Case and Plan:

55-year-old male presented with new onset CCS Class II angina and known intermediate two vessel CAD from angiogram in 2018. A Cardiac Cath on August 13, 2024 revealed calcified 2 V CAD: 70-80% proximal-mid RCA, 80-90% prox LAD-D2 bifurcation with CTO of mid LAD (JCTO Score 4), SYNTAX Score of 26 and normal LVEF. Patient underwent FFR guided successful interventions of proximal and mid RCA using two Xience DES. Patient is now planned for staged PCI of long LAD CTO using antegrade approach guided by contralateral injection.


Q&A

Q. Where did everyone go wrong with CTO? All the unbridled enthusiasm is gone?
A. Intervention of a CTO is not supported routinely as person’s body has fully compensated physiologically mostly by collaterals. Hence even successful PCI can’t improve the cardiac outcomes. That is what 5 RCTs of CTO PCI vs MT showed. That led to recommendations of CTO PCI as IIb only for persistent symptoms or significant ischemia. Only caveat remains that presence of a CTO impart an adverse prognosis in a CAD pt, as event caused by the donor easel will manifest as 2 vessel occlusion and its consequences.
Q. How did we get the CTO Trial results so wrong? Wrong push by industry? Or some CTO experts?
A. I will say that many of us believed that opening CTO successfully will improve LV function and will improve QOL. But none was noted in the RCTs; it would not have been known if these RCTs were not done. Hence it is the better understanding of the CTO disease process now.
Q. Guidelines too - this could even go down to Class 3?
A. Fully agree that we need to make a strong case for CTO PCI based on AUC criteria. And yes it could very well be a class III soon.
Q. Regarding Senior RITA, what is the true take home practical message?
A. Most important message we got from senior RITA trial is that many of the elderly pts are frail and have multiple comorbidities. Hence a strategy of routine PCI in elderly NSTEMI pts is not beneficial. These pts can have invasive strategy in selected pts but not as a routine.
Q. It was also remarkable that bleeding was not increased in the invasive arm of Senior RITA.
A. Yes the bleeding was minimally higher as >85% of Cath PCI was done by radial approach; which traditionally has shown to have lower vascular bleeding.
Q. Is Flower MI the exception for lack of benefit from FFR, or there can be a contagion effect to other indications?
A. Based of the RCTs data, it is now clear that complete revascularization in STEMI pts, is best guided by angio only and physiological testing of FFR/iFR does not add anything.
Q. Is your use of coronary physiology testing on the increase?
A. Yes coronary physiology of FFR/iFR has increased in last few years and has plateaued around 60%; national average is 52%.
Q. Is INOCA bigger than obstructed CAD in prevalence?
A. INOCA comes in play only when there is nonobstructive CAD and microvascular dysfunction is more prevalent (10-12%) than obstructive CAD (3-5%).
Q. In today's case, what was the most likely reason for success?
A. Expert technical procedure was the core of success in today’s case.
Q. So, we do not need to answer your three questions to claim CME?
A. That is correct that to get the CME credit, answering three questions is not mandatory. We just want participants to go thru the live webcast and then get the CME certificate.

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