Interventional Cardiology Practice in Spain (2010) Featured

Introduction:

Dr Magdi El-Omar
Consultant Cardiologist & Lead Consulting Editor
Manchester Heart Centre

I am delighted to introduce to our readership Dr José F. Diaz Fernández whom I have had the pleasure of meeting and getting to know well in a Cairo conference last year.

Dr Diaz graduated from Universidad de Cádiz, Spain, in 1995, and has been practising interventional cardiology since 2000. He has directed the cath lab at the Juan Ramón Jiménez University Hospital, Huelva, since 2004. He is the current Secretary of the Spanish Working Group on Interventional Cardiology and is a Fellow of the European Society of Cardiology and a member of the European Association of Percutaneous Cardiovascular Interventions. He undertakes a large number of complex interventional procedures, including rotational atherectomy, IVUS, ASD closure, percutaneous mitral valvuloplasty and TAVI.

He has authored many publications in peer-reviewed journals, and has acted as local PI for numerous pivotal, multi-centre, international studies, including TAO, ATLAS ACS TIMI 51, STREAM, TRACER, CLARITY TIMI 28, MULTI-STRATEGY, PROTECT and CURRENT-OASIS 7. He is an editorial consultant for several cardiology journals, including Catheterization and Cardiovascular Interventions, Interventional Journal of Cardiology and Cardiocore.

In the following article, Dr Diaz provides us with an insightful overview of contemporary interventional practices in one of our dearest European neighbours, Spain. I am confident that you will find his article not only very interesting, but also 
highly informative and educating.

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INTRODUCTION

The Working Group on Cardiac Catheterisation and Interventional Cardiology of the Spanish Society of Cardiology presents on a yearly basis a report on the data collected from most centres in the country with catheterisation facilities for the national registry. This information shows how procedures are distributed throughout Spain and allows comparisons with other countries. This data collection has been refined throughout the years ^1-5 and is now 100% “on-line”, which renders the analysis more accurate. The data presented here represent the activity during 2010 and are a summary of the 20th report.

We would like to highlight three facts this year; firstly, the number of coronary interventions remains stable, with just a marginal growth. Secondly, procedures related to ST-elevation myocardial infarction (STEMI) continue to increase in the same way as in previous years, and finally, percutaneous aortic valve implantation procedures (TAVI) show a geometric growth, both in the number of patients treated and in the number of centers performing the technique.

METHODS

Data submission is not mandatory or audited. Only those discordant with previous years are required to be reviewed by the investigators. All calculations were made taking as a reference the official Spanish population at 3 December 31, 2010 (46,152,926 inhabitants). Centres were considered public when, irrespective of the funding source, they serve a specific area of population belonging to the National Health System. All the rest are considered private.

RESULTS

Infrastructure and resources

113 centres participated in the registry, 71 of them public (out of 74) and 41 private (out of 114). There are a total of 175 cath-labs, 64% public. 42 hospitals have more than one. 68% of the hospitals have 24-hour coverage and 69% have cardiac surgery on-site. The total number of interventional cardiologists is 441, with 552 nurses and 98 technicians. We will refer only to adult-treating hospitals.

Diagnostic activity

During 2010, 135,486 diagnostic procedures were carried out, 1.2% more than in 2009 (figure 1). 119,918 were coronary angiograms; 24.9% of them were done on women and 23% on old patients (>75 years). The average of diagnostic procedures in the country reaches 2945 per million, higher than in previous years but far from the 4030 procedures per million in Europe in 2005 (last data published) ⁶ or the 5500 procedures per million presented in the last euroPCR 7. 62 centres performed more than 1,000 diagnostic procedures, and 21 more than 2,000. The average number was 1198 procedures per centre and 774 per cath-lab.
Intravascular Ultrasound (IVUS), followed by Fractional Flow Reserve (FFR) were the most used invasive diagnostic techniques (figure 2). Optical Coherence Tomography (OCT) reached 557 cases.

Radial access continues to increase and for the first time overpasses the femoral approach (56% of cases).

Coronary interventions

Similar to diagnostic procedures, percutaneous coronary interventions (PCI) show just a slight increase. With a total number of 64,331, their growth is only 1.9% compared to 2009 (figure 3). PCIs per million were 1398, very far from the 1601 in Europe in 2005 6 or the almost 2000 in 2009 ⁷. The PCI/angiogram ratio grows to 0.54 (0.51 in 2009). Multivessel coronary interventions account for 25.4% and PCI carried out in the same session as the diagnostic angiogram for 77%. 20.9% of PCI were done on women and 23,3% on the elderly. 5.3% were restenotic lesions, a low percentage that may be a consequence of the high proportion of drug-eluting stents (DES) implanted.

Percutaneous treatment of left main lesions remain high (3.5% of the total number of PCI), with only 994 interventions on saphenous vein grafts and 184 on mammary artery grafts. GP IIbIIIa inhibitors were used in 21.5% of the procedures.
47% of the centres performed less than 500 PCI (most of them 
private) and 17 centres carried out more than 1000 interventions.
The use of IVUS reached 9.2% and FFR 3.7%, mostly for intermediate lesion assessment.
Radial interventions accounted for a 48.4%. Considering the femoral approach, more than 37,000 closure devices were used, 68% of them collagen plugs.

Stents

In 94.5% of PCI stents were implanted (62,045 units in total), with a stent/patient ratio of 1.56. This is, lower than in previous years most likely due to the increase in primary PCI. DES use was 61.3%, but only 37% of the cases were treated with DES only.

Other devices

Rotational atherectomy grew again (1213 procedures). 2092 cases with cutting-balloon were carried out, an increase of 17% when compared to 2009. These two facts can be explained on the basis of an increase in case complexity. Thrombectomy catheters were used in 7032 cases, 23% more than in 2009.

PCI for STEMI

In the acute phase of myocardial infarction (MI), 14,248 PCI were performed, 22% of the total number of PCI and 9% higher than in 2009. 22% of them involved women and 23% old patients. The most frequent modality was primary PCI (10,339 cases), 10% more than in 2009 and 29% more than in 2008. Although no data are published on the total number of MI in the country, and taking the estimate of 45,000 per year as a reference ^{8, 9}, primary PCI is applied only to 20% of the MI cases, far from the target (70%) of the stent for life initiative ¹⁰.
27 centres perform more than 200 STEMI-related PCI per year, and 40 less than 50 (figure 4).

Structural heart disease

Percutaneous mitral valvuloplasty (PMV), with 324 cases, is one the most frequent interventions, but its number decreases every year. Undoubtedly, transaortic percutaneous aortic valve implantation (TAVI) is the fastest-growing procedure, and accounted for 655 cases in 2010 (426 in 2009). In 51% of cases self-expandable valves were used and in 49% of them they were balloon-expandable, with in-hospital mortality rates of 5.6% and 7.9%, respectively.
Atrial septal defect (ASD) closure was carried out in 295 cases, and patent foramen ovale (PFO) closure in 265. 47 aortic coarctations were treated and 114 para-valvular leaks, 27 mitral and 87 aortic.

CONCLUSIONS

2010 shows a phase of marginal growth both in diagnostic and intervention procedures. The increase in procedures related to STEMI, especially primary PCI, is remarkable. The initiative ‘stent for life’ selected Spain as one of the target countries and this is, probably, one of the most important reasons for this increase. The use of DES remains high and stable compared to other countries. Cutting-balloon and rotablator also grew as a consequence of more complex cases treated. The increase in thrombectomy catheters can be explained by an increase in the rate of primary PCI.

REFERENCES

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