1. Ahmed A. Khattab, MD For the German Cypher Registry Investigators
Sirolimus-Eluting Stent Treatment at High-Volume Centers Confers Lower Mortality at 6-Month Follow-Up Results from the German Cypher Registry
Ahmed A. Khattab, MD
For the German Cypher Registry Investigators
University Hospital Bern - Switzerland

2. No conflict of interests for any of the authors
Disclosure
No conflict of interests for any of the authors

3. PCI volume is inversely related to adverse outcome
Background (I)
PCI volume is inversely related to adverse outcome
Both for hospital and operator volumes
Threshold activity level of > 400 PCI annually for hospitals and > 75 for operators
Outcome measures include death and emergent CABG within 30 days

4. DES volume-outcome relation is not known
Background (II)
DES volume-outcome relation is not known
Volume-outcome relation beyond one month is not known

5. To investigate the institutional SES procedural volume-6-month-outcome
Study aim
To investigate the institutional SES
procedural volume-6-month-outcome
relation from the German Cypher Registry

6. The Prospective Multicenter German Cypher Registry
From April Dec Inclusion of patients with at least one SES
Central prospective data collection in 122 german centers via Internet by IKKF
Monitoring in 15 centers
91% follow-up (median 6.6 months)
This analysis includes 8201 patients:
1140 (13.9%) in low-volume centers
2360 (28.8%) in intermediate-volume
4701 (57.3%) in high-volume centers

7. < 150 SES patients = low volume
Tertiles definition
< 150 SES patients = low volume
150 – 400 SES patients = intermediate
> 400 SES patients = high-volume

8. Baseline criteria (I) Variable Low-volume Intermediate High-volume
Men,%
73.6
75.2
75.5
Age (y), mean
63.3
64.5
65.5
Diabetes,%
28.3
36.9
25.7
Hypertension,%
78.4
84.2
85.7
Dyslipidemia,%
85.2
86.7
89.9
Smoker,%
29.5
33.2
31.1
LV EF <40,%
12.9
16.9
12.4
Multivessel CAD,%
68.1
69.2
71.5
ACS,% 50
44.3
37.8

9. Baseline criteria (II)
Variable
Low-volume
Intermediate
High-volume
Ostial lesion,% 11
12.7
7.9
Bifurcated lesion,%
14.6 17
12.9
CTO,%
5.6
In-stent restenosis,%
22.8
23.9
16.6
Treated vessel:
Left main,%
1.7
2.7
3.0
LAD,%
57.7
54.3
60.6
LCX,%
14.8 14
14.2
RCA,%
25.7 29
22.2
SVG,%
5.4
5.2

10. Procedural characteristics
Variable
Low-volume
Intermediate
High-volume
P-value
Direct stenting,%
37.3
32.8 33
<0.01
Inflation pressure 13 14
<0.0001
Inflation >16 atm,%
26.2
33.8
35.5
Stent diameter, mm
2.89
2.94
2.95
<0.001
Stented length, mm
17.9 18
20.4
Residual dissection,%
2.7
2.8
1.9
<0.05
Residual stenosis >30%
1.4
1.3
0.6
Final TIMI flow < 3
3.1
2.2
2.3
0.17

11. Early outcome (in-hospital)
Variable
Low-volume
Intermediate
High-volume
P-value
All deaths,%
0.7
0.6
0.3
0.08
Cardiac,%
0.5
Non-cardiac,%
1 patient
Unknown,%
New MI,%
1.7
1.2
<0.0001
Urgent TVR,%
2.8
1.4
1.1
Death/MI/TVR,%
4.4
1.6

12. Clinical events at 6-month Follow-up
Variable
Low-volume
Intermediate
High-volume
P-value
All deaths,%
1.9
2.0
1.3
<0.05
Cardiac,%
0.7
1.2
0.5
Non-cardiac,%
0.3
0.92
Unknown,%
0.9
0.23
New MI,%
1.1
1.8
0.8
<0.001
TVR,%
7.2
7.8
6.9
0.38
CVA,%
0.54
Death/MI/TVR,%
11.3
12.1 9
0.0001

13. Adverse clinical events at 6-month follow-up

14. Adverse clinical events at 6-month follow-up

15. Medication at 6-month Follow-up
Low-volume
Intermediate
High-volume
P-value
Aspirin,%
91.5
90.5
91.9
0.19
Clopidogrel,%
57.9
61.3
40.3
<0.0001
weeks 12 24 26
< 8 weeks,%
27.6
11.2
11.8
Beta blocker,%
80.5
84.9
87.2
ACE-I/ARB,%
71.3
78.7
76.4
Ca-antag.,%
15.2
15.6
15.4
0.97
Statins,%
81.6 87 90

16. This association cannot be explained
Conclusion
Patients receiving SES at high-volume centers have lower mortality and MI at 6 months
No difference in TVR
This association cannot be explained
Significant differences in procedural conduct were documented
The underlying etiology of death/MI cannot be defined