single institution were included and compared according to whether the primary operator was an experienced, high-volume LM operator (defined as an operator who performed at least 15 LM PCIs per year for at least 3 consecutive years) or not. Kaplan-Meier estimates and Cox proportional hazards models are presented. From January 2004 to December 2011, a total of 1,948 patients underwent unprotected LM PCI by 25 operators. Of these, 7 operators (28%) were considered experienced, and 18 (72%) were considered less experienced, with an overall mean experience of 12.0 ± 11.5 LM PCIs per year. LM PCI was performed in 1,422 patients (73%) by experienced operators and in 526 patients (27%) by less experienced operators. Patients treated by experienced operators had more complex and extensive coronary artery disease. Unadjusted and adjusted risks for cardiac death were lower for patients who were treated by experienced operators, both at 30-day (unadjusted hazard ratio [HR]: 0.23; 95% confidence interval [CI]: 0.09 to 0.60; p= 0.003; adjusted HR: 0.22; 95% CI: 0.09 to 0.59; p= 0.003) and 3-year (unadjusted HR: 0.53; 95% CI: 0.32 to 0.89, p=0.02; adjusted HR: 0.49; 95% CI: 0.29 to 0.84; p= 0.009) follow-up. Discrimination improved when operator experience was added to Cox proportional hazards models containing the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (integrated discriminatory index= 0.004, p=0.03) or SYNTAX score II (integrated discriminatory index= 0.007, p= 0.02). No significant interaction was detected between operator experience and distal bifurcation LM lesion, 2-stent bifurcation stenting, and intravascular ultrasound use (p > 0.10 forall). Patients who underwent LM PCI by high-volume and experienced operators had better short- andlong-term prognoses. Operator experience is an important factor in a complex intervention such as LM PCI.