Complex Coronary Cases

Supported by:

• Abbott Vascular

• Boston Scientific Corporation

• Medtronic, Inc.

• Astrazeneca

DisclosuresSamin K. Sharma, MBBS, FACC

Speaker’s Bureau – Boston Scientific Corporation, Abbott, The Medicines Company, Daiichi Sankyo, Inc. and Lilly USA, LLC

Annapoorna S. Kini, MBBS, FACC

Nothing to disclose

Sameer Mehta, MBBS, FACC

Consulting Fees – The Medicines Company

American College of Cardiology Foundation staff involved with this case have nothing to disclose

Presentation:

Presented on 2/26/2013 with vague chest pain with nonspecific pre-cordial T wave changes associated with variable dyspnea. Stress test suggested but declined and underwent cath revealing one vessel CTO (mLAD) with LVEF 56%. No PCI done as was inappropriate; not on any anti-ischemic meds and no documented ischemia. Pt was placed on Metoprolol XL 25mg and Amlodipine 5mg daily. A F/U stress MPI revealed moderate size large antero-

lateral and apical ischemia. Still has residual class I-II angina.

Prior History:

Hyperlipidemia, NIDDM, Ex-smoker, +F/H, H/o RA

Medications: All once daily dosage

Aspirin 81mg, Metoprolol XL 25mg, Amlodipine 5mg, Metformin XL 1000mg, Rosuvastatin 20mg, Methotrexate, Sulfasalazine

April 16th 2013 Case #10: SA, 53 yr M

Cardiac Cath 2/26/2013: Right Dominance

1 Vessel CAD with LVEF 56% (minimal apical hypokinesis)

Left Main: Short

LAD: 100% lesion in mid and distal fills via RCA and bridge

collaterals, 90% D1

LCx: Non-obstructive

RCA: No obstruction

Plan Today:

- PCI of CTO mid LAD via antegrade or retrograde

approach

Case# 10: cont… SYNTAX score 19.5

Appropriateness Criteria for Coronary Revascularization

Issues Involving The Case

• Predictors of CTO lesion success

• Correlation of IVUS, OCT and FFR

CHRONIC TOTAL OCCLUSION

Anatomic Descriptors of Procedural Success

Predictors of Procedural Success

Multivariate analysis from TOAST-GISE

Variables Hazard Ratio p

Length ≥15 vs. <8 mm 3.9 0.028

Moderate to severe calcification 3.5 0.023

Duration ≥ 180 days 3.1 0.013

Multi-vessel disease 2.3 0.009

Bridge collaterals present 2.2 0.023

Stump morphology 2.2 0.048

Olivari et al., J Am Cardiol Coll 2003;41:1672

Patel et al., JACC Cardiovasc Interv 2013;6:128

Incidence of Procedural Complications in Successful vs. Unsuccessful CTO PCI

MACE (%) 3.7 4.3 0.68

Death (%) 0.4 1.5 <0.0001

Emergent CABG (%) 0.03 0.17 0.74

Stroke (%) 0.07 0.4 0.04

MI (%) 2.8 3.0 0.87

Q-wave MI (%) 0.3 0.5 0.26

Coronary perforation (%) 3.7 10.7 <0.0001

Tamponade (%) 0.0 1.7 <0.0001

Vascular complication (%) 1.7 0.9 0.20

Contrast nephropathy (%) 5.0 4.6 0.86

Successful Unsuccessful p value Complications

Patel et al., JACC Cardiovasc Interv 2013;6:128

Temporal Trends in Cumulative Angiographic Success Rates and Major Procedural Complication Rates

80%

0.5%

Predictors of Reocclusion After Successful Drug-Eluting Stent-Supported Percutaneous

Coronary Intervention of Chronic Total Occlusion:

Florence CTO PCI Registry

Valenti et al., J Am Coll Cardiol 2013;61:545

Successful CTO PCI (%)

1-Year clinical outcome MACE 16.0 Cardiac death 3.2 Myocardial Infarction 0.9 CABG 0.0 CTO vessel repeat PCI 12.8 First-generation PES and SES 14.1 EES 10.5 STAR 32.3 Definite stent thrombosis 0.4

Angiographic outcome (n=616); 82%

In-segment restenosis or reocclusion 20 Reocclusion rate 7.5 First-generation PES and SES 10.1* EES 3.0 STAR 57.0

CTO PCI Registry: Clinical and Angiographic Outcomes First-Generation DES vs. Second-Generation EES (N= 802)

Valenti et al., J Am Coll Cardiol 2013;61:545* p = 0.001

Valenti et al., J Am Coll Cardiol 2013;61:545

CTO PCI Outcomes: Predictors of Clinical and Angiographic Outcome

Clinical Outcome HR 95% CI p ValueCardiac death

Age >75 yrs 4.64 2.19-9.83 <0.001

LVEF <40% 7.25 2.77-19 <0.001

LAD-CTO 2.39 1.13-4.33 0.020

Completeness of revascularization 0.48 0.24-0.95 0.037

MACE

Age >75 yrs 1.64 1.17-2.31 0.004

STAR technique 2.26 1.21-4.22 0.010

LVEF <40% 1.47 1.06-20.6 0.023

LAD-CTO 1.42 1.02-2.01 0.046

Angiographic Outcome OR

Reocclusion

STAR technique 29.50 11.9-73.2 <0.001

EES 0.22 0.09-0.54 0.001

Non-occlusive restenosis

RCA-CTO 1.64 1.02-2.62 0.040

Valenti et al., J Am Coll Cardiol 2013;61:545

CTO PCI Outcomes: 3 Years MACE Free Survival Based on the Technique

P = 0.014

nonSTARSTAR

Whitlow et al., JACC Cardio Interv 2012;5:393

CrossBoss Crossing Catheter Stingray Re-Entry Balloon Catheter and Guidewire

Use of Novel Crossing and Re-Entry System in Coronary CTOs Failing Standard Crossing Techniques

CTO Dissection/Re-entry Strategies

CTO dissection/re-entry strategies

Antegrade Retrograde

Dissection Re-entry

• Knucle wire• CrossBoss

• STAR• Contrast-

guided STAR• mini-STAR• LAST• Stingray

Knucle wire • CART• Reverse Cart

Dissection Re-entry

Issues Involving The Case

• Predictors of CTO lesion success

• Correlation of IVUS, OCT and FFR

Schematic representation of various functional hemodynamic measurements

Microvasculature

MicrovasculatureOCT

Criteria for significant stenosis:IVUS = <4mm2

FFR = <0.8OCT = ?

Microvasculature

FIRST Study: Fractional Flow Reserve and Intravascular Ultrasound

Relationship Study

10 US/European centers enrolled 350 pts (367 lesions) with intermediate

angiographic lesions (40-80%) and underwent IVUS, VH and FFR

Waksman et al., JACC 2013;61:917

FIRST Study Scatterplots of IVUS MLA and FFR Correlation: Infarct of Vessel Size (RVD)

Waksman et al., JACC 2013;61:917

All Vessels

3.07 mm2

RVD <3.0mm

RVD 3-3.5mm RVD >3.5mm

2.68 mm2

3.16 mm2 3.74 mm2

FIRST Study: Diagnostic Accuracy of IVUS MLA in Prediction of Functionally Significant Stenosis and by RVD

Waksman et al., JACC 2013;61:917

%

sensitivity

specifity

ppv

npv

Waksman et al., JACC 2013;61:917

FIRST Study: Scatterplots of IVUS and FFRAll lesions that underwent PCI with FFR

of 0.8, MLA of 3.07 mm2

All lesions that did not undergo PCI with FFR of 0.8 and MLA of 3.07 mm2

OCT vs IVUS Assessment of Native Coronary Artery Disease

Bezzera et al., JACC Cardiovasc Interv 2013;6:228

p=0.294

p=<0.001

p=<0.001

p=0.226

IVUS (56)

FD-OCT (56)

OCT vs. IVUS Assessment of Stented Vessels Post PCI and at Follow Up

Bezzera et al., JACC Cardiovasc Interv 2013;6:228

Morris et al., JACC Cardiovasc Interv 2013;6:149

VIRTU-1 Study: Example of vFFR in a Left Anterior Descending Artery

DeFACTO Study: Computation of FFRCT

DeFACTO Study: Discrimination

DeFACTO Study: Per-Patient Diagnostic Performance for Intermediate Stenoses by

CT (30-70%)

Take Home Message:Predictors of CTO success and Correlation of

various non-invasive studies

In the current era of CTO recanalization, angiographic predictors of failure are few, important being heavy Ca++. Subintimal tracking is associated with high reocclusion rates and hence should be avoided. Unsuccessful recanalization is still associated with higher MACE rates

Recent data suggest IVUS lumen CSA of 3.1mm2 to correlate with FFR of <0.8 and is dependent on RVD. OCT provides on an average 1mm smaller lumen area compared to IVUS & hence OCT criteria for hemodynamic significant lesion may be different then IVUS

Following are the predictors of successful recanalization of the CTO lesions except :

A. Tapered end

B. Heavy calcification

C. No bridge collaterals

D. Short occlusion (8-15mm)

Question # 1

A recent multicenter registry showed current success of CTO to be :

A. <50%

B. 50-70%

C. 71-85%

D. >85%

Question # 2

Following observation about FFR and IVUS correlation was noted in the FIRST study :

A. There is a fixed relationship with RVD and FFR of <0.8

B. There is a good correlation of IVUS MLD and FFR

C. FFR cutoff of 0.8 will lead to less PCI vs. IVUS MLD cutoff

D. VH parameters on IVUS correlate well with FFR of <0.8

Question # 3

Following are the predictors of successful recanalization of the CTO lesions except :

A. Tapered end

B. Heavy calcification

C. No bridge collaterals

D. Short occlusion (8-15mm)

Question # 1

The correct answer is B. Heavily calcified lesions are associated with lower success of CTO recanalization

Olivari et al., J Am Cardiol Coll 2003;41:1672

A recent multicenter registry showed current success of CTO to be :

A. <50%

B. 50-70%

C. 71-85%

D. >85%

Question # 2

The correct answer is C. Recent multicenter CTO registry demonstrated increasing success of CTO recanalization

over the years with latest being over 80%

Patel et al., JACC Cardiovasc Interv 2013;6:128

Following observation about FFR and IVUS correlation was noted in the FIRST study :

A. There is a fixed relationship with RVD and FFR of <0.8

B. There is a good correlation of IVUS MLD and FFR

C. FFR cutoff of 0.8 will lead to less PCI vs. IVUS MLD cutoff

D. VH parameters on IVUS correlate well with FFR of <0.8

Question # 3

The correct answer is C. FIRST study showed that FFR and IVUS MLD has poor correlation and is dependent on RVD. FFR cutoff of 0.8 will lead to less PCI compared to

any IVUS MLD cutoff even of 3.1mm2Waksman et al., JACC 2013;61:917