Alfredo R. Galassi - How to deal with very LVEF: the last remaining option to improve survival in specific conditions

EURO CTO CLUBKrakow 2016

8th Experts "Live"

CTO Workshop 2016Sept 30th – Oct 01st, 2016

Alfredo R. Galassi MD, FESC, FACC, FSCAI

Department of Clinical and Experimental MedicineUniversity of Catania, Italy

How to deal with very LVEF: the last

remaining option to improve survival in

specific conditions

Indications of CTO revascularization

Galassi et al, Eur Heart J 2015

Potential time-dependent pathway of

dysfunctional myocardium

Wilcox JE et al, JACC 2015

How to deal with CTO in patients with

depressed LVF

Are there clinical symptoms?

- Relief of angina and myocardial ischemia

- Relief of heart failure symptoms

Is the myocardium viable?

Could we increase prognosis?

PCI or CABG for CTOs in case of MVD?

Case Summary

Clinical presentation: unstable angina + dyspnea NYHA III

Risk factors: smoker, diabetes type II, hypertension

2 D Echo:LVEF 24% midventricular inferolateral akinesia

global hypokinesia in the other segments

Target vessel: Mid RCA CTO

Septal collaterals from LAD and epicardial collaterals from LCx for RCA

Ostial LM stenosis Mid LAD stenosis

Ostial and proximal stenosis of OM2

62 year-old male

Ventriculography

LVEF 20-25%

Ischemia / Viability Assessment

Ischemia in LAD and RCA areas with

preserved viability

Stress/Perfusion Late Gadolinium

Inferolateral scar (distal segment)

Treatment Strategy

Euroscore 6

Logistic Euroscore II 2.41%

Syntax score 35

J-CTO score for CTO lesion 3

Heart Team Decision Surgical revascularization

However the patient refused surgery

staged PCI was proposed

RCA CTO revascularization

Double femoral 7Fr access

IABP Support

Failed Initial Antegrade Approach

Finecross (Terumo)

Fielder XT-R(Asahi)

1 DES implantation in proximal RCA

1 DES implantation in LM

Retrograde Approach(Hybrid Approach)

Retrograde Approach(Hybrid Approach)

Retrogradely

Corsair (Asahi)

Sion (Asahi)

Antegradely

Finecross (Terumo)

Fielder XT-R(Asahi)

Retrogradely

Corsair (Asahi)

Sion (Asahi)

Antegradely

Finecross (Terumo)

Fielder XT-R (Asahi)

Stent Facilitated Reverse CART Technique

Retrograde Approach(Reverse CART technique)

Angiographic Final Result

3 DES implantation

LAD PCI

1 DES implantation

Optimization of LM stenting by IVUS

Follow-upUneventful 6 month follow-up period

No angina, dyspnea (from NYHA III to NYHA II)

Baseline

LVEF 24%

At 6 months

LVEF 36%

Ventriculography

Baseline At 6 months

LVEF 24% LVEF 36%

Systematic Angiographic Control(6 months)

Intra-stent focal restenosis of mid RCA

Good result on LM and LAD

Stenosis of ostial and proximal OM 2 previously left untreated

PCI of RCA

1 DES implantation

PCI of LCx

Complete revascularization was attained

1 DES implantation

CTO PCI in patients with MVD and low EF

1. Viability / Ischemia assessment

2. Hemodynamic support during PCI

3. Procedural Tips & Tricks

4. Complete vs. Incomplete revascularization

5. Follow-up






5. Follow-up

Viability / Ischemia Assessment

Preserved LVEF Impaired LVEF

CTO territory

Necrotic or ischemic non-CTO related territory

Symptoms

QOLPrognosis

Symptoms

QOL

Prognosis






5. Follow-up

Hemodynamic Support and More

Use of LV support devices is recommended

Need for hemodynamic support is mandatory in

“retrograde approach (use of donor arteries and

collaterals)

Do not hesitate to use temporary pacing

Subset of patients unable to tolerate complications

(minor pericardial leakage due to coronary perforation

may result in cardiogenic shock)

Hemodynamic Support

Hemodynamic Support and More

Use of LV support devices is recommended (IABP,

ECMO, Impella, Tandem Heart)

Need for hemodynamic support is mandatory in

“retrograde approach (use of donor arteries and

collaterals)

Do not hesitate to use temporary pacing

Subset of patients unable to tolerate complications

(minor pericardial leakage due to coronary perforation

may result in cardiogenic shock)






5. Follow-up

Procedural Tips & Tricks

Example of possible accesses

- Right femoral: a guiding catheter for RCA

- Left femoral: IABP and pacing

- Right radial: a guiding catheter for LCA

Both antegrade and retrograde are feasible

If LVDd is 70mm, consider a retrograde short

guiding catheter to bring a retrograde 150cm Corsair

into an antegrade guiding catheter (even through

septal connections). When CTO is located in RCA,

right brachial approach is preferred for a retrograde

short guiding catheter into LCA

Objective

To be less traumatic as possible

“Loose Tissue Tracking Concept”

by new soft double coil polymeric wires

o

Galassi et al, Eur Heart J 2014

Case Summary

Clinical Presentation: NSTEMI complicated by VF and cardiac arrest

67 year-old male

Risk Factors Smoker Diabetes type II Hypertension

2-D Echo: LVEF 18%

CTOs of 3 vessels (LAD, LCx, RCA)

Bad candidate for surgery(very low EF and small diseased vessels with poor distal visualization)

PCI of RCA


ECMO hemodynamic support

Baseline Final result

PCI of LAD and LCx

Baseline Final resultFielder XT-R (Asahi)


PCI of LAD and LCx



Follow-up

Uneventful 12-month follow-up period

Patient asymptomatic

Improvement of LVEF (from 18% to 35%)

at 6 month follow-up






5. Follow-up

Revascularization Strategy

All non-CTO lesions need to be treated before hand

(consider viability)

Do not hesitate to consider staged revascularization

strategy in two procedures

Revascularization strategy should be functional

deriving from viability/ischemia assessment

In presence of multiple CTOs:

- Start with the “easiest” CTO lesion (J-CTO score)

- 1 CTO lesion/procedure (might facilitate other CTO treatment

by increase collateral flow, better distal visualization, better

tollerance to CTO

Sohn et al. J Korean Med Sci 2014

Généreux et al. Am J Cardiol 2014

SRI = SYNTAX Revascularization Index

SRI=100% (complete revascularization),

SRI<100% to 50%, and SRI <50%






5. Follow-up

During In-hospital Stay

Multidisciplinary team

Fragile patients requiring careful attention

and monitoring

Control of comorbidities ++++

- Diabetes

- Infections

- Electrolytes

Close clinical controls at 1, 3, 6, 12 months

We recommend systematic angiographic

control

- High rate of asymptomatic re-stenosis

- Long stented segments

- Susceptibility to any further ischemic events

Control of comorbidities ++++

Follow-up

From January 2013 to December 2015839 CTO patients attempted percutaneously

LVEF≥50%552 patients (65.8%)

LVEF 35-50%215 patients (25.6%)

LVEF≤35%72 patients (8.6%)

Successful CTO PCI66 patients (91.7%)

Failed CTO PCI6 patients (8.3%)

Clinical follow-up66 patients (100%)17.6±10.2 months

Angiographic follow-up49 patients (74.2%)

Flow ChartMulticentric Prospective Study

All 839 patients

LVEF≥50%552 patients

(Group 1)

LVEF 35-50%215 patients

(Group 2)

LVEF≤35%72 patients(Group 3)

Age, years, mean ± SD 64.6 ± 10.5 63.8 ± 10.2 65.8 ± 11.3* 66.4 ± 10

Age ≥ 75 years, n (%) 163 (19.4) 85 (15.4) 58 (27)* 20 (28.8)†

Males, n (%) 736 (87.7) 475 (86.1) 195 (90.7) 66 (91.7)

Diabetes, n (%) 252 (30) 152 (27.5) 67 (31.2) 33 (45.8)†‡

Smokers, n (%) 447 (53.3) 289 (52.4) 116 (54) 42 (58.3)

Hypertension, n (%) 695 (82.8) 455 (86.1) 179 (83.3) 61 (84.7)

Dyslipidemia, n (%) 607 (72.3) 385 (69.7) 174 (80.9)* 48 (66.7)†‡

BMI , kg/m2 , mean ±SD 28.6 ± 4.5 28.6 ± 4.5 28.9 ± 4.4 27.3 ± 4.2‡

Peripheral artery disease, n (%) 129 (15.4) 66 (12) 46 (21.4)* 17 (23.6)†

Chronic kidney disease, n (%) 130 (15.5) 68 (12.3) 44 (20.5)* 18 (25)†

Prior MI, n (%) 358 (42.7) 197 (35.7) 118 (54.9)* 43 (59.7)†

Prior PCI, n (%) 287 (34.2) 186 (33.7) 84 (39.1) 17 (23.6)‡

Prior CABG, n (%) 141 (16.8) 77 (13.9) 50 (23.3)* 14 (19.4)

Prior stroke, n (%) 13 (1.5) 6 (1.1) 5 (2.3) 2 (2.8)

Three-vessel disase, n (%) 370 (44.1) 211 (38.2) 117 (54.4)* 42 (58.3)†

> 1 CTO, n (%) 40 (4.7) 18 (3.2) 13 (6.9)* 9 (12.5)†

* Group 1 vs. Group 2, p<0.05 / † Group 2 vs. Group 3, p<0.05 / ‡ Group 1 vs. Group 3, p<0.05

Clinical characteristics

All 839 patients


(Group 1)


(Group 2)


Target CTO artery, n (%)LADLCxRCA

222 (26.5)123 (14.7)494 (58.9)

151 (27.4)76 (13.9)

325 (58.9)

55 (25.6)30 (14)

130 (60.4)

16 (22.2)17(23.6)39 (54.2)

Blunt Stump, n (%) 506 (60.3) 330 (59.8) 126 (58.6) 50 (69.4)

Bending >45°, n (%) 265 (31.6) 180 (32.6) 64 (29.8) 21 (29.2)

Severe Calcifications, n (%) 234 (27.9) 155 (28.1) 59 (27.4) 20 (27.8)

CTO length, mm, mean ± SD 42.2 ± 29.2 42.6± 29.6 42.5 ± 29 39 ± 27.3

CTO length ≥20mm, n (%) 674 (80.3) 441 (79.9) 179 (83.3) 56 (77.8)

Ostial location, n (%) 111(13.2) 68 (12.3) 31 (14.4) 48 (66.7)

In-stent CTO, n (%) 56 (6.7) 33 (6) 15 (7) 8 (11.1)

Previous attempt, n (%) 255 (30.4) 190 (34.4) 49 (22.8) 16 (22.2)†

Collateral filling Rentrop 2-3, n (%) 574 (68.4) 388 (70.3) 148 (68.8) 38 (52.8)†‡

J-CTO score ≥3, n (%) 402 (47.9) 273 (49.5) 97 (45.1) 32 (44.4)

ORA score ≥3, n (%) 103 (12.3) 53 (9.6) 35 (16.3)* 15 (20.8)†

Angiographic characteristics

* Group 1 vs. Goup 2, p<0.05 / † Group 2 vs. Goup 3, p<0.05 / ‡ Group 1 vs. Goup 3, p<0.05

0

20

40

60

80

100

All LVEF ≥50% LVEF 35-50% LVEF ≤ 35%

93.6 93.5 94.491.7

Su

ccess

rate

(%

)All p=NS

Procedural Success

0%

20%

40%

60%

80%

100%


Retrograde only Hybrid Antegrade only

55.9 55.1 59.551.4

19.414.41917.9

26.2 25.9 26.1 29.2

All p=NS

Recanalization Techniques

0%

20%

40%

60%

80%

100%


Dissection reentry True to True lumen

28.9 25.436.4 33.3

71.1 74.6

64.6 66.7

All p=NS

Recanalization Techniques

All 839 patients


(Group 1)


(Group 2)


Procedural Time, min, mean ± SD 118.1 ± 75.5 119 ± 75.3 118.1 ± 79.2 110.5 ± 61.9

Fluoroscopy time, min, mean ± SD 57.1 ± 39.2 57 ± 38.2 57.9 ± 43 54.8 ± 35.3

Contrast Load, ml, mean ± SD 358 ± 206.5 369.9 ± 213.9 349.1 ± 197.7 295.6 ± 159 †‡

Radiation Dose, mGy, mean ± SD3497.2 ± 2539 3578.8 ± 2574.6 3341.9 ± 2299.4 3335.3 ± 2854.6

* Group 1 vs. Goup 2, p<0.05† Group 2 vs. Goup 3, p<0.05‡ Group 1 vs. Goup 3, p<0.05

Procedural Details

All 839 patients


(Group 1)


(Group 2)


Coronary Perforation, n (%) 34 (4) 25 (4.5) 6(2.8) 3 (4.2)

Tamponade, n (%) 13 (1.5) 8 (1.4) 5 (2.3) 0

Death, n (%) 0 0 0 0

Non Q wave MI, n (%) 7 (0.8) 3 (0.5) 4 (1.9) 0

Q wave MI, n (%) 2 (0.2) 2 (0.4) 0 0

Stent thrombosis, n (%) 2 (0.2) 1 (0.2) 1 (0.5) 0

Stroke, n (%) 0 0 0 0

Need for emergency CABG, n (%) 1 (0.1) 1 (0.2) 0 0

All p=NS

Immediate Outcomes

CTO Patients with EF<35%

LV assistance device

62pts86.2%

10pts13.8%

No LV assistance device LV assistance device

8 2

IABP ECMO

Patients CTO Patients with EF<35%successfully revascularized

Improvement in LVEF

29.1

41.6

0

10

20

30

40

50

before CTO PCI after CTO PCI

FU 17.6 ± 10.2 months

P<0.001

Range

(17 – 34)

%

1

0.8

0.6

0.4

0.2

0

0 6 12 18 24 30 36

MA

CC

E f

ree s

urv

ival

Follow-up (months)

Patients(N=49)

Restenosis, n (%) 4 (8.2)

Focal Restenosis, n (%), 4 (8.2)

Diffuse Restenosis, n (%) 0

Re-occlusion, n (%) 0

CTO Patients with EF<35%

Clinical Outcome

No impact of LV assistance device use

Take Home Messages

In experienced hands, CTO PCI is efficient and

safe in patients with low EF<35%

PCI in very low LVEF patients is very often the

last «chance»

Successful CTO PCI might improve

- LVEF

- Clinical outcome +++

Thank You

For Your Attention

www.alfredogalassi.com

Health & Medicine

Alfredo R. Galassi - How to deal with very LVEF: the last remaining option to improve survival in specific conditions