8th Experts Live CTO Workshop 2016, September, 30th - October 1st, 20116 in Krakow, Poland

1. BAD KROZINGEN
Impact of Multivessel Versus Single-Vessel
Disease on Outcomes After Percutaneous
Coronary Interventions for Chronic Total
Occlusions
Euro CTO Club 8th Experts Live CTO workshop 2016 Krakow, Poland
AUREL TOMA MD

2. Case 1
40 years old
LVEF 50%
Positiv Stress MRI
Cx 100% and RCA 100%

3. Case 2
57 years old
LVEF 50%
Bypass 1998
NYHA III; CCS III
RCA 100%

4. Case 3
56 years old
LVEF 60%
Positiv Stress-Echo
RCA 100% and LAD 100%

5. George S et al JACC 2014

6. Nu. at risk
301340
1662 1554
Failure CTO
Success CTO
172198
914 791
48
223
0 1 2 3 4
0
15
10
20
25
30
5
Cumulative Mortality (%)
Success
Failure
CTO-PCI:
Years post PCI
Successful CTO PCI wa associated with a decrease in mortality (adjusted hazard ratio:
0.72; 95%-CI; 0.53 to 0.97; P=0.030). CTO = chronic total occlusion; PCI = percutaneous
coronary intervention.
Toma A, Büttner A et al Clin Res Cardiol. 2016

7. Toma A, Büttner A et al Eurointervention 2016

8. Toma A, Büttner et al Am J Cardiol. 2016

9. Lee et al JACC interv. 2016

10. Background
Successful recanalization of a cronic total occlusion
(CTO) has been associated with prognostic benefits
Whether the extent of coronary artery disease
interferes with these benefits has not been
investigated, yet.

11. Aim of the study
Clinical and long-term outcome after percutaneous
intervention (PCI) for chronic total occlusion between
patients with multivessel disease (MVD) or single vessel
disease (SVD).

12. Method
Inclusion criteria
- Angina and /or a positive functional test
- Elective PCI for chronic total occlusion
Definition of procedural success
- Residual diameter stenosis < 30% in at least one CTO
Patients group
- Were divided into patients with and without multivesel
disease

13. Study endpoint
Primary endpoint
All-cause mortality
Secondary endpoint
MACE, the composite of all-cause death, non fatal
myocardial infarction and clinically indicated TVR
including PCI and CABG

14. Patients population
2002 Patients
MVD
(82%)
Success CTO PCI
(N = 1332, 82%)
Failure CTO PCI
(N = 302, 18%)
SVD
(18%)
Success CTO PCI
(N = 330, 90%)
Failure CTO PCI
(N = 38, 10%)
Januar 2005- December 2013
Median follow-up 2.6 years (interquartile 1.1-3.1 years)

15. Baseline clinical characteristics
MVD
(N = 292)
SVD
(N = 1710)
P-value
Age (years) 65.9±10.4 62±10.9 <0.001
Current smoker (%) 304 (18.6) 97 (26.4) 0.001
Hypertension (%) 1374 (84.1) 273 (74.2) <0.001
Dyslipidemia (%) 1414 (86.5) 312 (84.8) NS
Diabetes mellitus (%) 507 (31.0) 83 (22.6) 0.001
eGFR, ml/min 87.4±33.9 94.2±34.1 0.001
Prior myocardial infarction (%) 435 (26.6) 58 (15.8) <0.001
Prior CABG 289 (17.7 3 (0.8) <0.001
LVEF < 40% 307 (18.8) 41 (11.1) <0.001

16. Baseline angiographic and procedural
characteristics
MVD
(N = 292)
SVD
(N = 1710)
P-value
CTO target vessel (%) <0.001
Right coronary artery 755 (46.2) 176 (47.8)
Left anterior descending artery 410 (25.1) 146 (39.7)
Left circumflex artery 454 (27.8) 46 (12.5)
Left main coronary artery 15 (0.9) 0 (0)
Retrograde approach 370 (22.6) 106 (28.8) 0.008
Success CTO PCI 1332 (81.5%) 330 (89.7%) <0.001

17. Long-term mortality in patients with and
without MVD
Multivessel disease (MVD)
Single-vessel disease (SVD)
Log rank p<0.001
All-cause mortality
Patientswithevents,(%)
Follow-up, months
0
5
20
10
15
25
0 6 12 18 3024
30
No at risk
MVD 1634 1556 1506 1005 902 822
SVD 368 358 350 227 216 202

18. Long-term mortality in patients with and
without MVD stratified to success
Log rank p=0.429
Patientswithevents,(%)
Follow-up, months
0
5
20
10
15
25
0 6 12 18 3024
30
No at risk
MVD
Procedural failure 302 274 264 195 176 165
Procedural success 1332 1282 1242 810 726 657
SVD
Procedural failure 38 38 38 21 21 20
Procedural success 330 321 311 205 194 182
Multivessel disease (MVD)
Procedural failure
Procedural success
Single-vessel disease (SVD)
Procedural failure
Procedural success
Log rank p<0.001
All-cause mortality

19. Clinical outcomes stratified for procedural
success
0 1 2 3 4
All-cause death
MVD
SVD
MVD
SVD
MVD
SVD
MVD
SVD
All-cause death and/or MI
TVR
MACE
Procedural
success
Procedural
failure
220
21
273
29
322
48
544
73
Nr
11.0%
5.2%
14.6%
7.3%
19.1%
13.3%
30.9%
19.4%
24.5%
10.5%
26.2%
13.2%
22.2%
10.5%
43.7%
23.7%
Adjusted Hazard ratio
(95% CI)
0.60 (0.45-0.80)
0.74 (0.24-2.26)
0.73 (0.56-0.96)
1.03 (0.38-2.77)
0.77 (0.59-1.01)
1.32 (0.46-3.74)
0.70 (0.58-0.86)
1.12 (0.55-2.29)
<0.001
0.429
<0.001
0.445
0.043
0.465
<0.001
0.909
P-value
<0.001
0.592
0.022
0.955
0.062
0.604
0.001
0.761
P-value
Procedural success better Procedural failure better

20. Discussion
Successful CTO PCI demonstrated prognostic benefits in
patients with MVD but not in those with SVD
In MVD patients, successful CTO revascularization
resulted in a significant reduction in all cause mortality
and MACE rates during a median follow-up of 2.6 years.

21. Conclusion
Beneficial effects of successful CTO PCI depend on the
coronary artery disease extent
MVD justifies more extensive efforts and procedural risk
with PCI for CTO than SVD

22. Case 1

23. Case 2

24. Case 3

26. Thank you

27. Toma A et al Clin Res Cardiol. 2016
Nu. at risk
9991100
902 856
Incomplete Revasc
Complete Revasc
487586
524 476
137
134
0 1 2 3 4
Cumulative Mortality (%)
0
15
10
20
25
30
5
complete
incomplete
Revascularisation:
Years post PCI
Complete revascularization was associated with a decrease in mortality
adjusted HR: 0.59; 95% CI: 0.42 to 0.82; P=0.002
Long rank p<0.001