Understanding the Role of Advanced Minh Vo, MD, FRCPC - - PowerPoint PPT Presentation

▶
understanding the role of advanced
SMART_READER_LITE
LIVE PREVIEW

Understanding the Role of Advanced Minh Vo, MD, FRCPC - - PowerPoint PPT Presentation

Nov 03, 2023 24 likes •667 views

Understanding the Role of Advanced Minh Vo, MD, FRCPC Interventional Cardiology Techniques to Treat University of Alberta Edmonton, Alberta, Canada Clinically Relevant Chronic Total Occlusions Banff, Alberta March 12-15, 2017 Disclosure

slide-1
SLIDE 1

Understanding the Role of Advanced Interventional Cardiology Techniques to Treat Clinically Relevant Chronic Total Occlusions

Minh Vo, MD, FRCPC University of Alberta Edmonton, Alberta, Canada

Banff, Alberta March 12-15, 2017

slide-2
SLIDE 2

Disclosure Statement of Financial Interest

  • Consulting Fees/Honoraria
  • Other Financial Benefit
  • Boston Scientific, Abbott Vascular
  • Medtronic, Medical Hospital Specialties,

AstraZeneca, Bayer, Johnson & Johnson, Edwards

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

slide-3
SLIDE 3

Relevance of CTO’s in 2017

1940

STAR

1960 2020 1980 2000

Carlino Retrograde Parallel Wiring HYBRID APPROACH

1950 1970 1990 2010

CTO first described Role of collaterals CTO PTCA Stenting CTO

2006

slide-4
SLIDE 4

Relevance of CTO’s in 2017

Azzalini L, Vo MN, Dens J, Agostoni P. Am J Cardiol. 2015; 116: 1774-1780

slide-5
SLIDE 5

Relevance of CTO’s in 2017

  • 3 Canadian Approach Centers (JACC 2012):

– CTO prevalence: 18% – CTO attempt rate: 10% (success rate only 70%)

  • MHI registry: (AMJ 2016):

– CTO prevalence: 20% – CTO attempt rate: 9% (success rate only 65%)

slide-6
SLIDE 6

Expected annual CTO PCI’s in Canada 5,355

Sunnybrook: 1700 -> 170 SMH: 1500 -> 150 HSN: 1600 -> 160 Ottawa Heart: 2400 -> 240 Kingston: 900 -> 90 Rouge Valley: 1300 -> 130 Hamilton: 2800 -> 280 TGH: 1600 -> 160 London: 1400 -> 140 Halifax: 2000 -> 200 St.John’s: 1500 -> 150 HSC NFLD: 1000 -> 100 IUCPQ: 2800 -> 280 CHUM: 2200 -> 220 Sacre-Coeur: 1200 -> 120 Pierre-Boucher: 600 -> 60 Cite de la Sante: 700 -> 70 Hotel Dieu: 800 -> 80 Chicoutimi: 700-> 70 Montreal heart: 2100 -> 210 Sherbrooke: 1200 -> 120 Hull: 1000 -> 100 Mais Rosemont: 1100 -> 110 Jewish: 650 -> 65 MUHC: 1800 -> 180

RUH: 1000 -> 100 SBH: 2300 -> 230 RAH: 1900 -> 190 U of A: 1500 -> 150 RGH: 880 -> 88 Foothills: 2300 -> 230 SPH: 1200 -> 120 VGH: 1250 -> 125 RJH: 1500 -> 150 RCH: 2300 -> 230 Kelowna: 1100 -> 110

slide-7
SLIDE 7

Contemporary Techniques Evidence for CTO PCI

slide-8
SLIDE 8

Contemporary CTO PCI Techniques

Antegrade/retrograde Wire Escalation Antegrade Dissection Re-entry Retrograde Dissection Re-entry

slide-9
SLIDE 9
slide-10
SLIDE 10
slide-11
SLIDE 11

Mean J-CTO score 2.3 ± 1.1 Technical success 46 [92%] Procedural success 46 [92%]

JIC 2015; 27(3): 139-44

slide-12
SLIDE 12

CTO PCI is more complex

J Am Coll Cardiol Intv 2015;8:245–53

slide-13
SLIDE 13

Higher Complications with CTO PCI

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% 4.5% 5.0% Non-CTO CTO J Am Coll Cardiol Intv 2015;8:245–53

slide-14
SLIDE 14

Importance of CTO Volume

J Am Coll Cardiol Intv 2015;8:245–53

slide-15
SLIDE 15

Contemporary Techniques Evidence for CTO PCI

slide-16
SLIDE 16

All CTOs are Ischemic

slide-17
SLIDE 17

Collaterals are inadequate

  • “Well-developed collaterals do not have the ability to

prevent ischemia in the supplied territory”

(Vo MN, Brilakis ES, Kass M, Ravandi A. Can. J. Physiol. Pharmacol 2015; 93: 1-5)

slide-18
SLIDE 18

All CTOs are ischemic

  • Werner 1(2006):

– 107 patients with CTOs – ALL patients had FFR <0.80 (ischemic)

  • Sachdeva2 (2014):

– 50 patients with CTOs – 78% had resting ischemia – ALL patients had ischemic FFR

  • 1. Werner, GS, R Surber, M Ferrari, et al. Euro Heart J 2006; 27: 2406-12
  • 2. Sachdeva, R, M Agrawal, SE Flynn, et al. CCI 2014; 83: 9-16
slide-19
SLIDE 19

Even “good” collaterals are NOT good enough

Sachdeva, R, M Agrawal, SE Flynn, et al. CCI 2014; 83: 9-16

slide-20
SLIDE 20
  • Patients with CTOs and well developed collaterals (Rentrop 3)
  • Follow up: 3.5 years

Jang, W. JACC Interv ; 2015: 271-9

slide-21
SLIDE 21

CTOs are associated with higher mortality

slide-22
SLIDE 22

Higher cardiac deaths with more ischemia (medically treated patients)

2 4 6 8 10 cardiac death

0% 1-5% 5-10% 11-20% >20%

% total myocardium ischemic

  • Hachamovitch. Circ; 2003: 2900-2906
slide-23
SLIDE 23

With revascularization, no mortality increase

2 4 6 8 10

0% 1-5% 5-10% 11-20% >20%

cardiac death % total myocardium ischemic

medical Rx revasc

  • Hachamovitch. Circ; 2003: 2900-2906
slide-24
SLIDE 24

12.5% jeopardize myocardium is the threshold for revascularization for mortality benefit

Medical Rx Revasc

  • Hachamovitch. Circ; 2003: 2900-2906
slide-25
SLIDE 25

PCI CTO reduces ischemic burden

5.39

  • 1.7
  • 6.32
  • 16.26
  • 20
  • 15
  • 10
  • 5

5 10 Baseline ischemia Change in % ischemia

  • Safley. Cath Card Int; 2011: 337-343
slide-26
SLIDE 26

Improvement in ischemia after PCI CTO portends better prognosis

improvement no improvement

  • Safley. Cath Card Int; 2011: 337-343
slide-27
SLIDE 27

12.5% threshold for improvement

  • Safley. Cath Card Int; 2011: 337-343
slide-28
SLIDE 28

CTO Non-CTO

14,441 CTO patients and 75,431 non-CTO patients

J Am Coll Cardiol Intv 2016;9:1535–44

slide-29
SLIDE 29

J Am Coll Cardiol Intv 2016;9:1535–44

slide-30
SLIDE 30

J Am Coll Cardiol Intv 2016;9:1535–44

slide-31
SLIDE 31

Impact of CTOs in NSTEMI

Int J Cardio 2013; 168: 250-254

slide-32
SLIDE 32

Impact of CTOs in STEMI

CTO Non-CTO

EuroIntervention 2017; 12: e1874-1882

slide-33
SLIDE 33

Impact of CTOs in Ischemic Systolic HF

CTO Non-CTO JACC Intv 2016; 9: 1790-7

slide-34
SLIDE 34

Impact of CTOs in Ischemic Systolic HF

JACC Intv 2016; 9: 1790-7

slide-35
SLIDE 35

CTO PCI improves patient outcomes

slide-36
SLIDE 36

CTO PCI in STEMI Patients

CTO PCI Residual CTO

Am J Cardiol 2016; 117: 1039-46

slide-37
SLIDE 37

Diabetic Patients Benefits from CTO PCI

EuroIntervention 2017; 12: e1889-97

DM, failed PCI DM, successful PCI

slide-38
SLIDE 38

Complete Revascularization is Better

complete 1 CTO >2V (no CTO) Hannan E, Racz M, Holmes D et al. Circulation 2006; 113: 2406-12

slide-39
SLIDE 39

Complete Revascularization is Better

Farooq V, Serruys P, Garcia H et al. JACC 2013; 61: 282-94

TO 2.70

slide-40
SLIDE 40

SCAAR Registry

J Am Coll Cardiol Intv 2016;9:1535–44

14,441 CTO patients and 75,431 non-CTO patients

slide-41
SLIDE 41

Am J Cardiol. 2015; 115: 1367-1375 50% reduction in mortality

slide-42
SLIDE 42

Am J Cardiol. 2015; 115: 1367-1375

slide-43
SLIDE 43

Am J Cardiol. 2015; 115: 1367-1375 70% reduction in angina

slide-44
SLIDE 44

Am J Cardiol. 2015; 115: 1367-1375 80% reduction in CABG

slide-45
SLIDE 45

Increase in LVEF after CTO PCI

Int J Cardiol 2015; 187: 90-96

slide-46
SLIDE 46

Reduction in LVEDV

Int J Cardiol 2015; 187: 90-96

slide-47
SLIDE 47

Improvement in QOL

Effect of Procedural Success

  • 40
  • 20

20 40

SAQ Quality of Life SAQ Physical Limitation SAQ Angina Frequency

Symptomatic

SAQ Quality of Life SAQ Physical Limitation SAQ Angina Frequency

Asymptomatic

27. 3 (16.5, 38.0) 15. 9 (5.1, 26.7) 10. 3 (-0.8, 21.3) 8. 5 (-3.7, 20.7) 6. 3 (-5.0, 17.6) 4. 3 (-5.4, 13.9)

Courtesy of A. Grantham. Grantham, A. Circ Cardiovasc Qual Outcomes; 2010: 284-290

slide-48
SLIDE 48

European Retrograde Registry

JACC 2015; 65: 2388-400

slide-49
SLIDE 49

Some evidence does NOT support CTO PCI

slide-50
SLIDE 50

ASAN Registry No Mortality Benefit of CTO PCI

Years

J Am Coll Cardiol Intv 2016;9:530–8

slide-51
SLIDE 51

Less CABG in Successful PCI

Years

J Am Coll Cardiol Intv 2016;9:530–8

slide-52
SLIDE 52

EXPLORE trial

J Am Coll Cardiol 2016;68:1622–32

slide-53
SLIDE 53

J Am Coll Cardiol 2016;68:1622–32

LAD

slide-54
SLIDE 54

LAD CTO PCI RCA CTO PCI

slide-55
SLIDE 55

Current available data for CTO PCI

  • Consistent improvement in QOL
  • Consistent reduction in CABG
  • Conflicting evidence in LVEF improvement
  • Conflicting evidence in mortality benefit
slide-56
SLIDE 56

Guidelines

ACC/AHA 2012

Although the technology and techniques for PCI of chronic total occlusions are improving, there remains no current evidence that survival is improved after successful PCI of a chronic total occlusion

slide-57
SLIDE 57

Guidelines

ACC/AHA 2014

slide-58
SLIDE 58

Guidelines

ACC/SCAI 2011

with appropriate clinical indications suitable anatomy

  • perators with appropriate expertise
slide-59
SLIDE 59

Guidelines

ischaemia reduction angina relief

ESC 2014

slide-60
SLIDE 60

Guidelines

CCS 2014

chronic total occlusions are evolving and cannot be addressed in this document

slide-61
SLIDE 61

CTO AUC

  • Appropriate:

– Symptomatic patients – High risk non-invasive testing

  • Uncertain:

– Intermediate test with minimal symptoms

  • Inappropriate:

– Asymptomatic patients (esp low risk testing) – Low risk non-invasive testing

slide-62
SLIDE 62

Symptomatic Patients High-risk Non-invasive Testing Contemporary Techniques Achieve Complete Revascularization Patient (age, comorbidities etc…)

slide-63
SLIDE 63

Conclusion

  • CTO patients are undertreated
  • Contemporary CTO PCI can achieve high success rate with

acceptable complication rate

  • There is lack of RCT (DECISION-CTO, EURO-CTO)
  • >20,000 patients in observational data in favor of CTO PCI
  • NO data to suggest CTOs are less relevant than non-CTOs

Is it uneasonable to give CTO patients the benefit of the doubt?

slide-64
SLIDE 64

Conclusion