Patient Selection for CTO Revascularization More than Just Symptom relief Gerald S. Werner, MD, FESC, FACC, FSCAI Klinikum Darmstadt GmbH Darmstadt, Germany

Potential conflicts of interest Speaker’s name: Gerald S. Werner  I have the following potential conflicts of interest to report:  Research contracts  Consulting  Employment in industry  Stockholder of a healthcare company  Owner of a healthcare company  Other(s)  I do not have any potential conflict of interest

A few facts on CTOs in daily practice Almost 20000 consecutive diagnostic angiographies in the Canadian CTO registry showed that in patients with significant CAD, 1 out of 5 lesions was a CTO (22%) : 32% of CTOs were in multivessel vessel disease Prior MI was reported in 41%, but only one third had ECG signs of prior MI Impaired LVEF was found in 50% of CTOs Only 17% underwent PCI of the CTO, only 2of 3 were successful Bradley Strauss et al. submitted

Patient Selection for PCI of CTOs To improve clinical symptoms Relief of angina and myocardial ischemia Relief of symptoms of heart failure To improve prognosis Efficacy as compared to CABG Patient and operator selection

Patient Selection for PCI of CTOs To improve clinical symptoms Relief of angina and myocardial ischemia Relief of symptoms of heart failure To improve prognosis Efficacy as compared to CABG Patient and operator selection

The ESC Guidelines and CTO-PCI Indication for revascularisation

Limited exercise capacity: 73 y, male

Collaterals do not prevent ischemia Ischemia no Ischemia Modified from Werner et al. Eur Heart J 2006;27:2406-12

Improved exercise capacity after CTO-PCI Baseline 12 month Maximum exercise 125 W 175 W Maximum heart rate 120 bpm 141 bpm Maximum oxygen uptake 20.8 ml/min/kg 28.8 ml/min/kg

MRI for patient selection with prior infarct Kirschbaum et al. Am J Cardiol 2008;101:179

Patient Selection for PCI of CTOs To improve clinical symptoms Relief of angina and myocardial ischemia Relief of symptoms of heart failure To improve prognosis Efficacy as compared to CABG Patient and operator selection

The ESC Guidelines and CTO-PCI Indication for revascularisation

Patient Selection for PCI of CTOs To improve clinical symptoms Relief of angina and myocardial ischemia Relief of symptoms of heart failure To improve prognosis Efficacy as compared to CABG Patient and operator selection

The ESC Guidelines and CTO-PCI Type of recommended revascularisation CTO target artery Galassi et al EuroIntervention. 2011 Aug;7(4):472-9

Recommended revascularisation: Impact of the SYNTAX score CABG PCI European Heart Journal (2010) 31, 2501–2555

The SYNTAX Score (www.syntaxscore.com) Only significant or occlusive lesions considered Multiplication factor based on level of stenosis: Total Occlusion x5 50-99% stenosis x2 + 4 Points based on CTO morphology + Points for Calcification Bifurcation Ostial location Diffuse disease Thrombus presence etc. 6 Points +6 +5 +3.5 +2.5 +1.5 +1 +0.5 Sianos et al EuroIntervention 2005;1:219-227

Total Occlusion Procedural characteristics CABG n=266 12 were not treated with CABG CABG n=254 Not Bypassed n=81 Bypassed n=173 Reason not bypassed: Not intended to treat (n=12) Diseased (n=11) Inadequate conduit (n=2) Too small (n=19) Unable to find (n=1) Other (n=36) Overall 68.1 % of TO were successfully bypassed ITT, Per Lesion

Procedural Characteristics Total Occlusion Subset: CABG RCT Patient-based CABG TO N=235 Off-pump surgery, % 17.0 Graft revascularization, % At least one arterial graft 97.8 Arterial graft to LAD 96.0 Double LIMA/RIMA 26.5 Complete arterial revascularization 20.6 Venous graft only 2.2 Grafts per patient, mean ± SD 2.8  0.7 Distal anastomosis/pt, mean ± SD 3.3  0.9 Complete Revascularization, % 49.6 Post-Proced. Hospital Stay, mean ± SD (d) 10.3  12.0 SYNTAX CTO Subset 27OCT08.doc exhibit 12 , 13 , 5 Site-reported data 18

Venous graft patency in CTOs About 75% of CTOs are located in the RCA or LCX PRAGUE IV. Circulation 2004;110:3418-3423

A 50 year old former soccer professional Reduced exercise capacity since may 2010 Moved from field position to goal keeping Ischemia detected by MRI collaterals SYNTAX Score 31.5

Total Occlusion Procedural characteristics PCI n=277 8 were not treated with PCI PCI n=269 The SYNTAX way to do PCI in CTOs is no option, however … Attempted to treat n=250 Not attempted n=19 Unsuccessful n=117 Successful n=133 Overall 49.4 % of TO successfully treated Per Lesion

Success rate and case load <40 / year 40-70 / year 70-100 / year >100 / year Galassi et al, EuroIngervention 2011;7:472-9

Advanced imaging tools improve outcome

MSCT reveals problem zone

Dear Surgeon …

… what would be the surgical outcome ?

PCI for CTO should be the primary option Revascularization of CTOs is the recommended strategy for symptomatic and ischemic patients based on studies and pathophysiologic findings The prognostic impact of a CTO is established in several clinical settings The complexity of the procedure requires expertise and experience Prevention of specific complications needs to be part of the procedural strategy

PCI for CTO should not be an option if... ...there is no viability in the myocardium subtended by the CTO (MRI required) ...there are severe additional lesions needing revascularization, when CABG is an option

Thank you ›› 4th Experts "Live" CTO Workshop 2012 Welcome to … September 20 - 21, 2012 London, UK www.eurocto.eu Course Director Carlo Di Mario London, UK Co-Directors Anthony Gershlick Leicester, UK David Hildick-Smith Brighton, UK Scientific Board Gerald S. Werner Darmstadt, Germany Nicolaus Reifart Bad Soden, Germany Alfredo R. Galassi Catania, Italy Hans Bonnier Brussels, Belgium George Sianos Thessaloniki, Greece Javier Escaned Madrid, Spain Thank you