Transcript slides

Tarek Helmy, MD, FACC, FSCAI
Professor of Cardiology
Director Of Cardiac Catheterization Laboratory
University of Cincinnati College of Medicine
I/we have no real or apparent conflicts of interest to report.
Off-Label: CTO Intervention
Tarek Helmy, MD
I/we have no real or apparent conflicts of interest to report.
Off-Label: CTO Intervention
Prevalence of CTO
 Overall incidence of CTO 17%
Canadian CTO registry 7559 patients
 NHLBI Dynamic Registry and BARI Study 1997-1999,
n=1,761
-Presence of total occlusion
31%
-Attempted total occlusion
7.5%
Srinivas , circ 2002
Barriers to CTO intervention
 Uncertainty about benefit to patients (unclear
indications)
 Adequate collaterals
 Perception of higher complication rates
 Complex techniques
 Long radiation times
 High contrast load
 Lengthy procedure time
What are we achieving with CTO PCI ?
 Angina relief, mostly benefit patients who have angina






refractory to optimal medical management
improve exercise tolerance
Improve left ventricular function, decrease remodeling
Improve outcome of a future acute coronary syndrome
Reduce the need for coronary artery bypass graft
surgery
Improve survival if successful (especially for PCI of
LAD artery CTOs)
Confer benefit in patients with large ischemic burden.
Indications for CTO Intervention
Patient selection is very important
 Viability
 Ischemia
 Large territory at jeopardy
 Symptoms
Freedom from angina
meta-analysis of 6 observational studies, average f/u 6 years
Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010
TOAST-GISE study for CTO PCI
prospective observational study of 390 CTO lesions
angina relief , reduced ischemic burden
P 0.008
P 0.0001
Olivari , J Am Coll Cardiol 2003;41:1672– 8
FACTOR STUDY
Impact of CTO Successful PCI on Angina and Quality of
Life seen in Symptomatic Patients
Grantham et al, Circ cardiovasc Qual outcomes 2010
Effect on LV Function and Remodeling
Van Belle E, et al. American
Journal of Cardiology 1997
Kirschbaum SW et al. American
Journal of Cardiology 2008
Benefit on LV Function: Transmural
Extent of Infarction as a Predictor
baseline, 5 months, 3 year f/u
Kirschbaum SW et al. American Journal of Cardiology 2008
Need for Subsequent CABG
meta-analysis of 13 observational studies,
7288 pts, average f/u 6 years
Joyal et al, AHJ 2010
CTO Effects in ACS
CTO Impact on Mortality in AMI of non CTO vessel
(esp collateral donor artery)
Van der Schaff RJ et al. Am J Cariol 2006
Survival Post STEMI With Concomitant CTO
Claessen et al. JACC: CI 2:11; Nov 2009, 1128-1134
Mortality benefit with successful PCI of CTO
20 year experience 1491 success,
514 failed, Suero JACC 2001
1791 pts attempted , 565 failed
PCI, Mehran JACC Int 2011
Survival Benefit with PCI of CTO
meta analysis of 13 trial with 6 year F/U
Joyal et al, AHJ 2010
KEEP IN MIND
 No randomized controlled trials have, to date, been
performed in which CTO PCI was compared with
either optimal medical therapy or CABG.
 Current evidence regarding the impact of CTOs
revascularization on survival is based on data from
multiple small observational studies comparing
clinical outcomes in patients with successful vs failed
CTO recanalization attempts.
ACC/AHA Guidelines 2011
 5.8. PCI in Specific Anatomic Situations
 5.8.1. CTOs: Recommendation
Class IIa
PCI of a CTO in patients with appropriate clinical
indications and suitable anatomy is reasonable
when performed by operators with appropriate
expertise. 699–703 (Level of Evidence: B)
CTO in Syntax Score
-Location
-Blunt vs
tapered
-calcified
-Side branch
-Bifurcation
disease
-angle of
bifurcation
-Bridging
collaterals
-Length of
lesion
Syntax
score for
proximal
LAD CTO
Lesion 1
segment number(s)
(segment 6): 3.5x5=
+ Blunt stump
+ Bridging
the first segment beyond the T.O. visualized by
contrast: 8
17.5
1
1
+ sidebranch: Yes, both sidebranches <1.5mm and
>=1.5mm are involved
1
Bifurcation Type: Medina 0,1,1:
Angulation <70º
Heavy calcification
Sub total lesion 1
2
1
2
27.5
Diffuse disease/Small vessels
Segment 6
Segment 7
Sub total diffuse disease/small vessels
1
1
2
TOTAL:
29.5
1
segment number(s)
Syntax score
for short Mid
LAD CTO
(segment 7): 2.5x2=
5
Age T.O. is yes
1
+ Blunt stump
1
+ Bridging
1
the first segment beyond the T.O.
visualized by contrast: 8
+ sidebranch: Yes, both sidebranches
<1.5mm and >=1.5mm are involved
Bifurcation Type: Medina 0,1,1:
Angulation <70º
Heavy calcification
Sub total lesion 1
1
1
2
1
2
15
Diffuse disease/Small vessels
Segment 6
Segment 7
Sub total diffuse disease/small vessels
1
1
2
TOTAL:
17
Residual Ischemic Burden:
Effect on Outcomes in COURAGE nuclear substudy
Death or MI Rate (%)
p=0.002
39.3%
40%
p=0.023
30%
p=0.063
20%
22.3%
15.6%
10%
0%
0.0%
0%
(n=23)
1%-4.9%
(n=141)
5%-9.9%
(n=88)
>10%
(n=62)
Shaw et al, Circ 2008;117
COURAGE NUCLEAR SUBSTUDY
Rates of death or MI by ischemia reduction
in subset of 105 patients with
moderate-to-severe pre-Rx ischemia
Death or MI rate (%)
p=0.001
32.4%
16.2%
(n=68)
(n=37)
COURAGE NUCLEAR SUBSTUDY
Ischemia reduction ≥ 5%
Effect of revascularization:
ischemia reduction ≥5% myocardium
(n=105 moderate-to-severe pre-Rx ischemia)
78.0%
p=0.007
52.0%
Does revascularization make a difference?
Is there a cut off ?
Mortality endpoint 10627 pts followed for 2 years
Hachamovitch, circ 2003
Ischemia Change in Stable Coronary Artery
Disease by management strategy
Duke databank 1425 pts, 2 serial scans, 6y f/u
Farzaneh-Far,JACC IMAGING June 2012
Ischemia Change in Stable Coronary Artery
Disease Is an Independent Predictor of
Death and Myocardial Infarction
Farzaneh-Far,JACC IMAGING June 2012
Patient Selection for CTO PCI
 Viability: small scar (less than 25% of
transmural extension).
 Substantially symptomatic, despite optimal medical
therapy.
 Large burden of ischemia, despite optimal medical
therapy (presence of more than 10% ischemic
myocardium).
 Benefit for LV function in selected patients.
Resurgence of CTO intervention
 Better understanding of the indications
 Emerging data on benefit of CTO intervention
 Improvement in technology and equipment improve
success rates
 New techniques for CTO, antegrade and retrograde
 Appropriate strategy: Lower procedure, radiation
times, and decrease contrast load
 Heart team approach for complex cases
Tamburino et al, AHJ 2013