Understanding the Role of Advanced Minh Vo, MD, FRCPC - PowerPoint PPT Presentation

Understanding the Role of Advanced Minh Vo, MD, FRCPC Interventional Cardiology Techniques to Treat University of Alberta Edmonton, Alberta, Canada Clinically Relevant Chronic Total Occlusions Banff, Alberta March 12-15, 2017

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company • Boston Scientific, Abbott Vascular • Consulting Fees/Honoraria • Medtronic, Medical Hospital Specialties, • Other Financial Benefit AstraZeneca, Bayer, Johnson & Johnson, Edwards

Relevance of CTO’s in 2017 STAR Carlino Parallel Wiring Retrograde Stenting CTO HYBRID APPROACH Role of CTO first CTO PTCA collaterals described 2006 1940 1960 1970 1980 1990 2000 2010 2020 1950

Relevance of CTO’s in 2017 Azzalini L, Vo MN, Dens J, Agostoni P. Am J Cardiol. 2015; 116: 1774-1780

Relevance of CTO’s in 2017 • 3 Canadian Approach Centers (JACC 2012): – CTO prevalence: 18% – CTO attempt rate: 10% (success rate only 70%) • MHI registry: (AMJ 2016): – CTO prevalence: 20% – CTO attempt rate: 9% (success rate only 65%)

E xpected annual CTO PCI’s in Canada 5,355 Mais Rosemont: 1100 -> 110 Chicoutimi: 700-> 70 Hull: 1000 -> 100 IUCPQ: 2800 -> 280 Cite de la Sante: 700 -> 70 Pierre-Boucher: 600 -> 60 Montreal heart: 2100 -> 210 Kelowna: 1100 -> 110 Sherbrooke: 1200 -> 120 SPH: 1200 -> 120 HSC NFLD: 1000 -> 100 CHUM: 2200 -> 220 Sacre-Coeur: 1200 -> 120 VGH: 1250 -> 125 RAH: 1900 -> 190 MUHC: 1800 -> 180 RUH: 1000 -> 100 Hotel Dieu: 800 -> 80 RCH: 2300 -> 230 St.John’s : 1500 -> 150 U of A: 1500 -> 150 London: 1400 -> 140 Jewish: 650 -> 65 SBH: 2300 -> 230 RJH: 1500 -> 150 Ottawa Heart: 2400 -> 240 Foothills: 2300 -> 230 HSN: 1600 -> 160 RGH: 880 -> 88 TGH: 1600 -> 160 Kingston: 900 -> 90 Halifax: 2000 -> 200 Hamilton: 2800 -> 280 Rouge Valley: 1300 -> 130 SMH: 1500 -> 150 Sunnybrook: 1700 -> 170

Contemporary Evidence for Techniques CTO PCI

Contemporary CTO PCI Techniques Antegrade/retrograde Wire Escalation Retrograde Antegrade Dissection Dissection Re-entry Re-entry

Mean J-CTO score 2.3 ± 1.1 46 [92%] Technical success Procedural success 46 [92%] JIC 2015; 27(3): 139-44

CTO PCI is more complex J Am Coll Cardiol Intv 2015;8:245 – 53

Higher Complications with CTO PCI 5.0% Non-CTO 4.5% CTO 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% J Am Coll Cardiol Intv 2015;8:245 – 53

Importance of CTO Volume J Am Coll Cardiol Intv 2015;8:245 – 53

Evidence for Contemporary CTO PCI Techniques

All CTOs are Ischemic

Collaterals are inadequate • “Well -developed collaterals do not have the ability to prevent ischemia in the supplied territory ” (Vo MN, Brilakis ES, Kass M, Ravandi A. Can. J. Physiol. Pharmacol 2015; 93: 1-5)

All CTOs are ischemic • Werner 1 (2006): – 107 patients with CTOs – ALL patients had FFR <0.80 (ischemic) • Sachdeva 2 (2014): – 50 patients with CTOs – 78% had resting ischemia – ALL patients had ischemic FFR 1. Werner, GS, R Surber, M Ferrari, et al. Euro Heart J 2006; 27: 2406-12 2. Sachdeva, R, M Agrawal, SE Flynn, et al. CCI 2014; 83: 9-16

Even “good” collaterals are NOT good enough Sachdeva, R, M Agrawal, SE Flynn, et al. CCI 2014; 83: 9-16

• Patients with CTOs and well developed collaterals (Rentrop 3) • Follow up: 3.5 years Jang, W. JACC Interv ; 2015: 271-9

CTOs are associated with higher mortality

Higher cardiac deaths with more ischemia (medically treated patients) 10 8 cardiac death 6 4 2 0 0% 1-5% 5-10% 11-20% >20% % total myocardium ischemic Hachamovitch. Circ; 2003: 2900-2906

With revascularization, no mortality increase 10 medical Rx revasc 8 cardiac death 6 4 2 0 0% 1-5% 5-10% 11-20% >20% % total myocardium ischemic Hachamovitch. Circ; 2003: 2900-2906

12.5% jeopardize myocardium is the threshold for revascularization for mortality benefit Medical Rx Revasc Hachamovitch. Circ; 2003: 2900-2906

PCI CTO reduces ischemic burden 10 5.39 5 Change in % ischemia 0 -1.7 -5 -6.32 -10 -15 -16.26 -20 Baseline ischemia Safley. Cath Card Int; 2011: 337-343

Improvement in ischemia after PCI CTO portends better prognosis improvement no improvement Safley. Cath Card Int; 2011: 337-343

12.5% threshold for improvement Safley. Cath Card Int; 2011: 337-343

14,441 CTO patients and 75,431 non-CTO patients CTO Non-CTO J Am Coll Cardiol Intv 2016;9:1535 – 44

J Am Coll Cardiol Intv 2016;9:1535 – 44

J Am Coll Cardiol Intv 2016;9:1535 – 44

Impact of CTOs in NSTEMI Int J Cardio 2013; 168: 250-254

Impact of CTOs in STEMI CTO Non-CTO EuroIntervention 2017; 12: e1874-1882

Impact of CTOs in Ischemic Systolic HF CTO Non-CTO JACC Intv 2016; 9: 1790-7

Impact of CTOs in Ischemic Systolic HF JACC Intv 2016; 9: 1790-7

CTO PCI improves patient outcomes

CTO PCI in STEMI Patients Residual CTO CTO PCI Am J Cardiol 2016; 117: 1039-46

Diabetic Patients Benefits from CTO PCI DM, failed PCI DM, successful PCI EuroIntervention 2017; 12: e1889-97

Complete Revascularization is Better complete >2V (no CTO) 1 CTO Hannan E, Racz M, Holmes D et al. Circulation 2006; 113: 2406-12

Complete Revascularization is Better TO 2.70 Farooq V, Serruys P, Garcia H et al. JACC 2013; 61: 282-94

SCAAR Registry 14,441 CTO patients and 75,431 non-CTO patients J Am Coll Cardiol Intv 2016;9:1535 – 44

50% reduction in mortality Am J Cardiol. 2015; 115: 1367-1375

Am J Cardiol. 2015; 115: 1367-1375

70% reduction in angina Am J Cardiol. 2015; 115: 1367-1375

80% reduction in CABG Am J Cardiol. 2015; 115: 1367-1375

Increase in LVEF after CTO PCI Int J Cardiol 2015; 187: 90-96

Reduction in LVEDV Int J Cardiol 2015; 187: 90-96

Improvement in QOL Asymptomatic 4. 3 (-5.4, 13.9) SAQ Angina Frequency SAQ Physical Limitation 6. 3 (-5.0, 17.6) SAQ Quality of Life 8. 5 (-3.7, 20.7) Symptomatic 10. 3 (-0.8, 21.3) SAQ Angina Frequency 15. 9 (5.1, 26.7) SAQ Physical Limitation 27. 3 (16.5, 38.0) SAQ Quality of Life -40 -20 0 20 40 Effect of Procedural Success Courtesy of A. Grantham. Grantham, A. Circ Cardiovasc Qual Outcomes; 2010: 284-290

European Retrograde Registry JACC 2015; 65: 2388-400

Some evidence does NOT support CTO PCI

ASAN Registry No Mortality Benefit of CTO PCI Years J Am Coll Cardiol Intv 2016;9:530 – 8

Less CABG in Successful PCI Years J Am Coll Cardiol Intv 2016;9:530 – 8

EXPLORE trial J Am Coll Cardiol 2016;68:1622 – 32

LAD J Am Coll Cardiol 2016;68:1622 – 32

RCA CTO PCI LAD CTO PCI

Current available data for CTO PCI • Consistent improvement in QOL • Consistent reduction in CABG • Conflicting evidence in LVEF improvement • Conflicting evidence in mortality benefit

Guidelines Although the technology and techniques for PCI of chronic total occlusions are improving, there remains no current evidence that survival is improved after successful PCI of a chronic total occlusion ACC/AHA 2012

Guidelines ACC/AHA 2014

Guidelines with appropriate clinical indications suitable anatomy operators with appropriate expertise ACC/SCAI 2011

Guidelines ischaemia reduction angina relief ESC 2014

Guidelines chronic total occlusions are evolving and cannot be addressed in this document CCS 2014

CTO AUC • Appropriate: – Symptomatic patients – High risk non-invasive testing • Uncertain: – Intermediate test with minimal symptoms • Inappropriate: – Asymptomatic patients (esp low risk testing) – Low risk non-invasive testing

Symptomatic Patients High-risk Contemporary Non-invasive Techniques Testing Achieve Complete Revascularization Patient (age, comorbidities etc … )

Conclusion Is it uneasonable to give CTO patients the benefit of the doubt? • CTO patients are undertreated • Contemporary CTO PCI can achieve high success rate with acceptable complication rate • There is lack of RCT (DECISION-CTO, EURO-CTO) • >20,000 patients in observational data in favor of CTO PCI • NO data to suggest CTOs are less relevant than non-CTOs

Conclusion