10:50 werner - identifying the patients that benefit from cto pci

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