APPROPRIATE CRITERIA FOR PATIENT SELECTION IN CTO INTERVENTION

  • Slides: 33
Download presentation
APPROPRIATE CRITERIA FOR PATIENT SELECTION IN CTO INTERVENTION Tarek Helmy, MD, FACC, FSCAI Professor

APPROPRIATE CRITERIA FOR PATIENT SELECTION IN CTO INTERVENTION Tarek Helmy, MD, FACC, FSCAI Professor of Cardiology Director Of Cardiac Catheterization Laboratory University of Cincinnati College of Medicine

Tarek Helmy, MD I/we have no real or apparent conflicts of interest to report.

Tarek Helmy, MD 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.

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

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

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

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

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,

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

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

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

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,

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

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

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

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,

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

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

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.

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

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. 5

Syntax score for proximal LAD CTO Lesion 1 segment number(s) (segment 6): 3. 5 x 5= + Blunt stump + Bridging the first segment beyond the T. O. visualized by contrast: 8 17. 5 1 1 + sidebranch: Yes, both sidebranches <1. 5 mm and >=1. 5 mm are involved 1 Bifurcation Type: Medina 0, 1, 1: Angulation <70º Heavy calcification Sub total lesion 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. 5 x

segment number(s) Syntax score for short Mid LAD CTO (segment 7): 2. 5 x 2= 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. 5 mm and >=1. 5 mm are involved Bifurcation Type: Medina 0, 1, 1: Angulation <70º Heavy calcification Sub total lesion 1 1 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

Residual Ischemic Burden: Effect on Outcomes in COURAGE nuclear substudy Death or MI Rate (%) p=0. 002 p=0. 023 p=0. 063 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

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=6 (n=3

COURAGE NUCLEAR SUBSTUDY Ischemia reduction ≥ 5% Effect of revascularization: ischemia reduction ≥ 5%

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

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,

Ischemia Change in Stable Coronary Artery Disease by management strategy Duke databank 1425 pts, 2 serial scans, 6 y f/u Farzaneh-Far, JACC IMAGING June 2012

Ischemia Change in Stable Coronary Artery Disease Is an Independent Predictor of Death and

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).

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

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

Tamburino et al, AHJ 2013