Complex Coronary intervention Ahsan (Sonny) Achtchi, DO, FACC

Disclosures & Conflict of Interest No relevant financial relationships with any commercial interests. No honorarium.

Patient 92 year old female No significant past medical history Lifelong nonsmoker Very active, participates in ballroom dancing several times per week Maintains her own household Independent with IADLs and ADLs Worsening exertional dyspnea and chest pain x 1 month Relieved with rest No rest pain EF gradually decreasing 40%->25%

Angiography

Management? Presumptive medical therapy? Stress testing? Diagnostic angiography?

Treatment options Medical therapy? Courage trial Surgery PCI

Selected graphs from Bell et al9 showing event-free survival stratified by several vessels grafted overall (upper left graphic), survival in patients with an ejection fraction (EF) <35% (upper right graphic), and event-free survival for the combined end point of death/myocardial infarction (MI)/reoperation and recurrence of angina (lower graphic). Selected graphs from Bell et al9 showing event-free survival stratified by several vessels grafted overall (upper left graphic), survival in patients with an ejection fraction (EF) <35% (upper right graphic), and event-free survival for the combined end point of death/myocardial infarction (MI)/reoperation and recurrence of angina (lower graphic). Mario Gössl et al. Circ Cardiovasc Interv. 2012;5:597-604 Copyright © American Heart Association, Inc. All rights reserved.

One-year outcomes results from the Arterial Revascularization Therapies Study trial.10 CABG, coronary artery bypass graft; CVA, cerebrovascular accident; MI, myocardial infarction; PTCA, percutaneous transluminal coronary angioplasty. One-year outcomes results from the Arterial Revascularization Therapies Study trial.10 CABG, coronary artery bypass graft; CVA, cerebrovascular accident; MI, myocardial infarction; PTCA, percutaneous transluminal coronary angioplasty. Mario Gössl et al. Circ Cardiovasc Interv. 2012;5:597-604 Copyright © American Heart Association, Inc. All rights reserved.

What is a CTO?

Possible results of CTO Transmural MI Hibernating myocardium Collateralization with functional but ischemic tissue

Collateral flow is almost always inadequate!

CTO is associated with higher mortality!

Patient 92 year old female No significant past medical history Lifelong nonsmoker Very active, participates in ballroom dancing several times per week Maintains her own household Independent with IADLs and ADLs Worsening exertional dyspnea and chest pain x 1 month Relieved with rest No rest pain EF gradually decreasing 40%->25%

Angiography

Management? Presumptive medical therapy? Stress testing? Diagnostic angiography?

Treatment options Medical therapy? Courage trial Surgery PCI

CTO PCI with impella support

LAD

RCA

Case #2 59 F HTN, HL Heavy smoker CABG 5 years ago, presented with ACS (CCS IV unstable angina) to local ER Referred for diagnostic coronary angiography

Angiography

Distal visualization

Case #3 85 year old patient COPD, DM2, HTN, former heavy smoker, HL CAD with prior CAGB and multiple PCIs Mild renal impairment Ischemic cardiomyopathy, EF 35% Disabling CCS IV angina Postural hypotension prohibiting antianginal use

Angiography

RCA CTO PCI

End result

Case #4 70 year old male Former heavy smoker DM2, HTN, HL Recent onset of CCS IV angina, NYHA class III CHF EF 20% by echo Severe PAD PET with entirely viable myocardium

Angiography

Retrograde left to left

Take home points Complex coronary intervention and CTO is an important and underutilized resource Many patients not eligible or unwilling to have surgery Incomplete revascularization leads to worse outcomes

Thank you!