CTOinHeartFailure

CristinaGavina,MD,PhD

Felkeretal,JAmCollCardiol,2002:39;210-218

CADis responsible for2/3of the casesof HFrEF

CTO in Heart FailureIschemic Heart Failure with reduced EF

R.Fontes-Carvalho

CTO in Heart FailurePathophysiology of Ischemic Heart Failure

CTO in Heart FailureRelevance of Chronic Total Occlusion

ChronicTotalOcclusion (CTO) isidentified inabout1/3ofallpatientsundergoing coronary angiograms forknownorsuspected CAD.AmHeartJ1993;126:561–4.ClinResCardiol2009;98:435–41.

Ofthesepatients, themajoritywillbetreatedmedically (64%)orarereferredforCABGsurgery (26%)whereasonly10%willbereferredforpercutaneous CTOrevascularization.TheCanadianMulticenterChronicTotalOcclusionsRegistry,J.Am.Coll.Cardiol.59(2012)991–997

IntheCOMMIT-HF single-center observational study,recruitingconsecutivenonselected patientshospitalizedwithadiagnosisofsystolicHF,oneormoreCTOofthemajorcoronaryarteries wasfoundin41.2%ofpatients.JAmCollCardiolIntv2016;9:1790–7

CTO in Heart FailureRelevance of Chronic Total Occlusion

What´s theroleofPCIinischemicHF?

What´stheroleofCTO-PCI?

• InHFrEF achievingcompletefunctional revascularisation ofischaemicmyocardiumisthegoal.

• CTO isfrequent butistechnicallychallenging, andisthemostcommonreason forselectingcoronary arterybypasssurgery.ButCABGisnotalwaysanoption…

CTO in Heart FailureRelevance of Chronic Total Occlusion

CTO in Heart Failure

WHAT DO WE EXPECT FROM CTO-PCI IN HF?

Improvesymptoms

ImproveLVfunction

Improvesurvival

JournalofCardiovascularMagneticResonance(2016)18:78

29patientswithHFrEF(EF31%)andevidenceofviabilityand/orischemiainCTOterritory

NoPCIrelatedcomplicationsortype4MI

BNP(baselinevs6months)NYHAclass(baselinevs6months)

CTO in Heart Failure

WHAT DO WE EXPECT FROM CTO-PCI IN HF?

Improvesymptoms

ImproveLVfunction

Improvesurvival

CTO in Heart FailureCTO-PCI: improvement in LV function

Bucciarelli-Ducci etal.JAmCollCardiol Img2016

Bucciarelli-Ducci etal.JAmCollCardiol Img2016

CTO in Heart FailureCTO-PCI: improvement in Myocardial Perfusion Reserve

CTOterritory Remoteterritory

InternationalJournalofCardiology169(2013)147–152

Patientswith≥2ischemicsegments Improvementofviabledysfuctionalsegments

InternationalJournalofCardiology187(2015)90–96

Meta-analysisof12studiesperformedbetween1987–2014in846patients

JournalofCardiovascularMagneticResonance (2016)18:78

CTO in Heart Failure

WHAT DO WE EXPECT FROM CTO-PCI IN HF?

Improvesymptoms

ImproveLVfunction

Improvesurvival

Eur.Heart J2012.33:768–775

Three-yearmortalityinpatientswithsingle-vessel disease(SVD)andmulti-vessel disease(MVD)accordingtothepresenceorabsenceofaCTO.

Eur.Heart J2012.33:768–775

Three-yearmortalityinpatientswithdouble-vessel diseaseandtriple-vessel diseaseaccordingtothepresenceorabsenceofaCTO.

CardiacsurvivalinCTO-PCIsuccesscomparedtoCTO–PCI failure.

Cardiacsurvivalinpatientswithcompletevsincompleterevascularization

CTO in Heart FailureImportance of complete revascularization

JAmCollCardiol Intv2016;9:1790–7

COMMIT-HFRegistry (consecutive nonselected patients hospitalized incardiologywardsandintensive cardiaccareunitswithadiagnosis ofsystolicHF)

CTO

Non-CTO

12monthmortality

COMMIT-HFobservationalstudy

JAmCollCardiol Intv2016;9:1790–7

CTO in Heart Failure

InternationalJournalofCardiology187(2015)90–96

CTO in Heart FailureCTO-PCI: improvement in mortality

CTO in Heart FailureTake-Home Messages

ChronicTotalOcclusion (CTO) isidentified inabout40%ofallpatientsundergoing coronary angiograms forsystolicHF.

ThepresenceofaCTO isnotabenigncondition, itisassociatedwithworseprognosis.

CTO-PCI inpatientswithHFrEFwithviablemyocardium canbeperformedwithhighsuccessratesand lowcomplications rate.

CTO-PCI improvessymptomsandLVEF.CTO-PCI andmayprobably reducemortality inthesepatients,butthisremains tobeproven…

Thechallengewillbetocompare theresultsofPCIwithCABGandwithOMT inpatientswithHFrEFandmultivesseldiseaseandCTO.