2. Affiliation/Financial Relationship
• Consulting Fees/Honoraria
Company
• Abboth, Abiomed, Ashai Intecc, Astra
Zeneca, Biotronik, Boston, Cardinal
Health, Daiichi Sankyo, Medtronic,
Schockwave, SIS, Teleflex,Terumo,
Disclosures
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or
affiliation with the organization(s) listed below.
3. Impact of left ventricular dysfunction in PCI:
230464 PCI procedures
Mamas MA et al, Eur Heart J. 2014 Nov
4. REVIVED-BCIS2
PCI vs OMT for Ischemic Left Ventricular Dysfunction
Perera D et al. N Engl J Med. 2022 Aug 27.
• ≈50% 2 VD
• No functional assessment
• No correlation between stenosis an
viability
• most extensive and severe coronary
artery disease were offered surgical
revascularization outside the trial
rather than being enrolled, a factor
that could dilute a treatment effect.
5. Impact of Initial Invasive Versus Conservative Management of stable ischemic heart disease in
Patients With a History of Heart Failure or Left Ventricular Dysfunction (≥35% but <45%)
Insights From the ISCHEMIA Trial
Lopes et al Circulation. 2020 Nov 3;142(18):1725-1735
*composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina,
HF, or resuscitated cardiac arrest
6.
7. Who should do high-risk PCI procedures?
Neumann et al. 2018
8. CTO as predictors of incomplete revascularization
in patients with multi-vessel disease
9. Impact of complete revascularization in multi vessel
coronary artery disease (Meta-analysis)
Gracia S. et al JACC 2013
10. CTO as strongest predictor for incomplete revascularization in
patients with MVD in stable CAD
Bangalore S et al. Am J Cardiol. 2020 Feb
New York State Percutaneous Coronary Intervention Reporting
System (PCIRS) registry 2008 - 2011
15046 patients
11. Total occlusion predictors incomplete revascularization
in the PCI arm of SYNTAX
Farooq V et al., J Am Coll Cardiol 2013
12. 10years Outcomes: OMT vs. CTO PCI
Clinical Outcomes in the Propensity Score–Matched Population (78.9% MVD)
Park TK et al. J Am Heart Assoc. 2021 Mar
13. Impact of CTO on long-term prognosis in ischemic
systolic heart failure (<35%)
Tajstra et al, J AM Coll Cardiol Intv 2016:9:1790-7
14. Successful CTO PCI improves survival in patients with
reduced (≤40%) left ventricular ejection fraction
Toma A ,… Mashayekhi K. et al. Am J Cardiol 2017
15. Impact on the residual Syntax Score with
successful CTO PCI in patient with EF <35%
Improvement of LV-Function after
CTO PCI in patient with EF <35%
How to treat a patient with CTO and low ejection fraction?
Galassi, ….Mashayekhi et al, Jacc Int 2017
16. CTO PCI with EF <35%
14%
86%
Hemodynamic Support
With hemodynamic support
No hemodynamic support
8 2
0 5 10
IABP ECMO
=62pts
=10pts
17. When to consider hemodynamic support?
Coronary anatomy Clinical circumstances
Consider hemodynamic
support
Periprocedural Planing
(CT Angio, Heartteam)
Device selection
18. Algorithmn of James McCabe, MD University of Washington Seattle, WA
When to consider hemodynamic support?
19. • About 57 patients (2% of the overall CTO volume of these centers)
• The primary indication in the majority (78.9%) of cases was chronic angina;
• In 21.1% the primary indication was for chronic congestive heart failure because of an
ischemic cardiomyopathy.
• The median LVEF was 20% [15%-30%] and 63.2% were surgical turndowns.
• Significant proportions of the group underwent multivessel PCI (91.2%), intervention on
an unprotected left main or last remaining conduit vessel (35.1%), and/or atherectomy
(17.5%).
• Technical success was 87.7%.
• In-hospital procedural complications included: vascular injury (5.3%), all-cause death
(5.3%), major bleeding (3.5%), stroke (1.8%), and coronary perforation resulting in
tamponade (1.8%).
Impella-assisted CTO PCI : A multicenter retrospective analysis
Riley RF et al. Catheter Cardiovasc Interv. 2018 Dec 1;92(7):1261-1267
20. Mechanical Circulatory Support in CTO PCI:
Insights From a Multicenter U.S. Registry
Danek BA et al J Invasive Cardiol. 2018 Mar;30(3):81-87. PMID: 29493509.
1598 CTO: MCS was used electively in 69 procedures (4%) and urgently in 22 procedures (1%).
21. CT for evaluating the access side
Elective planning of vascular access
22. CT for subclavian access Plaque morphology
Elective planning of vascular access
27. Changed to a 14F Cook Sheet, with difficulties to advance
28. CHIP CTO CASE for EuroPCR 2021:
Angiographic Syntax Score = 90.5
29. Summary
• There are clinical and anatomical indications for supported CTO PCI
• Most patients with need for LV support are patients with multivessel disease and
low ejection fraction
• Complete revascularization may even improve long term outcomes in CTO patients
• CTO is the strongest predictor for incomplete revascularization
• Procedural planning, including MSCT is mandatory
• Protect IV trial is designed to show superiority of protected PCI compared to
conventional PCI and will give us more scientific background information
