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The Take Home: C3
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Image: C3; reprinted with permission
This June, the Complex Cardiovascular Catheter Therapeutics (C3) conference took place in Orlando, Fla., and attracted close to 1,000 attendees. The 5-day conference featured presentations, live cases and informal exchanges between physicians in the fields of interventional cardiology, vascular surgery and interventional radiology, as well as fellows, residents and other health care professionals.
Attending the meeting were Bryan W. Kluck, DO, FACC, FSCAI, interventional cardiologist, The Heart Care Group, Allentown, Penn., and Parag Doshi, MD, FACC, FSCAI, president of the Chicago Cardiology Institute, who offered Cardiology Today’s Intervention their thoughts on the standout sessions.
Bryan W. Kluck, DO
Bryan W. Kluck, DO
Bryan W. Kluck
The ninth annual C3 conference was a fast-paced, provocative and interactive meeting that once again demonstrated its expanding role as the premier forum for collaborative discourse and the interchange of ideas in cardiac and vascular interventions. The course began this year with a fellows program providing these early interventionalists with a tremendous faculty discussing a range of topics. STEMI guidelines (Patrick O’Gara, MD), vascular anatomy (Jon George, MD) and fractional flow reserve (D. Lynn Morris, MD) were among the core topics. Fellow exposure to cutting-edge concepts, such as selection of tools to cross vascular chronic total occlusions (Sean Janzer, MD), completed a rigorous day that can adequately be described as a fellow’s “boot camp.”
Year in Review
This year’s main course added a feature called the “Year in Review.” Course director Rajesh Dave, MD, gave detailed coverage of key advances in interventional cardiology that had occurred in the year since C3 2012. FAME II, ADAPT-DES, CHAMPION PHOENIX and INFUSE-AMI were among the studies reviewed. This talk, likely to be an annual feature, set the tone for the ambitious agenda to follow.
Unprotected Left Main Coronary Debate
A fascinating debate led off the main conference. Featured “combatants” were cardiac surgeon Raymond Singer, MD, who is chief of cardiothoracic surgery at Lehigh Valley Health Network, Allentown, Penn., and interventional cardiologist Marie-Claude Morice, MD, FESC, FACC, who is the head of the Insitut Cardiovasculaire Paris Sud. This spirited, insightful and informative debate clearly demonstrated the role of both coronary intervention and surgery in this challenging disease subset. It further emphasized the need for collaborative evaluation between surgeon and interventionalist for optimal outcomes.
Spotlight on Antiplatelet Therapy
A summit on antiplatelet therapy was embedded within the course day, a major change from past years. The summit once again engendered significant interest among attendees, as the venue was filled to capacity. Catalin Toma, MD, Mohan Sathyamoorthy, MD, and Branavan Umakanthan, MD, were among an elite panel of interventionalists, each discussing their use of antiplatelet pharmacology in unique clinical circumstances. Dimitrios Alexopoulos, MD, from Rio, Greece, added an international perspective to the discussion and presented some of the newer PLATO data on elderly patients. He closed by presenting some of his own data directly comparing the third-generation agents.
Live Cases
A signature of C3 is a perfect balance between lecture and live coronary and peripheral interventional cases from both national and international sites. The cases were wide ranging and thought provoking. As an example from the coronary perspective, tools and techniques of coronary CTO intervention were demonstrated by Dimitrios Karmpaliotis, MD, and his team from Piedmont Hospital in Atlanta. Peripherally, Sameer Dani, MD, and his team from Apollo Hospital in Ahmedabad, India, treated a patient with symptomatic carotid stenosis and an underlying arteritis. This case generated a great discussion about the choice of modalities. In the United States, arbitrary regulations have limited choices, but international practice patterns at present here highlight the deficiencies in US policy.
Disclosure: Kluck is on the speakers’ bureau of AstraZeneca and Daiichi Sankyo.
Parag Doshi, MD
Parag Doshi, MD
CTO Symposium Highlights
Parag Doshi
The CTO Symposium differed from last year in that it featured the two major schools of thought on opening CTOs: one is the Japanese approach, which tries to stay in the true lumen as much as possible; however, the approach may be inefficient or not practical for North American reality in terms of the efficiency, contrast use and use of resources. The other approach, which was new to the symposium, was the North American hybrid approach that uses either the retrograde or antegrade approach. The hybrid technique is very algorithm driven, allowing the cases to be done quickly, and involves use of specialized technologies like the Stingray (BridgePoint Medical/Boston Scientific).
Also at the symposium were live case demonstrations of both the antegrade and retrograde approaches and a session in which Manesh Patel, MD, debated J. Aaron Grantham, MD, in terms of the appropriateness of CTO interventions today; they both agreed that as long as there is a clinical indication by appropriate documentation, the procedures are appropriate.
Upcoming Changes to the AUC
There was also a very solid session on the appropriate use criteria (AUC). Today, as interventional cardiologists, we are receiving pressure from CMS and private insurance, which are both looking closely at the AUC. The speakers who discussed the AUC at C3 were actually the authors of the document — Ralph Brindis, MD, MPH, and Dr. Manesh Patel. During the session, we got an indication of what’s coming up with the next edition of the AUC. Their take was that one of the big controversies currently is that when we do the procedures, they are classified as appropriate, uncertain or inappropriate. The term “inappropriate,” many times, makes a physician appear unethical or as someone who performs a procedure without reason. However, the criteria, as Drs. Brindis and Patel pointed out, often don’t span the entire clinical spectrum. They will be changing the terminology from appropriate, uncertain or inappropriate to appropriate, sometimes appropriate and rarely appropriate. I feel, with these changes, the AUC will become not only less controversial, but also more meaningful in terms of day-to-day clinical practice.
Drs. Brindis and Patel also mentioned that they are going to incorporate new data in the AUC, with an emphasis on FFR from the FAME and FAME II trials.
Emerging Imaging Modalities
Although there were excellent talks covering FFR and IVUS this year, what really stood out to me were the sessions on some of the upcoming modalities, such as optical coherence tomography. OCT is becoming more popular, and there were sessions detailing the use of OCT in bifurcation stenting and for assessing stent complications. There was also another nice talk on more advanced concepts, such as FFR-CT or FFR calculated from the CTA, which essentially combines the anatomical knowledge of CTA with the physiologic concept of FFR directly from the CTA. CTA has been widely available in terms of diagnosing CAD, but there has been an increasing emphasis on the physiologic importance of lesions. Although FFR-CT is still an investigational technology, having a modality that offers both anatomic and physiologic information would essentially be a game changer.
Disclosure: Doshi is a proctor for BridgePoint Medical/Boston Scientific.