A total of 109 hospitals performing interventional activity in adults participated in this registry; most of these centers (n=83) were public (appendix 1). This number effectively represents the activity carried out in Spain, with most of the volume performed in centers with public funding. There were 239 catheterization laboratories: 144 (60.2%) were exclusively for cardiac catheterization, 62 (25.9%) were shared rooms, and 33 (13.8%) were hybrid rooms.

In terms of staff, the 109 centers had 463 active interventional cardiologists in 2018 (411 of them accredited). Of the total number of interventional cardiologists recorded, 99 (21.4%) were women, a figure that progressively increases each year (and is 12.5% more than in 2017). The number of residents in training increased to 90 in 2018 (12% higher than in 2017). Of nursing staff, there were 701 registered nurses and 81 radiology technicians.

In 2018, 157 632 diagnostic studies were performed, representing a 2.1% increase vs 2017. Of these procedures, 140 670 (89.2%) were coronary angiograms (1.6% more than in 2017). There was another increase in the radial approach, used in 87.4% of all diagnoses in 2017 (a 1.7% increase vs 2017).

The average number of diagnostic studies was 3374 procedures per million population in Spain; in terms of coronary angiography, the Spanish average was 3011 per million, slightly higher than that registered in 2017 (2974). The distribution by autonomous community of coronary angiograms per million population is shown in figure 1.

Figure 1.

Coronary angiograms per million population. Spanish average and total by autonomous community in 2017 and 2018. Source: Spanish National Institute of Statistics.30

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In line with the tendency of previous years, there was another progressive increase in intracoronary diagnostic techniques. In total, 7640 functional study procedures were performed with the pressure guidewire (9% more than in 2017). The gradual decrease in intracoronary ultrasound in favor of optical coherence tomography in recent years stopped in 2016 and 2017 and even reversed in 2018, with a 2.4% increase. However, the use of optical coherence tomography, whose application had stagnated, also underwent significant growth in 2018 vs 2017 (8.1%; 2934 cases vs 2714 in 2017). The changes in intracoronary diagnostic techniques in recent years are shown in figure 2.

Figure 2.

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

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The number of percutaneous interventions (PCIs) recorded in 2018 was 72 520, which is 2.2% higher than the 70 928 PCIs in 2017. The changes in PCIs over time are shown in figure 3. There were 1551 PCIs per million population (vs 1524 in 2017 and 1478 in 2016). As in recent years, the PCI/coronary angiography ratio remained at around 0.5.

Figure 3.

Changes in the number of percutaneous coronary interventions between 2009 and 2018.

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The reported data reveal a clear tendency for an increase in the number of interventional procedures considered complex. There was further growth in procedures performed on the left main vessel, reaching a total of 3815 (4.2% more than in 2017), which comprised PCI of the unprotected left main coronary artery in 75%. In addition, 2594 lesions were considered by operators to be chronic total occlusions (10.6% more than in 2017), as well as 7768 bifurcation lesions (17% more than in 2017). Finally, the number of restenosis interventions fell to 2695 (vs 2812 in 2017). The progressive decrease in recent years in this procedure parallels the greater penetration of the drug-eluting stent.

As with diagnostic activity, the radial approach predominated in PCIs and was used in 89.4% of interventional procedures (88.4% in 2016). The changes over time since its introduction are shown in figure 4, from an equal standing with the femoral approach in 2010 to its current dominance.

Figure 4.

Changes in the number of diagnostic and interventional procedures involving the radial approach since 2004.

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The distribution by autonomous community of the 1551 PCIs per million population in Spain is shown in figure 5. Regarding the distribution per hospital, 23 centers performed more than 1000 PCIs in 2018 (2 less than in 2017) and 51 between 500 and 1000 (2 more than in 2017). In 2018, 72% of the centers reported the immediate outcome variables: a successful outcome without complications was reported for 96.6%; 1% reported severe complications (death, acute myocardial infarction [AMI], or the need for urgent cardiac surgery); and only 0.4% reported intraprocedural death.

Figure 5.

Percutaneous coronary interventions per million population, Spanish average and total by autonomous community in 2017 and 2018. Source: Spanish National Institute of Statistics.30

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Implanted stents numbered 108 398 in 2018, which was a slight increase vs 2017 (105 529 stents). The stent/procedure ratio was 1.6, similar to that of previous years. The percentage of drug-eluting stents continued to increase, reaching 93.8% (101 713) vs 90.3% (95 253) in 2017. When the use of drug-eluting stents was analyzed by autonomous community (figure 6), a generalized increase was observed. Notably, these stents comprised 98% of all stents implanted in more than half of communities. The number of procedures with bioabsorbable devices was still very low (488 cases, 0.5% of implanted stents), as well as the number of procedures performed with dedicated bifurcation stents (179 cases, 0.2% of the total) or with self-expanding stents (33 cases, 0.03%). There was a significant increase in the use of polymer-free stents, which represented 5.3% of all implanted stents in 2018 (5792 cases) vs 3.6% in 2017 (3711 cases).

Figure 6.

Use of drug-eluting stents by autonomous community.

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Parallel to the increased complexity of interventional procedures, there was a marked increase in the use of plaque modification devices. On the one hand, the use of rotational atherectomy devices reached a peak of the last 10 years with 1517 reported cases (1324 in 2017 and 1171 in 2016), while laser atherectomy devices experienced a marked increase vs 2017 (88 cases in 2018 vs 58 vs 2017). On the other hand, there was also an increased use of special balloons, such as cutting balloons (from 2096 in 2017 to 2925 in 2018), scoring balloons (from 1931 in 2017 to 2044 in 2018), and drug-coated balloons (from 2664 in 2017 to 2727 in 2018). Notably, due to their recent introduction, 47 procedures were performed with intracoronary lithotripsy balloons.

In 2018, there was a repeat in the tendency observed in 2017 for a significant increase in the implantation of short-term circulatory assist devices during complex interventions. The use was reported of 109 extracorporeal membrane oxygenators (vs 68 in 2017) and of 149 Impella devices (vs 106 in 2017).

The number of PCIs in AMI stabilized in 2018, with similar numbers to those recorded the previous year (21 261 interventions in AMI vs 21 395 in 2017). The most notable finding in this section is the marked increase in primary angioplasties, a 9.6% increase vs 2017 (19 490 vs 17 785), representing 91.6% of all PCIs in AMI. Regarding the pharmacoinvasive strategy, 680 rescue PCIs were recorded after fibrinolysis administration (3.1% of the total number of AMI procedures), as well as 1089 delayed or elective PCIs (5.1% of the total number of AMI procedures).

Primary PCI accounted for 26.8% of all angioplasties. The average number of primary PCIs per million population in Spain was 417 (vs 382 in 2017 and 356 in 2016). There was a largely generalized increase in the primary angioplasty rate by autonomous community (figure 7), although the growth was especially marked in Andalusia, the Balearic Islands, the Canary Islands, Aragon, and Castile and León. However, there may be a bias because some hospitals may not have introduced their data; thus, these figures should be taken with caution. The number of centers performing more than 300 primary PCIs per center was maintained (21 in 2018 and 2017), as well as the number of centers performing between 200 and 300 (21 in 2018 vs 22 in 2017). However, there was an increase in those that performed between 100 and 200 primary PCIs (31 in 2018 vs 27 in 2017.

Figure 7.

Primary angioplasties per million population, Spanish average and total by autonomous community in 2017 and 2018.

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In terms of the technical aspects of AMI treatment, the radial approach, in line with the above-mentioned results, was the approach of choice and was used in 87% of PCIs in AMI. The same situation was seen with the use of drug-eluting stents in the setting of infarction, which reached 98% (92% in 2017). Finally, the number of procedures using thrombus extractor devices slightly decreased, from 32% in 2017 (6907) to 29% in 2018 (6205).

The most noteworthy finding in this section is the considerable increase in the number of permeable foramen ovale closures, which doubled in 2018 (from 284 cases in 2017 to 514 in 2018). There were 2 cases of device embolization and 3 implantation failures without complications. The number of atrial septal defect closures was stable vs 2017 (294 cases in 2017 and 2018), with 3 cases of device embolization. There were 22 patent ductus arteriosus closures (25 in 2017) and 12 ventricular septal defect closures (11 in 2017), 3 congenital and 9 acquired. Percutaneous pulmonary valve implantations were performed in 35 cases (32 in 2019), with a success rate of 97%.

In 2018, 528 valvuloplasties were recorded in adults, 51% on the aortic valve, 42% on the mitral valve, and 7% on the pulmonary valve. The number of isolated aortic valvuloplasties continued to increase, with 268 procedures in 2018 (252 in 2017); success was achieved in 261 patients (98.8%). Breaking with the tendency of recent years, there were also more mitral valvuloplasties: 225 were reported in 2018 (202 in 2017). The technique was successful in 216 patients (96%) and 6 complications were reported (3 severe mitral regurgitations and 3 cardiac tamponades).

Once again, transcatheter aortic valve implantation (TAVI) was the interventional procedure showing the greatest increase in use in structural heart disease. Overall, 3537 implantations were registered in 2018 vs 2821 in 2017 (a 25.3% increase), representing an average of 76 procedures per million population (vs 61 in 2017). If this growth is assessed by autonomous community (figure 8), there was a substantial increase for most of them vs 2017, with Cantabria, Galicia, Principality of Asturias, Community of Madrid, Castile and León, and the Basque Country above the average. TAVIs were implanted in 1894 patients older than 80 years of age (53.5%) and, regarding the indication, half of the patients had surgical contraindication or high surgical risk (49.5% vs 61% in 2017); the risk was intermediate in 17% of patients and not specified in the remainder. In terms of the type of prosthesis used, the expandable balloon valve was used in 1441 cases (40.7%), whereas the self-expanding valve was used in 1623 cases (45.8%); in 473 procedures, the type of valve used was not specified. In percutaneous procedures, femoral access predominated and was used in 2722 cases. For the first time in Spain, the transsubclavian/axillary approach was used (16 cases), as well as the transcaval (2 cases); surgical access was used in 360 patients, 50% transfemoral, and the transapical approach fell from 2.5% of cases in 2017 to 1.8% in 2018. Regarding in-hospital outcomes, 143 major intraprocedural complications (4%) were reported. Conversion to surgery was required for 0.4% (14 cases, 13 of them urgent). In-hospital death was reported in 65 patients (1.7%). A total of 346 patients (9.8%) required definitive pacemaker implantation.

Figure 8.

Transcatheter aortic valve implantation per million population. Spanish average and total by autonomous community in 2017 and 2018. No data are available for La Rioja.

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In 2018, 644 left atrial appendage closure procedures were performed, representing a 10.6% increase vs 2017 (582 cases) (figure 9). Closures were performed with a disc-and-lobe device in 399 patients (58.8% of the total) and with a 1-piece device in 205 (31.8% of the total); in the remaining cases, the type of closure was not specified. There were 12 cases of procedural complications, defined as tamponade, embolism, or death, representing 1.8% of the total.

Figure 9.

Changes from 2015 to 2018 in atrial appendage closure and percutaneous mitral valve repair procedures.

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Another notable finding was the significant growth in 2018 in percutaneous valvular repair with the MitraClip device (figure 9). The registry recorded 328 cases of mitral repair (270 in 2017, a 21.4% increase), with a total of 469 clips (1.4 clips per procedure, the same as in 2017). In addition, functional mitral regurgitations comprised 65.8% while 19.1% were degenerative and 15.1% mixed. In terms of outcomes, the mitral regurgitation was reduced to <grade 2 in 306 patients (94%; 9 without residual mitral regurgitation, 192 with grade 1 residual mitral regurgitation, and 105 with grade 2); insufficient improvement was achieved in the remaining 6%. Complications developed in 9 patients. Another notable finding from analysis of the registry data was the introduction to Spain of percutaneous techniques for treating the tricuspid valve; in 2017, the MitraClip device was used for the compassionate treatment of tricuspid regurgitation in 4 patients. Its use increased in 2018: 18 patients were treated with this technique, without complications. In addition, the first 2 prostheses were percutaneously implanted in 2018 using a bicaval technique, as well as the first Navigate tricuspid prosthesis.

Finally, there were 38 cases of endovascular aortic repair and 29 cases of renal denervation (24 in 2017). Each year sees the inclusion of new variables to reflect all of the techniques that have been introduced. Thus, it is notable that 11 procedures were performed with a coronary sinus reducer device in 2018 (1 in 2017) and 10 with the V-wave device (3 in 2017).