The Impact of a Dedicated Chronic Total Occlusion PCI Program on Heart Team Decision Making

Abstract

Background. Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade—and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization. Methods. This observational study was conducted at St Thomas’ Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion. Results. From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy. Conclusions. A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.

Keywords: coronary artery disease, health outcomes, heart team, revascularization

In revascularization guidelines across the globe, the heart team (HT) model is recommended to optimize and standardize the decision-making process for patients with complex coronary, valvular, or inherited cardiac disease.^1-3 The European Society of Cardiology/European Association for CardioThoracic Surgery guidelines issue a clear recommendation in favor of multidisciplinary decision making to balance “underuse of revascularization procedures” with inappropriate use of revascularization strategies.” Marked variability between European countries was mentioned as a concern and the HT considered a solution to counteract this juxtaposition.^4,5

We have previously published on the implementation and consistency of HT decision making in complex coronary revascularizations⁶ and associated long-term outcomes.⁷ The host institution established a dedicated complex coronary intervention/percutaneous coronary intervention (PCI) service for chronic total occlusions (CTOs) in 2015. While previous work demonstrated that initial HT recommendations could be reproduced after repeat, blinded discussion, the focus of this study was to describe the real-life effect of a dedicated complex coronary intervention/CTO PCI service utilizing the HT approach in a major cardiac center. We hypothesized that practice had changed over the past decade, partially owing to the impact of revascularization guidelines and the availability of advanced technologies enabling percutaneous revascularization of CTOs.

Methods

St Thomas’ Hospital is a tertiary cardiac center for coronary intervention and cardiothoracic surgery in central London. In the audited period, HT meetings were held once weekly at a prearranged time and location, with at least 1 representative from the interventional cardiology and cardiac surgical services present. Patient details are presented using PowerPoint slides, alongside all the imaging modalities available for review. Each case is presented in a structured manner and coronary angiography is obtained and presented for each case. The attendees, discussion, and HT recommendation are documented in an electronic archive and added to the electronic patient record. Referrals are selected at the discretion of the treating physician and can originate from affiliated district general hospitals or in-house.

Data for the study were collected prospectively; decisions, implementation, and follow-up of 52 HT meetings were recorded between April 2018 and April 2019. A small subset of cases from a previous audit period (April 2012 to April 2013) was selected based on the presence of isolated CTO and re-presented with the same clinical dataset, but with the panel blinded to (1) previous discussions; and (2) patient outcomes. No HT meeting participant recognized the original case, but had this occurred the panellist would have been asked not to participate in the decision-making process.

For statistical analysis, proportions were compared using a 2-sample test for equality of proportions without Yates’ continuity correction. Statistical software R, version 3.6.1, was used for analysis.

Results

Patient demographics. The HT discussed a total of 335 unique patients at weekly meetings throughout a 12-month monitoring period; accounting for previously discussed patients, a total of 375 cases were discussed. The study group was predominantly male (77%) with a median age of 69 years (interquartile range [IQR], 61-76). Almost one-third of patients (32%) had a history of myocardial infarction and 27% had a history of prior revascularization (PCI or coronary artery bypass graft [CABG]). Comorbidities were common, with hypertension in 67%, hyperlipidemia in 55%, history of diabetes in 38%, and a history of current or prior smoking in 44% (Table 1).

HT meeting characteristics. Most patients (65%) had preserved left ventricular function with extensive coronary artery disease (3-vessel disease in 63%). The complexity and extent of CAD as reflected by the SYNTAX score was balanced across the tertiles: 35% had low, 36% had intermediate, and 29% had high SYNTAX scores. Median EuroScore was 3% (IQR, 1-7) (Table 2). A total of 117 patients had a CTO, with a majority (60%) affecting the right coronary artery. Median J-CTO score was 3 (IQR, 2-3).

Fifty-three percent of patients presented as an acute coronary syndrome (ACS), including angina, with the remainder (47%) representing patients managed in the outpatient setting.

On average, 2 interventional cardiologists and 2 cardiac surgeons attended each meeting. The proposed treatments following the first discussion were CABG in 31%, PCI in 29%, and optimal medical therapy (OMT) in 18%; 1 patient received no specific recommendation as there was equipoise concerning mode of revascularization and 4% of patients were referred for inclusion in research studies that would determine the revascularization strategy. Of those planned for PCI, 5% were dedicated CTO procedures.

Fifty-six patients (17%) required further assessment. Of those, 19 patients were discussed again at a later HT meeting, 11 patients were planned for further revascularization (CABG or PCI), 2 patients were planned for inclusion in research, and 1 patient was planned for transcatheter aortic valve implantation. Of those not requiring further discussion (n = 37), 18 patients continued with OMT, 7 patients were treated with CABG, 9 patients were treated with PCI (1 CTO-PCI), 1 patient was referred for TAVI, and 2 did require further investigations and were due to be seen in outpatient follow-up.

Trends and consistency of treatment decisions. Fifty-six patients (17%) received treatment that differed from the original HT recommendation (Supplemental Table S1). Of these, 26% were planned for CABG and 33% were planned for PCI and OMT. Most commonly, the divergence originated from a patient preference (27%), followed by anatomical considerations (23%) and frailty (16%)—albeit the latter was not formally assessed, but was a clinical impression.

Twelve percent of patients were rediscussed at the HT meeting after a median of 4 weeks (IQR, 3-12). As demonstrated in Figure 1, a total of 6 patients who were originally planned for CABG crossed over to treatment with PCI. Two patients from the original PCI group were planned for CABG.

Compared with a previous publication from the same center,⁶ the overall rates of revascularization have increased from 42.9% to 60.3% (P<.001); from 26.3% to 31% for CABG (P=.18) and from 16.5% to 29.6% for PCI (P<.001).

Supplemental Table S2 provides an overview of the patient characteristics stratified by ultimate treatment received (either as per first HT meeting or, if rediscussed, second HT meeting). The surgical patients tended to be younger, with lower rates of prior myocardial infarction and chronic kidney disease, and a significantly lower rate of diabetes (28% in CABG vs 40% in PCI; P=.04). Both SYNTAX and EuroScore were well balanced across most of the groups; notably, patients with a higher EuroScore were more likely to require a further assessment before proceeding to definitive treatment.

Has practice changed over time? Of 399 individual patient discussions conducted in HT meetings between April 2012 and April 2013, we selected patients with a CTO for rediscussion at a multidisciplinary team during the current analysis period. The rate of isolated CTO was 3.8% (n = 15); 13 patients were treated with OMT and 2 were treated with CABG. Upon rediscussion, a CTO operator was present at all meetings. Three patients received the same outcome (CABG 2, OMT 1). Six patients would have been referred for CTO-PCI. A further 6 patients were referred for surgical revascularization (with backup options of percutaneous revascularization if they failed surgical preassessment) (Figure 2 and Supplemental Figure S1).

Discussion

This retrospective study of current practice in the revascularization decision-making process for complex cardiac patients features the following findings: (1) The patients discussed have commonly 1 or more comorbidities, with an elevated EuroScore reflective of heightened surgical risk. SYNTAX score was balanced across the tertiles, and most patients had 2- or 3-vessel disease. (2) We observed a clear trend toward higher rates of revascularization, both by surgical and percutaneous methods. This was a function of treating more complex cases and the availability of novel therapeutic options for complex coronary artery stenoses, such as CTOs. (3) While CTOs were present in 35% of patients, the majority were observed in patients with multivessel CAD; dedicated CTO-PCI was recommended for nearly 7% of patients. It is unclear from the available data whether a proportion of patients with CTOs who were not felt to be surgical candidates were treated percutaneously in the residual coronary arterial tree to be then reassessed for residual symptoms, and subsequent consideration of complex coronary intervention. (4) We have demonstrated a shift in the decision-making process with the simulation of rediscussion of “old” cases in the same forum 8 years later; while this only represents a snapshot of current practice, it was striking that 80% of patients who were previously treated with OMT would have now been offered surgical or percutaneous revascularization for their chronic coronary syndrome. Furthermore, while not formally evaluated, percutaneous options as backup were frequently mentioned in the recommended outcome from the HT meetings.

Study limitations. The data presented in this study are subject to limitations inherent to observational studies reflecting contemporary clinical practice. Data available from a single tertiary cardiac center have been audited and presented, and only a subset of patients treated every year are discussed at HT meetings. These conventionally reflect the highest-risk cohort, or where there is clinical equipoise—thus, the data cannot be generalized to the wider patient population. The functional status of patients was not routinely collected and has therefore been omitted from the analysis. Due to well-described observer variation when calculating SYNTAX scores,⁸ the score was presented in tertiles reflecting overall complexity.

However, in line with international and national guidelines, there may well arise a need to lower the “threshold” to discuss patients with complex (or multivessel) CAD at HT meetings. First, as shown, a dedicated program supporting complex coronary intervention and treatment of CTOs is associated with a change in treatment recommendations. Second, rapidly evolving technology that supports the treatment of complex coronary disease might quickly render anecdotal experience obsolete—highlighting the need for periodic review of available treatment options and consideration of referral to multidisciplinary teams with established CTO programs outside non-CTO centers. Third, while age and other comorbidities have remained largely unchanged when compared with the data presented by Patterson et al,⁷ one-third of patients have underlying left ventricular dysfunction and the rate of peripheral vascular disease has increased from 4.4% to 14%. As not all complexities are reflected accurately in the EuroScore, there may be an emerging need for future dedicated complete higher-risk indicated ­PCI (“CHIP”)/CTO multidisciplinary teams.

Conclusion

Patients discussed and treated in tertiary cardiac center are becoming increasingly complex with respect to comorbidities and coronary anatomy. Regular HT meetings form the cornerstone of guideline-directed therapy, and dedicated CTO and complex PCI operators expand the therapeutic armamentarium available to enable coronary revascularization.

Affiliations and Disclosures

From ¹King’s College London BHF Centre, The Rayne Institute, St Thomas’ Hospital, London, United Kingdom; ²St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, United Kingdom; ³Department of Cardiothoracic Surgery, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, United Kingdom.

Funding: The following authors were supported by a National Institute for Health Research Academic Clinical Lectureship: Kaier (CL-2019-17-006); Patterson.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted January 15, 2022.

Address for correspondence: Antonis Pavlidis, PhD, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom. Email: antonis.pavlidis@gstt.nhs.uk

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