Debate #4: CTO Revascularization Samin K Sharma, MD, FACC, FSCAI Director Clinical & Interventional Cardiology Zena and Michael a Weiner Professor of Medicine Mount Sinai Hospital, NY Most CTO Should be Opened: Samin K Sharma, MD Only Limited CTO Should be Opened: Carlo Di Mario, MD CCCSymposium 2014
CCCSymposium 2014. Debate #4: CTO Revascularization. Most CTO Should be Opened: Samin K Sharma, MD Only Limited CTO Should be Opened: Carlo Di Mario, MD. Samin K Sharma, MD, FACC, FSCAI Director Clinical & Interventional Cardiology Zena and Michael a Weiner Professor of Medicine - PowerPoint PPT Presentation
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Debate #4: CTO Revascularization
Samin K Sharma, MD, FACC, FSCAIDirector Clinical & Interventional Cardiology
Zena and Michael a Weiner Professor of Medicine
Mount Sinai Hospital, NY
Most CTO Should be Opened: Samin K Sharma, MDOnly Limited CTO Should be Opened: Carlo Di Mario, MD
CCCSymposium 2014
I will make my point for;Most CTOs Should be Opened
Chronic Total Occlusion (CTO)
Presence of CTO in CAD Imparts Adverse Prognosis
NUnadjusted HR
Compared with CR [95%CI]
Adjusted HR Compared with CR
[95%CI]
Complete Revascularization 6817 1.00 1.00
1 IR vessel with no CTO 8518 1.20 [1.04-1.38] 1.00 [0.87-1.15]
2 IR vessel with no CTO 2057 1.88 [1.57-2.27] 1.25 [1.03-1.50]
1 IR vessel CTO 3232 1.81 [1.53-2.13] 1.35 [1.14-1.59]
2 IR vessels at least 1 CTO 1321 2.77 [2.29-3.35] 1.36 [1.12-1.66]
Impact of Completeness of PCI Revascularization on Long-Term Outcomes in the Stent Era
Hannah, Holmes, King, Sharma et al. Circulation 2006;113:2406
HRs for Mortality for Various Subgroups of Incomplete Revascularization
Hannan, Sharma et al. JACC Cardio Interv 2009;2:17
Incomplete Revascularization in the Era of DES: NY State Database Report
Conclusion: Pts with ≥2 IR vessels with a CTO, have the worst long-term prognosis and greater need for CABG or re-PCI
Effect of a Concurrent CTO on Long-Term Mortality and LVEF in Pts After Primary PCI in AMI
Retrograde Wire Technique for Chronic Total Occlusion Recanalization
Four Patterns of Success in Retrograde CTO Recanalization
Sumitsuji et al. J Am Coll Cardiol Intv 2011;4:941.
Increased Use of Retrograde Approach and Technical Success Rate Over Time
Michael et al., Am J Cardiol 2013;112:488
%
20062007
201020092008
2011
≈35%
ACCF/SCAI/STS/AATS/AHA/ASNC 2012Appropriateness Criteria for Coronary Revascularization
Patel et al. JACC 2012;53:530-553
Chronic Total Occlusions: Indications for PCI
INDICATION
Appropriateness Score (1-9)
CCS Angina Class
Asymptomatic I or II III or IV
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
I I I• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Low-risk findings on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
I U U
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• Intermediate-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk findings on noninvasive testing• Receiving no or minimal anti-ischemic medical therapy
U U A
• Chronic total occlusion of 1 major epicardial coronary artery, without other stenoses• High-risk criteria on noninvasive testing• Receiving a course of maximal anti-ischemic medical therapy
U A A
PCI of a CTO in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise
Chronic Total Occlusions
I IIaIIb III
Procedural Steps of Current CTO-PCI
Fundamental Wire Technique and Current Strategy for Chronic Total Occlusion PCI
CTO - PCI
Antegrade approach x2
Retrograde approach (ostial)
IVUS guide re-entry
Single Wire Technique
Parallel Wire Technique
Retrograde Wire Cross
Kissing Wire Cross
CART
Reverse CARTSuccess Failure
Cotralateral Dual Injection
Procedural Success of CTO PCI at MSH
0
20
40
60
80
100
%
2003-2005 2006-2008 2009-10 2011-12
397 806 665 782
9386
78
68
Asahi wires
Retrogradetechnique
Planned 2nd (18%) or 3rd (8%) attempt
EXPERT CTOUS Trial:90+ success
Conclusions:Rationale for CTO Recanalization in ALL
Presence of a CTO imparts adverse prognosis.
Therefore developing technical skills (dedicated centers and dedicated Interventionalists) is essential to tackle this “last frontier of Interventional Cardiology” to improve overall outcomes of our complex CAD pts.
Non randomized data support improved overall CV outcomes (including mortality) with successful CTO procedures. A randomized trial will be needed to establish the PCI efficacy in CTO pts.
KEY to better CTO outcomes is successful recanalization