Faut-il tenter une recanalisationvideos2.overcome.fr/.../mercredi/matisse/09h30/louvard.pdf · 2012-11-27 · T. Leong, Y. Louvard, ESC, AHA 2012 . Predictors of CTO PCI outcome:

Faut-il tenter une recanalisation

d’occlusion coronaire chronique ?

Yves Louvard

ICPS, Massy, France

Reduire l’angor, la dyspnée, l’ischémie…

Effectiveness of recanalization of CTO: systematic review / metaanalysis

Effect of successful versus failed CTO recanalization on residual / recurrent angina during FU

Joyal Am Heart J 2010;160:179-87

Quantifying the early health status benefits of successful CTO

recanalization

Grantham, Circ Cardiovasc Qual Outcomes. 2010;3:284-290

Effect of procedural success on adjusted health status outcomes among patients without

and with preprocedural angina

SAQ:Seattle Angina Questionnaire

Améliorer la fonction ventriculaire gauche…

Evaluation of Left Ventricular Function Three Years After

Percutaneous Recanalization of CTO

Improvement in SWT was related to (A) the TEI and (B) EDWT at baseline. Solid bars, SWT

before stent implantation; open bars, 5 months after revascularization; dotted bars, 3 years

after stent implantation. *p 0.05.

Kirschbaum Am J Cardiol 2008;101:179 –185

Resting 12-lead ECG as a reliable predictor of functional recovery after

recanalization of CTOs

Successful CTO recanalization: 127 pts, 62 pts with baseline impaired regional wall motion,

reocclusion in 8 patients. The 12-lead resting ECG was evaluated for Q-wave areas

Surber European Heart Journal (2006) 27, 2406–2412

WMSI (Wall Motion

Severity Index) Before procedure

Follow up

(5+1.4 months) p

No Q wave -2.92+0.28 -1.34+0.61 <0.001

Q wave -3.01+0.30 -2.81+0.32 ns

Absence of baseline Q waves at baseline predicted recovery of RWM

sensitivity 89%

specificity 67%

positive predictive value 68% (11% with Q waves)

Améliorer la stabilité électrique ?

Role of CTO in recurrence of ventricular arrhythmias in

ischaemic 1ary and 2ary prevention ICD recipients

Multivariate analysis:

CTO is a strong predictor of ICD therapy (HR 2.96: 1.9-4.6)

CV mortality / heart transplantation (HR 3.3: 1.3-7.9)

Nombela Franco EHJ 2010; 31: 891-892

log-rank=0.003 log-rank=0.001

331 pts, 155 with > one CTO, ICD (1ary

prevention in 53%)

Ventricular arrhythmias among Implantable Cardioverter-Defibrillator recipients

for primary prevention: impact of coronary CTO (VACTO Primary Study)

Nombela Franco, Circ Arrhythm Electrophysiol. 2012;5:147-154

Appropriate device therapy in 3 VD compared to 1- 2 VD (left) in the global population and after

adjusting for CTO (right)

90 non CTO

71 CTO

Revasculariser completement

Effect of CTO on treatment strategy (n= 3087)

Christofferson Am J Cardiol 2005; 95: 1088-1091

Impact of Completeness of PCI Revascularization on Long-

Term Outcomes in the Stent Era: Survival

Hannan Circulation 2006;113;2406-2412

Augmenter la survie

… sans infarctus

… sans chirurgie



Effect of successful versus failed CTO recanalization on all-cause mortality during FU

13 studies, n= 7288, published 1990-2008, balloon-stents


Effect of successful versus failed CTO recanalization on MI during FU



Effect of successful versus failed CTO recanalization on CABG during FU


Successful Recanalization of CTO Is Associated With

Improved Long-Term Survival

Jones, J Am Coll Cardiol Intv 2012;5:380–8

Univariate and Multivariate Analysis of Predictors of Mortality After PCI for CTO

Survival Following Successful PCI of CTO: Variability by Target Vessel

Safley J. Am. Coll. Cardiol. Intv. 2008;1;295-302

Survival Following Successful Versus Failed CTO PCI

RR of a MACE and TVR associated with DES and BMS use

Colmenarez J Am Coll Cardiol 2010;55:1854–66

Efficacy / Safety of DES in CTO : Systematic Review and Meta-Analysis

RR of restenosis and stent reocclusion with DES and BMS use




RR of ST associated with DES and BMS use


Ameliorer la tolérance aux futurs evènements

aigus

Impact of a CTO in a non-IRA in pts with STEMI and MVD: 2 years survival

Moreno R, Am J Cardiol. 2007 Feb 1;99(3):429-30

Group 1: SVD, group 2: MVD CTO -, group 3: MVD CTO +

n= 345

n= 201

n= 84

N= 630

The Impact of a Chronic Total Occlusion in STEMI

TCT 2007

Claessen, van der Schaaf, Henriques et al, AHA 2008

Time in years

Mo

rta

lity

(%

) 30

20

10

1 2 3 4 5 0

MVD: 26%

SVD: 14%

40 CTO: 38%

MVD no CTO: 20%

Impact of a CTO in STEMI

n= 3277

Mort

alit

y (

%)

Time in years

25

20

5

10

15

0 4 3 2 1 5

CTO: 19%

MVD: 14%

SVD 10%

MVD no CTO: 12%

Impact of a CTO in STEMI Long term mortality excluding 30 day death

Claessen, van der Schaaf, Henriques et al, AHA 2008

n= 3277

Impact of CTOs on Markers of Reperfusion, Infarct Size, and Long-Term Mortality:

from the TAPAS-Trial

Lexis, CCI 2011; 77:484–491

Cardiac death

N= 976

N= 90

N= 1066

5 Years outcomes of pts with/without CTO of Non-IRA after primary PCI for

STEMI

Tajstra, Am J Cardiol 2011;xx:xxx)

N= 1654

Impact of a CTO in a non-IRA in STEMI: 3-year results (HORIZONS-AMI)

Claessen, European Heart Journal (2012) 33, 768–775

Mortality between 0–30 days and 30 days–3 years

30d mortality : CTO vs. SVD, P < 0.0001; MVD wo a CTO vs. SVD, P < 0.0001; CTO vs. MVD wo a CTO, P = 0.02;

30d-3y mortality: CTO vs. SVD, P < 0.0001; MVD wo a CTO vs. SVD, P = 0.20; CTO vs. MVD wo a CTO, P < 0.0001.

N= 3254

Prevalence, predictors and clinical impact of unique and

multiple CTO in non-IRA in patients presenting with STEMI

Bataille, Heart, October 2, 2012

Survival Curve of Patients After Primary PCI According to the Presence of CTO

N= 2020

Impact of successful staged revascularization of a CTO in the non-IRA

on long-term outcome in patients with acute STEMI

Zhen Kun Yang, International Journal of Cardiology xxx (2011)

Cardiac survival at 2 years / outcome of attempted recanalization of a CTO in the non-IRA

Quel est le prix a payer ?

Outcomes of contemporary PCI in patients with CTO: J-CTO Registry

Morino, J. Am. Coll. Cardiol. Intv. 2010;3;143-151

Complications and In-Hospital Outcomes

In-hospital outcomes of contemporary PCI in patients with

CTO: J-CTO Registry


Frequency Distribution of Total Contrast Volume Used During the Procedures

In-hospital outcomes of contemporary PCI in patients with

CTO: J-CTO Registry


Frequency Distribution of Total Fluoroscopic Time Comparing Procedural Success and Failure

Radiation exposure to patient’s skin during PCI for various lesions,

including chronic total occlusion

Suzuki Circ J 2006; 70: 44 – 48

CTO PCI procedural datas: 1508 procedures (2004-2011, 14 operators)

0

50

100

150

200

250

300

350

400

2004 2005 2006 2007 2008 2009 2010 2011

Contrast volume (ml) Duration (min) X-Ray duration (min)

Predictors of acute CT0 PCI outcome: multivariable logistic regression

Successful PCI OR 95% CI P value

Tapered morphology 1.36 1.03, 1.78 <0.001

Lesion length (per 1 mm increase) 0.97 0.97, 0.98 <0.001

Operator experience (per 50 cases) 1.13 1.06, 1.19 <0.001

Previous CABG 0.44 0.29, 0.68 <0.001

Calcification 0.74 0.65, 0.84 <0.001

Previous MI 0.67 0.50, 0.88 0.005

Stump visible 1.51 1.12, 2.06 0.008

Age (per year increase) 0.99 0.98, 0.99 0.03

Any Tortuosity 0.72 0.53, 0.98 0.04

Male sex 0.76 0.52, 1.10 0.15

Previous Attempt 0.74 0.47, 1.14 0.17

T. Leong, Y. Louvard, ESC, AHA 2012

Predictors of CTO PCI outcome: operator experience and success

T. Leong, Y. Louvard, ESC, AHA 2012

Conclusion

Faut-il tenter une recanalisation

d’occlusion coronaire chronique ?

Yves Louvard

ICPS, Massy, France

Quand réaliser

Quand et comment désobstruer une CTO ?

• Symptomes et/ou ischémie étendue

• Viabilité et ischémie démontrées et localisées (IRM)

• Faisabilité (scores)

• Opérateur dédié

• Enjeu / difficulté

EUROCTO A Randomized Multicentre Trial to Evaluate the Utilization of

Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions

Study Protocol

-Multicenter European randomized trial (n= 1200)

-Optimal medical treatment (COURAGE) / PCI attempt

-1/3 versus 2/3

-Quality of life at one year

-Death / MI at 36 months

ONGOING

EURO CTO CLUB

5th Experts "Live" Workshop

September, 27th – 28th, 2013

www.eurocto.eu

Documents

Faut-il tenter une recanalisationvideos2.overcome.fr/.../mercredi/matisse/09h30/louvard.pdf · 2012-11-27 · T. Leong, Y. Louvard, ESC, AHA 2012 . Predictors of CTO PCI outcome: