CTO PCI success comes with experience

SAN FRANCISCO — Performing PCI on patients with chronic total occlusion is a tough but rewarding task, and a doctor’s success rates tend to increase with experience, three experts said at TCT 2013.

“This is a very technically complex procedure, so it makes sense that a learning curve exists,” said Dmitri Karmpaliotis, MD, of Piedmont Heart Institute, Atlanta.

Success rates increase with time, volume

The procedural success rate of CTO PCI at Piedmont increased from 85.6% in 2009 to 2010 to 91% in 2012. Karmpaliotis said that this was consistent with previous research. One study from the Yale Multicenter CTO Registry found that CTO technical success rates of experienced retrograde operators rose from approximately 50% in early 2005 to nearly 90% in early 2008, and corresponded with a stepwise increase in operator CTO volume.

Similarly, operators who perform more than 100 CTO PCI procedures per year have higher success rates than those who perform fewer procedures. In 2008, those with more than 100 procedures had an 89% success rate compared with 67% for those with fewer than 40 procedures. The trend continued in 2009 (88% vs. 81%) and 2010 (93% vs. 84%).

“Why perform CTO PCI? Because it helps patients and makes us better operators,” Karmpaliotis said.

Expands ability to tackle complex disease

Another reason to implement a CTO PCI program is that it enhances a team’s capabilities in other areas, said James B. Hermiller Jr., MD, of St. Vincent Hospital/The Heart Center of Indiana, Indianapolis.

“CTO skill sets don’t apply just to CTOs,” he said. “They expand the overall program’s ability to take on complex disease.”

This is especially true once a team has become proficient at performing CTO PCI. “I think what actually made this something we could succeed at in a private practice setting was the efficiency that we’ve seen, that it dropped the time to do these very complex cases, and made it something we can all employ in our daily practice,” Hermiller said.

Developing CTO PCI capabilities can also help make up for lost PCI volume, he said. At St. Vincent, overall PCI volume declined from 3,576 in 2009 to a projected 3,154 in 2013, while CTO PCI volume increased from 35 in 2009 to a projected 121 in 2013.

There are other financial advantages to developing a CTO PCI program, Hermiller said. While CTO PCI direct costs and procedural costs are higher than for regular PCI, the contribution margin is virtually the same (CTO PCI, $5,173 per patient; non-CTO PCI, $5,730 per patient; P=.58; based on data from Piedmont Heart Institute).

“What helped us [convince colleagues and administrators of value] was to demonstrate that we can do this, we can do it effectively with a high success rate, and the patients do well,” Hermiller said. “It takes a great deal of work to demonstrate that it’s not simply dollars and cents that we look at for individual patients.”

Must be done for the right reasons

However, CTO PCI is not for every cardiologist, and physicians should make sure that it is what they really want to do before developing expertise, said Christopher E. Buller, MD, of St. Michael’s Hospital, Toronto.

Those most likely to succeed at CTO PCI are technically accomplished, seek out complex cases, find themselves drawn to CTO cases, have a significant amount of time to commit and can shed ego, Buller said.

“If you go into this with the intention of building referrals, you will fail,” he said. “You have got to do this because you want to do it, you enjoy doing it, you seek out this difficult work and you want to do the right thing for patients. The referrals will follow.”

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Fortunately, Buller said, the CTO PCI community is full of operators who want to proctor others as they learn the technique and who want to collaborate on research in the field.

For more information:

Karmpaliotis D. The CTO PCI learning curve (and ancillary benefits for non-CTO PCI outcomes.

Hermiller JB. Institutional benefits of a CTO program.

Buller CE. Preparing my hospital to become a CTO PCI center. All presented at: TCT 2013; Oct. 27-Nov. 1, 2013; San Francisco.

Disclosure:Buller, Hermiller and Karmpaliotis report conflicts of interest with several device and pharmaceutical manufacturers.