1. Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com JOINT SYMPOSIUM WITH JACCT - Bologna, 25/9/2008 - 16:30-17:45 (12’) CHRONIC TOTAL OCCLUSIONS: WHY BOTHER? CHRONIC TOTAL OCCLUSIONS: WHY BOTHER?

2. LEARNING OBJECTIVES Defining the chronic total occlusion (CTO) context Pathophysiologic basis of CTO Clinical evidence on CTO

3. LEARNING OBJECTIVES Defining the chronic total occlusion (CTO) context Pathophysiologic basis of CTO Clinical evidence on CTO

4. MVD Incomplete revascularization Symptoms LV function Freedom from major adverse events, heart failure and angina Open artery hypothesis Silent ischemia Periprocedural necrosis DES thrombosis Avoiding CABG SCOPE OF THE PROBLEM

5. INCIDENCE AND IMPACT

6. CLUSTERING WITH MULTIVESSEL DISEASE

7. LEARNING OBJECTIVES Defining the chronic total occlusion (CTO) context Pathophysiologic basis of CTO Clinical evidence on CTO

8. Abbate et al, Cardiology 2003;100:196-206 NATURAL HISTORY OF UNFAVORABLE CARDIAC REMODELING

9. POTENTIAL IMPACT OF PCI ON CARDIAC REMODELING Abbate et al, Cardiology 2003;100:196-206

10. Abbate et al, J Cell Physiol 2002;193:145-153 THE OPEN ARTERY HYPOTHESIS: TRUE OR FALSE?

11. CORONARY OCCLUSION AND MYOCARDIAL APOPTOSIS

12. Abbate et al, Circulation 2002;106;1051-1054 PERMANENT CORONARY OCCLUSION AND INCREASES MYOCARDIAL APOPTOSIS

13. Biondi-Zoccai et al, Int J Cardiol 2004;94:105-110 DETRIMENTAL IMPACT OF CTO IN MULTIVESSEL DISEASE

14. Moretti et al, J Cardiovasc Med 2008 – in press 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 0,000,090,130,160,170,210,250,280,310,340,360,380,400,420,430,470,691,00 sens spec FFR coll COLLATERALS MOST OFTEN FAIL TO PREVENT SYMPTOMATIC ISCHEMIA

15. Before PCI for CTO 5 months after PCI for CTO PCI MAY PROVIDE CARDIAC REMODELING BENEFITS Baks et al, J Am Coll Cardiol 2006;47:721-725

16. Pristipino et al, Am J Cardiol 2005;96:769-72 PCI MAY PROVIDE ELECTRICAL STABILIZATION

17. Pristipino et al, Am J Cardiol 2005;96:769-72 SUCCESSFUL PCI FOR CTO UNSUCCESSFUL PCI FOR CTO PCI MAY PROVIDE ELECTRICAL STABILIZATION

18. LEARNING OBJECTIVES Defining the chronic total occlusion (CTO) context Pathophysiologic basis of CTO Clinical evidence on CTO

19. P=0.001 Long-term survival following CTO attempt (%) P=0.002P=0.01 SELECTION BIAS MAY UNDERMINE PROMISING LONG-TERM DATA FROM NON-RANDOMIZED STUDIES

20. Suero et al, J Am Coll Cardiol 2001;38:409-14; Safley et al, J Am Coll Cardiol Intv 2008;1:295-302 SELECTION BIAS MAY UNDERMINE PROMISING LONG-TERM DATA FROM NON-RANDOMIZED STUDIES and benefit mainly due to LAD recanalization

21. INTERVENTIONISTS’ NEW OATH: I WILL NOT TREAT CTO OAT TRIAL Hochman, New Engl J Med 2006;355:2395-2407

22. INTERVENTIONISTS’ NEW OATH: I WILL NOT TREAT CTO Hochman, New Engl J Med 2006;355:2395-2407

23. ONLINE ONLY ONLINE ONLY SUPPLEMENT – Hochman et al, New Engl J Med 2006;355:2395-2407 BUT OATHS ARE DIFFICULT TO MAINTAIN… OAT TRIAL

24. PCI WITH STENTS FOR CTO SURELY CARRIES A PERI-PROCEDURAL RISK

25. Agostoni et al, Am Heart J 2006;151:682-689 MI rate MACE rate PCI WITH STENTS FOR CTO SURELY CARRIES A PERI-PROCEDURAL RISK

26. SHOULD THUS INTERVENTIONISTS BE DISCOURAGED? Boden et al, New Engl J Med 2007;356:1503-1516

27. SHOULD THUS INTERVENTIONISTS BE DISCOURAGED?

28. Erne et al, JAMA 2007;297:1985-1991 NOT SWISS INTERVENTIONISTS! SWISSI-2 TRIAL

29. AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED… Shaw et al, Circulation 2008;117:1283-1291 COURAGE SUB-STUDY

30. Shaw et al, Circulation 2008;117:1283-1291 AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED…

31. Abbate et al, J Am Coll Cardiol 2008;51:956-64 IS ANY SYNTHESIS POSSIBLE?

32. Abbate et al, J Am Coll Cardiol 2008;51:956-64 IS ANY SYNTHESIS POSSIBLE?

33. Appleton et al, Catheter Cardiovasc Interv 2008;71:772-81 IS ANY SYNTHESIS POSSIBLE?

34. Appleton et al, Catheter Cardiovasc Interv 2008;71:772-81

35. TAKE HOME MESSAGES

36. 1. NOT ALL CTOS ARE BORN EQUAL

37. 2. BOTH PCI AND MAXIMAL MEDICAL RX ARE PIVOTAL

38. All from All different 3. AVOID ROUTINE (AGGRESSIVE) PCI FOR ALL CTO, AS EVERY SINGLE ONE SHOULD BE HANDLED DIFFERENTLY

39. For further slides on these topics please feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html http://www.metcardio.org/slides.html