- Email: [email protected]
TCT-258 Impact of Complications During Chronic Total Occlusion Angioplasty on Hospitalization Costs and Length of Stay: Insights from the OPEN-CTO Registry
B106
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
considered to have minimal impact if within normal range, so it is neglected in the equation. The aim of this study was to assess the impact of mean right atrial pressure (Pra) on collateral donor vessels FFR measurements in the presence of a chronic total occlusion. METHODS This was a single centre prospective observational cohort study. Consecutive patients who underwent PCI for a CTO of the right coronary artery (RCA) were included. Prior to RCA recanalization, FFR was measured in both donor vessels [left anterior descending (LAD) and circumflex (Cx) arteries]. FFR was calculated using the Pd/ Pa equation during maximum hyperaemia and also accounting for right atrial pressure (Pd–Pra/Pa-Pra). Pra was measured with a pigtail catheter positioned at the level of the right atrium. Maximum hyperaemia was achieved with intravenous infusion of adenosine via right femoral vein. Donor vessels were characterised as major or minor based on angiographic assessment of provided collateral significance. RESULTS FFR was measured in 68 arteries (34 LAD and 34 Cx) of 34 consecutive patients scheduled for RCA CTO PCI. Patients’ mean age was 62 10 years old and 88% were male. Mean left ventricular ejection fraction was 51% 20. During maximum hyperaemia, mean Pra, Pa, and Pd were 4.13.8 mmHg, 82.612.2 mmHg, and 63.814.3 mmHg, respectively. In the major donor vessel, corrected FFR with the inclusion of Pra showed a difference of 0.007 to classical FFR (0.760 0.113 vs. 0.767 0.112, p¼0.004). In the minor donor vessel the difference was 0.004 (0.895 0.067 vs. 0.899 0.065, p < 0.001). CONCLUSION In the presence of a CTO, RA pressure adjustment of FFR in the collateral donor vessels leads to trivial numerical changes, which are statistically significant but clinically negligible. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-256 Post-procedural pressure drift at the coronary ostium does not reflect peri-procedural drift assessed from stenosis hemodynamics at the time of physiological appraisal Lorena Casadonte,1 Jan Piek,1 Ed vanBavel,1 Jos Spaan,1 Maria Siebes1 1 Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands BACKGROUND Drift is a frequent problem affecting intracoronary (IC) pressure measurements. It is generally assumed that drift occurs early on in the procedure and that the pressure gradient at the coronary ostium, measured at the end of the procedure, equals the drift at the time of physiological assessment in the coronary artery, the periprocedural drift. A pressure drift of 2 mmHg is considered acceptable, while measurements should be repeated for larger pressure offsets. The quadratic stenosis pressure gradient-velocity (DP-v) relationship can be derived from combined pressure and flow velocity measurements during the response to a hyperemic stimulus. Since pressure gradient must be zero at no flow, the zero-flow intercept of this curve reveals peri-procedural drift. We hypothesized that postprocedural drift does not correspond to peri-procedural drift. METHODS In 70 patients, we analyzed 120 IC pressure and flow velocity tracings obtained in reference, stenotic and stented vessels during the response to a bolus of adenosine. Corresponding DP-v relationships and their intercepts were derived. Residual pressure gradient at the ostium was measured 89 times. RESULTS Peri- and post-procedural drift did not match in 42% of the cases. Post-procedural drift exceeded the 2 mmHg range for 64 ostium measurements (72%), which were associated with 87 IC measurements (73%). However, peri-procedural drift was within the acceptable range for 30 of those IC tracings (34%). Conversely, periprocedural drift exceeded 2 mmHg in 20 (61%) of the 33 IC measurements with acceptable drift at the ostium. Hence, for 17% of the tracings, unacceptable drift during the physiological appraisal was not noticeable at the ostium. CONCLUSION Post-procedural drift at the coronary ostium rarely matches peri-procedural drift. Mechanical stresses on the pressure sensor during the procedure are the likely culprit. Drift correction of individual IC tracings based on the intercept of the DP-v relationship can avoid inadvertent diagnostic misclassification due to unrecognized peri-procedural drift, and reduce repeat IC assessments, thereby lowering procedural time, cost, and patient discomfort. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment
TCT-257 Influence of heart rate on the FFR measurement - experimental and clinical study ski,2 Przemyslaw Kwasiborski,1 Wojciech Czerwin Paweł Kowalczyk,3 Kamil Derbisz,2 Mateusz Kachel,2 Adam Janas,4 Piotr Buszman,2 Paweł Buszman,2 Krzysztof Milewski2 1 Angiology and hemodynamics laboratory, Regional Specialist Hospital, Mie ˛dzylesie, Poland; 2Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland; 3 Department of Biophysics and Human Physiology, Medical University of Warsaw, Warsaw, Poland; 4Center of Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland BACKGROUND The physiological assessment of a lesion is a key to quality of life and prognosis of a patient with moderate coronary stenosis. Blood flow in coronary arteries occurs primarily during diastole, it is evident especially in the LAD. The systolic phase lasts roughly 300 ms and its duration is almost independent of the heart rate, consequently the higher heart rate the shorter diastole. Flow fluctuations associated with the cardiac cycle directly affect the pressures that are measured during FFR. In this study we tried to estimate that effect theoretically, experimentally in a porcine model and in clinical settings. METHODS The group of 4 healthy domestic pigs we used in experimental arm. Stenoses in RCA and LAD were induced by balloon inflation in previously stented segment of RCA or LAD respectively. Heart rate was stabilized by external cardiac peacemaker. Clinical arm of the study included 9 elective patients with isolated, moderate lesions in LAD or RCA who were admitted for FFR assessment. FFR measurements were repeated 3 times for each heart rate, starting from resting HR and during pacing at 100, 130, 160 (180 for pigs) beats per minute. All FFR measurements were performed after a stable hyperemia was reached. RESULTS In experimental arm 33 FFR measurements (14 RCA and LAD 19) were done (Fig. 1.). The experimental results indicate a significant correlation of FFR and HR in LAD (r2 ¼ 0.79, p < 0.0001), which agreed with in silico model (p¼0.11). In opposite, the results obtained in RCA indicate a lack of correlation between FFR and HR (r2 ¼ 0.03, p ¼ 0.52). In clinical arm 105 FFR measurements (48 RCA, 57 LAD) were done. Results achieved in LAD indicate that there is a significant correlation between FFR and HR (r¼0.53, p¼0.00002). Similarly, to the porcine model there is no significant correlation in RCA (r¼0.14, p¼0.35). CONCLUSION Presented results justify hypothesis of potential influence of HR on FFR value measured in LAD. Theoretical model of FFRHR dependency developed during the study gives upper estimate of HR impact on FFR that is probable possible to achieve only in the experiment. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment
CTO OUTCOMES
Abstract nos: 258 - 262 TCT-258 Impact of Complications During Chronic Total Occlusion Angioplasty on Hospitalization Costs and Length of Stay: Insights from the OPEN-CTO Registry Adam Salisbury,1 J. Aaron Grantham,2 Qingrui Meng,3 Suzanne Arnold,4 Hemal Gada,5 Suzanne Baron,6 William Lombardi,7 Dimitri Karmpaliotis,8 Jeffrey Moses,8 John Spertus,1 David Cohen4 1 Mid America Heart Institute, Kansas City, Missouri, United States; 2 University of Missouri Kansas City and Mid America Heart Institute, Kansas City, Missouri, United States; 3Saint Luke’s Hospital, Kansas City, Missouri, United States; 4Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, United States; 5PinnacleHealth CardioVascular Institute, Wormleysburg, Pennsylvania, United States; 6 St. Luke’s Mid America Heart Institute, Kansas City, Missouri, United States; 7University of Washington Medical Center, Seattle, Washington, United States; 8NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, United States BACKGROUND Chronic total occlusion (CTO) PCI frequently requires greater procedural resource use and carries higher risk for
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
complications than PCI of non-CTO vessels. The cost of CTO PCI using the hybrid approach has not been described, and no prior studies have examined the impact of complications on in-hospital costs and length of stay (LOS). METHODS Costs were calculated from 964 pts in the 12-center OPENCTO registry using prospectively collected resource utilization data and hospital billing data (for procedural and non-procedural costs, respectively). We developed multivariable models to estimate the incremental costs and LOS associated with specific periprocedural complications. Attributable costs and LOS for each complication were calculated by multiplying the independent cost of each event by its frequency in the population. RESULTS Mean and median costs for the index hospitalization were $17,106 $9,887 and $14,758, respectively; 14.5% of patients experienced at least 1 complication. Pts with one or more complications had significantly higher hospital costs (by $8,612) and LOS (by 1.5 days) than pts without complications. Seven complications were independently associated with increased in-hospital costs (Table); clinically significant perforation and myocardial infarction had the greatest attributable cost per pt. Overall, complications accounted for $911 per patient in hospital costs (5.3% of the total cost) and 0.2 days of hospitalization. Incremental Complication
Attributable
Cost
95% CI
cost
$13,276
$6,156 to $20,396
$110
Myocardial infarction
$7,862
$4,400 to $11,324
$212
Clinically significant peforation
$5,623
$2,574 to $8,671
$251
Vascular complication
$9,178
$2,901 to $15,455
$67
Contrast nephropathy
$8,285
$1,847 to $14,722
$69
Cardiac surgery
$15,601
$7,550 to $23,652
$81
Donor vessel thrombosis or dissection
$6,489
$2,335 to $10,643
$121
Death
Total cost of complications
$911
CONCLUSION Periprocedural complications had a significant impact on both LOS and in-hospital costs for patients undergoing attempted CTO PCI. Methods to identify patients at high risk for complications and strategies to reduce risk of complications may reduce the costs of CTO PCI. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-259 PERSPECTIVE Trial: Procedural, Clinical and Health Status Outcomes Among Patients Undergoing Chronic Total Occlusion Percutaneous Revascularization David Kandzari,1 Nicholas Lembo,2 Harold Carlson,1 Mike Gibson,3 Jayne Morgan,1 Sarah Rinehart,1 Amin Yehya,1 Dimitri Karmpaliotis4 1 Piedmont Heart Institute, Atlanta, Georgia, United States; 2Columbia University, New York, New York, United States; 3Harvard, Natick, Massachusetts, United States; 4NewYork-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States BACKGROUND Limited study has detailed the procedural, clinical and health status outcomes among patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using contemporary methods. METHODS The PERSPECTIVE trial included consecutive patients undergoing attempted CTO revascularization at a single center. Procedural and in-hospital outcomes, in addition to clinical events were assessed at baseline, 6 months and 1 year. The primary endpoint is 1year occurrence of death, myocardial infarction and target lesion revascularization. Among a pre-specified cohort of 250 prospectively followed consecutive patients, health status (CCS angina, Seattle Angina Questionnaire, EQ5D) outcomes were ascertained at baseline, 6 months and 1 year. Additional secondary endpoints include procedural success, completeness of revascularization and 1-year MACE among patients treated with zotarolimus-eluting stents. An independent clinical events committee adjudicated all clinical endpoints. Coronary angiograms performed at baseline and follow-up, if clinically indicated, were reviewed by an independent angiographic core laboratory. RESULTS Between June 2013 and March 2016, 491 consecutive CTO patients providing informed consent were enrolled. Angina class III/IV was 70.1%; diabetes, 35.4%; previous bypass surgery, 29.7%; prior attempted revascularization, 21.4%; and J CTO score, 2.5 1.1.
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Technical success with guidewire crossing was 90.3%. A primary antegrade strategy was attempted in 67.8% of procedures, and the mean number of guidewires/case was 7.5 4.6. Clinically significant perforation was 5.3%, and rates of in-hospital MI and death were 1.6% and 0.8%, respectively. The mean reduction in SYNTAX score with CTO PCI was 11.6 6.7. Final 1-year clinical and health status outcomes will be reported. CONCLUSION In a large series of patients undergoing attempted CTO PCI representing contemporary technique and strategy, the PERSPECTIVE trial informs the association between procedural results and the impact of CTO PCI on completeness of revascularization with clinical and health status outcomes. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-260 Safety and Effectiveness of XIENCE Stents in Chronic Total Occlusion Revascularization: Long-Term Results from the EXPERT CTO Multicenter Clinical Trial David Kandzari,1 Annapoorna Kini,2 Dimitri Karmpaliotis,3 Jeffrey Moses,3 Pradyumna Tummala,4 J. Aaron Grantham,5 William Lombardi,6 William Nicholson,7 Nicholas Lembo8 1 Piedmont Heart Institute, Atlanta, Georgia, United States; 2Mount Sinai Health System, New York, New York, United States; 3NewYorkPresbyterian Hospital/Columbia University Medical Center, New York, New York, United States; 4The Heart Center of Northeast Georgia Medical Center, Gainesville, Georgia, United States; 5University of Missouri Kansas City and Mid America Heart Institute, Kansas City, Missouri, United States; 6University of Washington Medical Center, Seattle, Washington, United States; 7York Hospital - Wellspan Health, York, Pennsylvania, United States; 8Columbia University, New York, New York, United States BACKGROUND Limited long term data exists regarding chronic total occlusion (CTO) revascularization with modern techniques and newgeneration drug-eluting stents. EXPERT CTO (NCT01435031) is a prospective, multicenter registration trial examining the safety and effectiveness of XIENCE everolimus eluting stents (EES) in CTO percutaneous coronary intervention (PCI) with dedicated long-term follow-up. METHODS Among patients undergoing attempted CTO PCI and stent revascularization with Xience everolimus eluting stents (EES), the primary endpoint of major adverse cardiac events (MACE: death, ARCdefined myocardial infarction (MI), or clinically-driven target lesion revascularization [CD-TLR)] at 1 year was compared with a pre-specified performance goal derived from prior CTO studies. Additional key outcomes included target lesion failure (TLF: cardiac death, ARCdefined target vessel myocardial infarction [TV-MI], or CD-TLR) and individual component endpoints. Annual follow-up through 4 years was protocol mandated. RESULTS Among 222 patients undergoing successful CTO PCI, treatment with EES was associated with significantly lower 1-year MACE for both intent-to-treat (ITT; 18.5%, 1-sided upper confidence interval: 23.4%, P¼0.025) and per-protocol populations (8.2%, 1-sided upper confidence interval: 12.3%, P< 0.0001) compared with a pre-specified performance goal derived from 6 prior CTO drug-eluting stent trials (1year MACE: 24.4%). Through 4 years, rates of MACE and TLF by ITT analysis were 31.6% and 24.1%, respectively. Four year TV-MI was 15.5%, and CD-TLR was 11.3%. There was no occurrence of definite/ probable stent thrombosis (ST) after 1 year.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
considered to have minimal impact if within normal range, so it is neglected in the equation. The aim of this study was to assess the impact of mean right atrial pressure (Pra) on collateral donor vessels FFR measurements in the presence of a chronic total occlusion. METHODS This was a single centre prospective observational cohort study. Consecutive patients who underwent PCI for a CTO of the right coronary artery (RCA) were included. Prior to RCA recanalization, FFR was measured in both donor vessels [left anterior descending (LAD) and circumflex (Cx) arteries]. FFR was calculated using the Pd/ Pa equation during maximum hyperaemia and also accounting for right atrial pressure (Pd–Pra/Pa-Pra). Pra was measured with a pigtail catheter positioned at the level of the right atrium. Maximum hyperaemia was achieved with intravenous infusion of adenosine via right femoral vein. Donor vessels were characterised as major or minor based on angiographic assessment of provided collateral significance. RESULTS FFR was measured in 68 arteries (34 LAD and 34 Cx) of 34 consecutive patients scheduled for RCA CTO PCI. Patients’ mean age was 62 10 years old and 88% were male. Mean left ventricular ejection fraction was 51% 20. During maximum hyperaemia, mean Pra, Pa, and Pd were 4.13.8 mmHg, 82.612.2 mmHg, and 63.814.3 mmHg, respectively. In the major donor vessel, corrected FFR with the inclusion of Pra showed a difference of 0.007 to classical FFR (0.760 0.113 vs. 0.767 0.112, p¼0.004). In the minor donor vessel the difference was 0.004 (0.895 0.067 vs. 0.899 0.065, p < 0.001). CONCLUSION In the presence of a CTO, RA pressure adjustment of FFR in the collateral donor vessels leads to trivial numerical changes, which are statistically significant but clinically negligible. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-256 Post-procedural pressure drift at the coronary ostium does not reflect peri-procedural drift assessed from stenosis hemodynamics at the time of physiological appraisal Lorena Casadonte,1 Jan Piek,1 Ed vanBavel,1 Jos Spaan,1 Maria Siebes1 1 Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands BACKGROUND Drift is a frequent problem affecting intracoronary (IC) pressure measurements. It is generally assumed that drift occurs early on in the procedure and that the pressure gradient at the coronary ostium, measured at the end of the procedure, equals the drift at the time of physiological assessment in the coronary artery, the periprocedural drift. A pressure drift of 2 mmHg is considered acceptable, while measurements should be repeated for larger pressure offsets. The quadratic stenosis pressure gradient-velocity (DP-v) relationship can be derived from combined pressure and flow velocity measurements during the response to a hyperemic stimulus. Since pressure gradient must be zero at no flow, the zero-flow intercept of this curve reveals peri-procedural drift. We hypothesized that postprocedural drift does not correspond to peri-procedural drift. METHODS In 70 patients, we analyzed 120 IC pressure and flow velocity tracings obtained in reference, stenotic and stented vessels during the response to a bolus of adenosine. Corresponding DP-v relationships and their intercepts were derived. Residual pressure gradient at the ostium was measured 89 times. RESULTS Peri- and post-procedural drift did not match in 42% of the cases. Post-procedural drift exceeded the 2 mmHg range for 64 ostium measurements (72%), which were associated with 87 IC measurements (73%). However, peri-procedural drift was within the acceptable range for 30 of those IC tracings (34%). Conversely, periprocedural drift exceeded 2 mmHg in 20 (61%) of the 33 IC measurements with acceptable drift at the ostium. Hence, for 17% of the tracings, unacceptable drift during the physiological appraisal was not noticeable at the ostium. CONCLUSION Post-procedural drift at the coronary ostium rarely matches peri-procedural drift. Mechanical stresses on the pressure sensor during the procedure are the likely culprit. Drift correction of individual IC tracings based on the intercept of the DP-v relationship can avoid inadvertent diagnostic misclassification due to unrecognized peri-procedural drift, and reduce repeat IC assessments, thereby lowering procedural time, cost, and patient discomfort. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment
TCT-257 Influence of heart rate on the FFR measurement - experimental and clinical study ski,2 Przemyslaw Kwasiborski,1 Wojciech Czerwin Paweł Kowalczyk,3 Kamil Derbisz,2 Mateusz Kachel,2 Adam Janas,4 Piotr Buszman,2 Paweł Buszman,2 Krzysztof Milewski2 1 Angiology and hemodynamics laboratory, Regional Specialist Hospital, Mie ˛dzylesie, Poland; 2Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland; 3 Department of Biophysics and Human Physiology, Medical University of Warsaw, Warsaw, Poland; 4Center of Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland BACKGROUND The physiological assessment of a lesion is a key to quality of life and prognosis of a patient with moderate coronary stenosis. Blood flow in coronary arteries occurs primarily during diastole, it is evident especially in the LAD. The systolic phase lasts roughly 300 ms and its duration is almost independent of the heart rate, consequently the higher heart rate the shorter diastole. Flow fluctuations associated with the cardiac cycle directly affect the pressures that are measured during FFR. In this study we tried to estimate that effect theoretically, experimentally in a porcine model and in clinical settings. METHODS The group of 4 healthy domestic pigs we used in experimental arm. Stenoses in RCA and LAD were induced by balloon inflation in previously stented segment of RCA or LAD respectively. Heart rate was stabilized by external cardiac peacemaker. Clinical arm of the study included 9 elective patients with isolated, moderate lesions in LAD or RCA who were admitted for FFR assessment. FFR measurements were repeated 3 times for each heart rate, starting from resting HR and during pacing at 100, 130, 160 (180 for pigs) beats per minute. All FFR measurements were performed after a stable hyperemia was reached. RESULTS In experimental arm 33 FFR measurements (14 RCA and LAD 19) were done (Fig. 1.). The experimental results indicate a significant correlation of FFR and HR in LAD (r2 ¼ 0.79, p < 0.0001), which agreed with in silico model (p¼0.11). In opposite, the results obtained in RCA indicate a lack of correlation between FFR and HR (r2 ¼ 0.03, p ¼ 0.52). In clinical arm 105 FFR measurements (48 RCA, 57 LAD) were done. Results achieved in LAD indicate that there is a significant correlation between FFR and HR (r¼0.53, p¼0.00002). Similarly, to the porcine model there is no significant correlation in RCA (r¼0.14, p¼0.35). CONCLUSION Presented results justify hypothesis of potential influence of HR on FFR value measured in LAD. Theoretical model of FFRHR dependency developed during the study gives upper estimate of HR impact on FFR that is probable possible to achieve only in the experiment. CATEGORIES IMAGING: FFR and Physiologic Lesion Assessment
CTO OUTCOMES
Abstract nos: 258 - 262 TCT-258 Impact of Complications During Chronic Total Occlusion Angioplasty on Hospitalization Costs and Length of Stay: Insights from the OPEN-CTO Registry Adam Salisbury,1 J. Aaron Grantham,2 Qingrui Meng,3 Suzanne Arnold,4 Hemal Gada,5 Suzanne Baron,6 William Lombardi,7 Dimitri Karmpaliotis,8 Jeffrey Moses,8 John Spertus,1 David Cohen4 1 Mid America Heart Institute, Kansas City, Missouri, United States; 2 University of Missouri Kansas City and Mid America Heart Institute, Kansas City, Missouri, United States; 3Saint Luke’s Hospital, Kansas City, Missouri, United States; 4Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, United States; 5PinnacleHealth CardioVascular Institute, Wormleysburg, Pennsylvania, United States; 6 St. Luke’s Mid America Heart Institute, Kansas City, Missouri, United States; 7University of Washington Medical Center, Seattle, Washington, United States; 8NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, United States BACKGROUND Chronic total occlusion (CTO) PCI frequently requires greater procedural resource use and carries higher risk for
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 70, NO. 18, SUPPL B, 2017
complications than PCI of non-CTO vessels. The cost of CTO PCI using the hybrid approach has not been described, and no prior studies have examined the impact of complications on in-hospital costs and length of stay (LOS). METHODS Costs were calculated from 964 pts in the 12-center OPENCTO registry using prospectively collected resource utilization data and hospital billing data (for procedural and non-procedural costs, respectively). We developed multivariable models to estimate the incremental costs and LOS associated with specific periprocedural complications. Attributable costs and LOS for each complication were calculated by multiplying the independent cost of each event by its frequency in the population. RESULTS Mean and median costs for the index hospitalization were $17,106 $9,887 and $14,758, respectively; 14.5% of patients experienced at least 1 complication. Pts with one or more complications had significantly higher hospital costs (by $8,612) and LOS (by 1.5 days) than pts without complications. Seven complications were independently associated with increased in-hospital costs (Table); clinically significant perforation and myocardial infarction had the greatest attributable cost per pt. Overall, complications accounted for $911 per patient in hospital costs (5.3% of the total cost) and 0.2 days of hospitalization. Incremental Complication
Attributable
Cost
95% CI
cost
$13,276
$6,156 to $20,396
$110
Myocardial infarction
$7,862
$4,400 to $11,324
$212
Clinically significant peforation
$5,623
$2,574 to $8,671
$251
Vascular complication
$9,178
$2,901 to $15,455
$67
Contrast nephropathy
$8,285
$1,847 to $14,722
$69
Cardiac surgery
$15,601
$7,550 to $23,652
$81
Donor vessel thrombosis or dissection
$6,489
$2,335 to $10,643
$121
Death
Total cost of complications
$911
CONCLUSION Periprocedural complications had a significant impact on both LOS and in-hospital costs for patients undergoing attempted CTO PCI. Methods to identify patients at high risk for complications and strategies to reduce risk of complications may reduce the costs of CTO PCI. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-259 PERSPECTIVE Trial: Procedural, Clinical and Health Status Outcomes Among Patients Undergoing Chronic Total Occlusion Percutaneous Revascularization David Kandzari,1 Nicholas Lembo,2 Harold Carlson,1 Mike Gibson,3 Jayne Morgan,1 Sarah Rinehart,1 Amin Yehya,1 Dimitri Karmpaliotis4 1 Piedmont Heart Institute, Atlanta, Georgia, United States; 2Columbia University, New York, New York, United States; 3Harvard, Natick, Massachusetts, United States; 4NewYork-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States BACKGROUND Limited study has detailed the procedural, clinical and health status outcomes among patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using contemporary methods. METHODS The PERSPECTIVE trial included consecutive patients undergoing attempted CTO revascularization at a single center. Procedural and in-hospital outcomes, in addition to clinical events were assessed at baseline, 6 months and 1 year. The primary endpoint is 1year occurrence of death, myocardial infarction and target lesion revascularization. Among a pre-specified cohort of 250 prospectively followed consecutive patients, health status (CCS angina, Seattle Angina Questionnaire, EQ5D) outcomes were ascertained at baseline, 6 months and 1 year. Additional secondary endpoints include procedural success, completeness of revascularization and 1-year MACE among patients treated with zotarolimus-eluting stents. An independent clinical events committee adjudicated all clinical endpoints. Coronary angiograms performed at baseline and follow-up, if clinically indicated, were reviewed by an independent angiographic core laboratory. RESULTS Between June 2013 and March 2016, 491 consecutive CTO patients providing informed consent were enrolled. Angina class III/IV was 70.1%; diabetes, 35.4%; previous bypass surgery, 29.7%; prior attempted revascularization, 21.4%; and J CTO score, 2.5 1.1.
B107
Technical success with guidewire crossing was 90.3%. A primary antegrade strategy was attempted in 67.8% of procedures, and the mean number of guidewires/case was 7.5 4.6. Clinically significant perforation was 5.3%, and rates of in-hospital MI and death were 1.6% and 0.8%, respectively. The mean reduction in SYNTAX score with CTO PCI was 11.6 6.7. Final 1-year clinical and health status outcomes will be reported. CONCLUSION In a large series of patients undergoing attempted CTO PCI representing contemporary technique and strategy, the PERSPECTIVE trial informs the association between procedural results and the impact of CTO PCI on completeness of revascularization with clinical and health status outcomes. CATEGORIES CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP) TCT-260 Safety and Effectiveness of XIENCE Stents in Chronic Total Occlusion Revascularization: Long-Term Results from the EXPERT CTO Multicenter Clinical Trial David Kandzari,1 Annapoorna Kini,2 Dimitri Karmpaliotis,3 Jeffrey Moses,3 Pradyumna Tummala,4 J. Aaron Grantham,5 William Lombardi,6 William Nicholson,7 Nicholas Lembo8 1 Piedmont Heart Institute, Atlanta, Georgia, United States; 2Mount Sinai Health System, New York, New York, United States; 3NewYorkPresbyterian Hospital/Columbia University Medical Center, New York, New York, United States; 4The Heart Center of Northeast Georgia Medical Center, Gainesville, Georgia, United States; 5University of Missouri Kansas City and Mid America Heart Institute, Kansas City, Missouri, United States; 6University of Washington Medical Center, Seattle, Washington, United States; 7York Hospital - Wellspan Health, York, Pennsylvania, United States; 8Columbia University, New York, New York, United States BACKGROUND Limited long term data exists regarding chronic total occlusion (CTO) revascularization with modern techniques and newgeneration drug-eluting stents. EXPERT CTO (NCT01435031) is a prospective, multicenter registration trial examining the safety and effectiveness of XIENCE everolimus eluting stents (EES) in CTO percutaneous coronary intervention (PCI) with dedicated long-term follow-up. METHODS Among patients undergoing attempted CTO PCI and stent revascularization with Xience everolimus eluting stents (EES), the primary endpoint of major adverse cardiac events (MACE: death, ARCdefined myocardial infarction (MI), or clinically-driven target lesion revascularization [CD-TLR)] at 1 year was compared with a pre-specified performance goal derived from prior CTO studies. Additional key outcomes included target lesion failure (TLF: cardiac death, ARCdefined target vessel myocardial infarction [TV-MI], or CD-TLR) and individual component endpoints. Annual follow-up through 4 years was protocol mandated. RESULTS Among 222 patients undergoing successful CTO PCI, treatment with EES was associated with significantly lower 1-year MACE for both intent-to-treat (ITT; 18.5%, 1-sided upper confidence interval: 23.4%, P¼0.025) and per-protocol populations (8.2%, 1-sided upper confidence interval: 12.3%, P< 0.0001) compared with a pre-specified performance goal derived from 6 prior CTO drug-eluting stent trials (1year MACE: 24.4%). Through 4 years, rates of MACE and TLF by ITT analysis were 31.6% and 24.1%, respectively. Four year TV-MI was 15.5%, and CD-TLR was 11.3%. There was no occurrence of definite/ probable stent thrombosis (ST) after 1 year.