Chronic total occlusion is a potentially serious heart condition that sometimes has no symptoms.
Learn more about the risk factors for chronic total occlusion and the available treatments from Dr. Michael Ragosta, a UVA specialist in chronic total occlusion and coronary artery disease.
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Identifying and Treating Chronic Total Occlusion
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Learn more about Dr. Michael Ragosta
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Michael Ragosta, MD
Dr. Michael Ragosta is board-certified in cardiovascular disease and interventional cardiology; his specialties include coronary artery disease and chronic total occlusion.Learn more about Dr. Michael Ragosta
Learn more about UVA Heart & Vascular Center
Transcription:
Identifying and Treating Chronic Total Occlusion
Melanie Cole (Host): Chronic total occlusion is a potentially serious heart condition that sometimes has no symptoms. My guest today is Dr. Michael Rogosta. He's board certified in cardiovascular disease and interventional cardiology. His specialties include coronary artery disease and chronic total occlusion. Welcome to the show, Dr. Rogosta. Let's start by telling the listeners a little bit about coronary artery disease and some of the things that go along with it.
Dr. Michael Rogosta (Guest): Thank you. Yes, as you know, coronary artery disease is a very common condition and, essentially, there's plaque in one or more of the coronary arteries. That plaque may obstruct or limit the blood flow in the coronary artery and that can cause symptoms such as chest pains, shortness of breath, fatigue and, of course, it can lead to heart attack and other more serious problems down the line.
Melanie: Are there certain risk factors for coronary artery disease as a whole? And then, we'll speak about chronic total occlusion.
Dr. Rogosta: Yes. So, you should first consider chronic total occlusion as a subset of coronary disease. That's the nature of it. It's a total occlusion of the artery instead of a narrowing to some percentage and it's been there for a long time. That's what is meant by chronic total occlusion. As a subset of coronary artery disease, it has the same risk factors as patients with other less severe forms of coronary artery disease. That includes high cholesterol, smoking history, diabetes, hypertension, and, of course, family history. So those are the important risk factors that lead to coronary artery disease.
Melanie: So, speak about chronic total occlusion as a subset of coronary artery disease. You mentioned symptoms – some of the symptoms you might experience – but often sometimes you don't experience these. How would you even know if you have coronary artery disease?
Dr. Rogosta: That's a great question and in a lot of people it is asymptomatic. For a lot of those folks it is asymptomatic because it's not causing a particular problem with the blood flow. So, it's a very prevalent condition but in a lot of folks who don't have symptoms and don't have any serious sequelae from the blockages, we just treat that medically with the goal to be to treat the risk factors that might lead to progression. So, it's really only when the disease becomes more severe and is obstructing blood flow and leading to some of the symptoms that we would then recommend more aggressive treatment which are the revascularization procedures such as stenting or coronary bypass surgery.
Melanie: And how is it diagnosed, Dr. Rogosta? Is this something you have to go in and have an angiogram to figure it out or can you tell by what they're experiencing?
Dr. Rogosta: Well, the symptoms would then lead you to probe more deeply. Usually, the first line of diagnosis is a stress test which shows you essentially the effect these blockages may have on the circulation of the heart in terms of how the heart is functioning or how the pattern of blood flow appears in an image that is done non-invasively. If that test comes back normal, then usually we treat that medically and, again, treat the risk factors of coronary disease. However, if the stress test does show evidence of lack of blood flow to the heart, then we would go to a more invasive approach like a coronary angiogram which is a type of cardiac catheterization procedure. That is considered the gold standard for diagnosing blockages in the coronaries because we can see the artery in fine detail and know exactly how blocked it is and that leads to how we would usually treat from the angiogram.
Melanie: So, speak about treatment then. What would be the first line of defense? If you've performed these exams and determined there's a total blockage, then what?
Dr. Rogosta: So, it depends on how severe the patient's symptoms are and how much it's affecting the blood flow to the heart. In some patients that have a chronically occluded artery, it leads to minimal or no symptoms and there's adequate blood flow to the heart because the heart actually creates what's called “collateral channels” which are essentially a rerouting of the circulation around the blockage. So your heart does that by itself. If that's adequate--in other words, if there's adequate blood flow to the heart through these collaterals, then we just treat the risk factors and treat medically those patients. However, if the symptoms are not controlled with medicines or there's really a large area of the heart muscle not getting blood flow during stress, then we would warrant more aggressive treatments. Chronic occlusions historically have been very difficult to treat with the catheter-based techniques like angioplasty and stenting. However, recently, in the last maybe 5-10 years, there have been great advances in the percutaneous treatment of chronic total occlusions that have led to greater successes. So, our success rate now is in the 80-90% range for a chronically occluded artery, to be able to open that using a catheter-based technique; whereas, historically, it was only in the 40-50% range.
Melanie: Isn't that amazing that the heart can actually make that collateral circulation? It always fascinates me. Now, what about after the procedure. What kind of lifestyle does that patient have afterward and what can they expect as far as their ability to exercise and conduct normal life?
Dr. Rogosta: Yes. If they were pretty symptomatic before the procedure and we're successful in restoring the blood flow, then usually we see a great improvement in their ability to exercise, in their exercise tolerance and in their symptom control. Many patients that we've been successful have had resolution of their angina, which is the chest pain syndrome that you typically get with a chronic total occlusion or their shortness of breath syndrome which also may be a manifestation of the chronic occlusion. So, usually, if they're very symptomatic they get a lot of symptom relief with this and are able to exercise more and then are able to do the more healthy things they need to do to maintain their health over a long time.
Melanie: What about it coming back? Does that happen in that area that you've cleared out? I mean, if there's a stent in there does that mean that it's not going to close up again?
Dr. Rogosta: No, unfortunately. Just like a stent placed for a less severe stenosis, the blockage can reoccur in the stent. Now, it is a different process. It tends to be scar tissue related rather than the atherosclerosis buildup that started the process in the first place. However, those can often be treated successfully with an additional procedure and, at the end of the day, if the stent procedures fail and they do occur, there's always the option of coronary bypass surgery which is also a treatment option for these patients if we aren't successful and are able to open their artery.
Melanie: In just the last few minutes, Dr. Rogosta, why should patients with chronic total occlusion come to UVA Heart and Vascular Center for their care?
Dr. Rogosta: Well, a couple of reasons. I think first, we have a really great team approach to patients with complex coronary disease and this would be a form of complex coronary disease. What I mean by that is, a lot of these patients are evaluated by the interventional cardiology group, which is the catheter-based techniques, but also by heart surgeons. We, together, decide what may be the best options for that patient. So, the team approach is very, very valuable at giving the patient the best care. In addition, we have a lot of interest in managing these types of complex diseases and have spent a lot of effort and time learning the special techniques that are needed to be successful and we really focus on this so our success rate is very high. So, for those reasons, that's a big advantage of coming to the University of Virginia.
Melanie Cole: Sounds like a great multidisciplinary approach to helping those with vascular disease. Thank you so much, Dr. Rogosta. You're listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That's UVAHealth.com. This is Melanie Cole, thanks so much for listening.
Identifying and Treating Chronic Total Occlusion
Melanie Cole (Host): Chronic total occlusion is a potentially serious heart condition that sometimes has no symptoms. My guest today is Dr. Michael Rogosta. He's board certified in cardiovascular disease and interventional cardiology. His specialties include coronary artery disease and chronic total occlusion. Welcome to the show, Dr. Rogosta. Let's start by telling the listeners a little bit about coronary artery disease and some of the things that go along with it.
Dr. Michael Rogosta (Guest): Thank you. Yes, as you know, coronary artery disease is a very common condition and, essentially, there's plaque in one or more of the coronary arteries. That plaque may obstruct or limit the blood flow in the coronary artery and that can cause symptoms such as chest pains, shortness of breath, fatigue and, of course, it can lead to heart attack and other more serious problems down the line.
Melanie: Are there certain risk factors for coronary artery disease as a whole? And then, we'll speak about chronic total occlusion.
Dr. Rogosta: Yes. So, you should first consider chronic total occlusion as a subset of coronary disease. That's the nature of it. It's a total occlusion of the artery instead of a narrowing to some percentage and it's been there for a long time. That's what is meant by chronic total occlusion. As a subset of coronary artery disease, it has the same risk factors as patients with other less severe forms of coronary artery disease. That includes high cholesterol, smoking history, diabetes, hypertension, and, of course, family history. So those are the important risk factors that lead to coronary artery disease.
Melanie: So, speak about chronic total occlusion as a subset of coronary artery disease. You mentioned symptoms – some of the symptoms you might experience – but often sometimes you don't experience these. How would you even know if you have coronary artery disease?
Dr. Rogosta: That's a great question and in a lot of people it is asymptomatic. For a lot of those folks it is asymptomatic because it's not causing a particular problem with the blood flow. So, it's a very prevalent condition but in a lot of folks who don't have symptoms and don't have any serious sequelae from the blockages, we just treat that medically with the goal to be to treat the risk factors that might lead to progression. So, it's really only when the disease becomes more severe and is obstructing blood flow and leading to some of the symptoms that we would then recommend more aggressive treatment which are the revascularization procedures such as stenting or coronary bypass surgery.
Melanie: And how is it diagnosed, Dr. Rogosta? Is this something you have to go in and have an angiogram to figure it out or can you tell by what they're experiencing?
Dr. Rogosta: Well, the symptoms would then lead you to probe more deeply. Usually, the first line of diagnosis is a stress test which shows you essentially the effect these blockages may have on the circulation of the heart in terms of how the heart is functioning or how the pattern of blood flow appears in an image that is done non-invasively. If that test comes back normal, then usually we treat that medically and, again, treat the risk factors of coronary disease. However, if the stress test does show evidence of lack of blood flow to the heart, then we would go to a more invasive approach like a coronary angiogram which is a type of cardiac catheterization procedure. That is considered the gold standard for diagnosing blockages in the coronaries because we can see the artery in fine detail and know exactly how blocked it is and that leads to how we would usually treat from the angiogram.
Melanie: So, speak about treatment then. What would be the first line of defense? If you've performed these exams and determined there's a total blockage, then what?
Dr. Rogosta: So, it depends on how severe the patient's symptoms are and how much it's affecting the blood flow to the heart. In some patients that have a chronically occluded artery, it leads to minimal or no symptoms and there's adequate blood flow to the heart because the heart actually creates what's called “collateral channels” which are essentially a rerouting of the circulation around the blockage. So your heart does that by itself. If that's adequate--in other words, if there's adequate blood flow to the heart through these collaterals, then we just treat the risk factors and treat medically those patients. However, if the symptoms are not controlled with medicines or there's really a large area of the heart muscle not getting blood flow during stress, then we would warrant more aggressive treatments. Chronic occlusions historically have been very difficult to treat with the catheter-based techniques like angioplasty and stenting. However, recently, in the last maybe 5-10 years, there have been great advances in the percutaneous treatment of chronic total occlusions that have led to greater successes. So, our success rate now is in the 80-90% range for a chronically occluded artery, to be able to open that using a catheter-based technique; whereas, historically, it was only in the 40-50% range.
Melanie: Isn't that amazing that the heart can actually make that collateral circulation? It always fascinates me. Now, what about after the procedure. What kind of lifestyle does that patient have afterward and what can they expect as far as their ability to exercise and conduct normal life?
Dr. Rogosta: Yes. If they were pretty symptomatic before the procedure and we're successful in restoring the blood flow, then usually we see a great improvement in their ability to exercise, in their exercise tolerance and in their symptom control. Many patients that we've been successful have had resolution of their angina, which is the chest pain syndrome that you typically get with a chronic total occlusion or their shortness of breath syndrome which also may be a manifestation of the chronic occlusion. So, usually, if they're very symptomatic they get a lot of symptom relief with this and are able to exercise more and then are able to do the more healthy things they need to do to maintain their health over a long time.
Melanie: What about it coming back? Does that happen in that area that you've cleared out? I mean, if there's a stent in there does that mean that it's not going to close up again?
Dr. Rogosta: No, unfortunately. Just like a stent placed for a less severe stenosis, the blockage can reoccur in the stent. Now, it is a different process. It tends to be scar tissue related rather than the atherosclerosis buildup that started the process in the first place. However, those can often be treated successfully with an additional procedure and, at the end of the day, if the stent procedures fail and they do occur, there's always the option of coronary bypass surgery which is also a treatment option for these patients if we aren't successful and are able to open their artery.
Melanie: In just the last few minutes, Dr. Rogosta, why should patients with chronic total occlusion come to UVA Heart and Vascular Center for their care?
Dr. Rogosta: Well, a couple of reasons. I think first, we have a really great team approach to patients with complex coronary disease and this would be a form of complex coronary disease. What I mean by that is, a lot of these patients are evaluated by the interventional cardiology group, which is the catheter-based techniques, but also by heart surgeons. We, together, decide what may be the best options for that patient. So, the team approach is very, very valuable at giving the patient the best care. In addition, we have a lot of interest in managing these types of complex diseases and have spent a lot of effort and time learning the special techniques that are needed to be successful and we really focus on this so our success rate is very high. So, for those reasons, that's a big advantage of coming to the University of Virginia.
Melanie Cole: Sounds like a great multidisciplinary approach to helping those with vascular disease. Thank you so much, Dr. Rogosta. You're listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That's UVAHealth.com. This is Melanie Cole, thanks so much for listening.