CTO and atrial fibrillation – Do we apply the ESC recommendations? Sudhir Rathore, Canberley, Great Britain 11th Experts Live CTO The annual Euro CTO meeting September 13th –14th, 2019 - Berlin, Germany

1. CTO and Atrial Fibrillation
Do we apply the ESC recommendation ?
Sudhir Rathore
MD, FRCP(UK), FACC, FESC
Consultant Interventional Cardiologist
Frimley Park Hospital NHS Trust &
St George’s Hospital,
London, UK

2. Conflicts of interests
No conflicts

3. Introduction
 20% to 40% of patients with AF also present with
coronary artery disease (CAD).
 5% to 10% of patients referred to coronary
angiography with or without PCI present with AF
or other indications for chronic OAC.
 DAPT following PCI reduces stent thrombosis.
 CTO PCI is associated with long stented
segment and high thrombotic risk.
 The optimal antithrombotic treatment regimen
for patients with AF undergoing PCI is a clinical
conundrum.

4. Clinical case
 82 yrs old, male, HT, Persistent AF, Angina with
ischaemia in RCA territory.
 LV: Mild inferior Hypokinesia, Moderate Aortic
Stenosis
 Previous stroke, CHADSvASC2: 5
 HAS- BLED Score: 3
 RCA CTO PCI: 11/2015
 DAPT (Aspirin/Clopidogrel Loading and
maintenance)
 Warfarin: Stopped 48 hrs prior to PCI with
bridging LMWH, INR: 1.5

5. RCA CTO: Bilateral angiogram

6. AWE/Retro failure

7. Knuckle Wire

8. Cross Boss/ Sting Ray

9. ADR

10. Final Result: 100 mm of overlapping
stents

11. Post PCI Antiplatelet/ Anticoagulant ??
 Aspirin (3M)+ Clopidogrel (>12 M) + Warfarin (Life
Long).
 Aspirin (1M)+ Clopidogrel (12M) + Warfarin(Life Long).
 Aspirin (1M)+ Clopidogrel (12M) + NOAC.
 Clopidogrel (12M) + NOAC.

12. Post PCI Regimen (2015) and progress
Aspirin (6M), Clopidogrel + Warfarin Long
term.
Seen 2/52 back with stable angina ISR in
RCA stent.
No major or relevant bleeding episode.
No Thrombo-embolic events.
??? Evidence

13. Potential issues during CTO PCI/AF
(DAPT+Anticoagulation)
Peri-procedural: Access site complications
as large bore access required, procedural
complications (perforation, tamponade
etc).
Post procedural: Need for long stents and
risk of stent thrombosis etc.

17. Trials with Vitamin K Antagonist (Warfarin)

18. Trials with NOAC
(PIONEER AF- Rivaroxaban)

19. RE-DUAL PCI- Dabigatran

20. AUGUSTUS-Apixaban

21. ENTRUST-AF-PCI (Edoxaban), ESC 2019
 RCT, 1506 Pts,
 Edoxaban 60 mg +P2Y12 inhibitor for 12 months
vs. VKA+P2Y12 inhibitor for 12 months +Aspirin
1-12 months
 Non-inferior and trend towards less major and
non-major bleeding episodes in Edoxaban arm
(17.0% vs. 20.1%)
 Composite of CV Death, Stroke, Systemic
embolization, MI, Stent thrombosis was similar
(6.5% vs. 6.1%).
 Safe alternative to TT.

26. Take home message
 Periprocedural:
Do not interrupt VKA and interrupt DOAC for 24-48 hrs.
Prefer radial access.
Avoid GP Inhibitors.
Prefer new generation DES (Intravascular imaging optimization).
 Post procedural antithrombotic regimen: Individualize Ischaemic
vs. Bleeding risk
Prefer DOAC: TAT (Dabigatran 15, Rivaroxaban 15, Apixaban 5x2,
Edoxaban 60 mg) DAT (Full dose)
If VKA used: TAT (INR 2.0-2.5), DAT (2-3)
Duration of TAT: Peri-procedure/ 1-3 months
Choice of P2Y12 I: Prefer Clopidogrel, Ticagrelor in some cases, avoid
Prasugrel
DAT: Preferable in high bleeding risk (DOAC+ P2Y12).
OAC: Life long
SAPT: 12 months and longer on high risk patients ??

27. Take home message
 Periprocedural:
Do not interrupt VKA and interrupt DOAC for 24-48 hrs.
Prefer radial access.
Avoid GP Inhibitors.
Prefer new generation DES (Intravascular imaging optimization).
 Post procedural antithrombotic regimen: Individualize Ischaemic
vs. Bleeding risk
Prefer DOAC: TAT (Dabigatran 15, Rivaroxaban 15, Apixaban 5x2,
Edoxaban 60 mg) DAT (Full dose)
If VKA used: TAT (INR 2.0-2.5), DAT (2-3)
Duration of TAT: Peri-procedure/ 1-3 months
Choice of P2Y12 I: Prefer Clopidogrel, Ticagrelor in some cases, avoid
Prasugrel
DAT: Preferable in high bleeding risk (DOAC+ P2Y12).
OAC: Life long
SAPT: 12 months and longer on high risk patients ??