Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.
Cardiovascular Research Foundation, New York, New York; Sahlgrenska University Hospital, Gothenburg, Sweden.
JACC Cardiovasc Interv. 2016 Oct 24;9(20):2086-2093. doi: 10.1016/j.jcin.2016.08.011.
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 for all).
Patients who underwent LM PCI by high-volume and experienced operators had better short- and long-term prognoses. Operator experience is an important factor in a complex intervention such as LM PCI.
本研究旨在评估术者经验对左主干（LM）经皮冠状动脉介入治疗（PCI）后预后的影响。
考虑到供应心肌的数量，LM PCI 技术上具有挑战性且潜在风险较大。
连续纳入在一家机构接受非保护 LM PCI 的患者，并根据主要术者是否为经验丰富、高容量 LM 术者（定义为每年至少进行 15 例 LM PCI 且至少连续 3 年）进行比较。Kaplan-Meier 估计和 Cox 比例风险模型用于评估。
2004 年 1 月至 2011 年 12 月，共有 1948 例患者由 25 名术者行非保护 LM PCI。其中，7 名术者（28%）被认为是经验丰富的术者，18 名术者（72%）为经验较少的术者，总体平均每年 LM PCI 经验为 12.0±11.5 例。1422 例患者（73%）由经验丰富的术者治疗，526 例患者（27%）由经验较少的术者治疗。经验丰富的术者治疗的患者冠状动脉疾病更复杂和广泛。未校正和校正后的 30 天（未校正风险比[HR]：0.23；95%置信区间[CI]：0.09 至 0.60；p=0.003；校正 HR：0.22；95%CI：0.09 至 0.59；p=0.003）和 3 年（未校正 HR：0.53；95%CI：0.32 至 0.89，p=0.02；校正 HR：0.49；95%CI：0.29 至 0.84；p=0.009）随访的心脏死亡风险较低。当术者经验被加入到包含 SYNTAX（紫杉醇与心脏手术的协同作用）评分（综合鉴别指数=0.004，p=0.03）或 SYNTAX 评分 II（综合鉴别指数=0.007，p=0.02）的 Cox 比例风险模型中时，区分度提高。术者经验与远端分叉 LM 病变、双支架分叉支架置入术和血管内超声应用之间无显著交互作用（p>0.10）。
由高容量、经验丰富的术者行 LM PCI 的患者具有更好的短期和长期预后。术者经验是 LM PCI 等复杂介入治疗的重要因素。
