This document discusses identifying patients that may benefit from percutaneous coronary intervention (PCI) to treat chronic total occlusions (CTOs). It notes that patients with clinical symptoms like angina or heart failure, or those with viable myocardium, are likely to benefit from CTO-PCI. The document also examines factors like the SYNTAX score and completeness of revascularization that influence whether PCI or coronary artery bypass grafting (CABG) is a better option for treating multi-vessel disease when one of the vessels is a CTO. It emphasizes the importance of assessing a patient's individual clinical presentation and ischemia to determine if CTO-PCI may provide symptom relief.

1. Identifying the patients that benefit
from CTO PCI
Gerald S. Werner, MD, FESC, FACC, FSCAI
Klinikum Darmstadt - Germany

2. Speaker’s name: Gerald S. Werner
 I have the following potential conflicts of interest to report:
 Research contracts
 Consulting
 Employment in industry
 Stockholder of a healthcare company
 Owner of a healthcare company
 Other(s)
 I do not have any potential conflict of interest
Potential conflicts of interest

3. Who benefits from CTO-PCI
• Are there clinical symptoms
• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?

4. If you consider CTO like any other lesion, then…
Eur Heart J 2014; e-pub

5. CTO-PCI improves QoL
N=42
N=83
Grantham JA et al. Circ Cardiovasc Qual Outcomes. 2010;3:284-290

6. The symptoms of CTOs may differ from non-CTOs
Safley DM et al. CCI 2013; e-pub

7. SAQ in CTO and non-CTO patients
0
10
20
30
40
50
60
70
80
90
100
Physical
limitation
Angina
frequency
Quality of life EQ5D
CTO
non-CTO
Safley DM et al. CCI 2013; e-pub

8. SAQ in CTO and non-CTO patients
0
10
20
30
40
50
60
70
80
90
100
Physical
limitation
Angina
frequency
Quality of life EQ5D
CTO
FU
non-CTO
Fup
Safley DM et al. CCI 2013; e-pub

9. Changes of ischemia after PCI of CTO
Safley DM et al. CCI 2011; 78: 337-43
SDS 0-3 4-8 9-13 >13
SDS – Summed Difference Score

10. Who benefits from CTO-PCI
• Are there clinical symptoms
• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?

11. 72 year old male, 10 years after anterior MI

12. Dyspnea as lead symptom: Evidence of viability ?
LVEF 58%

13. MRI for patient selection with akinesia
Kirschbaum et al. Am J Cardiol 2008;101:179

14. Predicting LV recovery in CTOs
Kirschbaum et al. Int J Cardiol 2012; 159:192-7

15. Influence of a CTO on ICD recipients for primary
prevention
Nombela –Franco L et al. Circulation: Arrythmia & Electrophysiology 2012;5:147-154
ICD intervention
Mortality
CTO observed in 44% of ICD recipients for ischemic cardiomyopathy

16. Who benefits from CTO-PCI
• Are there clinical symptoms
• Relief of angina and myocardial ischemia
• Relief of symptoms of heart failure
• Is the myocardium viable ?
• PCI or CABG for CTOs ?

17. SYNTAX influences the guidelines
Eur Heart J 2014; e-pub

18. Does SYNTAX change the case for CTOs ?
CTO still tips the decision towards CABG
Syntax has well above average CTOs as target
With CTOs a one-stop PCI may not be the best option

19. SYNTAX and CTO: Low revascularisation rates
Farooq et al. JACC 2013; 61: 282-94
PCI
No revasc.
51%
CABG
No revasc.
32%

20. New definition for IR: residual SYNTAX Score (rSS)
Sianos et al. EuroInterv 2005;1:219-227
Only significant or occlusive
lesions considered
Multiplication factor based on
level of stenosis:
• Total Occlusion x5
• 50-99% stenosis x2
Points added based on CTO
features:
Age >3 months or unknown
Blunt occlusion
Bridging collaterals
additional one point per
segment non-visible (not filled
by collateral flow) beyond
occlusion
+1
+1
+1
+1
Points
+6
+5
+3.5
+2.5
+1.5
+1
+0.5
6

21. rSS and outcome after PCI
Farooq V et al. Circulation 2013;128:141-51

22. Completeness of revascularization based on QCA
criteria in ACUITY trial
Rosner et al. Circulation 2012; 125: 2613-20

23. The more complex the case, the higher the rSS
Genereux et al. JACC 2012; 59: 2165-74
CTOs are more prevalent
in high rSS, as a CTO
multiplies the lesion
location by a factor of 5 in
the SYNTAX score
ACUITY Trial

24. Graft patency and CTO
PRAGUE IV. Circulation 2004;110:3418-3423
More than 50% of
CTOs are located in
the RCA and would
likely receive a
venous graft

25. What is needed for assessing the patient with a CTO
• Clinical symptoms
• Symptoms may be underestimated because of
their chronicity, and adaptation of the patient
• Ischemia
• In MVD you may prefer a thallium for local
attribution of ischemia or perfusion MRI
• In single vessel CTO stress EKG is enough
• Viability
• MRI is the gold standard, EKG may suffice in
some cases
• Have a strategy to discuss with the patient
• MVD or SVD, CABG an alternative or not ?

26. Despite all evidence and our convictions:
Eur Heart J 2014; e-pub

27. Despite all evidence and our convictions:
Eur Heart J 2014; e-pub