Επιλογή ασθενών για επαναιμάτωση στις χρόνιες ολικές αποφράξεις. Γιώργος Κ. Καραβόλιας Επεμβατικός Καρδιολόγος Ωνάσειο Καρδιοχειρουργικό Κέντρο

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1 Επιλογή ασθενών για επαναιμάτωση στις χρόνιες ολικές αποφράξεις Γιώργος Κ. Καραβόλιας Επεμβατικός Καρδιολόγος Ωνάσειο Καρδιοχειρουργικό Κέντρο

2 Επιλογή ασθενών για επαναιμάτωση στις χρόνιες ολικές αποφράξεις Δεν υπάρχει οποιαδήποτε σύγκρουση συμφερόντων

3 introduction CTOs: the last great barrier to success in interventional cardiology ~20% of all coronary angiograms reveal coronary chronic total occlusions (CTOs). there is growing interest in percutaneous treatment of CTO in coronary arteries due to improvements in technique and equipment lack of large clinical trial data on the benefits of CTO revascularization current guidelines downgrade CTO percutaneous coronary intervention revascularization relative to non-ctos and to surgical revascularization observational evidence that successful treatment of coronary CTO is associated with significant changes in cardiac function and outcome

4 appropriate use rating in CTOs and in non-ctos in single vessel disease 2012, Appropriate Use Criteria for Coronary Revascularization J Am Coll Cardiol 2012;59:857-81

5 2014 ESC/EACTS guidelines on myocardial revascularization European Heart Journal, Advance Access published August 29, 2014

6 current management of CTO patients The Canadian Multicenter Chronic Total Occlusions Registry J Am Coll Cardiol. 2012;59(11):

7 revascularization in CTO

8 critics of CTO PCI revascularization Indications do patients with CTO have symptoms? do patients with CTO have ischemia? complete vs incomplete revascularization Procedure can CTO s be reliably opened by PCI? is a CTO procedure more risky? the procedure is too complex we don t have time for long procedures results are not reproducible or teachable CTO-PCI is cost-prohibitive Potential Clinical Benefits?

9 do patients with CTO have symptoms? Symptoms in CTO pts Changes in physical limitation angina (less prominent) dyspnea fatigue patients minimize symptoms often inappropriately labeled asymptomatic EuroIntervention 2014;9:

10 do patients with CTO have ischemia? The Canadian Multicenter Chronic Total Occlusions Registry J Am Coll Cardiol. 2012;59(11):

11 do patients with CTO have ischemia? Sachdeva R, Catheterization and Cardiovascular Interventions 2014;83:9 16

12 do patients with CTO have ischemia? collaterals wall motion Sachdeva R, Catheterization and Cardiovascular Interventions 2014;83:9 16

13 complete vs incomplete revascularization New York State s Percutaneous Coronary Intervention Reporting System (11294 pts) Hannan E, J Am Coll Cardiol Intv 2009;2:17 25

14 complete vs incomplete revascularization Survival Survival Free From MI Hannan E, J Am Coll Cardiol Intv 2009;2:17 25

15 complete vs incomplete revascularization mortality Meta-Analysis of 89,883 Patients CABG + PCI Studies Garcia et al, J Am Coll Cardiol. 2013;62(16):

16 complete vs incomplete revascularization mortality Meta-Analysis of 89,883 Patients CABG Studies PCI Studies Garcia et al, J Am Coll Cardiol. 2013;62(16):

17 can CTOs be reliably opened by PCI? Meta-Analysis of 18,061 Patients Patel V, J Am Coll Cardiol Intv. 2013;6(2):

18 is a CTO procedure more risky? Meta-Analysis of 18,061 Patients Patel V, J Am Coll Cardiol Intv. 2013;6(2):

19 Potential Clinical Benefits of CTO PCI Improve symptoms, such as angina and dyspnea. Decrease the need for anti-anginal medications. Decrease the need for CABG surgery. Reduce mortality (compared to patients with failed CTO PCI). Improve left ventricular function. Decrease the risk for arrhythmias. Improve tolerance of acute coronary syndromes that may occur in the future.

20 successful vs. failed CTO recanalization residual/recurrent angina meta-analysis Dominique Joyal, Am Heart J 2010;160:179-87

21 decreased need for anti-anginal medications fewer or no anti-anginal medications medication-related cost and side effects patients may use phosphodiesterase inhibitors for erectile dysfunction.

22 decreased need for CABG at presentation pts decline CABG for non-medical reasons pts have increased risk for complications non-lad coronary artery CTO and intractable, medically refractory angina prior CABG, (especially if patent LIMA LAD) SYNTAX CTO sub-study

23 successful vs. failed CTO recanalization decreased need for CABG in the future Dominique Joyal, Am Heart J 2010;160:179-87

24 successful vs. failed CTO recanalization all-cause mortality single center meta-analysis J Am Coll Cardiol Intv. 2012;5(4): Dominique Joyal, Am Heart J 2010;160:179-87

25 successful vs. failed CTO recanalization all-cause mortality total mortality cardiac mortality Mehran R, J Am Coll Cardiol Intv 2011;4:952 61

26 successful vs. failed CTO recanalization all-cause mortality LAD LCx RCA Mehran R, J Am Coll Cardiol Intv 2011;4:952 61

27 successful vs. failed CTO recanalization left ventricular systolic function LVEF Segmental wall thickening (SWT) Heart, June 2011 Vol 97 Suppl 1

28 decreased risk for arrhythmias Cumulative Event Rates for Appropriate ICD Therapy Univariable and Multivariable Predictors of ICD Therapy Luis Nombela-Franco, Circ Arrhythm Electrophysiol. 2012;5:

29 freedom from first appropriate device therapy in CTO and non-cto Luis Nombela-Franco, Circ Arrhythm Electrophysiol. 2012;5:

30 all-cause mortality in patients with CTO and without CTO Luis Nombela-Franco, Circ Arrhythm Electrophysiol. 2012;5:

31 improved tolerance of a future acute coronary syndrome Bimmer E.P.M, J Am Coll Cardiol Intv 2009;2:

32 Contraindications to CTO PCI Absolute contraindications: inability to receive dual antiplatelet therapy prior radiation skin injury. Relative contraindications: inability to receive prolonged dual antiplatelet therapy chronic kidney disease prior radiation exposure, or multiple and prolonged prior cardiac procedures requiring fluoroscopy heparin-induced thrombocytopenia (HIT)

33 Consider CTO PCI symptomatic pts evidence of ischemia high risk CABG pts refusing CABG pts with prior CABG hybrid procedures (CTO PCI vs Vein grafts) aim for complete revascularization

34 Treat the Lesions that Need to Be Fixed, Not Just the Ones that You Can Fix