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Cardiology's Final Frontier: Confronting CTO

 |  By jcantlupe@healthleadersmedia.com  
   August 19, 2010

One of the joys of being a physician is simply doing what you do: the details of sorting through the complexities of ailments, evaluating medications, exploring the sinew of the body, the interwoven lines that carry the blood, saving a life.

Sometimes the business of what you do gets lost in the hubbub of money, and politics, and healthcare plans, but it’s nice to think about the purity of being a physician: and maybe being part of something that pushes you further into evolving realms of the science of what you do. Or at least spur some debate.

Like the place where Dimitri Karmpaliotis, MD, seems to be right now.

At 39, he is an interventional cardiologist at Piedmont Heart Institute, in Atlanta, GA, where he performs retrograde and antegrade angioplasty, loves it, and sees it expanding in the future in cardiac care. It is for the treatment of complex chronic total occlusion (CTO), and has been dubbed by some academics as being in the “last frontier” of cardiac intervention. Chronic occluded arteries account for 20 to 30% of coronary diseases, experts say.

Karmpaliotis’ specialty is maneuvering the arteries, declogging them with wires and a specificity that he says can be a major tool to help potentially hundreds of thousands of people. These are patients who, for example, had already undergone one bypass surgery operation, and their bypass grafts are failing and need more intensive doctor's care.

Piedmont Heart Institute is only one of about a dozen hospitals nationwide that perform more than 20 retrograde angioplasty cases a year for the treatment of CTO.

It’s an interesting time for Karmapliotis’ field. Piedmont, for instance, is considering doubling its CTO treatment at a time the treatment strategy has not been fully embraced in the U.S., although academic journals note considerable advances, with some criticism. The procedure is extremely popular in Japan, where it is considered home to the foremost experts in retrograde and antegrade angioplasty.

In June, Karmpaliotis was one of five U.S. cardiologists to attend the 2010 Japanese CTO Club conference. Japan is home to the foremost experts in retrograde and antegrade angioplasty. Karmpaliotis says the procedure developed in Japan where patients have been generally reluctant to have bypass surgeries and where cardiologists believe in complete cardiac revascularization.

 “In the spectrum of what we do [they are] the most complex, difficult, and fascinating cases,” he says of antegrade or retrograde angioplasty. “One reason it's so complicated is that the artery is closed for a long time, it’s as hard as a rock. If you don’t do it, you don’t get good at it. It’s a different beast than traditional angioplasty.”

For the past four years, Karmpaliotis has devoted much time to the retrograde and antegrade angioplasty, a procedure that can take four times as long as a stent. Since January, he and his team have performed 80 such procedures, with an established success rate of 89%, significantly more than significantly more than the national average of 65%, according to the hospital.

"Developments in guidewire technology, imaging technique, and coronary devices have contributed to the improved prognosis of patients affected by a CTO lesion," according to Current Cardiology Reports, in which "Enhancement in antegrade and retrograde techniques" also result in improved outcomes, the report stated.

Cardiac Interventions Today in 2008 described the strategies for confronting chronic occluded arteries as "conquering the last frontier of interventional cardiology."

The presence of CTOs often result in open heart surgery, though Karmpaliotis believes antegrade or retrograde angioplasty should be considered increasingly as a proper alternative option in carefully selected cases; to relieve a patient, too, of symptoms of angina, shortness of breath or compromised heart function.

In recent years, there has been much debate about the procedure in this country.

In April,  Rajesh Sachdeva, MD, Bradley Hughes, MD and Barry F. Uretsky, MD wrote that the retrograde technique has developed into a viable option, as the process continues to evolve, naming their article, in part "The Tale of a Long and Winding Wire." They add, "the retrograde approach for CTO is a relatively new treatment strategy with its attendant complications having not yet been fully appreciated and described."

Karmpaliotis acknowledges that there are skeptics because of the procedure complexities. But he is a firm believer in the procedure as taking on a more important role in the future across the country.

“There has been a lot of scrutiny not just by our peers; (but) the complication rates have been extremely low, almost better than regular angioplasty,” Karmpaliotis says, referring to work at Piedmont.

 “For patients with complex CTOs, traditional angioplasty may not be an option, open heart surgery may be risky or undesirable and the medications used for the relief of symptoms may cause side effects,” Karmaliotis says.

“There are hundreds of thousands of patients who had bypass surgery in the past 15 or 20 years,” Karmpaliotis says.  “So now we are faced with a problem, patients who had bypass surgery 15 years ago have bypass grafts that are not functioning anymore.They are blocked.”

William D. Knopf, MD, COO at Piedmont Heart Institute and vice president of Cardiovascular Services at Piedmont Hospital, in an interview, praised the “skill set and judgment and passion that Dimitri has.”

 “The complexity and time it takes for the procedure is not for the faint of heart,” Knopf says.

Karmapliotis leads a team of specialists who concentrate on the antegrade or retrograde angioplasty. According to Knopf, the hospital hopes to “double our volume in the next six months by adopting the latest technologies and continuing to work with world-renowned specialists in the field.”

Working with other experts around the nation, particularly William Lombardi, MD, based in Bellingham, WA, has been invaluable, says Karmapliotis.

 “What he taught us—it wouldn’t have been possible without his leadership,” he says.

“I am convinced there are a lot of opportunities to help people, and there are endless possibilities what we can do with this,” Karmapliotis says.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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