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(Circulation. 2009;120:600-606.)
© 2009 American Heart Association, Inc.

Interventional Cardiology

Sirolimus-Eluting Stent Treatment at High-Volume Centers Confers Lower Mortality at 6-Month Follow-Up

Results From the Prospective Multicenter German Cypher Registry

Ahmed A. Khattab, MD; Christian W. Hamm, MD; Jochen Senges, MD; Ralph Toelg, MD; Volker Geist, MD; Tassilo Bonzel, MD; Malte Kelm, MD; Benny Levenson, MD; Christoph A. Nienaber, MD; Thomas Pfannebecker, Dipl-Ing; Georg Sabin, MD; Steffen Schneider, PhD; Ulrich Tebbe, MD; Franz-Josef Neumann, MD; Gert Richardt, MD, for the German Cypher Registry

From Herz-Kreislauf-Zentrum (A.A.K., R.T., V.G., G.R.), Segeberger Kliniken GmbH, Bad Segeberg, Germany; Kerckhoff Klinik (C.W.H.), Kardiologie, Bad Nauheim, Germany; Institut für Herzinfarktforschung an der Universität Heidelberg (J.S., S.S.), Ludwigshafen, Germany; Klinikum Fulda (T.B.), Kardiologie, Fulda, Germany; Universitätsklinikum (M.K.), Kardiologie, Düsseldorf, Germany; Kardiologische Praxis (B.L.), Berlin, Germany; Universitätsklinikum (C.A.N.), Kardiologie, Rostock, Germany; Medical Affairs, Cordis Germany (T.P.), Langenfeld, Germany; Elisabeth Krankenhaus (G.S.), Kardiologie, Essen, Germany; Klinikum Lippe-Detmold (U.T.), Kardiologie, Detmold, Germany; and Herzzentrum (F.-J.N.), Bad Krozingen, Germany.

Correspondence to Ahmed A. Khattab, MD, Cardiology Department, University Hospital, 3010 Bern, Switzerland. E-mail ahmed.khattab{at}insel.ch

Received July 26, 2008; accepted June 8, 2009.

Background— Studies continue to identify percutaneous coronary intervention procedural volume both at the institutional level and at the operator level as being strongly correlated with outcome. High-volume centers have been defined as those that perform >400 percutaneous coronary intervention procedures per year. The relationship between drug-eluting stent procedural volume and outcome is unknown. We investigated this relationship in the German Cypher Registry.

Methods and Results— The present analysis included 8201 patients treated with sirolimus-eluting stents between April 2002 and September 2005 in 51 centers. Centers that recruited >400 sirolimus-eluting stent patients in this time period were considered high-volume centers; those with 150 to 400 patients were considered intermediate-volume centers; and those with <150 patients were designated as low-volume centers. The primary end point was all death, myocardial infarction, and target-vessel revascularization at 6 months. This end point occurred in 11.3%, 12.1%, and 9.0% of patients in the low-, intermediate-, and high-volume center groups, respectively (P=0.0001). There was no difference between groups in the rate of target-vessel revascularization (P=0.2) or cerebrovascular accidents (P=0.5). The difference in death/myocardial infarction remained significant after adjustment for baseline factors (odds ratio 1.85, 95% confidence interval 1.31 to 2.59, P<0.001 for low-volume centers; odds ratio 1.69, 95% confidence interval 1.29 to 2.21, P<0.001 for intermediate-volume centers). Patient and lesion selection, procedural features, and postprocedural medications differed significantly between groups.

Conclusions— The volume of sirolimus-eluting stent procedures performed on an institutional level was inversely related to death and myocardial infarction but not to target-vessel revascularization at 6-month follow-up. Safety issues are better considered in high-volume centers. These findings have important public health policy implications.

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