Chronic Total Occlusion: A case for coronary artery bypass grafting

Transcription

1 Chronic Total Occlusion: A case for coronary artery bypass grafting Prof. Alfredo R Galassi MD, FESC, FACC, FSCAI Director of Cardiac Catheterization and Interventional Cardiology Unit Department of Medical Sciences and Pediatrics Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy

2 Disclosure Statement of Financial Interest I, Alfredo Galassi DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation

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4 CTOs are common and influence management Analysis of consecutive patients undergoing angiography ( ), CTO was found in 52% patients with significant (> 70% DS) coronary disease Christofferson et al, Am J Cardiol 2005

5 12 CENTERS The IRCTO Registry patients enrolled with 1968 CTO lesions CTO prevalence 12.3% 44% 46% Optimal medical therapy 826 pts PCI 776 pts 10% CABG 175 pts Tomasello et al, GIC 2012

6 CTO PCI Success Rate Over Years Toyohashi Heart Center % ,9 71, , ,2 86,3 92,4 92,2 91,6 91,5 92,

7 Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

8 Success of CTO revascularization (%) 06/07: all members - since 2008 Online Registry Galassi et al, EuroIntervention 2011; 7: 472-9

9 Procedural and Fluoroscopy Time and Contrast Load (min) Procedure time (mean +SD) (min) Fluoroscopy time (mean +SD) ,3 1 hour and 40 mins 87,4 98, ,5 Overall LMT LAD LCX RCA Galassi et al, EuroIntervention ,9 219, ,2 45,3 36,3 (ml) Contrast load (mean +SD) 300 cc 45 mins 52,5 36,7 44,3 Overall LMT LAD LCX RCA 285,7 293,5 0 Overall LMT LAD LCX RCA

10 The EURO CTO Registry: A web-based registry ( OTHER COMPLICATIONS In Hospital Complications MACE (Major Adverse Cardiac Events) MI (Q-Wave, Non Q-Wavw) n (%) 21 (1.4) Cardiac Death n (%) 6 (0.4) Emergency CABG n (%) 3 (0.2) Emergency re-pci n (%) 2 (0.1) Stent Trombosis n (%) - Stroke n (%) 1 (0,1) Contrast Induced nephropathy) n (%) 17 (1.2) Coronary Perforation n (%) 37 (2.5) Cardiac Tamponade n (%) 11 (0.8) Vascular Complications n (%) 12 (0.8) BLEEDING Major Bleeding n (%) - Hb Reduction of > 5g/dL n (%) 1 (0.1) All other Bleeding not included as major n (%) 4 (0.3) Galassi et al, EuroIntervention 2011; 7: 472-9

11 J-CTO Multicenter Registry in Japan (498 pts, 528 lesions) Morino et al, JACC Intv 2010

12 Shah PB, Circulation 2011; 123:

13 Seven randomized studies sorted by FU lenght

14 RCA CTO Single-vessel Patient Clinical Presentation Exertional angina and dyspnea (CCSC III) Risk Factors Hypertension Dyslipidemia Non-invasive Testing Patient: V-S, male, 6 yrs 2D Echo: hypokinesia of inferior wall, EF 48%

15 RCA CTO Single-vessel Patient CTO PCI with DES

16 LAD CTO in a CABG Patient Risk Factors Patient: A-S, male, 60 yrs Past/Clinical hystory Hypertension Dyslipidemia Ex-smoker NID Diabetes Family history of CAD CABG: RIMA on lad, LIMA on OM, SVG on PDA 1999 Clinical Presentation September 2011: NSTEMI with ECG changes in lateral leads

17 LAD CTO in a CABG Patient

18 LAD CTO in a CABG Patient PCI with DES on native OM

19 LAD CTO in a CABG Patient Clinical Presentation March 2012:exertional angina and dyspnea (CCSC III) Non-invasive Testing Nuclear stress test: antero-septal reversible perfusion defect 2D Echo: hypokinesia of anterior wall, EF 55% Patient: A-S, male, 60 yrs CTO PCI with DES

20 LAD CTO in Single Vessel Disease Patient: V-M, female, 28 yrs Clinical Presentation Exertional angina and dyspnea (CCSC II) Risk Factors Family history of CAD Past/Clinical hystory Hodgkin Lymphoma treated with chemio- and radiotherapy 2005 Exertional angina since 2010 Non-invasive Testing Coronary MSCT: proximal LAD CTO 2D Echo: normokinesia of all segments, EF 60%

21 LAD CTO in Single Vessel Disease CTO PCI with DES

22 The EURO CTO Registry: A web-based registry ( CTO Vessel Distribution % % LAD LCX RCA LMT Procedural complication Angiographic Outcome % Galassi et al, EuroIntervention 2011; 7: 472-9

23 Evolution of DES as a standard in CTO Revascularization

24 Evolution of DES as a standard in CTO Revascularization

25 Evolution of DES as a standard in CTO Revascularization

26 Evolution of DES as a standard in CTO Revascularization

27 Evolution of DES as a standard in CTO Revascularization

28 Evolution of DES as a standard in CTO Revascularization

29 Evolution of DES as a standard in CTO Revascularization

30 Shah PB, Circulation 2011; 123:

31 Coronary angiographic findings in NSTEMI-ACS and STEMI patients Non-obstructive 40-50% Left main 4-10% Anderson et al, JACC 2007, Goldstein et al NEJM 2000

32 LAD CTO in a STEMI Multi-vessel Patient Clinical Presentation August 2011: lateral STEMI Risk Factors Hypertension Dyslipidemia Ex-smoker Patient: N-D, male, 63 yrs

33 LAD CTO in a STEMI Multi-vessel Patient Primary PCI with DES

34 LAD CTO in a STEMI Multi-vessel Patient Clinical Presentation March 2012: Exertional angina and dyspnea (CCSC III) Non-invasive Testing 2D Echo: hypokinesia of antero-septal wall, EF 44% Dobutamine Echo-Stress: bi-phasic response to dobutamine infusion Patient: N-D, male, 63 yrs CTO PCI with DES

35 TOAST study Olivari et al, JACC 2003

36 RCA CTO in a NSTEMI Multivessel Patient Risk Factors Hypertension Dyslipidemia Smoker Clinical Presentation August 2012 : NSTEMI Patient: V-P, female, 56 yrs

37 RCA CTO in a STEMI Patient

38 Rationale for CTO PCI in case of MVD A staged approach is reasonable in order to avoid excessively long procedures Which artery to tackle first, the CTO or the non CTO should be based on the importance of the vessel which is the first artery to be treated Inverted collateral flow through the recanalised CTO may protect the myocardium at risk during high risk complex lesions in the collateral donor vessel Sianos et al, EuroIntervention 2012

39 Course Directors Nicolaus Reifart Main Taunus Kliniken Bad Soden, Germany Gerald S. Werner Medizinische Klinik Klinikum Darmstadt Darmstadt, Germany Co-Directors Alfredo R. Galassi Ferrarotto Hospital University of Catania Catania, Italy George Sianos AHEPA University Hospital Thessaloniki, Greece Hans Bonnier University Hospital Brussels Brussels, Belgium

40 Success rate and case load <40 / year / year / year >100 / year Galassi et al, EuroIntervention 2011;7:472-9

41 Consensus on Training and Centre/Operator Competency 1. All the Interventional Trainees should have the theoretical knowledge for appropriate patient and lesions selection and the practical experience to avoid the most common mistakes in CTO recanalization 2. Sufficient training to work as independent primary operator for most angioplasty procedures does not automatically translate into an ability to approach any CTOs 3. The minimal number of 50 CTOs per year to maintain competency traslates ì into a model where only a limited number of operators and centres should perform CTO treatment safely based on workload, auditel success and complication rates Sianos et al, EuroIntervention 2012

42 Conclusions 1 Recent evidence from the japanese and european registries showed an high CTO s PCI procedural success (85-95%) without rise in complications rates PCI for isolated RCA and LCX, small vessel disease, previously by-pass CTO s is indicated when ischemic symptoms are associated with myocardial ischemia and viability CTO s PCI of LAD, might be choosen as appropriate strategy when clinical indicated in case of single vessel disease

43 Conclusions 2 MVD patients and CTO should deserve PCI considering recent high PCI success in experienced hands with low complication rates and restenosis by use of DES Moreover, CTO are found frequently during primary PCI procedures, making reasonable to stage CTO PCI after revascularization of the culprit vessel CABG might be choosen considering patient risk profile and life expectancy (patient selection is crucial)

44 The Boomerang effect The favourable result of a CTO recanalization, by expert and dedicated operators should not detemin an excessive enthusiasm of PCI utilization beyond the real and actual needs, which in turn might cause an underestimation of the procedure efficacy