1 / 25

Debate #4: CTO Revascularization

CCCSymposium 2014. Debate #4: CTO Revascularization. Most CTO Should be Opened: Samin K Sharma, MD Only Limited CTO Should be Opened: Carlo Di Mario, MD. Samin K Sharma, MD, FACC, FSCAI Director Clinical & Interventional Cardiology Zena and Michael a Weiner Professor of Medicine

darin
Download Presentation

Debate #4: CTO Revascularization

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CCCSymposium 2014 Debate #4: CTO Revascularization Most CTO Should be Opened: Samin K Sharma, MD Only Limited CTO Should be Opened: Carlo Di Mario, MD Samin K Sharma, MD, FACC, FSCAIDirector Clinical & Interventional CardiologyZena and Michael a Weiner Professor of Medicine Mount Sinai Hospital, NY

  2. I will make my point for; Most CTOs Should be Opened

  3. Chronic Total Occlusion (CTO) Presence of CTO in CAD Imparts Adverse Prognosis

  4. Impact of Completeness of PCI Revascularization on Long-Term Outcomes in the Stent Era HRs for Mortality for Various Subgroups of Incomplete Revascularization Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406

  5. Incomplete Revascularization in the Era of DES: NY State Database Report Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst long-term prognosis and greater need for CABG or re-PCI Hannan, Sharma et al. JACC Cardio Interv 2009;2:17

  6. Effect of a Concurrent CTO on Long-Term Mortality and LVEF in Pts After Primary PCI in AMI 3277 STEMI pts 1997-05: SVD 65%, MVD 22%, MVD + CTO 13% Landmark Survival Analysis Endpoint: Survival at 5 yrs, LVEF at 12 mo (median F/U 3.1 yrs) Claessen et al. JACC Cardio Interv 2009;2:1128.

  7. Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates 80% 0.5% Patel et al., JACC Cardiovasc Interv 2013;6:128

  8. Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI Complications Successful Unsuccessful p value Patel et al., JACC Cardiovasc Interv 2013;6:128

  9. CTO: Anatomic Descriptors of Procedural Success In the current ERA; Severe calcification

  10. Because successful CTO recanalization may result in Angina/Ischemia reliefFreedom from subsequent CABGImproved LV functionImprovement in event-free survival Chronic Total Occlusion (CTO) Why Bother to do PCI? Presence of CTO in CAD Imparts Adverse Prognosis

  11. Chronic Total Occlusion (CTO) CTO Recanalization and Angina Relief

  12. TOAST-GISE1 Year Clinical Status of Complication Free Patients Olivari Z et al, J Am Coll Cardiol 2003;41:1672

  13. Meta-Analysis of CTO Outcomes 13 Observational Studies, 7288 patients weighted averaged follow-up 6 years Joyal et al., Am Heart J 2010;160:179.

  14. Evaluation of LV Function 3-Yrs after Percutaneous Recanalization of CTO Changes in LV Volume Indexes and EF between Baseline and 3-Yr FU Measured Using Magnetic Resonance Imaging (N=21) 86 63 60 78 35 30 Mean ejection fraction improved slightly, but end-systolic and end-diastolic volume indexes decreased significantly. Kirschbaum S et al, Am J Cardiol 2008;101:179

  15. MRI Predicts LV EF & Wall Motion Improvement with CTO Revascularization (N=21) with prior MI SWT at Baseline (n=21) SWT 5 mths post Stent Implantation P=ns P<0.001 SWT 3 yrs post stent Implantation P<0.05 90 P=ns 80 P<0.05 70 P<0.05 60 P<0.001 50 P<0.05 40 P<0.05 Segmental wall thickening (%) P=ns 30 P=ns 20 P=ns 10 0 -10 -20 <25% 25-75% >75% Remote Transmural extent of infarction Kirschbaum et al, Am J Cardiol 2008;101:179

  16. Effect of Successful vs. Failed CTO PCI in All-Cause Mortality During Long-Term Follow-up Moses et al., JACC Cardio Interv 2012;5:389

  17. Successful Recanalization of CTO Associated with Improved Long-Term Survival Jones et al., JACC Cardio Interv 2012;5:380

  18. Advanced Techniques for Chronic Total OcclusionJapanese Specialized Technique • Anchor balloon technique • Mother-Child catheter technique • Parallel wire • IVUS guidance • Retrograde approach

  19. Retrograde Wire Technique for Chronic Total Occlusion Recanalization Four Patterns of Success in Retrograde CTO Recanalization Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.

  20. Increased Use of Retrograde Approach and Technical Success Rate Over Time 2006 2007 2008 2009 2010 2011 ≈35% % Michael et al., Am J Cardiol 2013;112:488

  21. ACCF/SCAI/STS/AATS/AHA/ASNC 2012Appropriateness Criteria for Coronary Revascularization Chronic Total Occlusions: Indications for PCI Patel et al. JACC 2012;53:530-553

  22. Chronic Total Occlusions I IIa IIb III PCI of a CTO in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise B

  23. Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI Procedural Steps of Current CTO-PCI Cotralateral Dual Injection CTO - PCI Single Wire Technique Antegrade approach x2 Parallel Wire Technique Retrograde approach (ostial) Retrograde Wire Cross Kissing Wire Cross IVUS guide re-entry CART Reverse CART Success Failure

  24. Planned 2nd (18%) or 3rd (8%) attempt Retrograde technique Asahi wires Procedural Success of CTO PCI at MSH 93 86 78 68 EXPERT CTO US Trial: 90+ success % 665 806 782 397 2003-2005 2006-2008 2009-10 2011-12

  25. Conclusions:Rationale for CTO Recanalization in ALL • Presence of a CTO imparts adverse prognosis. • Non randomized data support improved overall CV outcomes (including mortality) with successful CTO procedures. A randomized trial will be needed to establish the PCI efficacy in CTO pts. • Therefore developing technical skills (dedicated centers and dedicated Interventionalists) is essential to tackle this “last frontier of Interventional Cardiology” to improve overall outcomes of our complex CAD pts. • KEY to better CTO outcomes is successful recanalization

More Related