10:50 werner - identifying the patients that benefit from cto pci
TRANSCRIPT
Identifying the patients that benefit from CTO PCI
Gerald S. Werner, MD, FESC, FACC, FSCAIKlinikum Darmstadt - Germany
Speaker’s name: Gerald S. Werner
I have the following potential conflicts of interest to report:
Research contracts Consulting
Employment in industry Stockholder of a healthcare company
Owner of a healthcare company Other(s)
I do not have any potential conflict of interest
Potential conflicts of interest
Who benefits from CTO-PCI
• Are there clinical symptoms• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?
If you consider CTO like any other lesion, then…
Eur Heart J 2014; e-pub
CTO-PCI improves QoL
N=42
N=83
Grantham JA et al. Circ Cardiovasc Qual Outcomes. 2010;3:284-290
The symptoms of CTOs may differ from non-CTOs
Safley DM et al. CCI 2013; e-pub
SAQ in CTO and non-CTO patients
Physical limi-tation
Angina frequency
Quality of life EQ5D0
10
20
30
40
50
60
70
80
90
100
CTOnon-CTO
Safley DM et al. CCI 2013; e-pub
SAQ in CTO and non-CTO patients
Physical limi-tation
Angina frequency
Quality of life EQ5D0
10
20
30
40
50
60
70
80
90
100
CTOFUnon-CTOFup
Safley DM et al. CCI 2013; e-pub
Changes of ischemia after PCI of CTO
Safley DM et al. CCI 2011; 78: 337-43
SDS 0-3 4-8 9-13 >13SDS – Summed Difference Score
Who benefits from CTO-PCI
• Are there clinical symptoms• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?
72 year old male, 10 years after anterior MI
Dyspnea as lead symptom: Evidence of viability ?
LVEF 58%
MRI for patient selection with akinesia
Kirschbaum et al. Am J Cardiol 2008;101:179
Predicting LV recovery in CTOs
Kirschbaum et al. Int J Cardiol 2012; 159:192-7
Influence of a CTO on ICD recipients for primary prevention
Nombela –Franco L et al. Circulation: Arrythmia & Electrophysiology 2012;5:147-154
ICD intervention
Mortality
CTO observed in 44% of ICD recipients for ischemic cardiomyopathy
Who benefits from CTO-PCI
• Are there clinical symptoms• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?
SYNTAX influences the guidelines
Eur Heart J 2014; e-pub
Does SYNTAX change the case for CTOs ?
CTO still tips the decision towards CABG
Syntax has well above average CTOs as target
With CTOs a one-stop PCI may not be the best option
SYNTAX and CTO: Low revascularisation rates
Farooq et al. JACC 2013; 61: 282-94
PCINo revasc.
51%
CABGNo revasc.
32%
New definition for IR: residual SYNTAX Score (rSS)
Sianos et al. EuroInterv 2005;1:219-227
Only significant or occlusive lesions considered
Multiplication factor based on level of stenosis:
• Total Occlusion x5• 50-99% stenosis x2
Points added based on CTO features:
Age >3 months or unknown Blunt occlusion Bridging collaterals additional one point per segment non-visible (not filled by collateral flow) beyond occlusion
+1+1
+1
+1
Points +6 +5 +3.5 +2.5 +1.5 +1 +0.5
6
rSS and outcome after PCI
Farooq V et al. Circulation 2013;128:141-51
Completeness of revascularization based on QCA criteria in ACUITY trial
Rosner et al. Circulation 2012; 125: 2613-20
The more complex the case, the higher the rSS
Genereux et al. JACC 2012; 59: 2165-74
CTOs are more prevalent in high rSS, as a CTO multiplies the lesion location by a factor of 5 in the SYNTAX score
ACUITY Trial
Graft patency and CTO
PRAGUE IV. Circulation 2004;110:3418-3423
More than 50% of CTOs are located in the RCA and would
likely receive a venous graft
What is needed for assessing the patient with a CTO
• Clinical symptoms• Symptoms may be underestimated because of
their chronicity, and adaptation of the patient• Ischemia
• In MVD you may prefer a thallium for local attribution of ischemia or perfusion MRI
• In single vessel CTO stress EKG is enough• Viability
• MRI is the gold standard, EKG may suffice in some cases
• Have a strategy to discuss with the patient• MVD or SVD, CABG an alternative or not ?
Despite all evidence and our convictions:
Eur Heart J 2014; e-pub
Despite all evidence and our convictions:
Eur Heart J 2014; e-pub