A total of 119 hospitals participated in this registry, a higher number than in previous years (107 in 2017 and 109 in 2018); 83 were public and 36 were private (appendix 1). This high participation effectively represents Spanish catheterization activity. There were 263 catheterization laboratories: 148 (56.3%) were exclusively for cardiac catheterization, 70 (26.6%) were shared rooms, 30 (11.4%) were hybrid rooms, and 15 (15.7%) were supervised rooms.

In terms of staff, there were a total of 502 interventional cardiologists (464 accredited; 92.4%) in these hospitals in 2019. Of the total number of interventional cardiologists recorded, 114 (22.7%) were women, a slight increase vs the previous year (21.4% in 2018). The number of residents in training decreased in 2019 vs the trends seen in previous years (90 in 2018 vs 79 in 2019; a 12.2% decrease). There were 719 registered nurses in the catheterization laboratories and 83 radiology technicians.

In 2019, 165 124 diagnostic studies were performed, representing a 4.7% increase vs 2018. This increase was largely due to a higher number of coronary angiograms (140 670 in 2018 vs 145 715 in 2019; a 3.6% increase), with no major changes in other diagnostic procedures.

Regarding the activity per center, 60.5% of the participating hospitals performed more than 1000 diagnostic studies. The radial artery was the access site used in 87.8% of procedures, similar to 2018.

The average number of diagnostic studies was 3506 per million population in Spain (3374 in 2018), whereas that of coronary angiograms was 3094, a slight increase vs 2018 (3011). The distribution of coronary angiograms per million population by autonomous community is shown in figure 1.

Figure 1.

Coronary angiograms per million population. Spanish average and total by autonomous community in 2018 and 2019.

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The progressive increase in intracoronary diagnostic techniques seen in previous years was further accentuated in 2019. Both the pressure guidewire, which continued to be the most widely used technique, and intracoronary ultrasound showed an approximate 20% increase vs the previous year, with optical coherence tomography growing by 8.4% (figure 2).

Figure 2.

Changes over time in the numbers of the different intracoronary diagnostic techniques. OCT, optical coherence tomography.

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The number of percutaneous coronary interventions (PCIs) recorded in 2019 was 75 819, representing a 4.5% increase vs 2018 (75 520). Regarding the distribution per center, 49 hospitals performed between 500 and 1000 annual angioplasties (51 in 2018) while 24 performed more than 1000 (23 in 2018). The PCI/coronary angiogram ratio was 0.52; this figure has remained constant in recent years. The mean number of PCIs per million population increased by 3.8% vs 2018 (1610 in 2019 vs 1551 in 2018) (figure 3). Seven autonomous communities had rates below the Spanish average, the same as in 2018.

Figure 3.

Percutaneous coronary interventions per million population. Spanish average and total by autonomous community in 2018 and 2019.

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In terms of interventional procedures considered complex, there was another increase in the number of procedures performed on the left main vessel (3815 in 2018 and 4133 in 2019; an 8.3% increase). In addition, 79.9% of these procedures involved PCI of the unprotected left main coronary artery. Compared with 2018, there was also a significant 15.1% increase in the number of chronic occlusions and a 15.3% decrease in bifurcation lesions.

As for diagnostic procedures, radial access was the approach used for most PCIs (88.3%). This figure has been stable in recent years and consolidates this access site as the most widely used approach. The changes in radial access since 2005 are shown in figure 4. A practically linear increase was detected until a plateau was reached 3 years ago.

Figure 4.

Changes over time in the number of diagnostic and therapeutic procedures involving the radial approach.

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The immediate outcome variables after the PCI were available for between 65% and 77% of the centers, depending on the variable considered. In 2019, 95.3% of the procedures were completed without complications; 1.0% reported severe complications (death, acute myocardial infarction [AMI], or need for urgent cardiac surgery) and only 0.4% reported intraprocedural death.

In total, 112 845 stents were implanted in 2019, 4.1% more than in the previous year, in line with the increase in PCI activity. The stent/procedure ratio was stable at 1.6. Drug-eluting stents as a percentage of the total number of stents was 93.3%, with no increase vs 2018 after more than 5 years with a progressive increase. The use of bioabsorbable devices fell again, with 224 devices implanted in 2019 (0.2%) vs 488 (0.4%) in 2018. Similar percentages were found vs 2018 for the use of dedicated bifurcation stents (0.2%), self-expanding stents (0.02%), and polymer-free stents (4.9%).

The use of plaque modification techniques grew again, paralleling the increased treatment of more complex lesions. At 1635 procedures, rotational atherectomy was the most widely used technique, with a 7.8% increase vs 2018. Intracoronary lithotripsy was the technique showing the most growth, with almost 8 times the 2018 number (a 670.2% increase: 47 vs 362 procedures).31 In addition, there was a 20.4% increase in laser atherectomy procedures (88 vs 106) and an 8.7% increase in the use of special balloons.

Drug-coated balloon use grew by 16.9% (2727 in 2018 and 3188 in 2019).

The implantation of short-term circulatory assist devices during complex interventions expanded, mainly due to the Impella, whose use increased by 69.1% (149 in 2018 and 252 in 2019). Extracorporeal membrane oxygenation grew by 3.7% (109 in 2018 and 113 in 2019), whereas balloon pump use declined by 5.4% (1083 in 2018 and 1025 in 2019).

Finally, there was an increase in other PCI procedures: septal ablation (98 in 2018 vs 114 in 2019), coronary fistula closure (29 vs 34), and stem cell infusion (10 vs 25).

After 2 years with no changes in the numbers of AMI interventions, there was a 6.0% increase in 2019 (21 261 in 2018 vs 22 529 in 2019). At 91.8%, the percentage of primary angioplasties in AMI was practically identical to that of 2018, probably because it is reaching a plateau. These percentages were similar for the pharmacoinvasive strategy. After fibrinolysis, 557 rescue PCIs were recorded (2.5% of the total number of AMI interventions), as well as 1282 delayed or elective PCIs (5.7% of the total number of AMI interventions).

Primary PCI accounted for 27.3% of all angioplasties. The average number of primary PCIs per million population in Spain increased again (382 in 2017, 417 in 2018, and 439 in 2019). Almost all of the autonomous communities showed a higher primary angioplasty rate last year (figure 5). There was an increase in the number of centers that performed more than 300 primary angioplasties per year, from 21 to 26, and, at the other extreme, those that performed less than 50, from 23 to 34.

Figure 5.

Primary angioplasties per million population. Spanish average and total by autonomous community in 2018 and 2019.

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In terms of the technical aspects of AMI treatment, and in line with what occurred with diagnostic procedures and PCI outside the AMI setting, the preferred approach was radial, which was used in 96.8% of procedures (calculated based on centers reporting this figure). The same occurred with the use of drug-eluting stents, with a median procedural use of 99%. The number of procedures performed using thrombus extractor devices fell slightly, from 29.2% in 2018 (6205) to 26.8% in 2019 (6036).

Finally, immediate outcome variables after PCI were available for 75 of the participating centers, with an angiographic success rate of 94.4% and a 2.4% rate of severe complications (delayed-onset shock, need for revascularization surgery, or death).

In 2019, 549 valvuloplasties were recorded in adults, 323 (59.7%) on the aortic valve, 189 (34.9%) on the mitral valve, and 29 (5.4%) on the pulmonary valve. After a slight increase in 2018, the number of mitral valvuloplasties continued the decrease begun some years ago; 36 fewer such procedures were performed in 2019 vs 2018. There were 5 cases of severe mitral regurgitation and 2 of cardiac tamponade (1 patient had both complications). The number of isolated aortic valvuloplasties, not connected to transcatheter aortic valve implantation (TAVI), increased again, with 55 more procedures than in 2018. Two severe aortic regurgitations were reported, as well as 10 deaths.

TAVI showed another major increase. This increase has been practically linear in the last 5 years (figure 6). A total of 4281 TAVIs were performed in 2019, representing a 21.0% increase vs the previous year (3537 in 2018). The average number of PCIs per million population in Spain increased from 76 in 2018 to 90.9 in 2019. All autonomous communities showed marked growth in TAVI performance, with Galicia, Cantabria, Madrid, Principality of Asturias, Castile and León, the Basque Country, and the Chartered Community of Navarre showing an above-average number of implantations per million population (figure 7). Most patients treated were older than 80 years of age (67.4%) and 38.7% had surgical contraindication or high surgical risk; the risk was intermediate in 15.8% and not specified in 48.6%. The type of prosthesis implanted was specified in 3499 patients. The expandable balloon valve was used in 1704 (48.7%), whereas the remaining 1795 procedures (51.3%) involved various types of self-expanding valves. The type of approach was specified in 87.1% of implantations. The percutaneous transfemoral approach was the most widely used, with 3173 procedures (85.2%). The remaining percutaneous approaches, such as the transsubclavian/axillary and transcaval, continued to be rare (0.5% and 0.1% of procedures, respectively). Surgical transfemoral access (n = 333, 8.9%) was the preferred alternative to the percutaneous transfemoral approach. The percentages of surgical transsubclavian/axillary (2.8%), transapical (2.2%), and transaortic (0.2%) approaches were similar to those of 2018.

Figure 6.

Changes over time in TAVI from 2015 to 2019. TAVI, transcatheter aortic valve implantation.

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Figure 7.

Transcatheter aortic valve implantations per million population. Spanish average and total by autonomous community in 2018 and 2019. * No data are available for La Rioja.

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Regarding in-hospital outcomes, 161 major complications (AMI, stroke, or need for vascular surgery) were reported (3.8%) and conversion to surgery was required in 9 procedures (0.2%), 8 of them urgent. The in-hospital mortality rate was 1.8% (77 patients). In addition, 384 patients (9.0%) required definitive pacemaker implantation.

TAVI was performed after the treatment of other valvular heart diseases in 14 patients in the mitral position (12 in 2018), in 18 in the tricuspid position (9 in 2018), and in 29 in the pulmonary position (25 in 2018).

Another notable finding was the significant growth in percutaneous valvular repair with the MitraClip device (figure 8). A total of 385 procedures was recorded, 17.4% more than in 2018, with 538 clips used (1.4 clips per procedure, the same as in 2018).

Figure 8.

Changes over time in percutaneous mitral valve repair, left atrial appendage closure, and patent foramen ovale closure from 2015 to 2019.

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Functional mitral regurgitation was the most common etiology (60.5%), followed by degenerative (23.7%) and mixed (15.9%). Regarding outcomes, the mitral regurgitation was reduced to ≤ grade 2 in 370 patients (96.1%). Complications were reported in 11 patients.

Percutaneous treatment of tricuspid valve disease also showed significant growth, although it is still rare. A total of 49 such procedures were performed in 2019, a 63.3% increase vs 2018 (30 procedures). The MitraClip was used in 18 patients (the same number as in the previous year), as well as a bicaval valve in 6 patients (2 in 2018) and a tricuspid prosthesis in 7 (1 in 2018). In addition, TAVI was performed in the tricuspid position in 18 patients (9 in 2018).

Regarding nonvalvular structural heart interventions, there was marked growth in atrial appendage closure procedures (42.0%), which increased from 644 procedures in 2018 to 921 in 2019 (figure 8). The Amulet device was used in 513 patients (55.7%), the Watchman in 313 (34.0%), and the LAmbre device in the remaining 95 (10.3%). Twelve procedural complications (tamponade, embolism, or death) were reported (1.3% of the total).

In total, 203 patients underwent paravalvular leak treatment; there was an increase in the closure of aortic leaks (64 in 2018 vs 90 in 2019) and a decrease in that of mitral leaks (130 in 2018 vs 113 in 2019). Complications were reported in 6 patients (embolism or death).

There was an increase in endovascular aortic repair procedures (36 in 2018 vs 50 in 2019), renal denervation (29 vs 39), balloon pericardiotomy (53 vs 64), and percutaneous treatment of pulmonary embolism (112 vs 133). Also implanted were 9 coronary sinus reducer devices and 9 atrial septal defect devices, figures similar to those of 2018.

A total of 1268 procedures were performed for adult congenital heart diseases, 364 more than in 2018, with an increase in practically all procedure types. Foramen ovale closure, in line with the trends of recent years, showed the most growth, with 710 procedures in 2019 vs 514 in 2018 (a 38.1% increase) (figure 8). One device embolization was reported, as well as 5 implantation failures without complications. The number of atrial septal defect closures increased by 17.7% (294 in 2018 and 346 in 2019), with 4 cases of device embolization and 6 of implantation failure without complications. There were 37 patent ductus arteriosus closures (22 in 2018) and 59 atrial septal defect closures (12 in 2018); 59 aortic coarctations were treated (62 in 2018). Finally, 14 more percutaneous pulmonary valve implantations were performed than in 2018 (a total of 59), with a 98% success rate and without major complications.