Raising the bar for competency in high-risk coronary procedures

Rhian E Davies (University of Washington Medical Center, Seattle, USA) discusses a recent paper considering the importance of training in high-risk percutaneous coronary intervention (PCI) procedures, as well as a renewed interest in both the development of this skillset outside of fellowship and maintenance of competency.

The objective of our recent article in Catheterization and Cardiovascular Interventions, “Training in high-risk coronary procedures and interventions: Recommendations for core competencies,” was the desire to standardise the experience of fellowship training in high-risk interventions¹. As fellows leave their respective interventional fellowships, a wide variation of skillsets exists. Therefore, the goal of a high-risk fellowship was to ensure operators interested in high-risk intervention would receive the full complement of skills to successfully perform appropriately indicated percutaneous coronary interventions (PCI) in a safe and effective manner with the ultimate desire to improve patient care and outcomes. Of note, these recommendations were developed from review of available data and input from a cohort of high-volume high-risk operators, proctors, high-risk fellowship directors, former and current high-risk fellows.

With the release of this article, there has been renewed interest in both the development of this skillset outside of fellowship and maintenance of competency. Importantly, this article only addresses the skillsets and volume necessary to attain competency during a dedicated coronary fellowship training year in addition to the conventional Accreditation Council for Graduate Medical Education (ACGME)-approved year. We acknowledge that several operators (including several of the authors) have developed successful programmes without this additional fellowship and that there are multiple ways to attain competency in high-risk intervention including a combination of courses, books, instructional videos and proctorship^2–4. However, for a junior operator to safely tackle the complexity of these cases that are typically only performed by the most experienced operators, we felt that the bar needed to be set high.

Apart from procedural volume, maintaining competency is dependent on developing an infrastructure that supports the maintenance of skill and an operator’s desire for further growth.  Some components of a successful programme include administrative support, buy-in from colleagues, dedicated time, dedicated cath lab staff, and a referral network. Additionally, the field of interventional cardiology is rapidly evolving, therefore it is important to be engaged in mentorship, teaching, and research.

Numerous reports from databases such as the National Commissioning Data Repository (NCDR), demonstrate a clear association between improved outcomes, particularly for high-risk interventions, and higher operator procedural volume^5–8. To produce outcomes exhibited in clinical trials and registries, it is imperative that operators have the procedural volume to develop and maintain a high-risk skillset. These recommendations were made based on available data to provide the best care for patients who are at higher risk of experiencing an adverse event but also potentially have the most to gain from high-risk intervention⁹.

In regard to our unprotected left main (ULM) recommendations, data suggests a difference in mortality based on an operator volume of 15 ULM PCI cases per year¹⁰. The DKCRUSHV trial which evaluated ULM with distal bifurcations required operators perform ≥300 PCIs per year for five years with at least 20 ULM PCIs per year¹¹.

As target lesion revascularisation has been an ongoing challenge for PCI, it is imperative that operators are facile with both use and understanding of intravascular imaging. Imaging, more specifically intravascular ultrasound (IVUS), has been shown to change PCI strategy and reduce MACE^12–16.

Chronic total occlusion (CTO) PCI is arguably the most challenging subset managed by high-risk coronary operators. While the CTO PCI success rates have been relatively stagnant at around 50‒60% for all-comers, the goal of additional training is to produce operators with the ability to achieve >80% success rates that have been demonstrated in CTO PCI registries^6,17–22.  Although there is limited data on the learning curve of CTO PCI, there appears to be an inflection point at which improvements in technical success occurred around 120‒125 cases/CTO operator²³.

Given it is more commonly encountered in the peri-procedural period with high-risk intervention, it is important that operators are well-versed in both institution of haemodynamic support and management of heart failure and cardiogenic shock.

While occurrence of complications should decrease with proficiency, complications may arise more frequently with high-risk interventions. Therefore, the ability to manage complications can contribute significantly to reduction in morbidity and mortality. However, it is possible that not all of the complications—including urgent pericardiocentesis, coil embolisation, fat embolisation and snaring—can be directly observed or managed during the course of a single year of training. We therefore emphasise the importance in developing algorithms to manage these conditions.  Occasionally, some of these skills can be learned in non-emergent situations—for example: coiling an unnecessary graft when competitive flow is present from a newly re-opened native coronary vessel.

One pathway to allow operators to develop a high-risk skillset is through a high-risk PCI fellowship.  Fellowship provides a safe environment that allows trainees high procedural volume, teaching and mentorship to attain competency in a shorter timeframe. It goes without being said that the field of nterventional cardiology opens the door to a lifelong learning opportunity with a personal overall goal of improving our skills in order to provide the best possible patient care.

I gratefully acknowledge all the co-authors who participated in this initiative. I would also like to give special thanks to Ajay Kirtane and William Lombardi for their mentorship.

References

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