J aborde toute les CTO.

Transcription

1 J aborde toute les CTO. Quand le territoire est viable et ischémique Thierry Lefèvre

2 Prévalence des CTOs Patients 18% 54% 10% Fefer P et al. J Am Coll Cardiol. 2012;59:991-

3 What do we currently know? 1. 95% of patients with CTO have inadequate distal collateral supply (FFR <0.80) 2. Ischaemia is prognostically adverse 3. Successful CTO PCI cases have better prognosis than failed CTO PCI cases

4 Succès vs Echec Amélioration de l angor Amélioration de la capacité à l effort Amélioration de la qualité de vie Amélioration de l ischémie Amélioration de la fonction VG Diminution du risque rythmique Diminution des indications de pontage Amélioration de la survie

5 Ischaemia Shaw et al, Circulation 2008; 117;

6 Residual ischaemia Incomplete Revascularisation is associated with Poor Outcome Shaw et al, Circulation 2008; 117;

7 IRM et Indication de Revascularisation Kirschbaum Am J Cardiol 2008;101:179

8 CTO-PCI Améliore la Qualité de Vie N=42 N=83 Grantham JA et al. Circ Cardiovasc Qual Outcomes. 2010;3:

9 Effectiveness of recanalization of CTO Residual/recurrent angina during FU Joyal Am Heart J 2010;160:179-87

10 Meta-Analysis (successfull vs Unsuccessfull) All causes of Mortality Khan et al. CCI 2013; 82: 95 1

11 CTO-PCI in the UK central cardiac audit database 28% mortality Sudhakar et al. JACC 2014; 64: 235

12 CTO data from SYNTAX 51% non revasc. 32% non pontée Farooq et al. JACC 2013; 61: 282-9

13 Residual Syntax Score, a new predictor of outcomes Genereux et al. JACC 2012; 59:

14 Residual Syntax Score, a new predictor of outcomes Genereux et al. JACC 2012; 59:

15 Theoretical If the muscle subtended by the CTO is Alive (> 50%) Ischemic (10-20%) Then the patient would be better off if that artery were magically reopened (i.e.at zero risk)

16 To maximize potential benefit Know the predictors of success Assess the risk of the procedure Start by treating the CTO in Pts with MV disease Concentrate expertise Minimise contrast use and radiation exposure Adjust the difficulty to your level of expertise Know when to stop and ask to an expert

17 The Success Rate of CTO Lesion morphology Patient characteristics Learning curve

18 Guidewire Crossing < 30 min. Morino et al. JACC Interv 2011; 4:

19 Successfull CTO PCI Morino et al. JACC Interv 2011; 4:

20 CTO Success No ad Hoc PCI!

21 Good CTO Angiography No panning, large field Optimal view of the distal run off Optimal view of the donor vessel Good views of the collaterals Several views of the occluded vessel At least 1 same view for both vessels

22 What are the Questions? Proximal and/or distal ambiguity? Lesion length? Vessel course, Island? Lesion calcification and tortuosity? Distal run off? Collaterals? Good and safe support?

23 What about the support?

24 What about the support?

25 What about the support?

26 What about the support?

27 What about the support?

28 What about the support? Fielder XT + Finecross

29 What about the support? 3D right Miracle 12 + Finecross

30 What about the support? Anchoring balloon

31 What about the support?

32 What about the support?

33 Which Approach? Ostial and calcified lesion GC Support, Stability? Risk of ostial dissection?

34 Which Approach?

35 Which Approach?

36 Which Approach?

37 Which Approach?

38 Which Approach?

39 Which Approach?

40 Which Approach? «Mother and Child Technique»

41 Which Approach?

42 Vessel Course?

43 Vessel Course?

44 Vessel Course?

45 Vessel Course?

46 Proximal ambiguity? No Calcification Lesion length < 20 mm Proximal ambiguity? No distal ambiguity Good distal run-off?

47 Proximal Ambiguity

48 Proximal ambiguity? Proximal ambiguity?

49 Proximal ambiguity?

50 What about the support?

51 Proximal ambiguity?

52 Proximal ambiguity?

53 Proximal ambiguity? Finecross + Fielder XT

54 Proximal ambiguity?

55 Proximal ambiguity?

56 Collaterals

57 Collaterals

58 Collaterals

59 Collaterals

60 Collaterals

61 Collaterals

62 Collaterals

63 Collaterals

64 Conclusions Successful PCI of CTO s improves symptoms, ischemia, quality of life, left ventricular function, reduce the need for CABG and even may improve survival. The net benefit is strongly related to the amount of pre procedural myocardial ischemia.

65 Conclusions PCI of CTO s is not a high risk procedure in experience centers. The success rate is relatively high in non selected cases (70-90%) in Europe, depending mainly on the operator s and Team center experience.

66 Conclusions The balance between benefit (amount of ischemia) and risk (PCI attempt in a center x or y) should always be assessed before taking the decision. It is time to build strong networks between centers in order to treat better more patients.

67 CTO et IDM 8.6% des patients avec IDM Claessen BE et al. Eur Heart J, 2012; 33 :

68 NCDR : BMS and DES in CTOs patients, of these with a CTO PCI and stent (BMS: 2043, DES: 8218) Patel MR et al. JACC Interv 2012; 5:

69 EURO-CTO Trial Evaluation of the Utilisation of Revascularisation vs Optimal medical therapy for CTOs 1200 patients operators >80% success rate First patient enrolled March 2012 Primary efficacy endpoint: Improvement of QoL Safety endpoint: MACE

70 Conclusion Take extra time during the diagnostic angiogram to obtain specific anatomic information that will guide strategy (ies) for the subsequent CTO PCI. Study the film in detail (Team). Educate refering physicians Start the procedure with powerfull bilateral injection in the majority of cases

71

72

73

74