1. Is the Decision-Making after Failure of CTO Angioplasty Same? Infarct Related CTO or Non- Infarct Related CTO (Continue the Procedure in Other Vessel or Stop) / 梗死相关支 CTO 和非梗死 相关支 CTO 病变介入失败后的 PCI 决策相同吗？ 继续做其它血管病变 PCI ？中止手术？ 大庆油田总医院 温尚煜

2. 我们为什么要做多支 CTO? Patients with a single CTO and without angiographic significant disease in the other vessels had a very low mortality whatever the results of the PCI attempt The completeness of revascularization was a strong independent predictor of survival PCI for CTO is associated with improved long- term survival? CABG-free

3. 4-years outcomes for CTO revascularization

4. Kaplan–Meier analysis of cardiac survival in patients with complete revascularization when compared to patients with incomplete revascularization. Valenti R et al. Eur Heart J 2008;eurheartj.ehn357

5. Kaplan–Meier analysis of cardiac survival in patients with chronic total occlusion (CTO)– percutaneous coronary intervention (PCI) success when compared to patients with CTO–PCI failure. Valenti R et al. Eur Heart J 2008;eurheartj.ehn357

6. 非梗死相关 CTO 失败后会怎样 ? 会增加长期死亡率？ 影响心功能？

7. CTO Recanalization and Left Ventricular Recovery Van Belle E, et al. American Journal of Cardiology 1997

8. A CTO in a non-IRA, and not MVD without a CTO, is a strong and independent predictor of long-term mortality in STEMI patients with diabetes

9. Netherlands STEMI Study On multivariate analysis, CTO was the ONLY independent predictor of mortality. Conclusion: Patients with STEMI and MVD have a higher one year mortality rate than pts with SVD, which is dependent only on whether a CTO is present in the non-infarct related artery ?Also true for non STEMI/UA pts. Van der Schaaf, RJ et al. Am J Cardiol 2006;98:1165-69

10. 陈旧 STEMI 非梗死相关支 CTO 病 变介入失败后 应该终止 PCI 手术 CABG Hybrid?

11. non STEMI/UA 非梗死相关支 CTO 病变介入失败后 和 STEMI 相似应该停止 PCI 操作 CABG 除非 CTO 位于小 RCA 或非优势型 LCX ，缺 血心肌面积较小，患者心、肾功能较好， 能耐受继续 PCI 手术， Continue the Procedure in Other Vessel ? 部分血运重建？

12. 病例一 female ， 72 Angina 7years hypertension 3 月前患脑出血 CTA 提示三支血管严重钙化， LAD 重度狭窄， RCA 远端闭塞 肾功正常、 LVEF 58%

13. CAG

14. RCA PCI

15. LAD 旋磨

16. 最终结果

17. 治疗梗死相关 CTO 有何益处？ relieving symptomatic ischemia and angina enhancing left ventricular function reducing predisposition to ventricular arrhythmias improving tolerance of contralateral coronary occlusion. improved long-term survival ？ JACC 2008: 51 ； 965–7

18. 那种梗死相关 CTO 需要治疗？ From a clinical standpoint, CTO recanalization is usually attempted in symptomatic patients or in patients with evidence of silent ischemia in a large territory at risk and/or with the presence of viable myocardium

19. 梗死相关 CTO 失败后会怎样？ If the myocardium is not viable, it may not be beneficial to revascularize the region. Incomplete but adequate revascularization. PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct- related artery 3 to 28 days after myocardial infarction---OAT

20. PCI or CABG?

21. Safley, D. M. et al. J Am Coll Cardiol Intv 2008;1:295-302 Survival Following Successful Versus Failed CTO PCI

22. 梗死相关 CTO 失败 Higher mortality rate was also observed within the subgroups with diabetes (25.2% vs 4.8%) renal dysfunction (44.1% vs 13.8%) lowered ejection fraction (26.5% vs 10.5%, all P <.05) Am Heart J 2007;153(2):304-312.

23. 病例二 male ， 55, MI 2 years ， angina 2 months Hypertension 、 hypercholesterolaemia 、 current smoker LVEF 55%

24. 造影

25. RCA

26. RCA PCI

28. PCA PCI

29. Failure of Infarct Related CTO Angioplasty

30. Mini-culotte

37. IVUS

38. Symptoms ， Viability/ischemic burden LAD CTO Diminished LV function High atherosclerotic vascular risk (especially DM) 那些梗死相关支 CTO 病变介入失败 后 应该中止手术？

39. 那些梗死相关支 CTO 病变介入失败 后可以继续做其它血管病变 PCI ？ SYNTAX 积分 <33 非 LAD 病变 心功能正常 肾功能正常 无糖尿病

40. 谢谢！

41. Beside 介入技术我们还关心患者的躯体、心理和社 会