Impact of operator and institutional annual case volume on percutaneous coronary intervention clinical outcomes

Percutaneous coronary intervention (PCI) is one of the most frequently performed procedures and is being undertaken in increasingly complex patient populations. International studies have suggested an association between operator or institutional procedural volume and PCI outcomes, largely reflecting differences in experience and performance.

All adult procedures registered in the Victorian Cardiac Outcomes Registry undergoing PCI in Victoria, Australia between 1 January 2015 and 31 December 2024 were included. Operators were classified as low (<50 PCI/year), medium (50-99), or high (≥100), and institutions as low (<200), medium (200-399), or high (≥400) annual PCI volume. Multivariable logistic regression clustered at the hospital level assessed associations between operator volume and in-hospital mortality.

Across 34 institutions and 157 operators, 117,237 PCI procedures were analysed. High-volume operators performed 72.0% of all procedures, compared with 21.9% by medium-volume and 6.1% by low-volume operators. Similarly, high-volume institutions accounted for 71.2% of PCI, with 21.8% and 7.0% performed at medium- and low-volume centres, respectively. High-volume operators and institutions managed greater proportions of high-risk presentations (STEMI, out-of-hospital cardiac arrest, cardiogenic shock) and demonstrated comparable adjusted outcomes. Key PCI quality indicators such as radial access, coronary imaging use, and faster door-to-balloon times were more common among high-volume operators and institutions. After multivariable adjustment, neither operator nor institutional volume was independently associated with in-hospital mortality.

In contemporary Australian PCI practice, important differences in PCI care metrics were observed between high- and low-volume operators and institutions. Although a substantial proportion of PCI is performed by operators not meeting current national volume standards, adjusted survival was not independently associated with operator or institutional volume. Consistent with European data, these findings highlight the importance of performance monitoring and suggest that minimum PCI standards in Australia and comparable mixed public-private systems may need to be reviewed to focus more on quality metrics, rather than procedural volume alone.