James Sapontis

Procedural failure of chronic total occlusion percutaneous coronary intervention: Insights from a multicenter US registry

The hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly increased procedural success rates, yet some cases still fail. We sought to evaluate the causes of failure in a contemporary CTO PCI registry.

The Outcomes, Patient Health Status, and Efficiency IN Chronic Total Occlusion Hybrid Procedures registry: rationale and design

Background Patients with chronic total occlusions of a coronary artery represent a complex, yet common, clinical conundrum among patients with ischemic heart disease. Chronic total occlusion angioplasty is increasingly being used as a treatment for these complex lesions. There is a compelling need to better quantify the safety, efficacy, benefits, and costs of the procedure. Methods To address these gaps in knowledge, we designed the Outcomes, Patient Health Status, and Efficiency IN Chronic Total Occlusion Hybrid Procedures (OPEN CTO) study, an investigator-initiated multicenter, single-arm registry including 12 centers with a planned enrollment of 1000 patients. To ensure the accuracy of our observations, we used a unique auditing process through the National Cardiovascular Disease Registries’ Cath/PCI Registry, angiographic core lab analysis, clinical events adjudication, and a systematic collection of patient-reported outcomes and costs. Results Between 21 January 2014 and 22 July 2015, 1000 patients were enrolled in OPEN CTO. A total of 28 patients either refused (N=26) or were missed by the screening process (N=2). In the National Cardiovascular Disease Registry Cath/PCI registry audit, there were 1096 chronic total occlusion-percutaneous coronary intervention procedures that were performed by participating operators during the time they enrolled in OPEN CTO. Overall, 987 of those patients could be definitively matched to an OPEN CTO enrolled patient (enrolled group). The remaining 109 were considered to be not enrolled in OPEN CTO (not enrolled group). Compared with the enrolled group, the patients in the nonenrolled group were less frequently of White race and more frequently of Hispanic origin. Procedural outcomes including National Cardiovascular Disease Registry-defined technical success, procedural success, and major adverse coronary events rates were similar. Conclusion OPEN CTO is the most comprehensive and rigorously collected dataset to date that will provide unique insights into the success, safety, benefits, and the costs of chronic total occlusion-percutaneous coronary intervention using a reproducible technical approach to patients with these complex lesions.

Dyspnea Among Patients With Chronic Total Occlusions Undergoing Percutaneous Coronary Intervention: Prevalence and Predictors of Improvement

Background— Dyspnea is a common angina equivalent that adversely affects quality of life, but its prevalence in patients with chronic total occlusions (CTOs) and predictors of its improvement after CTO percutaneous coronary intervention (PCI) are unknown. We examined the prevalence of dyspnea and predictors of its improvement among patients selected for CTO PCI. Methods and Results— In the OPEN CTO registry (Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion) of 12 US experienced centers, 987 patients undergoing CTO PCI (procedure success 82%) were assessed for dyspnea with the Rose Dyspnea Scale at baseline and 1 month after CTO PCI. Rose Dyspnea Scale scores range from 0 to 4 with higher scores indicating more dyspnea with common activities. A total of 800 (81%) reported some dyspnea at baseline with a mean (±SD) Rose Dyspnea Scale of 2.8±1.2. Dyspnea improvement was defined as a ≥1 point decrease in Rose Dyspnea Scale from baseline to 1 month. Predictors of dyspnea improvement were examined with a modified Poisson regression model. Patients with dyspnea were more likely to be female, obese, smokers, and to have more comorbidities and angina. Among patients with baseline dyspnea, 70% reported less dyspnea at 1 month after CTO PCI. Successful CTO PCI was associated with more frequent dyspnea improvement than failure, even after adjustment for other clinical variables. Anemia, depression, and lung disease were associated with less dyspnea improvement after PCI. Conclusions— Dyspnea is a common symptom among patients undergoing CTO PCI and improves significantly with successful PCI. Patients with other potentially noncardiac causes of dyspnea reported less dyspnea improvement after CTO PCI.

TCT-303 Redefining Success in Hybrid Chronic Total Occlusion Angioplasty

The goal of percutaneous coronary intervention (PCI) in stable coronary disease is to improve quality of life (QoL). Historically, technical success in chronic total occlusion (CTO) PCI has been defined by angiographic surrogates including final TIMI flow (FTF) of 3 and residual stenosis (RS) ≤ 30

TCT-282 Risk Factors Associated with Adverse Events during Chronic Total Occlusion Percutaneous Coronary Interventions: A sub-Analysis of the OPEN-CTO Study

Coronary chronic total occlusions (CTOs) are prevalent and the development of the hybrid approach to CTO PCI has been associated with increased technical success rates. However, the incidence and predictors of adverse events (AEs) during CTO PCI remains poorly defined. We analyzed baseline patient

Excimer laser atherectomy to overcome intraprocedural obstacles in chronic total occlusion percutaneous intervention: Case examples.

Technical advances and the development of the Hybrid algorithm have been associated with higher success rates in chronic total occlusion percutaneous coronary intervention (CTO-PCI). Nevertheless, there are still intraprocedural obstacles that result in failure or prolonged procedure time. The Excimer coronary laser (EL) has been repurposed in CTO-PCI to overcome such obstacles. This case series illustrates the use of the EL in four technically complex scenarios including the balloon resistant lesion, the impenetrable proximal cap, device resistance in stent restenosis, and difficulty with device tracking in the subintima.

Impact of subintimal plaque modification procedures on health status after unsuccessful chronic total occlusion angioplasty

We sought to determine the impact of subintimal plaque modification (SPM) on early health status following unsuccessful chronic total occlusion (CTO) PCI.

APPROPRIATE USE CRITERIA AND HEALTH STATUS OUTCOMES AFTER CTO PCI: RESULTS FROM THE OPEN CTO REGISTRY

Background: The ACC/AHA Appropriate Use Criteria (AUC) were designed to aid clinical decision-making, yet their association with health status outcomes after CTO PCI is unknown. Methods: We enrolled 1,000 patients undergoing CTO PCI in the 12-center OPEN CTO registry. 52 patients were excluded due

Association of Stress Test Risk Classification With Health Status After Chronic Total Occlusion Angioplasty (from the Outcomes, Patient Health Status and Efficiency in Chronic Total Occlusion Hybrid Procedures [OPEN-CTO] Study)

Stress testing is endorsed by the American College of Cardiology/American Heart Association Appropriate Use Criteria to identify appropriate candidates for Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, the relation between stress test risk classification and health status after CTO PCI is not known. We studied 449 patients in the 12-center OPEN CTO registry who underwent stress testing before successful CTO PCI, comparing outcomes of patients with low-risk (LR) versus intermediate to high-risk (IHR) findings. Health status was assessed using the Seattle Angina Questionnaire Angina Frequency (SAQ AF), Quality of Life (SAQ QoL), and Summary Scores (SAQ SS). Stress tests were LR in 40 (8.9%) and IHR in 409 (91.1%) patients. There were greater improvements on the SAQ AF (LR vs IHR 14.2 ± 2.7 vs 23.3 ± 1.3 points, p <0.001) and SAQ SS (LR vs IHR 20.8 ± 2.3 vs 25.4 ± 1.1 points, p = 0.03) in patients with IHR findings, but there was no difference between groups on the SAQ QoL domain (LR vs IHR 24.8 ± 3.4 vs 27.3 ± 1.6 points, p = 0.42). We observed large health status improvements after CTO PCI in both the LR and IHR groups, with the greatest reduction in angina among those with IHR stress tests. Although patients with higher risk studies may experience greater reduction in angina symptoms, on average, patients with LR stress tests also experienced large improvements in symptoms after CTO PCI, suggesting patients with refractory symptoms should be considered appropriate candidates for CTO PCI regardless of stress test findings.

How to Fix Common Problems Encountered in CTO PCI: The Expanded Hybrid Approach

There remains a pressing need in the interventional cardiology community to narrow the existing gap in the success rates, safety, and efficiency of chronic total occlusion percutaneous coronary intervention (CTO-PCI) relative to non CTO-PCI. Success rates for non CTO-PCI are high (>98 %). The success rates of CTO-PCI at experienced CTO-PCI centers are catching up (>90 %) but are likely much lower (50–70 %) at the vast majority of other PCI centers. Complication rates appear to be equal between CTO and non-CTO procedures at experienced CTO centers but may not be at others. CTO-PCI is associated with higher procedural time, contrast use, radiation exposure and supply cost than non CTO PCI even at experienced CTO-PCI centers. Thus, a wide variability in the CTO-PCI cases being attempted persists in large part due to these gaps. This chapter provides an overview of the new expanded hybrid approach, commonly employed by successful CTO operators.