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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
Effectiveness of recanalization of CTO: systematic review / metaanalysis
Joyal Am Heart J 2010;160:179-87
Effect of successful versus failed CTO recanalization on all-cause mortality during FU
13 studies, n= 7288, published 1990-2008, balloon-stents
Effectiveness of recanalization of CTO: systematic review / metaanalysis
Effect of successful versus failed CTO recanalization on MI during FU
Joyal Am Heart J 2010;160:179-87
Effectiveness of recanalization of CTO: systematic review / metaanalysis
Effect of successful versus failed CTO recanalization on CABG during FU
Joyal Am Heart J 2010;160:179-87
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
Colmenarez J Am Coll Cardiol 2010;55:1854–66
Efficacy / Safety of DES in CTO : Systematic Review and Meta-Analysis
Colmenarez J Am Coll Cardiol 2010;55:1854–66
RR of ST associated with DES and BMS use
Efficacy / Safety of DES in CTO : Systematic Review and Meta-Analysis
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
Morino, J. Am. Coll. Cardiol. Intv. 2010;3;143-151
Frequency Distribution of Total Contrast Volume Used During the Procedures
In-hospital outcomes of contemporary PCI in patients with
CTO: J-CTO Registry
Morino, J. Am. Coll. Cardiol. Intv. 2010;3;143-151
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
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