I have financial relationships to disclose Honoraria from: StJude, Boston Scientific, Cordis, Eli Lilly Research support from: Medtronic, Abbott

Transcription

1 I have financial relationships to disclose Honoraria from: StJude, Boston Scientific, Cordis, Eli Lilly Research support from: Medtronic, Abbott

2 Carlo Di Mario, Matteo Ghione, Kadriye Kilickesmez, Alistair Lindsay, Dimitr Syrseloudis, Eduardo Alegria, Michael Chan, Nicola Viceconte, Tito Kabir, Rodrigo Terjero, Gioel Secco, Neville Kukreja, Francesco Borgia, Giuseppe Ferrante, Omar Ali, Francesca Mirabella, Rosario Parisi, Francesca Del Furia, Pablo Aguiar Soto, Nicolas Foin, Pawel Tzichinski, Omer Goktekin, Jun Tanigawa, Carl Schultz, Peter Barlis Royal Brompton Hospital, London, UK The Big 5 in Interventional Cardiology Chronic Total Occlusion (CTO)

3 The Big 5 in Interventional Cardiology Chronic Total Occlusion (CTO) Topics Addressed What is a CTO? Definitions Why should we bother opening it? Indications Jnkbmfnmgnb,.fdn.,g How good are we at doing it? Technique How can we become better? New developments

4 CTO Definition Lesions can be classified as CTOs when there is TIMI 0 flow and angiographic or clinical evidence or high likelihood of an occlusion duration > 3 months

5 OAT Trial 2166 patients with angiography on day 3-28 post-mi revealing total occlusion of the infarct-related artery with poor or absent antegrade flow (TIMI flow grade 0 or 1) MV or severe demonstrable ischaemia excluded OAT Inclusion Criteria CTO Definitions and Characteristics Primary Endpoint of death, remi, NYHA class IV Occlusion Duration 3-28 Days > 3 Months Q-wave MI Mandatory <30% Symptoms Asymptomatic Unresponsive severe angina Objective evidence of ischaemia Absent or minimal Present Viability Not assessed Present Hazard Ratio 1.16, p=0.20 Hochman et al, NEJM 2006

6 Incidence of CTO in Pts Undergoing Catheterisation Insights from the Canadian Registry (18.4%) CHF/Valves/Other Stable AP (56.4%) (10.1%) Unstable AP Excluded Courtesy of B Strauss

7 Incidence of CTO in Pts Undergoing Catheterisation Concordant Q waves in 32.0% and previous MI in 40.2% of 2,630 CTOs 18% 20% 16% Multivessel Disease 76% of Patients Courtesy of B Strauss

8 Canadian Registry: CTO Treatment Performed Multivessel Disease 76% of Patients Courtesy of B Strauss

9 Royal Brompton Experience: 4Yr Median FUp CCS Class Before F-Up and Changes Post-CTO Procedure Pre CTO Procedure Borgia, Di Mario et al, Internat J Cardiol 2010 % CABG Failed CTO Pts 17% p<0.02 Asympt I II III-IV Asympt I II III-IV Failed (n=65) Successful (n=237)

10 Royal Brompton Experience Cardiac Death Follow-up 4.0 years (median), Range 1-7 Borgia, Di Mario et al, Internat J Cardiol 2010 Unadjusted HR 3.39 (95%CI ) p=0.03 After propensity score adjustment HR 2.83 (95%CI ), p=0.07 Rate: 2.9% (7/278) in successful group vs 9.1% (6/65) in failed group

11 CTO Success and Late Mortality Mid-America (Rutheford et al) ; J Am Coll Cardiol 2001;38: Follow-up: 10 Years Technique: PTCA, Bail-out Stenting Nbs at Risk: Success 302 pts; Matched Suc: 280; Fail: 280 Thoraxcentre, R dam (Hoye, Serruys et al) ; Eur Heart J 2005;26: Follow-up: 5 Years Technique: BMS 81% Nbs at Risk: Success 168 pts; Failure: 113

12 CTO Success and Late Mortality GISE (Olivari, Di Mario et al) 2001; J Am Coll Cardiol 2003;41: Follow-up: 1 Years Technique: BMS Nbs at Risk: Success 259 pts; Failure: 117 Liverpool (Aziz, Stables et al) ; CCI 2007;70:15-20 Follow-up: 2 Years Technique: BMS 81% Nbs at Risk: Success 99 pts; Fail: 100

13 CTO Success and Late Mortality Florence(Valente, Antoniucci et al) ; J Am Coll Cardiol 2008;48: Follow-up: 3 Years Technique: DES Nbs at Risk: Success 334 pts; Failure: 142 Milan-NYC-London (Mehran, Colombo, Di Mario) ; JACC Cardiovasc Int 2011 Follow-up: 5 Years Technique: DES Nbs at Risk: Success 2340 pts; Fail: 571

14 CTO Success and Late Mortality US- Korea- Italy (Mehran et al) ; J Am Coll Cardiol Intev. 2011;4: Follow-up: 5 Years Technique: DES, BMS Nbs at Risk: Success 1226 pts; Fail: 565 Shangai (Shen et al) Int J Cardiol 2011 Epub ahead of print Follow-up: 2 Years Technique: Staged revascularization of CTO after ppci /DES, BMS Nbs at Risk: Success 87 pts; Fail: 49 pts

15 Recanalization of CTO- A Review and Metanalysis 5056 pts 2232 pts From Joyal et al, 2011

16 CTO Impact On AMI Mortality 1417 consecutive patients with acute STEMI year mortality SVD (n=839) and MVD (n=578) 12% of 1417 had a CTO Van der Schaff RJ et al. Am J Cardiol 2006

17 Which Test Should We Use to Define Indications? Each test has strengths and weaknesses (radiation, expected quality-feasibility, quantification fibrosis or ischaemia, availability-convenience) NUCLEAR STRESS ECHO CMR ISCHAEMIA Local expertise is paramount

18 Baseline Wall Motion, post-adenosine Perfusion, Viability Stress Rest LGE Bucciarelli Ducci et al, in press

19 Improvement Myocardial Perfusion post CTO Recanalisation Post-Adenosine Perfusion Images Pre PCI Post PCI Bucciarelli Ducci et al, in press

20 Improvement Global LV function and Myocardial Perfusion post CTO Recanalisation p< p = ns p< % ml ml Pre PCI Post PCI 40 EF 3 2,5 90 p= 0.02 p=0.01 EDV p= ns 40 ESV 2 MPR 1,5 1 Pre PCI Post PCI 0,5 0 CTO Territory Remote Territory Bucciarelli Ducci et al, in press

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22 Dedicated CTO Wires and Microcatheters Asahi Sion 0.8 g Fielder XT 0.7 g Medtronic Persuader 6 g Medtronic Persuader 9 g Asahi Corsair

23 The Risk Groups of Difficulty and Final Procedural Success Rates Mitsudo et al. JACC Cardiovasc Interv 2011

24 Increased CTO Complexity in the last 10 Years Single Centre Single Operator Experience in 500 CTOs % Lesions ,2 50,8 46,2 63, ,7 37, ,1 10 9,7 7,3 0 Blunt Stump Calcium >20 mm long >45 Bend Retry Lesion Blunt Stump Calcification Lenght 20mm Bend>45o Retry lesion Di Mario et al, in preparation

25 % success within lesion complexity class Improved Success with Novel Material and Strategies Single Centre Single Operator Experience in 500 CTOs , ,1 86,3 86,1 88,1 78, ,4 Period 1 Period Easy Intermediate Difficult Very Difficult Easy Intermediate Difficult Very Difficult 38,4 Di Mario et al, in preparation

26 My Patient of Last Tuesday Somebody I was not Really Doing in yr old male with heart attack in 1993 (no angio) and persistent Class 2 AP ever since (my only sport is playing chess). Because of positive treadmill at low threshold under therapy, CAD in 2009 showing long occlusion RCA; multiple concordant imaging tests showing viability/ischaemia large area inferior wall

27 Tip Injection at the Distal End via a Corsair Microcatheter Sion wire via an epicardial collateral from LCx + Corsair, knuckled Fielder XT, Valet + Ultimate wire anterograde

28 An Easy Predictable Retrograde Case Reverse CART and wire externalisation and 3 Everolimus eluting Xience stents ( mm)

29 se extra-attention if there is a valid surgical option 73 yr old male, with surgical indications for 3VD FFR= 0.86

30 Take extra Attention if the surgical option is Open 73 yr old male, with surgical indications for 3VD

31 My only in-hospital death:chronic RCA-CTO Admitted to ICU for anterior STEMI: intubated and in cardiogenic shock

32 Period of Enrollment 20 Operators who performed >50 CTO PCI during Jan 2008-Feb 2011 participated in the Registry Total Enrolled Patients 4831 (3840 complete)

33 Success of CTO (%) 06/07: all members - since 2008 Online Registry

34 In Hospital Complications MACE (Major Adverse Cardiac Events) MI (Q-Wave, Non Q-Wavw) n (%) 37 (0,9) Cardiac Death n (%) 10 (0.3) Emergency CABG n (%) 7 (0.2) Emergency re-pci n (%) 2 (0.1) OTHER COMPLICATIONS Stent Trombosis n (%) 2 (0,1) Stroke n (%) 4(0,1) Contrast Induced nephropathy) n (%) 29 (0,7) Coronary Perforation n (%) 98 (2.5) Cardiac Tamponade n (%) 22 (0.6) Vascular Complications n (%) 30 (0.8)

35 Better Angiographic Imaging, Ideally Biplane with a large Multiple Source Screen where IVUS and CT images can be displayed and merged with Angio NIHR Cardiovascular BRU

36 Co-registration Predefined Trajectory + Live Fluoroscopy Acquisition of 2 nearly orthogonal angiographic projections Co-registration (3 point along vessel trajectory Generation of magnetic vector CT cross-section and angioscopic views are available for each level of vessel trajectory

37 Distal Reentry with the StingRay Catheter Baseline Final Result Pointed sharp tip Metallic markers at lateral exit ports

38 The Big 5 in Interventional Cardiology Chronic Total Occlusion (CTO) Conclusions Unless there is overwhelming proof that no viability is present and the patient has no symptoms/ no large silent ischaemia, you have no excuse not to address a CTO We Jnkbmfnmgnb,.fdn.,g are still far from technical perfection but with retrograde approach and distal reentry (IVUS guided, StingRay) lesions impossible in the past are successfully treated A low complication rate is paramount