11:00 Trends and spin-offs from the EuroCTO Registry Kambis Mashayekhi (Lahr - D) _____________________________________________ PARALLEL SESSION Cto & Chip Regitries & Trials Auditorium Zubin Mehta - Friday 11:00 - 12:00 Chairpersons: Paul Knaapen (Amsterdam - NL), Gennaro Sardella (Rome) Discussants: Björn Billmann (Wolfenbuettel - D), Laurent Drogul (Nice - F), Sergey Furkalo (Kiev - UA), Maciej Lesiak (Poznan - PL) ___________________________________________ 15th Experts Live CTO, EUROCTO Club meeting in partnership with the GISE CTO meeting. September 8th - 9th, 2023 Florence, Italy

1. Trends and results
from the EuroCTO Registry
(ERCTO)
Kambis Mashayekhi.
Heart Center Lahr

2. Potential conflicts of interest:
Speaker: Dr. Kambis Mashayekhi
I have the following potential conflicts of interest to declare:
• Personal: None
• Institutional: Speaker honoraria, consultancy fees, and
research grants from Abbott, Abiomed, Asahi Intecc,
Astra Zeneca, Biotronik, Boston, Cardinal Health,
Daiichi-Sankyo, Medtronic, Philips Healthcare
Shockwave, SIS, Teleflex, Terumo.

3. Di Mario
When the club was formed, the data analysis was one of its core goals

4. … in order to advance the application of CTO PCI
• European CTO registry founded in 2008
• Consensus white papers to state the current approach to indicate and perform
CTO PCI
• Euro CTO trial conducted between 2013-2018, the first randomized trial to
compare OMT or PCI for the treatment of a CTO as the only remaining relevant
lesion

5. ERCTO 2008-2023: >50000 procedures recorded
www.ercto.org

6. ERCTO analysis – back to 2011
1) Galassi AR et al. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry.
EuroIntervention. 2011 Aug;7(4):472-9. doi: 10.4244/EIJV7I4A77

7. First reports on the retrograde approach based on ERCTO

8. Documentation of steady improvement of success rates over the years

9. Prediction of procedural success: The EuroCTO CASTLE Score

10. Prediction of retrograde success: Operator experience

11. Radiation exposure as procedural risk: improvement through education
Original Contribution
Radiation Exposure for Percutaneous
Interventions of Chronic Total
Coronary Occlusions in a Multicenter
Registry:The Influence of Operator
Variability and Technical Set-up
Gerald S. Wern er, MD1
; Alexan dre Avran , MD2
; Kam bis Mash ayekh i, MD1
;
Joerg Reifart , MD4
; Alfredo R. Galassi, MD5
; Nicolas Boudou, MD6
;
Markus Meyer-Gessn er, MD7
; Robert o Garbo, MD8
; Joach im H. Buet t n er, MD3
;
Alexan der Bufe, MD9
; Jam es C. Sprat t , MD10
; Leszek Bryn iar ski, MD11
;
Art is Kaln in s, MD12
; Aigars Lism an is, MD13
; Evald H. Ch rist ian sen , MD14
;
Vict oria Mart in -Yust e, MD15
; Karl Isaaz, MD16
; Georgios Sian os, MD17
;
An drea Gagn or, MD18
; Carlo di Mario, MD19
; David Hildick-Sm it h , MD20
;
An t on io Serra, MD21
; Luca Gran cin i, MD22
; Nicolaus Reifart , MD4
Abstract
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WERNER, et a l .
t r en d s in r a d iat io n expo s ur e f o r c t o -pc i
f igur e 1. e average air kerma plotted against the average uoroscopy time in (A) 2012 and (B) 2017. e values of 19 operators are shown who con-
tributed to thedataset in bo th 2012 and 2017.
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12. The EuroCTO trial: The rational for CTO PCI
•Improvement of clinical symptoms
• Relief of angina and physical capacity
•Improvement of LV function
•Improved prognosis ?
•But what can we realistically test in a RCT ?!!

13. EuroCTO: More patients free of angina, better symptom control, quality of life
and exercise capacity
0
10
20
30
40
50
60
70
80
90
100
Physical limitation ≥8 Anginal frequency ≥20 Freedom of angina (100%) Quality of life ≥16
OMT PCI
Higher score, better health status

14. Survival free of MI or cardiovascular death
OMT PCI P-value
Cardiac Death (%) 2.2 3.1 0.75
MI (%) 1.5 3.1 0.33
OMT PCI P-value
Cardiac Death (%) 2.9 2.4 0.76
MI (%) 2.9 2.4 0.76
1 2 3 1 2 3
OMT
PCI
OMT
PCI
1 2 3 1 2 3
P=0.64
P=0.28
OMT 137 137 131 85
PCI 259 249 237 124
OMT 140 138 132 85
PCI 254 248 236 124
Figure 3
1 2 3 1 2 3
OMT
PCI
OMT
PCI
1 2 3 1 2 3
P=0.64
P=0.28
OMT 137 137 131 85
PCI 259 249 237 124
OMT 140 138 132 85
PCI 254 248 236 124
Figure 3

15. MACCE free survival in EuroCTO trial
OMT
PCI
OMT
PCI
1 2 3 1 2 3
P<0.001
P=0.01
OMT 137 127 113 71
PCI 259 239 224 113
OMT 140 128 114 71
PCI 254 238 223 113
Figure 4

16. Failed PCI vs OMT vs successful PCI
OMT Failed
PCI
Successful
PCI
Primary endpoint (%) 5.7 12.2 3.6
MACCE (%) 22.9 15.2 8.6

17. Lessons learned from EuroCTO trial
• In RCT only less symptomatic patients are included if the alternative is
OMT vs PCI
• CTO PCI requires best possible success rates, but expert operators have
difficulties to randomise referred patients
• Mortality improvement cannot be the primary goal of therapy in stable
angina
• Improving the QoL is a valid goal of a physician‘s intervention for
symptomatic chronic coronary syndrome