CTO training for allMore operators are required to treat

more patients better

Javier Escaned MD PhD

Hospital Clínico San Carlos

Madrid / Spain

Which is the main difference?

On average, PCI willbe attempted in 99.9% of cases

On average, PCI willbe attempted in

…. ? cases

PCI difficulty(skills required)

Overall PCI success rate

Technical improvement and PCI skills

Non-CTO revascularization

“The great equalizer”

• PCI has been hugely simplified by standardization and better tools.

• Success rate is today >95% after a short learning curve, even in off-label contexts.

• On the contrary, CTOs constitutes a challenging PCI subset, with little adoption of proposed standardization approaches over the years.

• Success rates have remained low (50%) over decades for the non-trained operator, being a cause of frustration. Success rate in trained operators is 80-90%.

• Despite of the frequency of CTOs with a clinical indications for revascularization, patients with CTOs are largely undertreated with PCI.

• There is growing evidence that non-treated CTOs translate into worse patient outcomes.

Low CTO PCI success rates

PCI difficulty(skills required)

Overall PCI success rate

(most PCI operators)

Technical improvement and PCI skills

CTO revascularization

Success rateCTO operators

(minority)

• “Expert” clubs played a key role in standardization and consolidation of knowledge (J-CTO, EuroCTO, Hybrid Community)

• Success rate with these approaches is around 80-90% in overall CTO population

Technical improvement and PCI skills

CTO revascularization

1994

Technical improvement and PCI skills

CTO revascularization

1994 2014

Technical improvement and PCI skills

CTO revascularization

• Established interventionalists less prone to adopt new approaches, follow logistic recommendations or accept that a colleague focuses in CTO PCI.

• Consolidated habits and cathlab workflow in non-CTO PCI act as obstacles.

• Perception of “CTO experts” as elite guys who speak a complex jargon among themselves may deter interventionalists to embark in CTO treatment.

• Interventionalists are less challenged by CTOs than by other PCI subsets (bifurcations) in clinical practice

Obstacles to adoption of consolidated knowledge

• Success rate increases when more patients with CTOs are attempted according to consolidated knowledge.

• As success rate increases, more patients benefit from complete revascularization.

• This is followed by an increase in case volume, treatment reclassification and patient referrals.

Success rate influences CTO PCI adoption

expertbeginner

CTO difficulty

50% 80%

% of success

Success rate influences adoption

95%

expertbeginner

CTO difficulty

70%

% of success

More CTO

patients

treated

Success rate influences adoption

95%85%

Thompson et al: JACC:CI vol 2., No. 9, 2009

0

10

20

30

40

50

60

70

80

90

100

early 05 late 05 early 06 late 06 early 07 late

07/early08

Experienced retrograde operators

Non retrograde operators

P<0.0001

Pro

ce

du

ral S

uc

ce

ss

(%

)

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Success rate influences adoption

Learn, share, be proctored

Learn, share, be proctored

• Understand CTO PCI developments and terminology

• Perform adequate procedural planning

• Incorporate new skills and get a proper tool kit

• Grade CTO difficulty to match cases to your level of expertise

• Build your experience in a gradual fashion

• Ensure patient and PCI team safety

• Contribute to create a CTO culture in your cathlab

• Offer your patients with CTOs better treatment options

The Expert´s Live 2014 aims to help you to:

EuroCTO Club6th Experts "Live" Workshop 2014Septemper, 25th – 26th , 2014Madrid, Spain

Thank you for your attention