1
|
Jiang Y, Wei ZY, Wu YJ, Dou KF, Yang WX, Yang YJ, Zhao HJ, Ning Y, Li A, Chang Y, Li ZH, Qian HY. The impacts of percutaneous coronary intervention to treat chronic total occlusion of right coronary artery on the 5-year prognosis: A single-centered retrospective study. Int J Cardiol 2024; 414:132384. [PMID: 39032578 DOI: 10.1016/j.ijcard.2024.132384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 05/08/2024] [Accepted: 07/17/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Chronic total occlusions (CTO) occur in about 20% of patients referred for coronary angiography, and right coronary artery (RCA) CTO has been reported in 38-50% of the entire CTO population. Limited data on angiographic and procedural characteristics of RCA-CTO and the risk of adverse cardiac events asks for a detailed study. METHODS From 2010 to 2013, patients with attempted revascularization of at least one CTO lesion were included and followed up to 5 years after PCI. Eligible patients are assigned to RCA-CTO and non-RCA-CTO groups based on their target vessels. The primary endpoint was major adverse cardiovascular events (MACEs; a composite of all-cause death, myocardial infarction (MI) or rehospitalization for heart failure), and secondary endpoints were cardiac death, target lesion revascularization (TLR) and target vessel revascularization (TVR). RESULTS The present study included 2659 eligible patients, among which 1285 patients were assigned to the RCA-CTO group, whereas 1374 patients were assigned to the non-RCA-CTO group. Lesions in RCA had longer lesion length, higher J-CTO score, higher rates of severe vessel tortuosity, a higher percentage of Rentrop grade 2-3, and more likely to be re-try lesion than those in LAD or LCX (all P < 0.01). CTO lesions in RCA reached less successful recanalization and post-procedural TIMI 3 flow (all <0.01). Multivariate Cox analysis revealed that RCA-CTO was not associated with primary outcome MACEs. Besides MACEs, RCA-CTO was also not associated with cardiac death, but was significantly associated with TLR and TVR (adjusted HR: 1.37 [95% CI:1.07-1.76], P = 0.01; adjusted HR: 1.43 [95% CI:1.13-1.82], P = 0.003). CONCLUSION RCA-CTO lesions, which had more complex angiographic features, independently contributed to TLR and TVR but not to MACEs or cardiac death in the 5 years of follow-up.
Collapse
Affiliation(s)
- Yu Jiang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Yao Wei
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Jian Wu
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke-Fei Dou
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei-Xian Yang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han-Jun Zhao
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Ning
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ang Li
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Chang
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Hao Li
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Yan Qian
- Center for Coronary Heart Disease, Department of Cardiology, Fu Wai Hospital, National Center for Cardiovascular Diseases of China, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
2
|
Panuccio G, Abdelwahed YS, Carabetta N, Landmesser U, De Rosa S, Torella D. The Role of Coronary Imaging in Chronic Total Occlusions: Applications and Future Possibilities. J Cardiovasc Dev Dis 2024; 11:295. [PMID: 39330353 PMCID: PMC11432693 DOI: 10.3390/jcdd11090295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 09/17/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024] Open
Abstract
Chronic total occlusions (CTOs) represent a challenging scenario in coronary artery disease (CAD). The prevalence of CTOS in patients undergoing coronary angiography underscores the need for effective diagnostic and therapeutic strategies. Coronary angiography, while essential, offers limited insights into lesion morphology, vessel course, and myocardial viability. In contrast, coronary imaging techniques-including optical coherence tomography (OCT), intravascular ultrasound (IVUS), and coronary computed tomography angiography (CCTA)-provide comprehensive insights for each stage of CTO percutaneous coronary intervention (PCI). OCT facilitates the assessment of plaque morphology and stent optimization, despite low evidence and several limitations in CTO-PCI. IVUS offers deeper penetration, allowing managing proximal cap scenarios and guiding subintimal navigation. CCTA provides a non-invasive, three-dimensional view of coronary anatomy, enabling the precise evaluation of myocardial mass at risk and detailed procedural planning. Despite their individual limitations, these imaging modalities have enhanced the success rates of CTO-PCI, thus reducing procedural and long-term complications and improving patient outcomes. The future of CTO management lies in further technological advancements, including hybrid imaging, artificial intelligence (AI) integration, and improved fusion imaging. These innovations promise to refine procedural precision and personalize interventions, ultimately improving the care of patients with complex coronary artery disease.
Collapse
Affiliation(s)
- Giuseppe Panuccio
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy;
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12200 Berlin, Germany; (Y.S.A.); (U.L.)
| | - Youssef S. Abdelwahed
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12200 Berlin, Germany; (Y.S.A.); (U.L.)
| | - Nicole Carabetta
- Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (N.C.); (S.D.R.)
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12200 Berlin, Germany; (Y.S.A.); (U.L.)
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (N.C.); (S.D.R.)
| | - Daniele Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy;
| |
Collapse
|
3
|
Gikandi A, Stock EM, Dematt E, Quin J, Hirji S, Biswas K, Zenati MA. Chronic total occlusions and coronary artery bypass grafting outcomes. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00700-1. [PMID: 39173708 DOI: 10.1016/j.jtcvs.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/29/2024] [Accepted: 08/07/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVE To investigate the association between the presence and grafting of chronic total occlusions (CTOs) and coronary artery bypass grafting (CABG) outcomes. METHODS This was a post hoc analysis of the Randomized Endograft vs Open Prospective (REGROUP) trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified on the basis of the presence of at least 1 CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months) and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. RESULTS At least 1 CTO was present in 453 of 1149 patients (39.4%). Over a median follow-up of 4.7 years (interquartile range, 3.84-5.45), MACE rates were 23.4% versus 22.2% for the CTO versus no CTO group, respectively (adjusted hazard ratio [aHR], 0.92; 95% confidence interval [CI], 0.70-1.20). MACE rates for patients with complete CTO grafting versus not were 23.1% versus 25.0%, respectively (aHR, 0.95; 95% CI, 0.57-1.57). In patients with right coronary dominance undergoing left anterior descending artery grafting, bypassing a right coronary artery CTO was associated with significantly lower rates of all-cause mortality (aHR, 0.38; 95% CI, 0.17-0.83). CONCLUSIONS In this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels was associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside left anterior descending artery grafting warrants additional study.
Collapse
Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Eileen M Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Ellen Dematt
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Jacquelyn Quin
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass
| | - Sameer Hirji
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| |
Collapse
|
4
|
Gold DA, Sandesara PB, Jain V, Gold ME, Vatsa N, Desai SR, Elhage Hassan M, Yuan C, Ko YA, Liu C, Ejaz K, Alvi Z, Alkhoder A, Rahbar A, Murtagh G, Varounis C, Jaber WA, Nicholson WJ, Quyyumi AA. N terminal pro-brain natriuretic peptide level and benefits of chronic total occlusion revascularization. Int J Cardiol 2024; 409:132196. [PMID: 38782069 DOI: 10.1016/j.ijcard.2024.132196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/28/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The management of revascularization of chronic total occlusions (CTOs) remains controversial. Whether specific patients gain survival benefit from CTO revascularization remains unknown. OBJECTIVES We investigated whether (i) patients with CTO have higher N terminal pro-brain natriuretic peptide (NT pro-BNP) levels than patients without CTO, (ii) in patients with CTO, NT pro-BNP levels predict adverse events, and (iii) those with elevated levels benefit from revascularization. METHODS In 392 patients with stable, significant coronary artery disease (CAD) and CTO undergoing coronary angiography, rates of all-cause mortality, cardiovascular death, and a composite (cardiovascular death, myocardial infarction and heart failure hospitalizations) were investigated. Unadjusted and adjusted Cox proportional and Fine and Gray sub-distribution hazard models were performed to determine the association between NT pro-BNP levels and incident event rates in patients with CTO. RESULTS NT pro-BNP levels were higher in patients with, compared to those without CTO (median 230.0 vs. 177.7 pg/mL, p ≤0.001). Every doubling of NT pro-BNP level in patients with CTO was associated with a > 25% higher rate of adverse events. 111 (28.5%) patients underwent CTO revascularization. In patients with elevated NT pro-BNP levels (> 125 pg/mL), those who underwent CTO revascularization had substantially lower adverse event rates compared to patients without CTO revascularization (adjusted cardiovascular death hazard ratio 0.29, 95% confidence interval (0.09-0.88). However, in patients with low NT pro-BNP levels (≤ 125 pg/mL), event rates were similar in those with and without CTO revascularization. CONCLUSION NT pro-BNP levels can help identify individuals who may benefit from CTO revascularization.
Collapse
Affiliation(s)
- Daniel A Gold
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Pratik B Sandesara
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Vardhmaan Jain
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew E Gold
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nishant Vatsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Shivang R Desai
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Malika Elhage Hassan
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Chenyang Yuan
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Chang Liu
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kiran Ejaz
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zain Alvi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ayman Alkhoder
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alireza Rahbar
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Wissam A Jaber
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - William J Nicholson
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia..
| |
Collapse
|
5
|
Zheng N, Ai H, Zhao Y, Li H, Yang G, Tang G, Peng X, Sun F, Zhang H. Effects of a prior failed attempt on the outcomes of subsequent chronic total occlusion-percutaneous coronary intervention. Aging Med (Milton) 2024; 7:463-471. [PMID: 39234198 PMCID: PMC11369334 DOI: 10.1002/agm2.12350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024] Open
Abstract
Objectives Patients undergoing a prior failed attempt of chronic total occlusion-percutaneous coronary intervention (CTO-PCI) represent a challenging subgroup across all patients undergoing CTO-PCI. There are limited data on the effects of a prior failed attempt on the outcomes of subsequent CTO-PCI. We aimed to compare the procedural results and 24-month outcomes of prior-failed-attempt CTO-PCI with those of initial-attempt CTO-PCI. Methods Patients who underwent attempted CTO-PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 24-month major adverse cardiac events (MACE) between patients who underwent prior-failed-attempt and initial-attempt CTO-PCI. MACE was defined as a composite of cardiac death, target vessel-related myocardial infarction, and ischemia-driven target vessel revascularization (TVR) during follow-up. Results In total, 484 patients who underwent CTO-PCI (prior-failed-attempt, n = 49; initial-attempt, n = 435) were enrolled during the study period. After propensity score matching (1:3), 147 patients were included in the initial-attempt group. The proportion of the Japanese-CTO (J-CTO) score ≥2 was higher in the patients who underwent prior failed attempt than in those who underwent initial attempt (77.5% vs. 38.8%, p < 0.001). The retrograde approach was more often adopted in the prior-failed-attempt group than in the initial-attempt group (32.7% vs. 3.4%, [P< 0.001). Successful CTO revascularization rates were significantly lower in the prior-failed attempt-group than in the initial attempt group (53.1% vs. 83.3%, P < 0.001). The multivariate analysis revealed that J-CTO score ≥2 [odds ratio (OR), 0.359; 95% confidence interval (CI), 0.159-0.812; P = 0.014], intravascular ultrasound procedure (OR, 4.640; 95% CI, 1.380-15.603; P = 0.013), and prior failed attempt (OR, 0.285; 95% CI, 0.125-0.648; P = 0.003) were the independent predictors for successful CTO revascularization. There were no significant differences in major procedural complications (2.0% vs. 0.7%, p = 0.438) and MACE rates (4.1% vs. 8.8%, p = 0.438) between the groups, mainly due to the TVR rate (4.1% vs. 8.2%, P = 0.522). Conclusions Compared with initial-attempt CTO-PCI, prior-failed-attempt CTO-PCI deserves more attention, since it is associated with a lower successful CTO revascularization rate. Prior failed attempt, J-CTO score ≥2, and IVUS procedure are the determining factors for predicting successful CTO revascularization. There are no significantly different unfavorable outcomes between patients who undergo prior-failed-attempt and initial-attempt CTO-PCI.
Collapse
Affiliation(s)
- Nai‐Xin Zheng
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Hu Ai
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Ying Zhao
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Hui Li
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Guo‐Jian Yang
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Guo‐Dong Tang
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Xi Peng
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Fu‐Cheng Sun
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| | - Hui‐Ping Zhang
- Department of Cardiology, Beijing HospitalNational Center of GerontologyBeijingChina
| |
Collapse
|
6
|
Sahu AK, Kazmi DH, Kaushik A. Is it Worthy Enough to Revascularize Chronically Occluded Coronaries? Cardiol Rev 2024; 32:338-347. [PMID: 36912530 DOI: 10.1097/crd.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.
Collapse
Affiliation(s)
- Ankit Kumar Sahu
- From the Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | | | | |
Collapse
|
7
|
O'Brien JM, Dautov R, Sapontis J. Chronic Total Occlusions: A State-of-the-Art Review. Heart Lung Circ 2024; 33:764-772. [PMID: 38565438 DOI: 10.1016/j.hlc.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 04/04/2024]
Abstract
The percutaneous management of chronic total occlusions (CTO) is a well-established sub-specialty of Interventional Cardiology, requiring specialist equipment, training, and techniques. The heterogeneity of approaches in CTO has led to the generation of multiple algorithms to guide operators in their management. The evidence base for management of CTOs has suffered from inconsistent descriptive and quantitative terminology in defining the nature of lesions and techniques utilised, as well as seemingly contradictory data about improvement in ventricular function, symptoms of angina, and mortality from large-scale registries and randomised controlled trials. Through this review, we explore the history of CTO management and its supporting evidence in detail, with an outline of limitations of CTO-percutaneous coronary intervention and a look at the future of this growing field within cardiology.
Collapse
Affiliation(s)
- Joseph M O'Brien
- Victorian Heart Hospital, Cardiology, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia. joseph.o'
| | - Rustem Dautov
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - James Sapontis
- Victorian Heart Hospital, Cardiology, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| |
Collapse
|
8
|
Suleman M, Arif N, Khan MI, Jibran MS, Jamil M, Khan SU, Khan SS, Maken GR. The outcomes and complications of percutaneous interventions in chronic total coronary occlusion. Egypt Heart J 2024; 76:62. [PMID: 38782836 PMCID: PMC11116340 DOI: 10.1186/s43044-024-00490-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The limited availability of complex coronary intervention facilities and qualified operators, due to the high cost associated with chronic total occlusion (CTO) percutaneous intervention (PCI) equipment and a shortage of necessary skills, has led to a scarcity of capable medical centers in Pakistan. This study seeks to examine the outcomes and potential complications associated with CTO PCI procedures conducted at the Cardiac Catheterization Laboratories of a prominent national institute in Pakistan, which handles a large volume of cases. RESULTS Three hundred and six patients were included in the study in the study period of six months. The mean age was 59.49 (± 9.16) years: 256 (83.66%) were male and 50 (16.34%) were female. CTO was successfully re-vascularized in 237 (77.5%) with a complication rate of 13.7%. Two hundred and ninety-eight (97.39%) patients underwent an antegrade approach, while RCA was the most common target vessel (47.71%). Diabetes was the only significant associated risk factor with CTO PCI failure (30.43% vs. 30.43%, P-value = 0.015). CONCLUSION We achieved an excellent procedural success rate with a low complication rate. CTO procedural failure is associated with a higher complication rate, and diabetes is among the risk factors that lead to higher procedural failure.
Collapse
Affiliation(s)
- Muhammad Suleman
- Department of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi, Punjab, Pakistan
- Department of Cardiology, Peshawar Institute of Cardiology, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Nayyar Arif
- Department of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi, Punjab, Pakistan
| | - Muhammad Ishaq Khan
- Department of Cardiology, Peshawar Institute of Cardiology, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Muhammad Saad Jibran
- Department of Cardiology, Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Khyber Pakhtunkhwa, Pakistan
| | - Muhammad Jamil
- Department of Cardiology, Services Hospital Peshawar, Peshawar, Pakistan
| | - Shafi Ullah Khan
- Department of Medicine, District Headquarters Teaching Hospital, Kohat, Khyber Pakhtunkhwa, Pakistan.
| | - Shah Sawar Khan
- Department of Cardiology, Peshawar Institute of Cardiology, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Ghulam Rasool Maken
- Department of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi, Punjab, Pakistan
| |
Collapse
|
9
|
Macherey-Meyer S, Salem K, Heyne S, Meertens MM, Finke K, Mauri V, Baldus S, Adler C, Lee S. Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Chronic Total Occlusion: A Meta-Analysis. J Clin Med 2024; 13:2919. [PMID: 38792462 PMCID: PMC11122436 DOI: 10.3390/jcm13102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Chronic total occlusion (CTO) is a prevalent finding in patients with coronary artery disease and is associated with increased mortality. Prior reports on the efficacy of percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) were controversial. Following the emergence of recently published new evidence, a meta-analysis is warranted. The current meta-analysis assessed the effects of PCI compared to OMT in the treatment of CTO. Methods: A structured literature search was performed. Randomized controlled trials (RCTs) and non-randomized controlled studies of interventions were eligible. The primary outcome was an accumulated composite of cardiac mortality, myocardial infarction and target vessel/lesion revascularization events. Results: Thirty-two studies reporting on 11260 patients were included. Of these, 5712 (50.7%) were assigned to the PCI and 5548 (49.3%) were allocated to the OMT group. The primary outcome occurred in 14.6% of the PCI and 20.1% of the OMT group (12 trials, OR 0.66, 95% CI 0.50 to 0.88, p = 0.005, I2 = 67%). Subgrouping demonstrated a consistent reduction in the primary outcome for the PCI group in RCTs (six trials, OR 0.58, 95% CI 0.33 to 0.99, p = 0.05). The primary outcome reduction was irrespective of the study design, and it was replicable in sensitivity and subgroup analyses. Advantages in other outcomes were rather related to statistical pooling effects and dominated by observational data. Conclusions: CTO-PCI was associated with improved patient-oriented primary outcome compared to OMT in a study-level meta-analysis. This composite outcome effect was mainly driven by target vessel treatment, but a significant reduction in mortality and myocardial infarction was observed, irrespectively. These findings have hypothesis-generating implications. Future RCTs with adequate statistical power are eagerly awaited.
Collapse
Affiliation(s)
- Sascha Macherey-Meyer
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Khalid Salem
- Faculty of Medicine, University Hospital Cologne, University of Cologne, 50937 Köln, Germany
| | - Sebastian Heyne
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Max Maria Meertens
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Cardiology III—Angiology, Center of Cardiology, University Medical Center, Johannes Gutenberg-University, 55122 Mainz, Germany
| | - Karl Finke
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Victor Mauri
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Stephan Baldus
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Christoph Adler
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Samuel Lee
- Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| |
Collapse
|
10
|
Gold DA, Sandesara PB, Jain V, Gold ME, Vatsa N, Desai SR, Hassan ME, Yuan C, Ko YA, Ejaz K, Alvi Z, Jaber WA, Nicholson WJ, Quyyumi AA. Long-Term Outcomes in Patients With Chronic Total Occlusion. Am J Cardiol 2024; 214:59-65. [PMID: 38195045 PMCID: PMC10947430 DOI: 10.1016/j.amjcard.2023.12.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/27/2023] [Accepted: 12/24/2023] [Indexed: 01/11/2024]
Abstract
Although a chronic total occlusion (CTO) in the setting of an acute coronary syndrome is associated with greater risk, the prognosis of patients with a CTO and stable coronary artery disease (CAD) remains unknown. This study aimed to investigate adverse event rates in patients with stable CAD with and without a CTO. In 3,597 patients with stable CAD (>50% coronary luminal stenosis) who underwent cardiac catheterization, all-cause mortality, cardiovascular mortality, and the composite major adverse cardiac event (MACE) rates for cardiovascular death, myocardial infarction, and heart failure hospitalization were evaluated. Cox proportional hazards and Fine and Gray subdistribution hazard models were used to compare event-free survival in patient subsets after adjustment for covariates. Event rates were higher in patients with CTOs than in those without CTOs after adjusting for demographic and clinical characteristics (cardiovascular death hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.05 to 1.57, p = 0.012). Patients with CTO revascularization had lower event rates than those of patients without CTO revascularization (cardiovascular death HR 0.43, CI 0.26 to 0.70, p = 0.001). Those with nonrevascularized CTOs were at particularly great risk when compared with those without CTO (cardiovascular death HR 1.52, CI 1.25 to 1.84, p <0.001). Moreover, those with revascularized CTOs had similar event rates to those of patients with CAD without CTOs. Patients with CTO have higher rates of adverse cardiovascular events than those of patients with significant CAD without CTO. This risk is greatest in patients with nonrevascularized CTO.
Collapse
Affiliation(s)
- Daniel A Gold
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Pratik B Sandesara
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Vardhmaan Jain
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew E Gold
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nishant Vatsa
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Shivang R Desai
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Malika Elhage Hassan
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Chenyang Yuan
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kiran Ejaz
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zain Alvi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Wissam A Jaber
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - William J Nicholson
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| |
Collapse
|
11
|
Winther NS, Holck EN, Mogensen LJH, Karim SR, Eftekhari A, Christiansen EH. Early and long-term prognosis in patients with remaining chronic total occlusions after revascularization attempt. A cohort study from the SKEJ-CTO registry. Scand Cardiovasc J Suppl 2023; 57:17-24. [PMID: 36428263 DOI: 10.1080/14017431.2022.2150787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The present study aimed to compare safety and long-term prognosis of patients with chronic total coronary occlusions (CTO) stratified for remaining CTOs after percutaneous coronary intervention (PCI). DESIGN The study cohort consisted of patients with coronary artery disease who underwent CTO PCI in a high volume tertiary center from 2009 to 2019 and were registered in Danish high-quality registers. Patients with successful PCI of all CTOs were compared to patients with ≥1 remaining CTO post-procedural. Primary endpoints were analysed using Cox-regression and Kaplan-Meier estimates, and included all-cause mortality, major adverse cardio- and cerebrovascular events (MACCE) and a 30-day safety endpoint. RESULTS Procedural success rate was 87.7%, and 76.5% of patients had all CTO(s) opened post-PCI. Safety endpoint occurred in 4.6% of patients, and more frequently in patients with remaining CTO(s) (RD 4.9, 95%CI 0.1, 9.8). All-cause mortality was higher in patients with remaining CTO(s) (Unadjusted HR 1.65, 95% CI 1.03, 2.47, p = .015. Adjusted HR 1.32, 95%CI 0.88-1.99, p = .18) after eight years of follow-up. Risk of MACCE was significantly higher in patients with remaining CTO(s) (Unadjusted HR 1.79, 95% CI 1.34-2.41, p < .001. Adjusted HR 1.51, 95% CI 1.11-2.05, p = .009). CONCLUSIONS In our centre, CTO PCI was associated with high success rate and low risk of 30-days complications. Presence of remaining CTO(s) after final revascularization attempt was associated with higher but statistically insignificant long-term mortality but was an independent predictor of MACCE.
Collapse
Affiliation(s)
- Naja Stausholm Winther
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Nielsen Holck
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Salma Raghad Karim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
12
|
Miyashita H, Mansikkaniemi L, Sinisalo J, Stewart J, Laine P. Long-term improvement of symptoms of angina pectoris after successful revascularization of coronary artery chronic total occlusions. SCAND CARDIOVASC J 2023; 57:2161621. [PMID: 36587829 DOI: 10.1080/14017431.2022.2161621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objectives. To compare long-term angina pectoris relief of successful versus failed percutaneous coronary intervention of chronic total occlusions (CTO PCI). Background. Previous studies demonstrate better short-term angina pectoris relief of CTO PCI than with optimal medical treatment (OMT), however, data on the long-term effects are lacking. Methods. 295 patients undergoing CTO PCI were analyzed retrospectively, with a follow-up evaluation of symptoms of angina pectoris and all-cause death one to four years after the intervention. The primary outcome was long-term relief of symptoms of angina pectoris. Secondary outcomes included a composite of major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke, and later target vessel revascularization (TVR). At follow-up, patients were interviewed for symptoms of angina pectoris at 1, 6, 12, and 22 to 48 months after the intervention. Results. CTO PCI was successful in 225 (76%) patients and failed in 70 (24%) patients. Short-term (six months) relief of angina pectoris was observed in both groups, but only the successful CTO PCI group showed long-term relief. The Kaplan-Meier curves of all-cause death did not differ between the groups (p = .715). The final follow-up was a mean (range) of 37 (25 to 44) months after the intervention in the successful CTO PCI group, and 33 (28 to 48) months in the failed CTO PCI group. Conclusions. Successful CTO PCI is associated with better long-term relief of symptoms of angina pectoris compared to failed CTO PCI.
Collapse
Affiliation(s)
- Hirokazu Miyashita
- Department of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | | | - Juha Sinisalo
- Department of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Juhani Stewart
- Department of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Petri Laine
- Department of Cardiology, Heart and Lung Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| |
Collapse
|
13
|
Gold DA, Sandesara PB, Jain V, Gold ME, Vatsa N, Desai SR, Hassan ME, Yuan C, Ko Y, Alkhoder A, Ejaz K, Alvi Z, Rahbar A, Murtagh G, Jaber WA, Nicholson WJ, Quyyumi AA. High Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization. J Am Heart Assoc 2023; 12:e031431. [PMID: 37929763 PMCID: PMC10727412 DOI: 10.1161/jaha.123.031431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
Background The survival benefit of revascularization of chronic total occlusion (CTO) of the coronary arteries remains a subject of controversy. We measured high sensitivity troponin-I (hsTn-I) levels as an estimate of myocardial ischemia in patients with stable coronary artery disease, with the hypothesis that (1) patients with CTO have higher levels of hsTn-I than patients without CTO, (2) hsTn-I levels will predict adverse cardiovascular events in patients with CTO, and (3) patients with elevated hsTn-I levels will have a survival benefit from CTO revascularization. Methods and Results In 428 patients with stable coronary artery disease and CTO undergoing coronary angiography, adverse event rates were investigated. Cox proportional hazards models and Fine and Gray subdistribution hazard models were performed to determine the association between hsTn-I level and incident event rates in patients with CTO. HsTn-I levels were higher in patients with compared with those without CTO (median 6.7 versus 5.6 ng/L, P=0.002). An elevated hsTn-I level was associated with higher adverse event rates (adjusted all-cause mortality hazard ratio, 1.19 [95% CI, 1.08-1.32]; P=0.030) for every doubling of hsTn-I level. CTO revascularization was performed in 28.3% of patients. In patients with a high (>median) hsTn-I level, CTO revascularization was associated with substantially lower all-cause mortality (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.88]; P=0.030) compared with those who did not undergo revascularization. In patients with a low (
Collapse
Affiliation(s)
- Daniel A. Gold
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Pratik B. Sandesara
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Vardhmaan Jain
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Matthew E. Gold
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Nishant Vatsa
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Shivang R. Desai
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Malika Elhage Hassan
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Chenyang Yuan
- Department of Biostatistics and Bioinformatics, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Yi‐An Ko
- Department of Biostatistics and Bioinformatics, Rollins School of Public HealthEmory UniversityAtlantaGA
| | - Ayman Alkhoder
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Kiran Ejaz
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Zain Alvi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Alireza Rahbar
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | | | - Wissam A. Jaber
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - William J. Nicholson
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| | - Arshed A. Quyyumi
- Division of Cardiology, Department of MedicineEmory Clinical Cardiovascular Research Institute, Emory University School of MedicineAtlantaGA
| |
Collapse
|
14
|
Wang C, Liu S, Kamronbek R, Ni S, Cheng Y, Yan H, Zhang M. Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Chronic Total Occlusion of Coronary Arteries: A Systematic Review and Meta-Analysis. J Interv Cardiol 2023; 2023:9928347. [PMID: 37965179 PMCID: PMC10643034 DOI: 10.1155/2023/9928347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/01/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Chronic total occlusion (CTO) of coronary arteries constitutes a substantial clinical challenge and has historically been managed through medical management and coronary artery bypass grafting (CABG). However, with the advancement in interventional technology, the success rate of percutaneous treatment has been significantly improved, and percutaneous coronary intervention (PCI) has emerged as a primary mode of treatment for CTOs, demonstrating remarkable clinical efficacy. The objective of this systematic review and meta-analysis is to evaluate and contrast the outcomes of PCI and CABG in patients with CTO. Methods and Results A systematic search was conducted in the databases of PubMed, Embase, and Web of Science. The primary endpoints evaluated in this meta-analysis were the occurrence of major adverse cardiac events (MACE) and all-cause mortality. Secondary endpoints included myocardial infarction (MI), cardiac death, and the need for repeat revascularization. Nine studies, encompassing a total of 8,674 patients, were found to meet the criteria for inclusion and had a mean follow-up duration of 4.3 years. The results of the meta-analysis revealed that compared to CABG, PCI was associated with a lower incidence of all-cause mortality (RR: 0.78, 95% CI: 0.66-0.92; P = 0.003) and cardiac death (RR: 0.55; 95% CI: 0.31-0.96; P < 0.05), but an increased risk of myocardial infarction (MI) (RR: 1.96; 95%CI: 1.07-3.62; P < 0.05) and repeat revascularization (RR: 7.13; 95% CI: 5.69-8.94; P < 0.00001). There was no statistically significant difference in MACE (RR: 1.11; 95% CI: 0.69-1.81; P = 0.66) between the PCI and CABG groups. Conclusion In the present meta-analysis comparing PCI and CABG in patients with chronic total occlusion of the coronary arteries, the results indicated that PCI was superior to CABG in reducing all-cause mortality and cardiac death but inferior in decreasing myocardial infarction and repeat revascularization. There was no statistically significant difference in MACE between the two groups.
Collapse
Affiliation(s)
- Chenyang Wang
- Center for Coronary Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Sheng Liu
- Center for Coronary Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Raimov Kamronbek
- Center for Coronary Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Siyao Ni
- Center for Coronary Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunjiu Cheng
- Key Laboratory on Assisted Circulation, Ministry of Health, Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huiyuan Yan
- Department of Cardiology, Hangjinqi People's Hospital, Hangjinqi, Mongolia
| | - Ming Zhang
- Center for Coronary Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
15
|
Ahn J, Yu H, Rha SW, Choi BG, Park S, Park EJ, Kang DO, Choi CU. Long-term clinical outcomes following successful percutaneous coronary intervention in patients with extremely long coronary chronic total occlusion lesions. Catheter Cardiovasc Interv 2023; 102:878-884. [PMID: 37681968 DOI: 10.1002/ccd.30829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/20/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Lesion length is related to worse clinical outcomes following percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO). However, the data to confirm the association between extremely long lesions and clinical hard endpoints have been limited. Therefore, we investigated the impact of extremely long CTO lesions (≥50 mm, treated lesion length) on the long-term clinical outcomes following successful PCI. METHODS A total of 333 consecutive patients with CTO who underwent successful PCI with drug-eluting stents (DESs) were allocated to either the extremely long or the short CTO group according to their CTO lesion length. The 5-year clinical outcomes were compared between the two groups. The incidence of myocardial infarction, cardiac death (CD), revascularization, and major adverse cardiovascular events (MACE) was higher in the extremely long CTO group. The 5-year clinical outcomes were analyzed using the Cox hazard ratio (HR) model. RESULTS In the entire study population, the extremely long CTO lesion was an independent predictor for higher rate of revascularization, MACE, CD, or mortality. CONCLUSIONS In our study, CTO patients with extremely long lesions (≥50 mm) who underwent successful PCI were associated with a higher risk of worse long-term clinical outcomes, including hard clinical endpoints such as CD and mortality even in the DESs era.
Collapse
Affiliation(s)
- Jihun Ahn
- Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - HyeYon Yu
- School of Nursing, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Byoung Geol Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Soohyung Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Eun Jin Park
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dong Oh Kang
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| |
Collapse
|
16
|
Masoomi R, Azzalini L. Survival Following Recanalization of Chronic Total Occlusion: The Devil Is in the Details. J Am Heart Assoc 2023; 12:e032178. [PMID: 37830351 PMCID: PMC10757515 DOI: 10.1161/jaha.123.032178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Affiliation(s)
- Reza Masoomi
- Division of Cardiology, Department of MedicineUniversity of WashingtonSeattleWA
| | - Lorenzo Azzalini
- Division of Cardiology, Department of MedicineUniversity of WashingtonSeattleWA
| |
Collapse
|
17
|
Holck EN, Winther NS, Mogensen LJ, Christiansen EH. Chronic Total Occlusion is Not a Risk Factor for Mortality in Patients With Successful Percutaneous Coronary Intervention: A Cohort Study. J Am Heart Assoc 2023; 12:e030989. [PMID: 37830355 PMCID: PMC10757529 DOI: 10.1161/jaha.123.030989] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/09/2023] [Indexed: 10/14/2023]
Abstract
Background Fifteen percent of patients with coronary artery disease undergoing angiography have a chronic total occlusion (CTO). The current study aimed to investigate the long-term prognosis after successful and unsuccessful CTO percutaneous coronary intervention (PCI) compared with PCI for non-CTO lesions. Methods and Results The current study was designed as an observational, region-wide, register-based cohort study enrolling all patients undergoing PCI in the Central Region of Denmark in 2009 to 2019. Patients were stratified into non-CTO, successful CTO, and unsuccessful CTO revascularization. Patients were followed until an event or January 1, 2022. The primary end point was all-cause mortality. In 21 141 patients enrolled, 2108 underwent CTO PCI. Clinical presentation was acute coronary syndrome in 11 879 patients and chronic coronary syndrome in 7887 patients. After a median of 5.7 years (interquartile range, 3.3-8.8), long-term all-cause mortality was higher after CTO PCI compared with non-CTO PCI, but the difference was statistically insignificant when adjusting for clinical factors (unadjusted hazard ratio [HR], 1.19 [95% CI, 1.09-1.29], adjusted HR, 1.08 [95% CI, 0.97-1.20]; P=0.165). After successful CTO PCI, no difference compared with non-CTO PCI was observed (unadjusted HR, 0.99 [95% CI, 0.90-1.10], adjusted HR, 0.99 [95% CI, 0.87-1.12]; P=0.873). After unsuccessful CTO PCI, long-term all-cause mortality was higher than non-CTO PCI (unadjusted HR, 1.82 [95% CI, 1.59-2.08], adjusted HR, 1.35 [95% CI, 1.13-1.63]; P<0.001). Conclusions Patients undergoing PCI for CTO have elevated long-term mortality compared with patients without CTO. Successful opening of the CTO(s) is associated with equal mortality compared with non-CTO PCI. In contrast, failed CTO PCI is associated with worse long-term mortality. These findings suggest the need for CTO programs with high success rates and low complication rates.
Collapse
Affiliation(s)
- Emil N. Holck
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Institute of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Naja S. Winther
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Institute of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Lone Juul‐Hune Mogensen
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Institute of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Evald Høj Christiansen
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Institute of Clinical MedicineAarhus UniversityAarhusDenmark
| |
Collapse
|
18
|
Nathan A, Hashemzadeh M, Movahed MR. Percutaneous Coronary Intervention of Chronic Total Occlusion Associated with Higher Inpatient Mortality and Complications Compared With Non-CTO Lesions. Am J Med 2023; 136:994-999. [PMID: 37356643 DOI: 10.1016/j.amjmed.2023.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) in patients with chronic total occlusion is commonly performed despite unclear long-term benefits. The goal of this study was to evaluate the postprocedural outcome of patients with chronic total occlusion intervention. METHODS The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients with chronic total occlusion interventions were compared with patients without chronic total occlusion. We evaluated postprocedural mortality and complications. RESULTS PCI in patients with chronic total occlusion was associated with higher total inhospital mortality and all postprocedural complications. A weighted total of 10,059,269 patients underwent PCI, with 259,574 having chronic total occlusion. The chronic total occlusion group had a 3.17% mortality rate vs 2.57% of nonchronic total occlusion PCIs (odds ratio [OR] 1.24; 95% confidence interval [CI], 1.18-1.31; P < .001). Using multivariate analysis adjusting for basline charcteristics and high risk features such as age, sex, race, diabetes mellitus, chronic kidney disease, systolic heart failure, 3-vessel PCI, hypertension, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, prior PCI, history of coronary artery bypass graft, history of anemia, smoking status, atrial fibrillation/flutter, valvular heart disease, and , history of stroke, chronic total occlusion PCI remained significantly associated with higher total mortality (OR 1.07; 95% CI, 1.02-1.13; P = .02). Patients with chronic total occlusion compared with nonchronic total occlusion PCI had also higher rates of myocardial infarction (OR 2.85; 95% CI, 2.54-3.21; P < .001), coronary perforation (OR 6.01; 95% CI, 5.25-6.89; P < .001), tamponade (OR 3.36; 95% CI, 2.91-3.88; P < .001), contrast-induced nephropathy (OR 2.05; 95% CI, 1.45-2.90; P < .001), procedural bleeding (OR 3.57; 95% CI, 3.27-3.89; P < .001), and acute postprocedural respiratory failure (OR 2.07; 95% CI, 1.81-2.36; P < .001). All postprocedural complications were more than 3 times the nonchronic total occlusion patients (OR 3.45; 95% CI, 3.24-3.67; P < .001). CONCLUSION Using a large national inpatient database, PCI performed in patients with chronic total occlusion was associated with significantly much higher mortality and postprocedural complications compared with PCI in nonchronic total occlusion patients.
Collapse
Affiliation(s)
| | | | - Mohammad Reza Movahed
- University of Arizona College of Medicine-Phoenix; University of Arizona Sarver Heart Center, Tucson.
| |
Collapse
|
19
|
Werner GS, Hildick-Smith D, Martin Yuste V, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, Di Mario C, Teruel L, Bufe A, Lauer B, Galassi AR, Louvard Y. Three-year outcomes of A Randomized Multicentre Trial Comparing Revascularization and Optimal Medical Therapy for Chronic Total Coronary Occlusions (EuroCTO). EUROINTERVENTION 2023; 19:571-579. [PMID: 37482940 PMCID: PMC10493774 DOI: 10.4244/eij-d-23-00312] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTO) improves clinical symptoms and quality of life. The longer-term safety of PCI compared to optimal medical therapy (OMT) remains uncertain. AIMS We sought to evaluate the long-term safety of PCI for CTO in a randomised trial as compared to OMT. METHODS A total of 396 patients with a symptomatic CTO were enrolled into a randomised, multicentre clinical trial comparing PCI and OMT. Half of the patients had a single CTO; the others had multivessel disease. Non-CTO lesions were treated prior to randomisation (2:1 ratio). During follow-up, crossover from OMT to PCI occurred in 7.3% (1 year) and 17.5% (3 years) of patients. RESULTS At 3 years, the incidence of cardiovascular death or nonfatal myocardial infarction was not significantly different between the groups (OMT 3.7% vs PCI 6.2%; p=0.29). By per-protocol analysis, the difference remained non-significant (OMT 5.7% vs PCI 4.7%; p=0.67). Overall, major adverse cardiovascular events (MACE) were more frequent with OMT (OMT 21.2% vs PCI 11.2%), largely because of ischaemia-driven revascularisation. The rates of stroke or hospitalisation for bleeding were not different between the groups. CONCLUSIONS At 3 years there was no difference in the rate of cardiovascular death or myocardial infarction between PCI or OMT among patients with a remaining single coronary CTO. The MACE rate was higher in the OMT group due largely to ischaemia-driven revascularisation. CTO PCI appears to be a safe option for patients with a single remaining significant coronary CTO. CinicalTrials.gov: NCT01760083.
Collapse
Affiliation(s)
| | | | | | - Nicolas Boudou
- Interventional Cardiology, Clinique Saint Augustin, Bordeaux, France
| | | | | | | | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Javier Escaned
- Hospital Clinico San Carlos IdISSC, Complutense University of Madrid, Madrid, Spain
| | - Carlo Di Mario
- Department of Cardiology, University of Florence, Florence, Italy
| | - Luis Teruel
- Bellvitge University Hospital, Barcelona, Spain
| | | | - Bernward Lauer
- Medizinische Klinik 1, Klinikum der Friedrich-Schiller Universität, Jena, Germany
| | | | | |
Collapse
|
20
|
Areiza LA, Rodriguez JF. Successful Percutaneous Coronary Intervention in Chronic Total Occlusion after Coronary Perforation. Case Rep Cardiol 2023; 2023:6640439. [PMID: 37680568 PMCID: PMC10482517 DOI: 10.1155/2023/6640439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/05/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023] Open
Abstract
Coronary chronic total occlusions are challenging lesions with high rates of complications related to percutaneous intervention. We describe a successful angioplasty in a patient with a recent coronary perforation, using multiple techniques, such as stick and swap with Stingray, subintimal transcatheter withdrawal, and investment.
Collapse
Affiliation(s)
- Luis A. Areiza
- Department of Interventional Cardiology, HUM Mederi, Bogota, Colombia
| | - Juan F. Rodriguez
- Department of Interventional Cardiology, HUM Mederi, Bogota, Colombia
| |
Collapse
|
21
|
Kucukseymen S, Iannaccone M, Grantham JA, Sapontis J, Juricic S, Ciardetti N, Mattesini A, Stojkovic S, Strauss BH, Wijeysundera HC, Werner GS, D'Ascenzo F, Di Mario C. Association of Successful Percutaneous Revascularization of Chronic Total Occlusions With Quality of Life: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2324522. [PMID: 37471086 PMCID: PMC10359963 DOI: 10.1001/jamanetworkopen.2023.24522] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Importance Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is not usually offered because of skepticism about long-term clinical benefits. Objective To assess the association of successful CTO-PCI with quality of life by analyzing the relevant domains of the Seattle Angina Questionnaire (SAQ). Data Sources PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane databases were searched to identify randomized trials and observational studies specifically addressing quality of life domains of SAQ from January 2010 to June 2022. Study Selection Studies included reporting SAQ metrics such as angina frequency, physical limitation, and quality of life, before and after CTO-PCI. Data Extraction and Synthesis The present study was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements, in which fixed-effect or random-effect models with generic inverse-variance weighting depending on statistical homogeneity were applied. Data were extracted by 3 independent reviewers. Outcomes and Measures The primary outcome was angina frequency; physical limitation and quality of life were assessed as secondary outcomes. Results Seven prospective randomized or observational studies (2500 patients) were included, with a mean (SD) participant age of 61.2 (2.1) years. CTO-PCI was associated with significantly improved quality-of-life metrics during a mean (SD) follow-up of 14.8 (16.3) months. In patients with successful procedures, angina episodes became less frequent (mean [SD] difference for SAQ angina frequency of 12.9 [3.1] survey points [95% CI, 7.1-19.8 survey points]; standardized mean difference was 0.54 [95% CI, 0.21-0.92]; P = .002; I2 = 86.4%) and they experienced less physical activity limitation (mean [SD] difference for SAQ physical limitation of 9.7 [6.2] survey points [95% CI, 3.5-16.2 survey points]; standardized mean difference was 0.42 [95% CI, 0.24-0.55]; P < .001; I2 = 20.9%), and greater quality-of-life domain (mean [SD] difference for SAQ quality of life of 14.9 [3.5] survey points [95% CI, 7.7-22.5 survey points]; standardized mean difference was 0.41 [95% CI, 0.25-0.61]; P < .001; I2 = 58.8%) compared with patients with optimal medical therapy or failed procedure. Furthermore, follow-up duration (point estimate, 0.03; 95% CI, 0.01-0.04; P = .01) was associated with a significant decrease in angina frequency in meta-regression analysis. Conclusions and Relevance In this systematic review and meta-analysis examining quality of life following CTO-PCI, successful procedures were associated with improved quality-of-life parameters compared with patients on optimal medical therapy or after failed CTO-PCI. These findings suggest support for using PCI to treat CTOs in symptomatic patients unresponsive to medical treatment.
Collapse
Affiliation(s)
- Selcuk Kucukseymen
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Mario Iannaccone
- Cardiology Department, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - James A Grantham
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Stefan Juricic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Niccolò Ciardetti
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Sinisa Stojkovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bradley H Strauss
- Schulich Heart Program, Division of Cardiology, University of Toronto, Ontario, Canada
| | | | - Gerald S Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science, University of Turin, Turin, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| |
Collapse
|
22
|
Shoaib A, Sharma V, Spratt JC, Wilson S, Hussain ST, Velagapudi P, Siller-Matula JM, Rashid M, Ludman P, Cockburn J, Kinnaird T, Mamas MA. Sex Differences in Clinical Profile and Outcome After Percutaneous Coronary Intervention for Chronic Total Occlusion. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:34-41. [PMID: 36549927 DOI: 10.1016/j.carrev.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. METHODS & RESULTS We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men. CONCLUSION Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients.
Collapse
Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | | | - James C Spratt
- Department of Cardiology, St George's University Hospital NHS Trust, London, UK
| | - Simon Wilson
- Department of Cardiology, St George's University Hospital NHS Trust, London, UK
| | - Shazia T Hussain
- Cardiology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Poonam Velagapudi
- Division of Cardiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jolanta M Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology, Warsaw, Poland
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, UK
| | - James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Tim Kinnaird
- Department of Cardiology, University hospital of Wales, Cardiff, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK.
| | | | | |
Collapse
|
23
|
Tsao AL, Boden WE. Chronic Total Occlusion PCI and Optimal Medical Therapy: Are We Still Putting the Cart Before the Horse? Circ Cardiovasc Qual Outcomes 2023; 16:e009604. [PMID: 36722335 DOI: 10.1161/circoutcomes.122.009604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Allison L Tsao
- VA Boston Healthcare System and Harvard Medical School, MA (A.L.T.)
| | - William E Boden
- VA Boston Healthcare System and Boston University School of Medicine, MA (W.E.B.)
| |
Collapse
|
24
|
Albaeni A, Chatila KF, Thakker RA, Kumfa P, Alwash H, Elsherbiny A, Gilani S, Khalife WI, Jneid H, Motiwala A, Motiwala A. In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients. Curr Probl Cardiol 2023; 48:101458. [PMID: 36261103 DOI: 10.1016/j.cpcardiol.2022.101458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.
Collapse
Affiliation(s)
- Aiham Albaeni
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX.
| | - Khaled F Chatila
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Ravi A Thakker
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Paul Kumfa
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Haider Alwash
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Ahmed Elsherbiny
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Syed Gilani
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Wissam I Khalife
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Hani Jneid
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | - Afaq Motiwala
- Department of Medicine, Division of Cardiology, University of Texas Medical branch, Galveston, TX
| | | |
Collapse
|
25
|
Li W, Wu Z, Liu T, Wu X, Liu J. Long term clinical outcome after success re-attempt percutaneous coronary intervention of chronic total occlusion. BMC Cardiovasc Disord 2023; 23:23. [PMID: 36646993 PMCID: PMC9841955 DOI: 10.1186/s12872-023-03045-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/05/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To evaluate the long-term outcome after re-attempt CTO-PCI. METHODS This is a retrospective cohort study that included 113 re-attempt CTO-PCI patients who were consecutively registered from January 2019 to December 2020 at Beijing Anzhen Hospital's Center of Coronary Artery Disease. All patients were divided into two groups based on procedural success or failure. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality, myocardial infarction and target vessel revascularization (TVR). The secondary endpoint was angina after PCI. RESULTS Overall, the successful re-attempt CTO-PCI was archived in 77 patients, the failed CTO-PCI was performed in 36 patients. After a median follow-up of 21.7 months (interquartile range: 10.9-26.0), the incidence of the primary outcome was significantly lower in the success group [14.2% vs. 38.9%, adjusted hazard ratio (HR) 0.351, 95% CI 0.134-0.917, P = 0.033], mainly driven by the reduction of TVR (9.1% vs. 30.6%, adjusted HR 0.238, 95% CI: 0.078-0.72, P = 0.011). Furthermore, patients who had successful re-attempt CTO-PCI had a lower risk of angina after PCI (27.3% vs.61.1%, adjusted HR 0.357, 95% CI 0.167-0.76, P = 0.008). The risk factors of TVR in the patients with successful re-attempt CTO-PCI were stent length > 100 mm (adjusted HR 21.805, 95% CI 1.765-269.368, P = 0.016) and J-CTO score > 3(adjusted HR: 9.733, 95% CI:1.533-61.797, P = 0.016). CONCLUSIONS For the patients with previous CTO-PCI failure, a successful re-attempt CTO-PCI was associated with significantly lower MACE, which was primarily driven by a lower TVR rate. More complex CTO lesions and longer stents were the independent predictors of TVR after successful CTO-PCI.
Collapse
Affiliation(s)
- Wenzheng Li
- grid.411606.40000 0004 1761 5917Center of Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Zheng Wu
- grid.411606.40000 0004 1761 5917Center of Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Tong Liu
- grid.411606.40000 0004 1761 5917Center of Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiaofan Wu
- grid.411606.40000 0004 1761 5917Center of Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jinghua Liu
- grid.411606.40000 0004 1761 5917Center of Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| |
Collapse
|
26
|
Juricic SA, Stojkovic SM, Galassi AR, Stankovic GR, Orlic DN, Vukcevic VD, Milasinovic DG, Aleksandric SB, Tomasevic MV, Dobric MR, Nedeljkovic MA, Beleslin BD, Dikic MP, Banovic MD, Ostojic MC, Tesic MB. Long-term follow-up of patients with chronic total coronary artery occlusion previously randomized to treatment with optimal drug therapy or percutaneous revascularization of chronic total occlusion (COMET-CTO). Front Cardiovasc Med 2023; 9:1014664. [PMID: 36698926 PMCID: PMC9868942 DOI: 10.3389/fcvm.2022.1014664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background The COMET-CTO trial was a randomized prospective study that assessed long-term follow-up in patients with chronic total occlusion (CTO) in coronary arteries treated with percutaneous coronary intervention (PCI) or with optimal medical therapy (OMT). During the 9-month follow-up, the incidence of major adverse cardiac events (MACE) did not differ between the two groups; no death or myocardial infarction (MI) was observed. There was a significant difference in quality of life (QoL), assessed by the Seattle Angina Questionnaire (SAQ), in favor of the PCI group. Here we report long-term follow-up results (56 ± 12 months). Methods Between October 2015 and May 2017, a total of 100 patients with CTO were randomized into two groups of 50 patients: PCI CTO or OMT group. The primary endpoint of the current study was the incidence of MACE defined as cardiac death, MI, and revascularization [PCI or coronary artery bypass graft (CABG)]. As the secondary exploratory outcome, we analyzed all the cause-mortality rate. Results Out of 100 randomized patients, 92 were available for long-term follow-up (44 in the PCI group and 48 in the OMT group). The incidence of MACE did not differ significantly between the two groups (p = 0.363). Individual components of MACE were distributed, respectively: cardiac death (OMT vs. PCI group, 6 vs. 3, p = 0.489), MI (OMT vs. PCI group, 1 vs. 0, p = 1), and revascularization (PCI: OMT vs. PCI group, 2 vs. 2, p = 1; CABG: OMT vs. PCI group, 1 vs. 1, p = 1). There was no significant difference between the two groups regarding the individual component of MACE. Six patients died from non-cardiac causes [five deaths were reported in the OMT group and one death in the PCI group (p = 0.206)]. Kaplan-Meier survival curves for MACE did not differ significantly between the study groups (log-rank 0.804, p = 0.370). Regarding the secondary exploratory outcome, a total of 15 patients died at 56 ± 12 months (11 in the OMT and 4 in the PCI group) (p = 0.093). The Kaplan-Meier survival curves for all-cause mortality rates did not differ significantly between the two groups (log rank 3.404, p = 0.065). There were no statistically significant differences between OMT and PCI groups in all five SAQ domains. There was a significant improvement in three SAQ domains in the PCI group: PL (p < 0.001), AF (p = 0.007), and QoL (p = 0.001). Conclusion After 56 ± 12 months of follow-up, the incidence of MACE, as well as QoL measured by SAQ, did not differ significantly between the PCI and OMT groups.
Collapse
Affiliation(s)
- Stefan A. Juricic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sinisa M. Stojkovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia,*Correspondence: Sinisa M. Stojkovic,
| | - Alfredo R. Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy,Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Goran R. Stankovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Dejan N. Orlic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan D. Vukcevic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dejan G. Milasinovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan B. Aleksandric
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miloje V. Tomasevic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Milan R. Dobric
- School of Medicine, University of Belgrade, Belgrade, Serbia,Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Milan A. Nedeljkovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko D. Beleslin
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miodrag P. Dikic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Marko D. Banovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miodrag C. Ostojic
- School of Medicine, University of Belgrade, Belgrade, Serbia,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Milorad B. Tesic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia,School of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
27
|
Hamzaraj K, Kammerlander A, Gyöngyösi M, Frey B, Distelmaier K, Graf S. Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization-A Workflow Focusing on Non-Invasive Cardiac Imaging. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010004. [PMID: 36675954 PMCID: PMC9864679 DOI: 10.3390/life13010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician's discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions.
Collapse
|
28
|
Ybarra LF, Rinfret S. Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions. Can J Cardiol 2022; 38:S42-S53. [PMID: 33075456 DOI: 10.1016/j.cjca.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/30/2022] Open
Abstract
Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.
Collapse
Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Stéphane Rinfret
- Division of Cardiology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
| |
Collapse
|
29
|
Holck EN, Winther NS, Mogensen LJH, Christiansen EH. Cost-Effectiveness in Patients Undergoing Revascularization of Chronic Total Occluded Coronary Arteries—A Cohort Study. Front Cardiovasc Med 2022; 9:849942. [PMID: 35694673 PMCID: PMC9177990 DOI: 10.3389/fcvm.2022.849942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Revascularization of patients with chronic total occluded coronary arteries (CTO) is recommended if they have symptoms despite medical treatment. The cost-effectiveness of treatment with percutaneous coronary intervention (PCI) was investigated in this cohort study. Materials and Methods The study was designed as a cohort study enrolling all patients undergoing PCI for a CTO in the Central Region of Denmark and recorded in the EUROCTO database. Major adverse cardio- and cerebrovascular events (MACCE) and admissions for cardiac symptoms were collected in the Western Denmark Heart Registry and through medical Journal Audits. Exposure was defined as successful revascularization of all CTO lesions compared with having one or more remaining CTOs after PCI attempt(s). Cost-effectiveness was evaluated as the net benefit (NB) at the patient level 3 years after treatment and through cost-effectiveness planes. The cost was defined as the cumulative cost of the index procedure and admissions due to MACCE and cardiac symptoms. Effectiveness was defined as the difference in MACCE for the primary analysis and the difference in death and symptomatic admissions for the secondary. Results Between 2009 and 2019, 441 patients with ≥ 3 years of follow-up were treated with PCI for at least one CTO lesion (342 in the successful arm and 99 in the unsuccessful arm). The technical success rate was 85.4%. In total, 155 MACCE and 184 symptomatic admissions occurred in the follow-up period. The mean total cost was EUR 11.719 (11.034; 12.406) in the successful group vs. EUR 13.565 (11.899; 15,231) (p = 0.02) in the unsuccessful group. Net-benefit was EUR 1.846 (64; 3,627) after successful revascularization for MACCE. The adjusted analysis found an NB of EUR 1,481 (–118; 3,079). Bootstrap estimates showed cost-effectiveness planes in favor of successful revascularization. Conclusion Patients fully revascularized for all CTO lesions had a more cost-efficient treatment. However, results need confirmation in a randomized controlled trial due to the risk of residual confounding after adjustment.
Collapse
Affiliation(s)
- Emil Nielsen Holck
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- *Correspondence: Emil Nielsen Holck,
| | - Naja Stausholm Winther
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Juul Hune Mogensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
30
|
Butala NM, Tamez H, Secemsky EA, Grantham JA, Spertus JA, Cohen DJ, Jones P, Salisbury AC, Arnold SV, Harrell F, Lombardi W, Karmpaliotis D, Moses J, Sapontis J, Yeh RW. Predicting Residual Angina After Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the OPEN-CTO Registry. J Am Heart Assoc 2022; 11:e024056. [PMID: 35574949 PMCID: PMC9238547 DOI: 10.1161/jaha.121.024056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/06/2022] [Indexed: 12/12/2022]
Abstract
Background Given that percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is indicated primarily for symptom relief, identifying patients most likely to benefit is critically important for patient selection and shared decision-making. Therefore, we identified factors associated with residual angina frequency after CTO PCI and developed a model to predict postprocedure anginal burden. Methods and Results Among patients in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry, we evaluated the association between patient characteristics and residual angina frequency at 6 months, as assessed by the Seattle Angina Questionnaire Angina Frequency Scale. We then constructed a prediction model for angina status after CTO PCI using ordinal regression. Among 901 patients undergoing CTO PCI, 28% had no angina, 31% had monthly angina, 30% had weekly angina, and 12% had daily angina at baseline. Six months later, 53% of patients had a ≥20-point increase in Seattle Angina Questionnaire Angina Frequency Scale score. The final model to predict residual angina after CTO PCI included baseline angina frequency, baseline nitroglycerin use frequency, dyspnea symptoms, depressive symptoms, number of antianginal medications, PCI indication, and presence of multiple CTO lesions and had a C index of 0.78. Baseline angina frequency and nitroglycerin use frequency explained 71% of the predictive power of the model, and the relationship between model components and angina improvement at 6 months varied by baseline angina status. Conclusions A 7-component OPEN-AP (OPEN-CTO Angina Prediction) score can predict angina improvement and residual angina after CTO PCI using variables commonly available before intervention. These findings have implications for appropriate patient selection and counseling for CTO PCI.
Collapse
Affiliation(s)
- Neel M. Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Division of CardiologyMassachusetts General HospitalBostonMA
| | - Hector Tamez
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of CardiologyBeth Israel Deaconess Medical CenterBostonMA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of CardiologyBeth Israel Deaconess Medical CenterBostonMA
| | | | | | | | - Philip Jones
- Saint Luke’s Mid America Heart Institute/UMKCKansas CityMO
| | | | | | - Frank Harrell
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTN
| | | | | | | | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDivision of CardiologyBeth Israel Deaconess Medical CenterBostonMA
| |
Collapse
|
31
|
Chen S, Ma C, Feng X, Cui M. Nicorandil Improves Left Ventricular Myocardial Strain in Patients With Coronary Chronic Total Occlusion. Front Cardiovasc Med 2022; 9:864223. [PMID: 35647043 PMCID: PMC9135107 DOI: 10.3389/fcvm.2022.864223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nicorandil is recommended as a second-line treatment for stable angina; however, randomized-controlled trials to evaluate the benefit of nicorandil for patients with chronic total occlusion (CTO) are lacking. Objective To determine whether nicorandil can improve left ventricular (LV) myocardial strain in patients with CTO. Methods Patients with CTO were included and randomized to the nicorandil group (n = 31) and the control group (n = 30). Nicorandil was given orally at 15 mg/day for 3 months in the nicorandil group. Three-dimensional speckle-tracking echocardiography and the Seattle Angina Questionnaire (SAQ) survey were performed at baseline and at 3 months. The primary study endpoint was the LV global area strain (GAS) at 3 months. Results The nicorandil and the control groups were well-matched at baseline, including the mean GAS and SAQ scores. At 3 months, GAS in the nicorandil group was significantly higher than that in the control group (−23.7 ± 6.3% vs. −20.3 ± 5.6%, respectively; p = 0.033). There were no significant differences in LV global longitudinal strain, global circumferential strain, global radial strain, LV ejection fraction, LV end-diastolic volume, and LV end-systolic volume at 3 months between the two groups. At 3 months, the SAQ scores for angina stability, angina frequency, and treatment satisfaction in the nicorandil group were significantly higher than those in the control group. Conclusion Nicorandil treatment can improve GAS and angina symptoms in patients with CTO. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT05087797.
Collapse
Affiliation(s)
- Shaomin Chen
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
| | - Chen Ma
- Healthcare Department, National Center of Gerontology, Beijing Hospital, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinheng Feng
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
| | - Ming Cui
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, China
- *Correspondence: Ming Cui
| |
Collapse
|
32
|
Melotti E, Belmonte M, Gigante C, Mallia V, Mushtaq S, Conte E, Neglia D, Pontone G, Collet C, Sonck J, Grancini L, Bartorelli AL, Andreini D. The Role of Multimodality Imaging for Percutaneous Coronary Intervention in Patients With Chronic Total Occlusions. Front Cardiovasc Med 2022; 9:823091. [PMID: 35586657 PMCID: PMC9108201 DOI: 10.3389/fcvm.2022.823091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPercutaneous coronary intervention (PCI) of Chronic total occlusions (CTOs) has been traditionally considered a challenging procedure, with a lower success rate and a higher incidence of complications compared to non-CTO-PCI. An accurate and comprehensive evaluation of potential candidates for CTO-PCI is of great importance. Indeed, assessment of myocardial viability, left ventricular function, individual risk profile and coronary lesion complexity as well as detection of inducible ischemia are key information that should be integrated for a shared treatment decision and interventional strategy planning. In this regard, multimodality imaging can provide combined data that can be very useful for the decision-making algorithm and for planning percutaneous CTO recanalization.AimsThe purpose of this article is to appraise the value and limitations of several non-invasive imaging tools to provide relevant information about the anatomical characteristics and functional impact of CTOs that may be useful for the pre-procedural assessment and follow-up of candidates for CTO-PCI. They include echocardiography, coronary computed tomography angiography (CCTA), nuclear imaging, and cardiac magnetic resonance (CMR). As an example, CCTA can accurately delineate CTO location and length, distal coronary bed, vessel tortuosity and calcifications that can predict PCI success, whereas stress CMR, nuclear imaging and stress-CT can provide functional evaluation in terms of myocardial ischemia and viability and perfusion defect extension.
Collapse
Affiliation(s)
- Eleonora Melotti
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Marta Belmonte
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlo Gigante
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Vincenzo Mallia
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Saima Mushtaq
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Edoardo Conte
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Danilo Neglia
- Fondazione Toscana G. Monasterio, Pisa, Italy
- Istituto di Scienze della Vita Scuola Superiore Sant'Anna, Pisa, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Grancini
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Antonio L. Bartorelli
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
- *Correspondence: Daniele Andreini
| |
Collapse
|
33
|
Procedural Outcomes in Patients Treated with Percutaneous Coronary Interventions within Chronic Total Occlusions Stratified by Gender. J Clin Med 2022; 11:jcm11051419. [PMID: 35268510 PMCID: PMC8911020 DOI: 10.3390/jcm11051419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
It has been demonstrated that gender differences are related to different procedural and long-term clinical outcomes among a general patient population treated using percutaneous coronary interventions (PCI). The objective of our analysis was to conduct assessment regarding the relationship between gender and procedural outcomes in patients treated for PCI regarding chronic total occlusions (CTO), based on a large, real-life registry. Data used to conduct the following analysis was derived from the national registry of percutaneous coronary interventions (ORPKI), upheld in co-operation with the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The study involved data procured from the registry within the period from January 2014 to December 2020. All subsequent CTO procedures recorded in the registry during that period were included in the analysis. We assessed the correlation between gender and the overall rate of periprocedural complications, procedure-related mortality, and success evaluated as TIMI flow grade 3 after the procedure by univariate and multivariable modeling. At the time of conducting our investigation, there were 162 existing and active CathLabs, at which 747,033 PCI procedures were carried out during the observational period. Of those, 14,903 (1.99%) were CTO-PCI procedures, and 3726 were women (25%). The percentage share between genders did not experience any significant changes during the consecutive years observed in the current analysis. Overall periprocedural complication rate was greater among women than men (3.45% vs. 2.31%, p = 0.02). A comparable relationship was noted for procedural mortality (0.7% vs. 0.2%, p = 0.006), while procedural success occurred more often in the case of women (69.3% vs. 65.2%, p < 0.001). Women were found to be more frequently affected by periprocedural complications (OR = 1.553; 95%CI: 1.212−1.99, p < 0.001) as well as procedural success (OR = 1.294; 95%CI: 1.151−1.454, p < 0.001), evaluated using multivariable models. Based on the current analysis performed on all-comer patients treated using PCI in CTO, women are affected by more frequent procedural complication occurrence as well as greater procedural success compared to men.
Collapse
|
34
|
Verreault-Julien L, Bhatt DL, Jung RG, Di Santo P, Simard T, Avram R, Hibbert B. Predictors of angina resolution after percutaneous coronary intervention in stable coronary artery disease. Coron Artery Dis 2022; 33:98-104. [PMID: 34148973 DOI: 10.1097/mca.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Elective percutaneous coronary intervention (PCI) is performed to relieve symptoms of angina. Identifying patients who will benefit symptomatically after PCI would be clinically advantageous but robust predictors of symptom resolution are ill-defined. METHODS Prospective indexing of baseline angina status, clinical, and procedural characteristics were collected over a 5-year period in a regional revascularization registry. At 1-year follow-up, angina resolution was assessed. We performed a stepwise selection algorithm to identify predictors of persistent angina at 1 year. RESULTS A total of 777 patients were included in the analysis and the median follow-up was 387 days. Mean age of the cohort was 66.6 years, 23.8% were female and 23.3% had baseline Canadian Cardiovascular Society class 3 or 4 angina. Overall, 13.1% had persistent angina. The only predictor of persistent angina was the presence of a residual chronic total occlusion after PCI with odds ratio of 3.06 (95% confidence interval, 1.81-5.17). Residual stenoses 50-69%, 70-89%, and 90-99% were not associated with residual angina after PCI. CONCLUSION Most patients achieved symptom resolution with PCI and optimal medical therapy. A residual chronic total occlusion after PCI was associated with persistent angina. Other degrees of stenoses were not associated with persistent angina.
Collapse
Affiliation(s)
- Louis Verreault-Julien
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Harvard T.H. Chan School of Public Health, Harvard University
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center
- Harvard Medical School, Boston, MA, USA
| | - Richard G Jung
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine
| | - Pietro Di Santo
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine
- School of Epidemiology and Public Health
| | - Trevor Simard
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Avram
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine
- School of Epidemiology and Public Health
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
35
|
Muraca I, Carrabba N, Virgili G, Bruscoli F, Migliorini A, Pennesi M, Pontecorboli G, Marchionni N, Valenti R. Chronic total occlusion revascularization: A complex piece to "complete" the puzzle. World J Cardiol 2022; 14:13-28. [PMID: 35126869 PMCID: PMC8788177 DOI: 10.4330/wjc.v14.i1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/15/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of “contemporary” strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a “complex” piece to “complete” the puzzle.
Collapse
Affiliation(s)
- Iacopo Muraca
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Nazario Carrabba
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giacomo Virgili
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Filippo Bruscoli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Angela Migliorini
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Matteo Pennesi
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Giulia Pontecorboli
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Niccolò Marchionni
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| | - Renato Valenti
- Cardiovascular Department, Careggi University Hospital, Florence 50134, Italy
| |
Collapse
|
36
|
Qin Q, Chen L, Ge L, Qian J, Ma J, Ge J. A comparison of long-term clinical outcomes between percutaneous coronary intervention (PCI) and medical therapy in patients with chronic total occlusion in noninfarct-related artery after PCI of acute myocardial infarction. Clin Cardiol 2022; 45:136-144. [PMID: 34989416 PMCID: PMC8799053 DOI: 10.1002/clc.23771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is one of the risk factors for mortality after acute myocardial infarction (AMI). However, there are limited data comparing the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with patients having medical therapy (MT) in CTO lesion after AMI PCI. METHODS We retrospectively enrolled 330 patients (successful CTO PCI in 166 patients, failed CTO PCI in 32 patients, MT in 132 patients) with non-IRA CTO from a total of 4372 patients who underwent PCI after AMI in our center. Propensity score matching (PSM) was used to adjust for baseline differences. RESULTS The primary analysis is based on the intention-to-treat population. During a median follow-up period of 946 days, patients in the PCI group (n = 198) had significantly higher cardiac death-free survival (96.6% vs. 82.8%, p = .004) compared with patients in MT group (n = 132). However, no significant difference in the occurrence of cardiac death was observed after PSM. The analysis based on the per-protocol population demonstrated significantly higher cardiac death-free survival in the successful CTO PCI group (n = 166) compared with the occluded CTO group (n = 164) both before and after PSM. In subgroup analysis, successful CTO PCI was associated with less cardiac death in patients over 65 years old, with LVEF < 50%, left anterior descending (LAD) IRA, and non-LAD CTO lesion compared with occluded CTO group. CONCLUSIONS Patients undergoing successful revascularization of non-IRA CTO after AMI might have a better long-term prognosis. Moreover, patients with LVEF < 50% may benefit from successful non-IRA CTO PCI after AMI.
Collapse
Affiliation(s)
- Qing Qin
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| | - Lu Chen
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| | - Lei Ge
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| | - Jianying Ma
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan UniversityShanghai Institute of Cardiovascular DiseaseShanghaiChina
| |
Collapse
|
37
|
Cao M, Li B, Li Q, Sun C. The Comparison of Long-Term Outcome Between Patients with Single and Multiple Coronary Chronic Total Occlusions After Percutaneous Coronary Intervention. Int J Gen Med 2022; 15:729-736. [PMID: 35082521 PMCID: PMC8786357 DOI: 10.2147/ijgm.s348035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Rapid advancements in percutaneous coronary intervention (PCI) have improved the outcome of chronic coronary total occlusions (CTOs); however, data regarding the difference in long-term outcomes in stable coronary artery disease (CAD) patients with single and multiple CTOs who underwent PCI are scarce. This study aimed to compare the long-term outcomes of patients with multiple CTOs and single CTO after PCI. Methods This study cohort included stable CAD patients who were diagnosed with CTO and treated with PCI from a single center. The primary endpoint was all-cause death. Results We retrospectively reviewed 670 consecutive patients with CTO-PCI. Among them, 539 patients had a single CTO, and 131 (19.7%) patients had multiple (at least two) CTOs. CTO revascularization was achieved in 470 (70.1%) patients. After a median follow-up duration of 33.7 months, the cumulative all-cause mortality (p = 0.037) and cardiac mortality (p = 0.003) were higher in patients with multiple CTOs than in those with a single CTO. In the multivariable model, multiple CTOs and left ventricular ejection fraction (LVEF) less than 40% were independent predictors for cardiac death (adjusted hazard ratio (HR) 2.53; P = 0.013 and adjusted HR 3.95; P < 0.001), while age older than 65 and LVEF less than 40% were independent predictors for all-cause death in CTO-PCI patients (adjusted hazard ratio (HR) 1.84; P = 0.035 and adjusted HR 2.54; P = 0.001). Conclusion In CTO-PCI patients, long-term survival was associated with multiple CTOs, age and LVEF, but not with CTO revascularization.
Collapse
Affiliation(s)
- Miaomiao Cao
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, 710061, People’s Republic of China
| | - Bolin Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, 710061, People’s Republic of China
| | - Qian Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, 710061, People’s Republic of China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, 710061, People’s Republic of China
- Correspondence: Chaofeng Sun, Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, No. 277 Yanta West Road, Xi’an, 710061, People’s Republic of China, Email
| |
Collapse
|
38
|
Nef HM, Achenbach S, Birkemeyer R, Bufe A, Dörr O, Elsässer A, Gaede L, Gori T, Hoffmeister HM, Hofmann FJ, Katus HA, Liebetrau C, Massberg S, Pauschinger M, Schmitz T, Süselbeck T, Voelker W, Wiebe J, Zahn R, Hamm C, Zeiher AM, Möllmann H. Manual der Arbeitsgruppe Interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e.V. (DGK). DER KARDIOLOGE 2021. [DOI: 10.1007/s12181-021-00504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
39
|
Yoon YH, Han S, Kwon O, Lee K, Kim JH, Lee J, Kim TO, Roh JH, Lee PH, Kang SJ, Lee JH, Kim YH, Lee CW, Moon DH, Lee SW. Ischemic Burden Assessment Using Single Photon Emission Computed Tomography in Single Vessel Chronic Total Occlusion of Coronary Artery. Korean Circ J 2021; 52:150-161. [PMID: 35043605 PMCID: PMC8819571 DOI: 10.4070/kcj.2021.0240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/20/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Studies evaluating the nature of ischemic burden of chronic total occlusion (CTO) vessels are still lacking. METHODS A total of 165 patients with single vessel CTO >2.5 mm in an epicardial coronary artery who underwent single photon emission computed tomography (SPECT) were enrolled in the study. Ischemic burden was calculated with the use of semi-quantitative SPECT analysis, and was defined as the summed difference score (SDS) divided by the maximal limit of the score (=SDS/68). RESULTS The mean age of the participants was 59.5 years and the CTO of the left anterior descending coronary artery (LAD), left circumplex coronary artery (LCX), and right coronary artery (RCA) accounted for 93 (56.4%), 18 (10.9%), and 54 (32.7%) patients, respectively. The median ischemic burden of the total population was 8.8%, and it was highest in the LAD CTO (10.3%) compared with the LCX (5.9%) and RCA CTO (5.9%, p<0.001). High-ischemic burden (ischemic burden >10%) was observed in 66 patients (40.0%), and in 47 patients (50.5%) of the LAD CTO. Ischemic burden was different according to the CTO location only in LAD CTO. The statistically significant predictors for high-ischemic burden were hypertension, baseline ejection fraction >45%, LAD CTO, proximal CTO location, and de novo CTO. Japanese-CTO score and Rentrop scale collateral grade were not associated with high-ischemic burden. CONCLUSIONS Only 40% of patients with single vessel CTO had ischemic burden >10%. For CTO vessels, measurement of ischemic burden using SPECT prior to revascularization may be helpful in identifying beneficial subjects.
Collapse
Affiliation(s)
- Yong-Hoon Yoon
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Sangwon Han
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Osung Kwon
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Seoul, Korea
| | - Kyusup Lee
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Hyeon Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hyung Roh
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo-Jin Kang
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hwan Lee
- Department of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Young-Hak Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Hyuk Moon
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| |
Collapse
|
40
|
Shoaib A, Spratt JC, Curzen N, Wilson S, Rashid M, Ahmad F, Ludman P, Kinnaird T, Mamas MA. Clinical outcomes of percutaneous coronary intervention for chronic total occlusion by treated segment length. Catheter Cardiovasc Interv 2021; 99:234-244. [PMID: 34797596 DOI: 10.1002/ccd.30015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/16/2021] [Accepted: 10/27/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO). METHODS AND RESULTS We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death. CONCLUSION Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.
Collapse
Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK.,Victoria Heart Institute Foundation, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | | | - Nick Curzen
- University of Southampton, Southampton, & University Hospital Southampton NHS Trust, Southampton, UK
| | - Simon Wilson
- St Georges' Hospitals, NHS Foundation trust, London, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Fatima Ahmad
- Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | | |
Collapse
|
41
|
Megaly M, Khalil M, Basir MB, McEntegart MB, Spratt JC, Yamane M, Tsuchikane E, Xu B, Alaswad K, Brilakis ES. Outcomes of successful vs. failed contemporary chronic total occlusion percutaneous coronary intervention. Cardiovasc Interv Ther 2021; 37:483-489. [PMID: 34716883 DOI: 10.1007/s12928-021-00819-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are limited contemporary data on the impact of success vs. failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS We conducted a systematic review and a meta-analysis of contemporary studies that compared the outcomes in patients who underwent successful vs. failed contemporary (2010 onwards) CTO PCI. We performed a sensitivity analysis limited to studies that started enrollment after the publication of the hybrid algorithm in 2012. RESULTS We included five studies with a total of 6,084 patients (successful CTO PCI n = 4,861, failed CTO PCI n = 1,223). During a median follow-up time of 12 months (range 6-60 months), successful CTO PCI was associated with a lower risk of major adverse cardiovascular events [OR: 0.61, 95% CI (0.41, 0.92), p = 0.02, I2 = 63%] and all-cause death [OR: 0.57, 95% CI (0.33, 0.99), p = 0.05, I2 = 60%]. Both groups had similar risk of myocardial infarction (MI) [OR 0.69, 95% CI (0.43, 1.10), p = 0.38, I2 = 80%], target vessel revascularization (TVR) [OR: 0.56, 95% CI (0.25, 1.27), p = 0.17, I2 = 80%], and stroke [OR: 0.52, 95% CI (0.14, 1.91), p = 0.33, I2 = 0%]. CONCLUSION In contemporary practice, successful CTO PCI was associated with a lower incidence of MACE driven by lower all-cause mortality compared with failed CTO PCI at a median follow-up of 1 year.
Collapse
Affiliation(s)
- Michael Megaly
- Division of Cardiology, Banner University Medical Center, Phoenix, AZ, USA
| | - Mahmoud Khalil
- Department of Medicine, Lincoln Medical Center, New York, NY, USA
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | | | - James C Spratt
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E 28th Street #300, Minneapolis, MN, 55407, USA.
| |
Collapse
|
42
|
A Novel Clinical Scoring Model for Interventional Therapy in Chronic Total Occlusion of the Coronary Artery. J Interv Cardiol 2021; 2021:9988943. [PMID: 34629988 PMCID: PMC8463195 DOI: 10.1155/2021/9988943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/30/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022] Open
Abstract
Objective With the rapid development of technology and experience, the current percutaneous coronary intervention of chronic total occlusion (CTO-PCI) preoperative scoring model needs to be updated. This study aimed to evaluate the clinical value of the operator-CTO score in predicting the outcome of interventional therapy for chronic total occlusion of the coronary artery. Methods The data of 144 lesions in 130 patients with CTO were analyzed prospectively. The CTO procedures were performed by 10 operators with different skills and experiences. Before the procedures, J-CTO, progress, ORA, recharge, and operator-CTO scores were determined. Then, the clinical, imaging, and procedural data of patients in different operator-CTO score groups and between different operators were compared. The final focus was on comparing the predictive ability of each score on the outcome of CTO-PCI. Results The overall technical and procedural success rates were 90.9% and 88.9%, respectively. A decreasing trend in the technical success of CTO-PCI was observed according to the operator-CTO score hierarchy of “easy (≤2 points), moderate (3 points), difficult (4 points), and extremely difficult (≥5 points)” (99.0%, 87.5%, 53.8%, and 25.0%, respectively). All five scoring models were well calibrated, and the area under the curve (AUC) for the operator-CTO score was 0.901 (95% CI: 0.821–0.982, P < 0.01), larger than the AUC for the remaining four scoring models, showing excellent ability to predict technical outcomes. Conclusion The operator-CTO score is a new clinical scoring tool that can predict the outcome of CTO-PCI and can be used to grade the difficulty of the procedure, with the potential to work well with a broad group of operators.
Collapse
|
43
|
Voll F, Kuna C, Kufner S, Cassese S. [Technical armamentarium for chronic total occlusion of coronary vessels]. Herz 2021; 46:406-418. [PMID: 34398249 DOI: 10.1007/s00059-021-05053-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
Percutaneous revascularization of chronic total occlusion (CTO) of coronary vessels represents a major challenge for contemporary interventional cardiologists. In the last decade there has been an unprecedented effort towards the standardization of revascularization procedures for CTO of coronary vessels. This endeavour has been possible by virtue of the growing interest of various cardiological societies for this patient group. Along with supportive endovascular technologies and percutaneous devices specifically dedicated to this interventional target, the increasing experience of interventionalists enabled continuously growing success for revascularization of CTO of coronary vessels. This review article highlights the currently available tools as well as technologies, techniques and strategies for the percutaneous recanalization of CTO of coronary vessels.
Collapse
Affiliation(s)
- F Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - C Kuna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - S Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - S Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland.
| |
Collapse
|
44
|
Vanneman MW. Anesthetic Considerations for Percutaneous Coronary Intervention for Chronic Total Occlusions-A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:2132-2142. [PMID: 34493436 DOI: 10.1053/j.jvca.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/18/2021] [Accepted: 08/01/2021] [Indexed: 11/11/2022]
Abstract
Advancing stent technology has enabled interventional cardiologists to perform percutaneous coronary intervention (PCI) to open chronic total occlusions (CTOs). Because PCI for CTOs improve patient anginal symptoms and quality of life, these procedures have been increasing over the past decade. Compared to standard PCI, these procedures are technically more difficult, with prolonged procedure time and increased risk of complications. Accordingly, anesthesiologists are increasingly being asked to provide sedation for these patients in the cardiac catheterization suite. In CTO PCI, anesthesiologists are more likely to encounter complications such as coronary artery perforation, malignant arrhythmias, non-target vessel ischemia, bleeding and shock. Additionally, CTO PCI may be supported by mechanical circulatory support devices. Understanding the procedural techniques of these complex PCI procedures is important to enable optimal anesthetic care in these patients. This narrative review discusses the pathophysiology, risks, benefits, procedural steps, and main anesthetic considerations for patients undergoing CTO PCI. Despite a growing body of literature, future research is still required to elucidate optimal anesthetic and mechanical support strategies in patients undergoing CTO PCI.
Collapse
Affiliation(s)
- Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| |
Collapse
|
45
|
Reducing Ischemia With CTO PCI: Good News, But Questions Remain. JACC Cardiovasc Interv 2021; 14:1419-1422. [PMID: 34238552 DOI: 10.1016/j.jcin.2021.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 11/22/2022]
|
46
|
Abstract
PURPOSE OF THE REVIEW Ischemic heart disease is among the most common causes of morbidity and mortality worldwide. In its stable manifestation, obstructing coronary artery stenoses prevent myocardial blood flow from matching metabolic needs of the heart under exercise conditions, which manifests clinically as dyspnea or chest pain. Prolonged bouts of ischemia may result in permanent myocardial dysfunction, heart failure, and eventually reduced survival. The aim of the present work is to review currently available approaches to provide relief of ischemia in stable coronary artery disease (CAD). RECENT FINDINGS Several pharmacological and interventional approaches have proven effectiveness in reducing the burden of ischemia in stable CAD and allow for symptom control and quality of life improvement. However, substantial evidence in favor of improved survival with ischemia relief is lacking, and recently published randomized controlled trial suggests that only selected groups of patients may substantially benefit from this approach. Pharmacological treatments aimed at reducing ischemia were shown to significantly reduce ischemic symptoms but failed to provide prognostic benefit. Myocardial revascularization is able to re-establish adequate coronary artery flow and was shown to improve survival in selected groups of patients, i.e., those with significant left main CAD or severe left ventricular dysfunction in multivessel CAD. Outside the previously mentioned categories, revascularization appears to improve symptoms control over medical therapy, but does not confer prognostic advantage. More studies are needed to elucidate the role of systematic invasive functional testing to identify individuals more likely to benefit from revascularization and to evaluate the prognostic role of chronic total occlusion recanalization.
Collapse
|
47
|
Wu X, Zhang D, Liu H, Li S, Fu C, Liu J, Cui J. A Clinical Analysis of the Treatment of Chronic Coronary Artery Occlusion With Antegrade Dissection Reentry. Front Surg 2021; 8:609403. [PMID: 34136525 PMCID: PMC8200522 DOI: 10.3389/fsurg.2021.609403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to investigate the efficacy and safety of antegrade dissection re-entry (ADR) technique in the percutaneous coronary intervention (PCI) to open chronic total occlusion (CTO) lesions. Methods: The baseline, angiographic results, PCI success rate, and major adverse cardiac events (MACE) during the 12 months of follow-up were compared between 48 patients who did not use ADR in the treatment of CTO lesions (control group) and 50 patients who used ADR (treatment group). Results: The control group comprised 48 patients who had 52 CTO lesions, and the treatment group comprised 50 patients who had 58 CTO lesions. The success rate of PCI in the treatment group (89.7 vs. 71.2%, P = 0.047) was significantly higher than in the control group, where six patients had in-stent restenosis (ISR, ISR-CTO) that were all recanalized. The mean PCI time (71 ± 25 min vs. 95 ± 33 min, P = 0.041), X-ray exposure time (42 ± 17 min vs. 71 ± 22 min, P = 0.032), contrast agent dosage (98 ± 26 ml vs. 178 ± 63 ml, P = 0.029), MACE incidence during the 12 months of follow-up (22.0 vs. 41.7%, P = 0.046) and recurrent myocardial infarction incidence (10.0 vs. 27.1%, P = 0.047) were significantly lower in the treatment group than in the control group. The differences were all statistically significant. Conclusion: It is safe and effective to use the ADR technique in PCI for coronary artery CTO lesions. The technique shortens the operation time, reduces the radiation dose of doctors and patients and the use dose of contrast agents, and improves patients' prognoses.
Collapse
Affiliation(s)
- Xiangjun Wu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Dan Zhang
- Department of Cardiology, Zouping People's Hospital Affiliated to Shandong First Medical University, Zouping, China
| | - Haitao Liu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Shuai Li
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chao Fu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Jiyuan Liu
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| | - Jiayu Cui
- Department of Cardiology, Binzhou People's Hospital Affiliated to Shandong First Medical University, Binzhou, China
| |
Collapse
|
48
|
Xenogiannis I, Varlamos C, Benetou DR, Alexopoulos D. Antithrombotic Therapy in Chronic Total Occlusion Interventions. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chronic total occlusion (CTO) recanalization is among the most complex subsets of coronary interventions. Hence, optimum peri- and post-procedural anticoagulation and antiplatelet therapy is key for the achievement of successful revascularization and reduction of major adverse cardiovascular outcomes in patients undergoing CTO percutaneous coronary intervention (PCI). Unfractionated heparin is still considered the gold standard anticoagulant because its action can be reversed by protamine administration, with bivalirudin being reserved mainly for patients with heparin-induced thrombocytopenia. However, small studies comparing unfractionated heparin with bivalirudin in CTO interventions have shown similar outcomes. Glycoprotein IIb/IIIa inhibitors should, in general, be avoided. Aspirin in combination with clopidogrel for 6–12 months is the standard post CTO PCI dual antiplatelet regimen. For the most complex cases, clopidogrel can be substituted by a more potent P2Y12 inhibitor, namely ticagrelor or prasugrel.
Collapse
Affiliation(s)
- Iosif Xenogiannis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
49
|
Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J 2021; 42:269-283. [PMID: 33367764 DOI: 10.1093/eurheartj/ehaa820] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/17/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.
Collapse
Affiliation(s)
- Allan Davies
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | | | - Shmuel Banai
- Slezak Super Centre for Cardiac Research, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Medical Centre, Tel Aviv, Israel
| | | | - Thomas F Lüscher
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK.,University of Zurich, Center for Molecular Cardiology, University of Zurich, Switzerland
| |
Collapse
|
50
|
Zografos T, Tsiafoutis I, Tsoumeleas A, Floropoulou C, Gkini C, Koutouzis M. Chronic Total Occlusion PCI Techniques in 2020. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|