Impact of the learning curve and the time of day on the procedure in STEMI patients undergoing primary PCI with left radial approach

1. Gabric ID1, Pintaric H1, Babic Z1, Trbusic M1, Krcmar T1, Stambuk
K2, Budimilic-Mikolaci J3, Benko I1, Vinter O1, Zeljkovic I1, Manola
S1, Radeljic V1, Planinc D1, Delic-Brkljacic D1
1 University Hospital Center “Sestre milosrdnice”, Zagreb,
Croatia
2 Special Hospital for Cardiovascular Surgery and Cardiology,
Krapinske Toplice, Croatia
3 Croatian National Public Health Institute, Zagreb, Croatia

2. CROSS – STEMI
CROatian Single center Study
in STEMI patients

3.  Dr. Ivo Darko Gabrić has no relevant
financial interests to disclose

4. Croatian PPCI Network
2005 -2014
1800
1600
1400
1200
1000
800
600
400
200
0
pPCI ~ 40% PCI
pPCI elective PCI Diagnostic

5. 100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
2008 2009 2010 2011 2012 2013 2014
+ ulnar
+ brachial
Diagnostic
Elective PCI
pPCI
left radial
set up

6. 01.01.2011. - 31.05.2014.
STEMI pts - 1010
Radial 750
(74,3%)
Femoral 260
(25,7%)
Left radial
596 (79,5%)
Right radial
154 (20,5%)
584 (57,8%)
Transported
426 (42,2%)
Directly admitted

7. - 0,02 - 0,01 1 + 0,01
Procedural success
(%)
Total procedure time
(min)
Fluoroscopy time
(min)
„Door to balloon” time
(min)
Radiation dose
(cGy/cm2)
Contrast used (ml)
Left Radial Femoral
NS
Gabrić ID, Pintarić H, Babić Z et all: STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center
can be Equally Treated with Either Femoral, Left, or Right Radial Access, J. Invasive Cardiol, Vol 25, Supp E, 2013

8. - 0,04 - 0,02 1 + 0,02
Procedural success
(%)
Total procedure time
(min)
Fluoroscopy time
(min)
„Door to balloon” time
(min)
Radiation dose
(cGy/cm2)
Contrast used (ml)
Left Radial Right Radial
NS
Gabrić ID, Pintarić H, Babić Z et all: STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center
can be Equally Treated with Either Femoral, Left, or Right Radial Access, J. Invasive Cardiol, Vol 25, Supp E, 2013

9.  in STEMI pts  primary PCI using left
radial approach
 Learning period and time of day
 influence on:
 Efficiency: procedure success, total
procedure and “door to balloon” time
 Operator and pts safety: contrast,
fluoroscopy time and radiation dose

10.  Data from registry and medical records
 Two analysis
1. Learning curve  pts divided into 6
month period groups (7 groups)
2. Time of day  3 groups (A: 8-16, B: 16-
24 and C: 24-8 h)

11. 12.5
10.5
8.5
6.5
4.5
2.5
0.5
Fluoroscopy time
8.0
12.0
(min)
p=0,001
9.1 9.1 9.1
8.4
10.0
1 2 3 4 5 6 7
8001
7001
6001
5001
4001
3001
2001
1001
1
3970
7314
6003
4542
p=0,001
4034 4086 4062
1 2 3 4 5 6 7
1 2 3 4 5 6 7
2011 2012 2013 2014

12. 201
181
161
141
121
101
81
61
41
21
1
Contrast used (ml)
177
191
154
p=0,001
140 141 141 143
1 2 3 4 5 6 7
Median Range P-level
Procedure
success (%)
90,3 %
1 2 3 4 5 6 7
2011 2012 2013 2014
89,5 –
93,1%
0,873
„door to
ballon” time
(min)
36 12-113 0,589
Total
procedure
time (min)
73 24-171 0,723

13. 100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5 6 7 8
2011
2012
2013
2014
(% of pPCI with radial approach)
Operators

14. A
(08 -16 h)
B
(16-24 h)
C
(24-08 h)
Total P-level
% of LR
56%
(262 of 468)
62,6%
(219 of 350)
59,9%
(115 of 192)
59%
(596 of 1010)
0,435
Procedure
success (%)
91,2 89,7 88,9 90,3 0,875
Contrast used
(ml)
155
(50-614)
136,5
(54-642)
154
(54-430)
150
(50-642)
0,286
Fluoroscopy
time (min)
9,9
(2,1-49,5)
8,5
(2,2-45)
10,0
(3,12-34,2)
9,4
(2,1-49,5)
0,364
Radiation dose
(cGy/cm2)
4671
(381-56178)
4520
(420-46059)
5211
(807-52073)
4723
(381-56178)
0,785
„door to ballon”
time (min)
40
(20-113)
35
(15-85)
40
(20-110)
36
(12-113)
0,414
Total procedure
time (min)
80,5
(24-162)
71
(28-142)
72
(31-171)
73
(24-171)
0,125

15.  Fluoroscopy time, amount of contrast used
and fluoroscopy dose are higher in STEMI pts
treated with primary PCI in the first year after
changing the setup of the cath lab from
femoral to left radial.
 with more experience of the operators, they
can be significantly improved.
 Time of day when the pPCI with left radial
approach in pts with STEMI was done did not
show any significant influence on procedure
efficiency or safety.