Abstract image of a woman sitting on books and studying on a laptop

A.Bufe - Session1 - Ischemia and Viability - How to select the right patient

E
Euro CTO Club

1) The document discusses strategies for selecting the right patients for recanalization of a chronic total occlusion (CTO), including evaluating ischemia, viability of myocardium, and prognostic factors. 2) It reviews evidence from studies on the outcomes of CTO recanalization in different patient groups, such as those with low ejection fraction. 3) The key factors discussed for selecting patients include evaluating ischemic burden through stress testing, assessing viability through cardiac MRI, and aiming for complete revascularization of still viable myocardium.

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A. Bufe Helios Klinikum Krefeld - Heartcenter Dep. of Cardiology and Intensive Care Ischemia and Viability – How to select the right patient
A.Bufe - EuroCTO Club 2020 Berlin I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation Disclosure Statement of Financial Interest
Why should we recanalize a CTO ? A.Bufe - EuroCTO Club 2020 Berlin
CTO-Patients are often severely symptomatic (exertional dyspnoe, angina pectoris, physical impairment) A.Bufe - EuroCTO Club 2020 Berlin
CTO-Patients often have a poor prognosis A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin 1 vessel disease Patient is severely symptomatic, AP CCS III Normal LV-function Do we really need ischaemia test?
n = 1000 Success rate 86% A.Bufe - EuroCTO Club 2020 Berlin Sapontis et al., JACC Cariovasc Intv 2017
EURO-CTO Study Success Failure Decision as per usual clinical care Medical Rx CABG Ongoing angina despite OMT* Clinically indicated interim PCI Repeat Exercice Tolerance Test (ETT) for objective assessment of ischaemia @ 12m and 36months Single-vessel disease CTO only Multivessel CAD including CTO Treat non-occlusive disease by PCI before CTO with DES Angina or angina- equivalent symptoms Randomisation 2:1 PCI with DES + OMT n=800 2 OMT to include: - Aspirin, - Statin, - ACE-inhibitor where tolerated - + up to 2 anti-anginal agents at max tolerated dose including rate- limiting agent where appropriate. Ischaemic symptoms should be confirmed with non-invasive test. OMT n=400 1 A.Bufe - EuroCTO Club 2020 Berlin Efficacy: Quality of Life @ 12 and 36 months Safety: Death, non-fatal myocardial infarction (ITT, PP) @ 36 months
A.Bufe - EuroCTO Club 2020 Berlin Werner et al., EHJ 2018
A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin Bangalore et al., Circulation 2020; 142:841-857
A.Bufe - EuroCTO Club 2020 Berlin
Werner et al., TCT 2019 A.Bufe - EuroCTO Club 2020 Berlin
Werner et al., TCT 2019 A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin Lee et al, Decision CTO Study, Circulation 2019;139:1674-1683
A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin n = 19088 Multicenter registry - propensity score - mulivariable analysis Azadani et al., JACC Cardiovac Img 2020 SPECT MPI
A.Bufe - EuroCTO Club 2020 Berlin ESC Guidelines 2018
A.Bufe - EuroCTO Club 2020 Berlin CTO LCX 1 vessel disease No symtoms
A.Bufe - EuroCTO Club 2020 Berlin Rest 30yg 20yg 40yg Dobutamin Stress-MRI
A.Bufe - EuroCTO Club 2020 Berlin 6.389 patients Revascularization was associated with a protective effect only in the subset of extensive CMR-related ischaemia Extensive ischaemic burden was related to a higher risc of long term mortality 516/516 matched patients
A.Bufe - EuroCTO Club 2020 Berlin LAD-Stenoses RCA-CTO RCA distal NSTEMI anterior wall Hypokinesia anterior and severe Hypokinesia inferior (EF 38%)
Claessen et al., EHJ 2012;33:768-775 A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin epicardial collaterals Stents septal collaterals
A.Bufe - EuroCTO Club 2020 Berlin reverse CART Subendocardial Scar inferior MRI for viability
A.Bufe - EuroCTO Club 2020 Berlin Complete Revascularization in viable myocardium
A.Bufe - EuroCTO Club 2020 Berlin Metha et al., NEJM 2019; 381:1411-1421
A.Bufe - EuroCTO Club 2020 Berlin
A.Bufe - EuroCTO Club 2020 Berlin Galassi, Mashajekhi et al., J Am Coll Cardiol Intv 2017 n = 839 PCI of CTO in patients with low EF
A.Bufe - EuroCTO Club 2020 Berlin n = 72 Galassi, Mashajekhi et al., J Am Coll Cardiol Intv 2017 PCI of CTO in patients with low EF
A.Bufe - EuroCTO Club 2020 Berlin Conclusion Galassi et al., EuroCTO Club consensus document, Eurointervention 2019
A.Bufe - EuroCTO Club 2020 Berlin Thank you
A.Bufe - EuroCTO Club 2020 Berlin Thank you

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A.Bufe - Session1 - Ischemia and Viability - How to select the right patient

  • 1. A. Bufe Helios Klinikum Krefeld - Heartcenter Dep. of Cardiology and Intensive Care Ischemia and Viability – How to select the right patient
  • 2. A.Bufe - EuroCTO Club 2020 Berlin I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation Disclosure Statement of Financial Interest
  • 3. Why should we recanalize a CTO ? A.Bufe - EuroCTO Club 2020 Berlin
  • 4. CTO-Patients are often severely symptomatic (exertional dyspnoe, angina pectoris, physical impairment) A.Bufe - EuroCTO Club 2020 Berlin
  • 5. CTO-Patients often have a poor prognosis A.Bufe - EuroCTO Club 2020 Berlin
  • 6. A.Bufe - EuroCTO Club 2020 Berlin
  • 7. A.Bufe - EuroCTO Club 2020 Berlin 1 vessel disease Patient is severely symptomatic, AP CCS III Normal LV-function Do we really need ischaemia test?
  • 8. n = 1000 Success rate 86% A.Bufe - EuroCTO Club 2020 Berlin Sapontis et al., JACC Cariovasc Intv 2017
  • 9. EURO-CTO Study Success Failure Decision as per usual clinical care Medical Rx CABG Ongoing angina despite OMT* Clinically indicated interim PCI Repeat Exercice Tolerance Test (ETT) for objective assessment of ischaemia @ 12m and 36months Single-vessel disease CTO only Multivessel CAD including CTO Treat non-occlusive disease by PCI before CTO with DES Angina or angina- equivalent symptoms Randomisation 2:1 PCI with DES + OMT n=800 2 OMT to include: - Aspirin, - Statin, - ACE-inhibitor where tolerated - + up to 2 anti-anginal agents at max tolerated dose including rate- limiting agent where appropriate. Ischaemic symptoms should be confirmed with non-invasive test. OMT n=400 1 A.Bufe - EuroCTO Club 2020 Berlin Efficacy: Quality of Life @ 12 and 36 months Safety: Death, non-fatal myocardial infarction (ITT, PP) @ 36 months
  • 10. A.Bufe - EuroCTO Club 2020 Berlin Werner et al., EHJ 2018
  • 11. A.Bufe - EuroCTO Club 2020 Berlin
  • 12. A.Bufe - EuroCTO Club 2020 Berlin Bangalore et al., Circulation 2020; 142:841-857
  • 13. A.Bufe - EuroCTO Club 2020 Berlin
  • 14. Werner et al., TCT 2019 A.Bufe - EuroCTO Club 2020 Berlin
  • 15. Werner et al., TCT 2019 A.Bufe - EuroCTO Club 2020 Berlin
  • 16. A.Bufe - EuroCTO Club 2020 Berlin Lee et al, Decision CTO Study, Circulation 2019;139:1674-1683
  • 17. A.Bufe - EuroCTO Club 2020 Berlin
  • 18. A.Bufe - EuroCTO Club 2020 Berlin n = 19088 Multicenter registry - propensity score - mulivariable analysis Azadani et al., JACC Cardiovac Img 2020 SPECT MPI
  • 19. A.Bufe - EuroCTO Club 2020 Berlin ESC Guidelines 2018
  • 20. A.Bufe - EuroCTO Club 2020 Berlin CTO LCX 1 vessel disease No symtoms
  • 21. A.Bufe - EuroCTO Club 2020 Berlin Rest 30yg 20yg 40yg Dobutamin Stress-MRI
  • 22. A.Bufe - EuroCTO Club 2020 Berlin 6.389 patients Revascularization was associated with a protective effect only in the subset of extensive CMR-related ischaemia Extensive ischaemic burden was related to a higher risc of long term mortality 516/516 matched patients
  • 23. A.Bufe - EuroCTO Club 2020 Berlin LAD-Stenoses RCA-CTO RCA distal NSTEMI anterior wall Hypokinesia anterior and severe Hypokinesia inferior (EF 38%)
  • 24. Claessen et al., EHJ 2012;33:768-775 A.Bufe - EuroCTO Club 2020 Berlin
  • 25. A.Bufe - EuroCTO Club 2020 Berlin epicardial collaterals Stents septal collaterals
  • 26. A.Bufe - EuroCTO Club 2020 Berlin reverse CART Subendocardial Scar inferior MRI for viability
  • 27. A.Bufe - EuroCTO Club 2020 Berlin Complete Revascularization in viable myocardium
  • 28. A.Bufe - EuroCTO Club 2020 Berlin Metha et al., NEJM 2019; 381:1411-1421
  • 29. A.Bufe - EuroCTO Club 2020 Berlin
  • 30. A.Bufe - EuroCTO Club 2020 Berlin Galassi, Mashajekhi et al., J Am Coll Cardiol Intv 2017 n = 839 PCI of CTO in patients with low EF
  • 31. A.Bufe - EuroCTO Club 2020 Berlin n = 72 Galassi, Mashajekhi et al., J Am Coll Cardiol Intv 2017 PCI of CTO in patients with low EF
  • 32. A.Bufe - EuroCTO Club 2020 Berlin Conclusion Galassi et al., EuroCTO Club consensus document, Eurointervention 2019
  • 33. A.Bufe - EuroCTO Club 2020 Berlin Thank you
  • 34. A.Bufe - EuroCTO Club 2020 Berlin Thank you