Post on 29-Aug-2019
Felkeretal,JAmCollCardiol,2002:39;210-218
CADis responsible for2/3of the casesof HFrEF
CTO in Heart FailureIschemic Heart Failure with reduced EF
CTO in Heart FailureRelevance of Chronic Total Occlusion
ChronicTotalOcclusion (CTO) isidentified inabout1/3ofallpatientsundergoing coronary angiograms forknownorsuspected CAD.AmHeartJ1993;126:561–4.ClinResCardiol2009;98:435–41.
Ofthesepatients, themajoritywillbetreatedmedically (64%)orarereferredforCABGsurgery (26%)whereasonly10%willbereferredforpercutaneous CTOrevascularization.TheCanadianMulticenterChronicTotalOcclusionsRegistry,J.Am.Coll.Cardiol.59(2012)991–997
IntheCOMMIT-HF single-center observational study,recruitingconsecutivenonselected patientshospitalizedwithadiagnosisofsystolicHF,oneormoreCTOofthemajorcoronaryarteries wasfoundin41.2%ofpatients.JAmCollCardiolIntv2016;9:1790–7
• InHFrEF achievingcompletefunctional revascularisation ofischaemicmyocardiumisthegoal.
• CTO isfrequent butistechnicallychallenging, andisthemostcommonreason forselectingcoronary arterybypasssurgery.ButCABGisnotalwaysanoption…
CTO in Heart FailureRelevance of Chronic Total Occlusion
CTO in Heart Failure
WHAT DO WE EXPECT FROM CTO-PCI IN HF?
Improvesymptoms
ImproveLVfunction
Improvesurvival
JournalofCardiovascularMagneticResonance(2016)18:78
29patientswithHFrEF(EF31%)andevidenceofviabilityand/orischemiainCTOterritory
NoPCIrelatedcomplicationsortype4MI
BNP(baselinevs6months)NYHAclass(baselinevs6months)
CTO in Heart Failure
WHAT DO WE EXPECT FROM CTO-PCI IN HF?
Improvesymptoms
ImproveLVfunction
Improvesurvival
CTO in Heart FailureCTO-PCI: improvement in LV function
Bucciarelli-Ducci etal.JAmCollCardiol Img2016
Bucciarelli-Ducci etal.JAmCollCardiol Img2016
CTO in Heart FailureCTO-PCI: improvement in Myocardial Perfusion Reserve
CTOterritory Remoteterritory
InternationalJournalofCardiology169(2013)147–152
Patientswith≥2ischemicsegments Improvementofviabledysfuctionalsegments
InternationalJournalofCardiology187(2015)90–96
Meta-analysisof12studiesperformedbetween1987–2014in846patients
CTO in Heart Failure
WHAT DO WE EXPECT FROM CTO-PCI IN HF?
Improvesymptoms
ImproveLVfunction
Improvesurvival
Eur.Heart J2012.33:768–775
Three-yearmortalityinpatientswithsingle-vessel disease(SVD)andmulti-vessel disease(MVD)accordingtothepresenceorabsenceofaCTO.
Eur.Heart J2012.33:768–775
Three-yearmortalityinpatientswithdouble-vessel diseaseandtriple-vessel diseaseaccordingtothepresenceorabsenceofaCTO.
CardiacsurvivalinCTO-PCIsuccesscomparedtoCTO–PCI failure.
Cardiacsurvivalinpatientswithcompletevsincompleterevascularization
CTO in Heart FailureImportance of complete revascularization
JAmCollCardiol Intv2016;9:1790–7
COMMIT-HFRegistry (consecutive nonselected patients hospitalized incardiologywardsandintensive cardiaccareunitswithadiagnosis ofsystolicHF)
CTO
Non-CTO
12monthmortality
InternationalJournalofCardiology187(2015)90–96
CTO in Heart FailureCTO-PCI: improvement in mortality
CTO in Heart FailureTake-Home Messages
ChronicTotalOcclusion (CTO) isidentified inabout40%ofallpatientsundergoing coronary angiograms forsystolicHF.
ThepresenceofaCTO isnotabenigncondition, itisassociatedwithworseprognosis.
CTO-PCI inpatientswithHFrEFwithviablemyocardium canbeperformedwithhighsuccessratesand lowcomplications rate.
CTO-PCI improvessymptomsandLVEF.CTO-PCI andmayprobably reducemortality inthesepatients,butthisremains tobeproven…
Thechallengewillbetocompare theresultsofPCIwithCABGandwithOMT inpatientswithHFrEFandmultivesseldiseaseandCTO.