The Take Home: C3

Issue: September/October 2012

In June 2012, the Complex Cardiovascular Catheter Therapeutics (C3) meeting was held in Orlando, Fla. The meeting featured discussions on a wide range of issues, including coronary, peripheral, extracranial, intracranial, aortic, structural and vascular therapy, and involved cardiologists, vascular surgeons and interventional radiologists. Andreas Wali, MD, FACC, FSCAI, director of research at the Holy Spirit Cardiovascular Institute and director of structural heart disease at Holy Spirit Hospital, Camphill, Penn., and Bryan W. Kluck, DO, interventional cardiologist, The Heart Care Group, Allentown, Penn., were among those who attended, and they shared with Cardiology Today Intervention their highlights from the meeting.

Andreas Wali, MD, FACC, FSCAI

Globalization of CV and Endovascular Therapy

Andreas Wali

CV and endovascular therapy has become a truly global endeavor, as evidenced by the participation of the attendees and faculty from over 40 countries at C3 2012. The live cases transmitted from Europe, Southeast Asia and the Middle East, as well as the United States, served to show that although significant innovation is based in the United States, currently the United States operates at usually 2 or more years behind their colleagues in Europe in being able to access the latest CE-marked equipment or even to access them in the clinical trial setting. For example, the current iteration of the Sapien valve (Edwards Lifesciences), which is approved in the United States, is two generations behind the devices currently used in Europe, which have a much lower profile. In addition, in the US, the CoreValve (Medtronic) is only accessible in the trial setting.

Image: C3; reprinted with permission.

During a live TAVR case broadcast from the Netherlands at C3, an embolic protection device (Claret, Claret Medical) was elegantly used for cerebral embolic protection, but is not available in the United States even as part of a trial.

The other potential effect of globalization of CV care in our era of cost-consciousness may be the outsourcing of CV care to neighboring countries where similar care at lower costs might be available. It is evident in the cases broadcast from India and China that the cardiac and endovascular therapies are on par with those in Europe and the United States.

Adjunct Imaging

Adjunct imaging received a lot of attention, with discussion of novel ways to use coronary CTA to plan chronic total occlusion interventions by the faculty from Japan. There was a lot of emphasis on the treatment of CTOs and the use of intravascular ultrasonography. Optical coherence tomography also received a lot of attention with multiple OCT-guided interventions performed during the live sessions.

The importance of intravascular ultrasonography and fractional flow reserve received prominence, especially in the current era of appropriate use criteria (AUC). The current results from FAME II suggesting that fractional flow reserve-guided PCI is beneficial in stable CAD patients was also a topic of major discussion.

AUC

There was discussion about AUC, which was moderated by Ralph Brindis, MD, MPH, and Manesh Patel, MD. AUC are here to stay in one iteration or another. Discussions about the term “inappropriate” were addressed and discussions about ways to ensure proactive documentation prior to PCI were seen as a way to ensure accurate assessments of appropriateness. Fears were expressed that AUC might be misused by insurance companies to deny payments, and also expose the practitioner to litigation, especially when not every clinical scenario can be encompassed. Finally, the composition of the AUC panel with a minority of interventional cardiologists was raised.

Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement received significant attention at this meeting with a complete session and live cases performed in Europe utilizing devices not yet available in the United States. Discussion revolved around the use of positioning devices like the Paeion and DynaCT for valve positioning as well as plain angiography.

The newer generations of self-expanding valves were also discussed and appear to be true contenders in the near future. Data from PARTNER, as well as worldwide experience with TAVR, were presented, demonstrating that in the short to intermediate term, the results with TAVR are as good as surgical aortic valve replacement and better than medical therapy in patients with aortic stenosis who are at high risk for surgical AVR.

Antiplatelet Therapy

There was a session dedicated to antiplatelet therapy and discussion regarding third-generation antiplatelet agents, especially in light of the recent availability of the less expensive generic clopidogrel. There appeared to be consensus that at least for patients with ACS who are not at high risk for bleeding, third-generation antiplatelet agents prasugrel (Effient, Daiichi Sankyo/Eli Lilly) and ticagrelor (Brilinta, AstraZeneca) were preferred over clopidogrel.

Disclosure: Dr. Wali is on the faculty for C3; he reports no relevant financial disclosures regarding the products discussed.

Bryan W. Kluck, DO

Case-Based Presentations

Bryan W. Kluck

At C3, a major emphasis was placed on learning though case-based examples. There were a couple of standout cases, including a taped case from Rajesh Dave, MD, and Andreas Wali, MD, FACC, FSCAI, in Harrisburg, Penn., of an acute MI that was excellent. It is quite hard to get a taped case of an acute MI since it is obviously not a planned event. It is even harder to perform the necessary interventions during that sort of procedure while commenting audibly on thought processes running through the interventionalist’s head during the taping of the session. Drs. Dave and Wali were able to do that very well. The case was commented on by, among others, Gregg W. Stone, MD. During his prior talk, Dr. Stone had discussed some of the features of the INFUSE-AMI trial. The trial was an extremely complicated design, including one arm involving manual aspiration thrombectomy, as well as intracoronary superselective delivery of abciximab (ReoPro, Centocor) via the ClearWay catheter (Atrium). During the following taped case, the audience, now up-to-date on the latest concerning thrombectomy, was asked if they would consider thrombectomy if they were performing the case just shown. Although the INFUSE-AMI trial has had a significant impact on our understanding of treatment of large burden in MI, the audience response hinted that perhaps more work in the area of thrombectomy is necessary.

There were numerous live cases from the United States, as well as international sites. Although each had unique teaching points, there were several focusing on CTOs that were extraordinary. These cases were supremely valuable to the experienced interventionalist beginning a CTO program.

AUC and Antiplatelet Therapies

There was a session on AUC where multiple presenters, including Drs. Manesh Patel and Ralph Brindis, spoke about appropriate use. This session was also quite controversial, largely because this is an unpopular subject. Dr. Patel in particular was quite successful in not only explaining the importance of AUC but also the profound difficulty in molding them. The important point made was that there is a call from outside the field to create guidelines and mandate their utilization. The hard work put in by busy, front-line interventionalists has put us a long way toward sensible criteria we can abide and practice. There was also the clear sense that these were works in progress.

There was a fantastic evening session covering the very fast moving field of antiplatelet therapies in ACS. There was a full, rich discussion not only about efficacy and mechanism, but also an analysis of the recent financial data for both “third-generation” antiplatelet agents. With clopidogrel becoming generic just a month before, there were many questions about how to position these agents in various clinical situations. Clearly intelligent, informed use of these newer agents stands to improve patient outcomes. Just as clearly, generic clopidogrel, although potentially an attractive alternative in some situations, is not the only answer.

The Final Take Home

The skillful use of live cases, taped cases and didactic sessions (often coupled with taped cases) made the meeting uniquely successful no matter where you were in your career. The course continues to grow and diversify. Perhaps there can be no better example of this than the acute stroke program that extended late into Thursday evening. Interventional cardiologists, interventional radiologists and interventional stroke neurologists discussed the rapidly evolving field of acute stroke intervention. This area is potentially on the verge of a major paradigm shift. There is opportunity for interdisciplinary collaboration as this seismic shift takes place.

The most important take home from C3, though, was the great opportunity it afforded attendees to interact with the coronary, peripheral and structural heart community, providing a sense of what the practice of interventional cardiology is like all over the world. In Tunisia, for example, the health care system faces profound economic challenges. Yet the experience of Essie Boughzela, MD, with balloon mitral valvuloplasty is staggering. Having an opportunity to converse with her during the session on structural heart disease was very valuable. The diverse international faculty freely shared expertise often including solutions to problems brought on by profound geographic and economic barriers. Coming away from C3 really drives home the point that as we work in our communities, we are clearly a part of a global CV community.

Disclosure: Dr. Kluck is on the speakers’ bureau for AstraZeneca and Daiichi-Sankyo.