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

2. 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

3. A few facts on CTOs in daily practice
Almost 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

4. 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

5. 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

6. The ESC Guidelines and CTO-PCI
Indication for revascularisation

7. Limited exercise capacity: 73 y, male

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

9. 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

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

11. 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

12. The ESC Guidelines and CTO-PCI
Indication for revascularisation

13. 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

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

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

16. 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:

17. 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

18. 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

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

20. 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

21. 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

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

23. Advanced imaging tools improve outcome

24. MSCT reveals problem zone

25. Dear Surgeon …

26. … what would be the surgical outcome ?

27. 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

28. 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

29. Thank you ›› 4th Experts "Live" CTO Workshop 2012 Welcome to …
September , 2012
London, UK
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