14th Experts "Live" CTO September 2nd- 3rd, 2022 - Mainz, Germany Main Session - Session 2: Selecting the patient and planning the procedure B The patient with severe LV dysfunction Mohamed Ayoub, Bad Oeynhausen, Germany Room: Guteberg Hall (Auditorium) - Friday 11:20 Chairmen: Alexander Bufe, Krefeld, Germany; Leszek Bryniarski, Krakow, Poland; Hans Bonnier, Nuenen, Belgium

1. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
CTO and Severe Reduced LV- Function
Mohamed Ayoub
Director CHIP and CTO Program
University Heart Center Bad Oeynhausen

2. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
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
Consultant, Proctor
Company
BostonScientific,
Teleflex, Asahi
intecc, Cordis,
Terumo
Disclosures

3. Patient
Comorbidities
Heart failure, diabetes,
advanced age, peripheral
vascular disease, complex
lesions, unstable
angina/NSTEMI, prior
surgery
Hemodynamic
Compromise
Depressed ejectionfraction
(LVEF≤35%)
KirtaneAJetal.Circulation. 2016;134:422-431
Complex
Coronary
Artery
Disease Multi-vessel disease,
Left Main disease,
CTO, calcification
High Risk
Patients
2/3 of these
patients are turned
down for surgery
Treatment of Higher-Risk Patients With an Indication
for Revascularization

4. • 2,002 consecutive patients undergoing elective CTO PCI in tertiary German
center
• Median follow-up was 2.6 (1.1 to 3.1) years
• 17.4% patients had LV dysfunction (EF<40%)
• Successful CTO recanalization was independently associated with reduced
all-cause mortality, with similar relative risk reductions in both groups
(EF<40% and EF>40%)
Toma A, StähliBE et al, Am J Cardiol 2017;120:1780–
1786
Comparison of Benefit of Successful PCI for CTO in Patients
With Versus Without Reduced (EF <40%) LV- Function

5. Tajstra M et al, JACC Intv 2016
CTOs and Outcome in Systolic Heart Failure (12-month mortality)
Impact of CTO on Long-Term Prognosis in
Patients With Ischemic Systolic Heart Failure

6. Predictors of MACE
Galassi A, Boukhris M et al J Am Coll Cardiol Intv

7. Patients CTO Patients with EF<35%
successfully revascularized
Improvement in LVEF
41.6
10
30
29.1
20
40
P<0.001
Range
(17 – 34)
FU 17.6 ± 10.2 months
% 50
0
before CTO PCI after CTO PCI
Galassi et al. JACC Intv in press

8. Changes in symptoms 6 months after CTO PCI
according to LVEF
Galassi A, Boukhris M et al J Am Coll Cardiol Intv

9. Perera D et. al., REVIVED-BCIS2 Trial NEJM 2022
Study Design

10. Inclusion and Exclusion Criteria
Perera D et. al., REVIVED-BCIS2 Trial NEJM 2022

11. Perera D et. al., REVIVED-BCIS2 Trial NEJM 2022
Primary Endpoint

12. Secondary Endpoint: LVEF Improvement
Perera D et. al., REVIVED-BCIS2 Trial NEJM 2022

13. REVIVED Trial: Limitation
• No data about PCI charachteristics available
• No ischemia test
• Patients with limiting angina excluded
• Complete Revasclularisation performed?
• Short follow-up

14. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
CTO with EF < 35%
Large access
Right heart
catheter
Mechanical
support
(ECMO, Impella)
Low contrast
PCI
Good planning
How to deal with CTO in patients with
depressed LVEF

15. Thiele et. Al. Eur Heart Journal 2015:36:1223-30

16. 90-DAY MACCE: PROTECT III PROTECT II-LIKE PATIENTS VERSUS
PROTECT II RCT
31.0%
21.9%
15.0%
Impella 2.5 / CP
N = 373
N = 210 N = 215
PROTECT III
PII-like
p= 0.03*
p<0.0001
IABP Impella 2.5
PROTECT II
N = number of patients with 90-dayfollow-up
P=0.035
MACCE: Death, Stroke, MI, Repeat Revascularization
*Dangas et al. Am J Cardiol. 2014;113:222-228

17.  Reduced LVEF = lower safety margin
 Patient factors
– Elevated LVEDP, low CO, boarderline blood pressure, valve
disease
 Procedure factors:
– Prolonged ischemia – last patent conduit, retrograde
approach, collateral compromise, multivessel PCI
Goals of Hemodynamic Support

18. Proposed algorithm for screening patients for protected PCI. BP, blood pressure; PA sat, pulmonary artery saturation.
Courtesy of James M. McCabe, MD (University of Washington).
PROTECTED PCI ALGORITHM

19. CTO LAD and CX - Severe Reduced LV- Function
82J, CCS II, NYHA II, EF 30%, CTO LAD and CX- PL, CTO PCI with Impella CP

20. CTO LAD and CX - Severe Reduced LV- Function
82J, CCS II, NYHA II, EF 30%, CTO LAD and CX- PL, CTO PCI with Impella CP

21. CTO LAD and CX - Severe Reduced LV- Function
Single Wire > Corsair MC, Fieder XT-R, Rotablation 1,5 burr

22. CTO LAD and CX - Severe Reduced LV- Function
Turnpike MC, Gaia 3rd

23. Contrast 80ml
Final result

24. CTO RCX Post CABG - Severe Reduced LV- Function
56y, CABG 2020, CTO RCX (J-CTO 3), EF 25%

25. CTO RCX Post CABG - Severe Reduced LV- Function
Corsair Pro, selective injection

26. Antegrade puncture Supercross MC 120 and Gaia 3rd >> reverse CART
CTO RCX Post CABG - Severe Reduced LV- Function

27. CTO RCX Post CABG- Severe Reduced LV- Function
Final result

28. Take Home Message
In Patients with Low Ejection Fraction
• In experienced hands, CTO PCI is effective and safe
• Successful CTO PCIs improve LVEF, Symptoms and provides
good clinical outcome
• Don`t forget the right heart catheterization
• Use enough support when performing protected PCI
• Use IVUS and consider low contrast PCI

29. T H A N K Y O U !

30. T H A N K Y O U !