Giuseppe Biondi ZoccaiUniversity of Turin, Turin, Italy

METCARDIO, Turin, Italygbiondizoccai@gmail.com

JOINT SYMPOSIUM WITH JACCT - Bologna, 25/9/2008 - 16:30-17:45 (12’)

CHRONIC TOTAL OCCLUSIONS: CHRONIC TOTAL OCCLUSIONS:

WHY BOTHER?WHY BOTHER?

LEARNING OBJECTIVES

Defining the chronic total

occlusion (CTO) context

Pathophysiologic basis of CTO

Clinical evidence on CTO

LEARNING OBJECTIVES

Defining the chronic total

occlusion (CTO) context

Pathophysiologic basis of CTO

Clinical evidence on CTO

MVD

Incomplete revascularization

SymptomsLV function

Freedom from major adverse events, heart failure and anginaFreedom from major adverse events, heart failure and angina

Open artery hypothesis

Silent ischemia

Periprocedural necrosis

DES thrombosis

Avoiding CABG

SCOPE OF THE PROBLEM

INCIDENCE AND IMPACT

CLUSTERING WITH MULTIVESSEL DISEASE

LEARNING OBJECTIVES

Defining the chronic total

occlusion (CTO) context

Pathophysiologic basis of CTO

Clinical evidence on CTO

Abbate et al, Cardiology 2003;100:196-206

NATURAL HISTORY OF UNFAVORABLE CARDIAC REMODELING

POTENTIAL IMPACT OF PCI ON CARDIAC REMODELING

Abbate et al, Cardiology 2003;100:196-206

Abbate et al, J Cell Physiol 2002;193:145-153

THE OPEN ARTERY HYPOTHESIS: TRUE OR FALSE?

CORONARY OCCLUSION AND MYOCARDIAL APOPTOSIS

Abbate et al, Circulation 2002;106;1051-1054

PERMANENT CORONARY OCCLUSION AND INCREASES

MYOCARDIAL APOPTOSIS

Biondi-Zoccai et al, Int J Cardiol 2004;94:105-110

DETRIMENTAL IMPACT OF CTO IN MULTIVESSEL DISEASE

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

0,00 0,09 0,13 0,16 0,17 0,21 0,25 0,28 0,31 0,34 0,36 0,38 0,40 0,42 0,43 0,47 0,69 1,00

sens

spec

FFRcoll

COLLATERALS MOST OFTEN FAIL TO PREVENT SYMPTOMATIC ISCHEMIA

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

Pristipino et al, Am J Cardiol 2005;96:769-72

PCI MAY PROVIDE ELECTRICAL STABILIZATION

Pristipino et al, Am J Cardiol 2005;96:769-72

SUCCESSFUL PCI FOR CTO

UNSUCCESSFUL PCI FOR CTO

PCI MAY PROVIDE ELECTRICAL STABILIZATION

LEARNING OBJECTIVES

Defining the chronic total

occlusion (CTO) context

Pathophysiologic basis of CTO

Clinical evidence on CTO

50

60

70

80

90

100

TOAST-GISE (1 y) Thoraxcenter (2 y) MAHA (10 y)

Success

Failure

P=0.001

Long

-ter

m s

urvi

val

follo

win

g C

TO

att

empt

(%

) P=0.002P=0.01

SELECTION BIAS MAY UNDERMINE PROMISING LONG-TERM DATA FROM

NON-RANDOMIZED STUDIES

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

INTERVENTIONISTS’ NEW OATH:I WILL NOT TREAT CTO

OAT

TRIAL

Hochman, New Engl J Med 2006;355:2395-2407

INTERVENTIONISTS’ NEW OATH:I WILL NOT TREAT CTO

Hochman, New Engl J Med 2006;355:2395-2407

ONLINE ONLY ONLINE ONLY SUPPLEMENT – Hochman et al, New Engl J Med 2006;355:2395-2407

BUT OATHS ARE DIFFICULT TO MAINTAIN…

OAT

TRIAL

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

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

SHOULD THUS INTERVENTIONISTS BE DISCOURAGED?

Boden et al, New Engl J Med 2007;356:1503-1516

Boden et al, New Engl J Med 2007;356:1503-1516

SHOULD THUS INTERVENTIONISTS BE DISCOURAGED?

Erne et al, JAMA 2007;297:1985-1991

NOT SWISS INTERVENTIONISTS!

SWISSI-2

TRIAL

AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED…

Shaw et al, Circulation 2008;117:1283-1291

COURAGE SUB-STUDY

Shaw et al, Circulation 2008;117:1283-1291

AND NOT PROVIDED ISCHEMIC MYOCARDIUM IS VISUALIZED…

Abbate et al, J Am Coll Cardiol 2008;51:956-64

IS ANY SYNTHESIS POSSIBLE?

Abbate et al, J Am Coll Cardiol 2008;51:956-64

IS ANY SYNTHESIS POSSIBLE?

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

IS ANY SYNTHESIS POSSIBLE?

IS ANY SYNTHESIS POSSIBLE?

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

TAKE HOME MESSAGES

1. NOT ALL CTOS ARE BORN EQUAL

2. BOTH PCI AND MAXIMAL MEDICAL RX ARE PIVOTAL

All from

All different

3. AVOID ROUTINE (AGGRESSIVE) PCI FOR ALL CTO, AS EVERY SINGLE ONE

SHOULD BE HANDLED DIFFERENTLY

For further slides on these topics please feel free to visit the

metcardio.org website:

http://www.metcardio.org/slides.html