1 / 39

Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy

CHRONIC TOTAL OCCLUSIONS: WHY BOTHER?. Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com. JOINT SYMPOSIUM WITH JACCT - Bologna, 25/9/2008 - 16:30-17:45 (12’). LEARNING OBJECTIVES. Defining the chronic total occlusion (CTO) context

salene
Download Presentation

Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy

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. CHRONIC TOTAL OCCLUSIONS: WHY BOTHER? Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com JOINT SYMPOSIUM WITH JACCT - Bologna, 25/9/2008 - 16:30-17:45 (12’)

  2. LEARNING OBJECTIVES • Defining the chronic total occlusion (CTO) context • Pathophysiologic basis of CTO • Clinical evidence on CTO

  3. LEARNING OBJECTIVES • Defining the chronic total occlusion (CTO) context • Pathophysiologic basis of CTO • Clinical evidence on CTO

  4. SCOPE OF THE PROBLEM Incomplete revascularization Avoiding CABG MVD LV function Symptoms Silent ischemia Open artery hypothesis DES thrombosis Periprocedural necrosis Freedomfrom major adverseevents, heartfailure and angina

  5. INCIDENCE AND IMPACT

  6. CLUSTERING WITH MULTIVESSEL DISEASE

  7. LEARNING OBJECTIVES • Defining the chronic total occlusion (CTO) context • Pathophysiologic basis of CTO • Clinical evidence on CTO

  8. NATURAL HISTORY OF UNFAVORABLE CARDIAC REMODELING Abbate et al, Cardiology 2003;100:196-206

  9. POTENTIAL IMPACT OF PCI ON CARDIAC REMODELING Abbate et al, Cardiology 2003;100:196-206

  10. THE OPEN ARTERY HYPOTHESIS: TRUE OR FALSE? Abbate et al, J Cell Physiol 2002;193:145-153

  11. CORONARY OCCLUSION AND MYOCARDIAL APOPTOSIS

  12. PERMANENT CORONARY OCCLUSION AND INCREASES MYOCARDIAL APOPTOSIS Abbate et al, Circulation 2002;106;1051-1054

  13. DETRIMENTAL IMPACT OF CTO IN MULTIVESSEL DISEASE Biondi-Zoccai et al, Int J Cardiol 2004;94:105-110

  14. COLLATERALS MOST OFTEN FAIL TO PREVENT SYMPTOMATIC ISCHEMIA 1 0,9 0,8 0,7 0,6 sens 0,5 spec 0,4 0,3 0,2 0,1 0 0,00 0,09 0,13 0,16 0,17 0,21 0,25 0,28 0,31 0,34 0,36 0,38 0,40 0,42 0,43 0,47 0,69 1,00 FFRcoll Moretti et al, J Cardiovasc Med 2008 – in press

  15. PCI MAY PROVIDE CARDIAC REMODELING BENEFITS Before PCI for CTO 5 months after PCI for CTO Baks et al, J Am Coll Cardiol 2006;47:721-725

  16. PCI MAY PROVIDE ELECTRICAL STABILIZATION Pristipino et al, Am J Cardiol 2005;96:769-72

  17. PCI MAY PROVIDE ELECTRICAL STABILIZATION UNSUCCESSFUL PCI FOR CTO SUCCESSFUL PCI FOR CTO Pristipino et al, Am J Cardiol 2005;96:769-72

  18. LEARNING OBJECTIVES • Defining the chronic total occlusion (CTO) context • Pathophysiologic basis of CTO • Clinical evidence on CTO

  19. SELECTION BIAS MAY UNDERMINE PROMISING LONG-TERM DATA FROM NON-RANDOMIZED STUDIES P=0.001 P=0.01 P=0.002 Long-term survival following CTO attempt (%)

  20. SELECTION BIAS MAY UNDERMINE PROMISING LONG-TERM DATA FROM NON-RANDOMIZED STUDIES and benefit mainly due to LAD recanalization Suero et al, J Am Coll Cardiol 2001;38:409-14; Safley et al, J Am Coll Cardiol Intv 2008;1:295-302

  21. INTERVENTIONISTS’ NEW OATH:I WILL NOT TREAT CTO OAT TRIAL Hochman, New Engl J Med 2006;355:2395-2407

  22. INTERVENTIONISTS’ NEW OATH:I WILL NOT TREAT CTO Hochman, New Engl J Med 2006;355:2395-2407

  23. BUT OATHS ARE DIFFICULT TO MAINTAIN… OAT TRIAL ONLINE ONLY SUPPLEMENT – Hochmanet al, New Engl J Med 2006;355:2395-2407

  24. PCI WITH STENTS FOR CTO SURELY CARRIES A PERI-PROCEDURAL RISK

  25. PCI WITH STENTS FOR CTO SURELY CARRIES A PERI-PROCEDURAL RISK MI rate MACE rate Agostoni et al, Am Heart J 2006;151:682-689

  26. SHOULD THUS INTERVENTIONISTS BE DISCOURAGED? Boden et al, New Engl J Med 2007;356:1503-1516

  27. SHOULD THUS INTERVENTIONISTS BE DISCOURAGED? Boden et al, New Engl J Med 2007;356:1503-1516

  28. NOT SWISS INTERVENTIONISTS! SWISSI-2 TRIAL Erne et al, JAMA 2007;297:1985-1991

  29. AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED… COURAGE SUB-STUDY Shaw et al, Circulation 2008;117:1283-1291

  30. AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED… Shaw et al, Circulation 2008;117:1283-1291

  31. IS ANY SYNTHESIS POSSIBLE? Abbate et al, J Am Coll Cardiol 2008;51:956-64

  32. IS ANY SYNTHESIS POSSIBLE? Abbate et al, J Am Coll Cardiol 2008;51:956-64

  33. IS ANY SYNTHESIS POSSIBLE? Appleton et al, Catheter Cardiovasc Interv 2008;71:772-81

  34. IS ANY SYNTHESIS POSSIBLE? Appleton et al, Catheter Cardiovasc Interv 2008;71:772-81

  35. TAKE HOME MESSAGES

  36. 1. NOT ALL CTOS ARE BORN EQUAL

  37. 2. BOTH PCI AND MAXIMAL MEDICAL RX ARE PIVOTAL

  38. 3. AVOID ROUTINE (AGGRESSIVE) PCI FOR ALL CTO, AS EVERY SINGLE ONE SHOULD BE HANDLED DIFFERENTLY All from All different

  39. For further slides on these topics please feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

More Related