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

1. EURO CTO CLUB
Krakow 2016
8th Experts "Live"
CTO Workshop 2016
Sept 30th – Oct 01st, 2016
Alfredo R. Galassi MD, FESC, FACC, FSCAI
Department of Clinical and Experimental Medicine
University of Catania, Italy
How to deal with very LVEF: the last
remaining option to improve survival in
specific conditions

2. Indications of CTO revascularization
Galassi et al, Eur Heart J 2015

3. Potential time-dependent pathway of
dysfunctional myocardium
Wilcox JE et al, JACC 2015

4. How to deal with CTO in patients with
depressed LVF
 Are there clinical symptoms?
- Relief of angina and myocardial ischemia
- Relief of heart failure symptoms
 Is the myocardium viable?
 Could we increase prognosis?
 PCI or CABG for CTOs in case of MVD?

5. Case Summary
Clinical presentation: unstable angina + dyspnea NYHA III
Risk factors: smoker, diabetes type II, hypertension
2 D Echo:LVEF 24% midventricular inferolateral akinesia
global hypokinesia in the other segments
Target vessel: Mid RCA CTO
Septal collaterals from LAD and epicardial collaterals from LCx for RCA
Ostial LM stenosis Mid LAD stenosis
Ostial and proximal stenosis of OM2
62 year-old male

6. Ventriculography
LVEF 20-25%

7. Ischemia / Viability Assessment
Ischemia in LAD and RCA areas with
preserved viability
Stress/Perfusion Late Gadolinium
Inferolateral scar (distal segment)

8. Treatment Strategy
Euroscore 6
Logistic Euroscore II 2.41%
Syntax score 35
J-CTO score for CTO lesion 3
Heart Team Decision Surgical revascularization
However the patient refused surgery
 staged PCI was proposed

9. RCA CTO revascularization
Double femoral 7Fr access
IABP Support

10. Failed Initial Antegrade Approach
Finecross (Terumo)
Fielder XT-R(Asahi)
1 DES implantation in proximal RCA

11. 1 DES implantation in LM
Retrograde Approach
(Hybrid Approach)

12. Retrograde Approach
(Hybrid Approach)
Retrogradely
Corsair (Asahi)
Sion (Asahi)
Antegradely
Finecross (Terumo)
Fielder XT-R(Asahi)

13. Retrogradely
Corsair (Asahi)
Sion (Asahi)
Antegradely
Finecross (Terumo)
Fielder XT-R (Asahi)
Stent Facilitated Reverse CART Technique
Retrograde Approach
(Reverse CART technique)

14. Angiographic Final Result
3 DES implantation

15. LAD PCI
1 DES implantation

16. Optimization of LM stenting by IVUS

17. Follow-up
Uneventful 6 month follow-up period
No angina, dyspnea (from NYHA III to NYHA II)
Baseline
LVEF 24%
At 6 months
LVEF 36%

18. Ventriculography
Baseline At 6 months
LVEF 24% LVEF 36%

19. Systematic Angiographic Control
(6 months)
Intra-stent focal restenosis of mid RCA
Good result on LM and LAD
Stenosis of ostial and proximal OM 2 previously left untreated

20. PCI of RCA
1 DES implantation

21. PCI of LCx
Complete revascularization was attained
1 DES implantation

22. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

23. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

24. Viability / Ischemia Assessment
Preserved LVEF Impaired LVEF
CTO territory
Necrotic or ischemic non-CTO related territory
Symptoms
QOL
Prognosis
Symptoms
QOL
Prognosis

25. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

26. Hemodynamic Support and More
 Use of LV support devices is recommended
 Need for hemodynamic support is mandatory in
“retrograde approach (use of donor arteries and
collaterals)
 Do not hesitate to use temporary pacing
 Subset of patients unable to tolerate complications
(minor pericardial leakage due to coronary perforation
may result in cardiogenic shock)

27. Hemodynamic Support

28. Hemodynamic Support and More
 Use of LV support devices is recommended (IABP,
ECMO, Impella, Tandem Heart)
 Need for hemodynamic support is mandatory in
“retrograde approach (use of donor arteries and
collaterals)
 Do not hesitate to use temporary pacing
 Subset of patients unable to tolerate complications
(minor pericardial leakage due to coronary perforation
may result in cardiogenic shock)

29. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

30. Procedural Tips & Tricks
 Example of possible accesses
- Right femoral: a guiding catheter for RCA
- Left femoral: IABP and pacing
- Right radial: a guiding catheter for LCA
 Both antegrade and retrograde are feasible
 If LVDd is  70mm, consider a retrograde short
guiding catheter to bring a retrograde 150cm Corsair
into an antegrade guiding catheter (even through
septal connections). When CTO is located in RCA,
right brachial approach is preferred for a retrograde
short guiding catheter into LCA

31. Objective
To be less traumatic as possible
“Loose Tissue Tracking Concept”
by new soft double coil polymeric wires

32. o
Galassi et al, Eur Heart J 2014

33. Case Summary
Clinical Presentation: NSTEMI complicated by VF and cardiac arrest
67 year-old male
Risk Factors Smoker Diabetes type II Hypertension
2-D Echo: LVEF 18%
CTOs of 3 vessels (LAD, LCx, RCA)
Bad candidate for surgery
(very low EF and small diseased vessels with poor distal visualization)

34. PCI of RCA
Fielder XT-R (Asahi)
ECMO hemodynamic support
Baseline Final result

35. PCI of LAD and LCx
Baseline Final result
Fielder XT-R (Asahi)
ECMO hemodynamic support

36. PCI of LAD and LCx
Fielder XT-R (Asahi)
ECMO hemodynamic support

37. Follow-up
Uneventful 12-month follow-up period
Patient asymptomatic
Improvement of LVEF (from 18% to 35%)
at 6 month follow-up

38. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

39. Revascularization Strategy
 All non-CTO lesions need to be treated before hand
(consider viability)
 Do not hesitate to consider staged revascularization
strategy in two procedures
 Revascularization strategy should be functional
deriving from viability/ischemia assessment
 In presence of multiple CTOs:
- Start with the “easiest” CTO lesion (J-CTO score)
- 1 CTO lesion/procedure (might facilitate other CTO treatment
by increase collateral flow, better distal visualization, better
tollerance to CTO

40. Sohn et al. J Korean Med Sci 2014

41. Généreux et al. Am J Cardiol 2014
SRI = SYNTAX Revascularization Index
SRI=100% (complete revascularization),
SRI<100% to 50%, and SRI <50%

42. CTO PCI in patients with MVD and low EF
1. Viability / Ischemia assessment
2. Hemodynamic support during PCI
3. Procedural Tips & Tricks
4. Complete vs. Incomplete revascularization
5. Follow-up

43. During In-hospital Stay
Multidisciplinary team
Fragile patients requiring careful attention
and monitoring
Control of comorbidities ++++
- Diabetes
- Infections
- Electrolytes

44. Close clinical controls at 1, 3, 6, 12 months
We recommend systematic angiographic
control
- High rate of asymptomatic re-stenosis
- Long stented segments
- Susceptibility to any further ischemic events
Control of comorbidities ++++
Follow-up

45. From January 2013 to December 2015
839 CTO patients attempted percutaneously
LVEF≥50%
552 patients (65.8%)
LVEF 35-50%
215 patients (25.6%)
LVEF≤35%
72 patients (8.6%)
Successful CTO PCI
66 patients (91.7%)
Failed CTO PCI
6 patients (8.3%)
Clinical follow-up
66 patients (100%)
17.6±10.2 months
Angiographic follow-up
49 patients (74.2%)
Flow Chart
Multicentric Prospective Study

46. All
839 patients
LVEF≥50%
552 patients
(Group 1)
LVEF 35-50%
215 patients
(Group 2)
LVEF≤35%
72 patients
(Group 3)
Age, years, mean ± SD 64.6 ± 10.5 63.8 ± 10.2 65.8 ± 11.3* 66.4 ± 10
Age ≥ 75 years, n (%) 163 (19.4) 85 (15.4) 58 (27)* 20 (28.8)†
Males, n (%) 736 (87.7) 475 (86.1) 195 (90.7) 66 (91.7)
Diabetes, n (%) 252 (30) 152 (27.5) 67 (31.2) 33 (45.8)†‡
Smokers, n (%) 447 (53.3) 289 (52.4) 116 (54) 42 (58.3)
Hypertension, n (%) 695 (82.8) 455 (86.1) 179 (83.3) 61 (84.7)
Dyslipidemia, n (%) 607 (72.3) 385 (69.7) 174 (80.9)* 48 (66.7)†‡
BMI , kg/m2 , mean ±SD 28.6 ± 4.5 28.6 ± 4.5 28.9 ± 4.4 27.3 ± 4.2‡
Peripheral artery disease, n (%) 129 (15.4) 66 (12) 46 (21.4)* 17 (23.6)†
Chronic kidney disease, n (%) 130 (15.5) 68 (12.3) 44 (20.5)* 18 (25)†
Prior MI, n (%) 358 (42.7) 197 (35.7) 118 (54.9)* 43 (59.7)†
Prior PCI, n (%) 287 (34.2) 186 (33.7) 84 (39.1) 17 (23.6)‡
Prior CABG, n (%) 141 (16.8) 77 (13.9) 50 (23.3)* 14 (19.4)
Prior stroke, n (%) 13 (1.5) 6 (1.1) 5 (2.3) 2 (2.8)
Three-vessel disase, n (%) 370 (44.1) 211 (38.2) 117 (54.4)* 42 (58.3)†
> 1 CTO, n (%) 40 (4.7) 18 (3.2) 13 (6.9)* 9 (12.5)†
* Group 1 vs. Group 2, p<0.05 / † Group 2 vs. Group 3, p<0.05 / ‡ Group 1 vs. Group 3, p<0.05
Clinical characteristics

47. All
839 patients
LVEF≥50%
552 patients
(Group 1)
LVEF 35-50%
215 patients
(Group 2)
LVEF≤35%
72 patients
(Group 3)
Target CTO artery, n (%)
LAD
LCx
RCA
222 (26.5)
123 (14.7)
494 (58.9)
151 (27.4)
76 (13.9)
325 (58.9)
55 (25.6)
30 (14)
130 (60.4)
16 (22.2)
17(23.6)
39 (54.2)
Blunt Stump, n (%) 506 (60.3) 330 (59.8) 126 (58.6) 50 (69.4)
Bending >45°, n (%) 265 (31.6) 180 (32.6) 64 (29.8) 21 (29.2)
Severe Calcifications, n (%) 234 (27.9) 155 (28.1) 59 (27.4) 20 (27.8)
CTO length, mm, mean ± SD 42.2 ± 29.2 42.6± 29.6 42.5 ± 29 39 ± 27.3
CTO length ≥20mm, n (%) 674 (80.3) 441 (79.9) 179 (83.3) 56 (77.8)
Ostial location, n (%) 111(13.2) 68 (12.3) 31 (14.4) 48 (66.7)
In-stent CTO, n (%) 56 (6.7) 33 (6) 15 (7) 8 (11.1)
Previous attempt, n (%) 255 (30.4) 190 (34.4) 49 (22.8) 16 (22.2)†
Collateral filling Rentrop 2-3, n (%) 574 (68.4) 388 (70.3) 148 (68.8) 38 (52.8)†‡
J-CTO score ≥3, n (%) 402 (47.9) 273 (49.5) 97 (45.1) 32 (44.4)
ORA score ≥3, n (%) 103 (12.3) 53 (9.6) 35 (16.3)* 15 (20.8)†
Angiographic characteristics
* Group 1 vs. Goup 2, p<0.05 / † Group 2 vs. Goup 3, p<0.05 / ‡ Group 1 vs. Goup 3, p<0.05

48. 0
20
40
60
80
100
All LVEF ≥50% LVEF 35-50% LVEF ≤ 35%
93.6 93.5 94.4
91.7
Successrate(%)
All p=NS
Procedural Success

49. 0%
20%
40%
60%
80%
100%
All LVEF ≥50% LVEF 35-50% LVEF ≤ 35%
Retrograde only Hybrid Antegrade only
55.9 55.1 59.5
51.4
19.4
14.41917.9
26.2 25.9 26.1 29.2
All p=NS
Recanalization Techniques

50. 0%
20%
40%
60%
80%
100%
All LVEF ≥50% LVEF 35-50% LVEF ≤ 35%
Dissection reentry True to True lumen
28.9 25.4
36.4 33.3
71.1 74.6
64.6 66.7
All p=NS
Recanalization Techniques

51. All
839 patients
LVEF≥50%
552 patients
(Group 1)
LVEF 35-50%
215 patients
(Group 2)
LVEF≤35%
72 patients
(Group 3)
Procedural Time, min, mean ± SD 118.1 ± 75.5 119 ± 75.3 118.1 ± 79.2 110.5 ± 61.9
Fluoroscopy time, min, mean ± SD 57.1 ± 39.2 57 ± 38.2 57.9 ± 43 54.8 ± 35.3
Contrast Load, ml, mean ± SD 358 ± 206.5 369.9 ± 213.9 349.1 ± 197.7 295.6 ± 159 †‡
Radiation Dose, mGy, mean ± SD
3497.2 ± 2539 3578.8 ± 2574.6 3341.9 ± 2299.4 3335.3 ± 2854.6
* Group 1 vs. Goup 2, p<0.05
† Group 2 vs. Goup 3, p<0.05
‡ Group 1 vs. Goup 3, p<0.05
Procedural Details

52. All
839 patients
LVEF≥50%
552 patients
(Group 1)
LVEF 35-50%
215 patients
(Group 2)
LVEF≤35%
72 patients
(Group 3)
Coronary Perforation, n (%) 34 (4) 25 (4.5) 6(2.8) 3 (4.2)
Tamponade, n (%) 13 (1.5) 8 (1.4) 5 (2.3) 0
Death, n (%) 0 0 0 0
Non Q wave MI, n (%) 7 (0.8) 3 (0.5) 4 (1.9) 0
Q wave MI, n (%) 2 (0.2) 2 (0.4) 0 0
Stent thrombosis, n (%) 2 (0.2) 1 (0.2) 1 (0.5) 0
Stroke, n (%) 0 0 0 0
Need for emergency CABG, n (%) 1 (0.1) 1 (0.2) 0 0
All p=NS
Immediate Outcomes

53. CTO Patients with EF<35%
LV assistance device
62pts
86.2%
10pts
13.8%
No LV assistance device LV assistance device
8 2
IABP ECMO

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

55. 1
0.8
0.6
0.4
0.2
0
0 6 12 18 24 30 36
MACCEfreesurvival
Follow-up (months)
Patients
(N=49)
Restenosis, n (%) 4 (8.2)
Focal Restenosis, n (%), 4 (8.2)
Diffuse Restenosis, n (%) 0
Re-occlusion, n (%) 0
CTO Patients with EF<35%
Clinical Outcome
No impact of LV
assistance device use

56. Take Home Messages
 In experienced hands, CTO PCI is efficient and
safe in patients with low EF<35%
 PCI in very low LVEF patients is very often the
last «chance»
 Successful CTO PCI might improve
- LVEF
- Clinical outcome +++

57. Thank You
For Your Attention
www.alfredogalassi.com