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30 to 50 cases necessary to overcome transradial PCI learning curve
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Researchers of a study published in Circulation have concluded that the threshold for overcoming the learning curve of transradial PCI in current US practice is 30 to 50 cases. They also found that adoption of the technique is related to issues concerning operator proficiency and the need to overcome the assumed learning curve.
The study was conducted by researchers from six US institutions and included 54,561 transradial intervention (TRI) procedures from the CathPCI Registry that were performed at 704 sites from July 2009 to December 2012. New radial operators were defined as those who performed PCI exclusively from the femoral approach for 6 months after their first PCI in the database and at least 15 total TRIs thereafter.
Researchers selected markers of technical proficiency — fluoroscopy time, contrast volume and procedure success — to serve as primary outcome measures, whereas in-hospital mortality, bleeding and vascular complications served as secondary outcomes.
In all, 942 operators performed one to 10 cases; 942 performed 11 to 50 cases; 375 performed 51 to 100 cases; and 148 performed 101 to 200 cases.
“As radial caseload increased, more TRIs were performed in women, in STEMI patients and for emergency indications,” the researchers wrote.
There was also a decrease in fluoroscopy time and contrast use (P<.001 for both), with faster reductions reported for newer (<30 cases) vs. more experienced (>50 cases) operators.
In other data, procedural success was 96%, and success remained consistently high across categories of TRI experience (P=.44) despite there being a more complex patient case-mix for operators with greater TRI experience.
Researchers also reported the following rates of the secondary outcomes: in-hospital mortality, 0.5%; vascular complications, 0.1%; access-site bleeding, 0.1%; access-site hematoma, 0.1%; or any observed bleeding event, 2.3%.
These data, according to the researchers, show that despite overall lower TRI volumes and predominance of post-fellowship TRI training, the learning curve is similar for US vs. non-US operators.
“Therefore, these data may facilitate the development and adoption of formal TRI training guidelines in the [United States],” they wrote. “These data also provide a national benchmark against which individual operators can track their progress along their own learning curves.”
In an accompanying editorial, J. Dawn Abbott, MD, with Rhode Island Hospital, Brown Medical School, Providence, R.I., wrote that this study suggests interventional cardiologists can rapidly incorporate new skills into their armamentarium.
“Widespread adoption of techniques that improve patient outcomes, including TRI, therefore are inevitable, and as a profession we should set standards for training and maintenance of competency,” she wrote.
For more information:
Abbott JD. Circulation. 2014;doi:10.1161/circulationaha.114.010061.
Hess CN. Circulation. 2014;doi:10.1161/circulationaha.113.006356.
Disclosure: The researchers and Abbott report no relevant financial disclosures.
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Jordan Safirstein, MD
I read with interest this retrospective analysis of transradial intervention (TRI) operator volume and its impact on procedural proficiency and outcomes. It is worth noting that this is the first multicenter, US-based study to examine the learning curve phenomenon. Utilizing CathPCI Registry data from 2007 to 2012, they demonstrated that with increased TRI volume came decreased fluoroscopy time and contrast volume, as well as more TRIs in women, STEMIs and emergency indications. Regardless of operator TRI volume, procedural success was high and vascular complications were low. Finally, the threshold for improved radial proficiency occurred at approximately 30 to 50 cases, perhaps giving some guidance for training requirements in the future.Click Here to Manage Email Alerts