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Completeness of Revascularization as a Determinant of Outcome: A Contemporary Review and Clinical Perspectives. Can J Cardiol 2019; 35:948-958. [PMID: 31167712 DOI: 10.1016/j.cjca.2018.12.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/24/2018] [Accepted: 12/30/2018] [Indexed: 11/23/2022] Open
Abstract
It has been debated whether patients with multivessel coronary artery disease should undergo complete revascularization (CR). The benefit of CR is biologically plausible, and numerous studies and large meta-analyses suggested that CR achievement was associated with a substantial reduction of mortality and future coronary events. In patients with multivessel coronary artery disease, the aim of myocardial revascularization is to minimize residual ischemia. Therefore, CR of all significant coronary lesions has been proposed as the first priority in decision-making for myocardial revascularization between coronary artery bypass grafting and percutaneous coronary intervention (PCI). Reflecting the contemporary practice of ischemia-based revascularization, a physiological/functional approach, such as measurement of fractional flow reserve or instantaneous wave-free ratio, is considered more reasonable and should be encouraged for appropriate CR. In patients who present with acute ST-elevation myocardial infarction, current evidence suggests that an immediate or staged CR strategy might be equivalent or superior to culprit-only revascularization. There is still uncertainty on when and how to perform CR in ST-elevation myocardial infarction patients; comprehensive studies dedicated to this issue are required. Hybrid coronary revascularization includes the advantages of minimally invasive bypass grafting for the left anterior descending artery and PCI for non-left anterior descending arteries and has been proposed as a viable alternative for coronary artery bypass grafting or PCI only for achieving CR. In clinical practice, the extent of revascularization and strategy for CR should be individualized, taking account of different aspects of the patients, lesions, and treating physicians. Collaboration of coronary heart teams would confer balanced decision-making and advanced therapeutic capabilities.
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Iannaccone M, D'ascenzo F, Piazza F, De Benedictis M, Doronzo B, Behnes M, Garbo R, Mashayekhi K. Optimal medical therapy vs. coronary revascularization for patients presenting with chronic total occlusion: A meta-analysis of randomized controlled trials and propensity score adjusted studies. Catheter Cardiovasc Interv 2018; 93:E320-E325. [PMID: 30549199 DOI: 10.1002/ccd.28037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/21/2018] [Accepted: 12/02/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The optimal management of patients with coronary chronic total occlusions (CTO) remains controversial. This meta-analysis aims to compare percutaneous coronary intervention of CTO (CTO-PCI) versus optimal medical therapy (OMT) in CTO patients. METHODS A literature search with highly specific terms was conducted using MEDLINE, EMBASE, and Web of Science to identify most relevant randomized controlled trials (RCTs) and observational studies with propensity score matching (PSM) evaluating differences in between CTO-PCI versus OMT. The primary endpoint was the incidence of major adverse cardiac events (MACEs, composite of cardiovascular death, acute coronary syndrome, and repeat PCI, re-PCI) while its single components were defined as secondary endpoints. RESULTS A total of eight studies was included, four RCTs and four PSMs. 3,971 patients were included in the analysis (2,050 CTO-PCI versus 1,921 OMT) with a mean follow-up of 3 years. No significant differences were found regarding overall MACE, re-PCI and AMI. Regarding CV-death, CTO-PCI was associated with a better outcome compared with OMT driven by PSMs (OR 0.52, 0.0.81, P < 0.01). CONCLUSIONS As compared to OMT, CTO-PCI was associated with similar MACE rate; however, CTO-PCI may be associated with reduced CV death, mainly due to PSMs effect.
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Affiliation(s)
| | - Fabrizio D'ascenzo
- Department of Cardiology, Città della Scienza e dalla Salute Hospital, University of Turin, Turin, Italy
| | - Fabio Piazza
- SS. Annunziata Hospital, ASL CN 1, Savigliano, Italy
| | | | | | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (German Center for Cardiovascular Research) Partner Site, Mannheim, Germany
| | | | - Kambis Mashayekhi
- Department of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany
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Dash D. A step-by-step guide to mastering retrograde coronary chronic total occlusion intervention in 2018: The author's perspective. Indian Heart J 2018; 70 Suppl 3:S446-S455. [PMID: 30595306 PMCID: PMC6310897 DOI: 10.1016/j.ihj.2018.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 11/23/2022] Open
Abstract
Chronic total occlusion remains one of the most challenging subsets and represents the "last frontier" of percutaneous coronary intervention. Retrograde recanalization is one of the most significant amendments of the technique and has become an important complement to the classical antegrade approach. It yields a high success rate even in most complex patients. With emergence of important iterations, this approach has become safer, faster, and more successful. The author proposes a step-by-step guide to the retrograde approach with alternatives to various steps for operators wishing to embark on this strategy.
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Affiliation(s)
- Debabrata Dash
- Thumbay Hospital, Ajman, United Arab Emirates; Beijing Tiantan Hospital, Beijing, China.
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54
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van Dongen IM, Kolk MZH, Elias J, Meijborg VMF, Coronel R, de Bakker JMT, Claessen BEPM, Delewi R, Ouweneel DM, Scheunhage EM, van der Schaaf RJ, Suttorp MJ, Bax M, Marques KM, Postema PG, Wilde AAM, Henriques JPS. The effect of revascularization of a chronic total coronary occlusion on electrocardiographic variables. A sub-study of the EXPLORE trial. J Electrocardiol 2018; 51:906-912. [PMID: 30177338 DOI: 10.1016/j.jelectrocard.2018.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/10/2018] [Accepted: 07/18/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Chronic total coronary occlusions (CTOs) have been associated with a higher prevalence of ventricular arrhythmias compared to patients without a CTO. We evaluated the effect of CTO revascularization on electrocardiographic (ECG) variables. METHODS We studied a selection of ST-elevation myocardial infarction patients with a concomitant CTO enrolled in the EXPLORE trial. ECG variables and cardiac function were analysed at baseline and at 4 months follow-up. RESULTS Patients were randomized to percutaneous coronary intervention (PCI) of their CTO (n = 77) or to no-CTO PCI (n = 81). At follow-up, median QT dispersion was significantly lower in the CTO PCI group compared to the no-CTO PCI group (46 ms [33-58] vs. 54 ms [37-68], P = 0.043). No independent association was observed between ECG variables and cardiac function. CONCLUSION Revascularization of a CTO after STEMI significantly shortened QT dispersion at 4 months follow-up. These findings support the hypothesis that CTO revascularization reduces the pro-arrhythmic substrate in CTO patients.
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Affiliation(s)
- Ivo M van Dongen
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands.
| | - Maarten Z H Kolk
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Joëlle Elias
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | - Ruben Coronel
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Ronak Delewi
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar M Ouweneel
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Esther M Scheunhage
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Matthijs Bax
- Haga Teaching Hospital, The Hague, The Netherlands
| | - Koen M Marques
- Free University Medical Center, Amsterdam, The Netherlands
| | - Pieter G Postema
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
| | - José P S Henriques
- Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
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Burger H, Schmitt J, Knaut M, Eitz T, Starck CT, Hakmi S, Siebel A, Böning A. Einsatz des tragbaren Kardioverter-Defibrillators nach kardiochirurgischen Eingriffen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0246-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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56
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Saad M, Stiermaier T, Fuernau G, Pöss J, Desch S, Thiele H, Eitel I. Impact of chronic total occlusion in a non-infarct-related coronary artery on myocardial injury assessed by cardiac magnetic resonance imaging and prognosis in ST-elevation myocardial infarction. Int J Cardiol 2018; 265:251-255. [DOI: 10.1016/j.ijcard.2018.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/05/2018] [Accepted: 03/09/2018] [Indexed: 02/06/2023]
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Impact of Coronary Artery Chronic Total Occlusion on Arrhythmic and Mortality Outcomes: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2018; 4:1214-1223. [PMID: 30236396 DOI: 10.1016/j.jacep.2018.06.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/03/2018] [Accepted: 06/07/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to examine the relationship between chronic coronary artery total occlusion (CTO) status and the occurrence of ventricular tachycardia (VT)/ventricular fibrillation (VF) or appropriate implantable cardioverter-defibrillator (ICD) therapy. BACKGROUND CTO is a significant problem in patients with ischemic heart disease. However, the extent to which it predisposes affected individuals to VT/VF and whether these arrhythmic events could be prevented by revascularization are unclear. Therefore, a systematic review and meta-analysis were conducted to examine the relationship between CTO status and the occurrence of VT/VF or appropriate ICD therapy. METHODS PubMed and Embase databases were searched until November 16, 2017, identifying 137 studies. RESULTS Seventeen studies involving 54,594 subjects (mean age, 61 ± 21 years of age, 81% male) with a mean follow-up of 43 ± 31 months were included. The presence of CTO was associated with higher risk of VT/VF or appropriate ICD therapy (adjusted hazard ratio [aHR]: 1.99; 95% confidence interval (CI): 1.53 to 2.59; p < 0.0001, I2 = 3%) but not in cardiac mortality (aHR: 2.59; 95% CI: 0.64 to 10.59; p = 0.18, I2 = 86%) or in all-cause mortality (aHR: 1.70; 95% CI: 0.84 to 3.46; p = 0.14; I2 = 64%). Compared to patients with non-infarct-related CTOs, those with infarct-related CTOs have a higher risk of VT/VF or appropriate ICD therapy (aHR: 2.47; 95% CI: 1.76 to 3.46; p < 0.0001; I2 = 14%), cardiac mortality (aHR: 2.73; 95% CI: 1.02 to 7.30; p < 0.05; I2 = 79%) and higher all-cause mortality (aHR: 1.69; 95% CI: 1.19 to 2.40; p < 0.01; I2 = 40%). Nonrevascularization of CTOs tended to be associated with an increased risk of all-cause mortality compared to successful revascularization (unadjusted HR: 1.52; 95% CI: 0.96 to 2.43; p = 0.08; I2 = 76). CONCLUSIONS CTOs, especially infarct-related, are associated with high risk of VT/VF or appropriate ICD therapy and mortality. ICD implantation could be beneficial. However, it is not clear that revascularization has an impact on the outcome of patients with CTOs.
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Riley RF, McCabe JM, Kalra S, Lazkani M, Pershad A, Doshi D, Kirtane AJ, Nicholson W, Kearney K, Demartini T, Aaron Grantham J, Moses J, Lombardi W, Karmpaliotis D. Impella‐assisted chronic total occlusion percutaneous coronary interventions: A multicenter retrospective analysis. Catheter Cardiovasc Interv 2018; 92:1261-1267. [DOI: 10.1002/ccd.27679] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/15/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Robert F. Riley
- The Christ Hospital Heart and Vascular Center and The Lindner Research CenterCincinnati Ohio
| | | | | | | | | | | | | | | | | | | | - J. Aaron Grantham
- University of MissouriKansas City Missouri
- Mid America Heart InstituteKansas City Missouri
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Sugizaki Y, Shinke T, Doi T, Igarashi N, Otake H, Kawamori H, Hirata KI. Impact of the angiographic burden on the incidence of out-of-hospital ventricular fibrillation in patients with acute myocardial infarction. Heart Vessels 2018; 34:52-61. [DOI: 10.1007/s00380-018-1225-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
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Saad M, Fuernau G, Desch S, Eitel I, de Waha S, Pöss J, Ouarrak T, Schneider S, Zeymer U, Thiele H. Prognostic impact of non-culprit chronic total occlusions in infarct-related cardiogenic shock: results of the randomised IABP-SHOCK II trial. EUROINTERVENTION 2018; 14:e306-e313. [PMID: 29205158 DOI: 10.4244/eij-d-17-00451] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the current study was to investigate the impact of a chronic total occlusion (CTO) in a non-infarct-related coronary artery (non-IRA) on one-year mortality and occurrence of cardiac arrhythmia in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). METHODS AND RESULTS In a retrospective sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II trial (IABP-SHOCK II) and its accompanying registry, 201 (26%) of 761 patients had a CTO in a non-IR major coronary artery. Mortality was significantly higher in the CTO group at day of admission (19% vs. 11%; p=0.005), 30 days (53% vs. 41%, p=0.002), and 12 months (63% vs. 51%, p=0.002). In the adjusted multivariate Cox regression analysis, a CTO in a non-IRA was an independent predictor of mortality at 12 months (hazard ratio 1.30, 95% confidence interval [CI]: 1.02-1.67, p=0.03). At 30-day follow-up, ventricular arrhythmias requiring defibrillation occurred more frequently in patients with non-IRA CTO in the univariate analysis (33% vs. 21%, odds ratio 1.83, 95% CI: 1.28-2.62, p=0.002). CONCLUSIONS In patients with CS complicating AMI, the presence of CTO in a non-IRA is associated with a higher incidence of ventricular arrhythmias and is an independent predictor of mortality at 12-month follow-up.
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Affiliation(s)
- Mohammed Saad
- Medical Clinic II, University Heart Center Lübeck, Lübeck
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Wang ZQ, Qiang H, Luo X, Li W, Guo K, Li YG. Meta-Analysis of Risk of Ventricular Arrhythmias and All-Cause Mortality in Patients With Chronic Total Occlusion of a Coronary Artery and/or Implantable Cardioverter-Defibrillator. Am J Cardiol 2018; 121:1149-1154. [PMID: 29548677 DOI: 10.1016/j.amjcard.2018.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/25/2018] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
Implantable cardioverter-defibrillator (ICD) has been increasingly used to prevent sudden death in patients with high risk of ventricular arrhythmias (VAs). Chronic total occlusion (CTO) is a severe condition of coronary artery disease. However, the prognostic impact of CTO in ICD recipients remains controversial. We systematically searched the PubMed, EMBASE, and Cochrane databases for documents published before October 1, 2017 to identify studies that investigated the prognostic impact of CTO on VAs and all-cause mortality (ACM) in ICD recipients. The effect size was expressed by hazard ratio (HR) and 95% confidence interval (CI). Overall, 6 studies with 1,423 patients were included. We found that CTO independently predicted the occurrence of VAs in the global population (HR 1.77, 95% CI 1.14 to 2.76, p = 0.01). Subgroup analysis revealed that CTO only predicted VAs in patients receiving ICD as secondary prevention (HR 1.96, 95% CI 1.55 to 2.48, p <0.01). However, CTO was not associated with ACM in the global population (HR 1.51, 95% CI 0.99 to 2.32, p = 0.06). Further subgroup analysis still showed no association between CTO and ACM in patients receiving ICD as primary prevention (HR 1.49, 95% CI 0.43 to 5.21, p = 0.53) or secondary prevention (HR 1.56, 95% CI 0.87 to 2.78, p = 0.13). In conclusion, CTO is an independent predictor of VAs in patients with secondary-prevention ICD, but not for ACM. Our study provided additional evidence for improving the risk stratification and management of VAs in ICD recipients.
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van Dongen IM, Yilmaz D, Elias J, Claessen BEPM, Delewi R, Knops RE, Wilde AAM, van Erven L, Schalij MJ, Henriques JPS. Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long-Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator (the eCTOpy-in-ICD Study). J Am Heart Assoc 2018; 7:JAHA.118.008609. [PMID: 29720502 PMCID: PMC6015331 DOI: 10.1161/jaha.118.008609] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Previous studies report conflicting results about a higher incidence of ventricular arrhythmias in patients with a chronic total coronary occlusion (CTO). We aimed to investigate this association in a large cohort of implantable cardioverter defibrillator patients with long‐term follow‐up. Methods and Results All consecutive patients from 1992 onwards who underwent implantable cardioverter defibrillator implantation for ischemic cardiomyopathy at the Leiden University Medical Center were evaluated. Coronary angiograms were reviewed for the presence of a CTO. The occurrence of ventricular arrhythmias and survival status at follow‐up were compared between patients with and patients without a CTO. A total of 722 patients constitute the study cohort (age 66±11 years; 84% males; 74% primary prevention, median left ventricular ejection fraction 30% [first–third quartile: 25–37], 44% received a cardiac resynchronization therapy defibrillator). At baseline, 240 patients (33%) had a CTO, and the CTOs were present for at least 44 (2–127) months. The median follow‐up duration was 4 (2–6) years. On long‐term follow‐up, CTO patients had a higher crude appropriate device therapy rate (37% versus 27%, P=0.010) and a lower crude survival rate (51% versus 67%, P<0.001) compared with patients without a CTO. Corrected for baseline characteristics including left ventricular ejection fraction, the presence of a CTO was an independent predictor for appropriate device therapy. Conclusions The presence of a CTO in implantable cardioverter defibrillator patients was associated with more appropriate device therapy and worse prognosis at long‐term follow‐up. Further investigation is warranted regarding a potential beneficial effect of CTO revascularization on the incidence of ventricular arrhythmias.
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Affiliation(s)
- Ivo M van Dongen
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Dilek Yilmaz
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joëlle Elias
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Reinoud E Knops
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
| | - Lieselot van Erven
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Heart Center, Academic Medical Center - University of Amsterdam, The Netherlands
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Di Marco A, Oloriz Sanjuan T, Paglino G, Baratto F, Vergara P, Bisceglia C, Trevisi N, Sala S, Marzi A, Gulletta S, Cireddu M, Anguera I, Della Bella P. Late potentials abolition reduces ventricular tachycardia recurrence after ablation especially in higher-risk patients with a chronic total occlusion in an infarct-related artery. J Cardiovasc Electrophysiol 2018. [DOI: 10.1111/jce.13488] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Andrea Di Marco
- Arrhythmia Unit, Heart Disease Institute; Bellvitge University Hospital; Barcelona Spain
| | - Teresa Oloriz Sanjuan
- Arrhythmia Unit; Hospital Miguel Servet; Zaragoza Spain
- Arrhythmia Unit; San Raffaele Hospital; Milán Italy
| | | | | | | | | | | | - Simone Sala
- Arrhythmia Unit; San Raffaele Hospital; Milán Italy
| | | | | | | | - Ignasi Anguera
- Arrhythmia Unit, Heart Disease Institute; Bellvitge University Hospital; Barcelona Spain
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Marechal P, Davin L, Gach O, Martinez C, Lempereur M, Lhoest N, Lancellotti P. Coronary chronic total occlusion intervention: utility or futility. Expert Rev Cardiovasc Ther 2018; 16:361-367. [PMID: 29589974 DOI: 10.1080/14779072.2018.1459187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Despite an incidence of about 18-52% of the patients undergoing coronary angiography, chronic total occlusions (CTO) are rarely revascularised by percutaneous angioplasty (PCI). Nevertheless, current evidence suggests that successful CTO angioplasty improves symptoms, quality of life and long-term survival. During the last decade, the improvement of specific tools and techniques for these complex procedures, and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO angioplasty. Areas covered: This review focuses on the clinical benefits of CTO revascularization and on appropriate patient selection. Expert commentary: Current evidence suggests that successful CTO-PCI improves symptoms, quality of life and long-term survival. During the last years, the improvement of specific techniques for these complex procedures and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO lesion angioplasty.
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Affiliation(s)
- Patrick Marechal
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Laurent Davin
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Olivier Gach
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Christophe Martinez
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | - Mathieu Lempereur
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium
| | | | - Patrizio Lancellotti
- a GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman , University of Liège Hospital , Liège , Belgium.,c Gruppo Villa Maria Care and Research , Anthea Hospital , Bari , Italy
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van Dongen IM, Elias J, Meijborg VM, De Bakker JM, Limpens J, Conrath CE, Henriques JP. Electrocardiographic changes after successful recanalization of a chronic total coronary occlusion. A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:221-228. [DOI: 10.1016/j.carrev.2017.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 09/05/2017] [Indexed: 12/21/2022]
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Affiliation(s)
- Peter Tajti
- Minneapolis Heart Institute Abbott Northwestern Hospital, Minneapolis, MN
- Department of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Abbott Northwestern Hospital, Minneapolis, MN
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX
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Yap SC, Sakhi R, Theuns DA, Yasar YE, Bhagwandien RE, Diletti R, Zijlstra F, Szili-Torok T. Increased risk of ventricular arrhythmias in survivors of out-of-hospital cardiac arrest with chronic total coronary occlusion. Heart Rhythm 2018; 15:124-129. [DOI: 10.1016/j.hrthm.2017.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Indexed: 12/20/2022]
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Bergau L, Tichelbäcker T, Kessel B, Lüthje L, Fischer TH, Friede T, Zabel M. Predictors of mortality and ICD shock therapy in primary prophylactic ICD patients-A systematic review and meta-analysis. PLoS One 2017; 12:e0186387. [PMID: 29040341 PMCID: PMC5645142 DOI: 10.1371/journal.pone.0186387] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/30/2017] [Indexed: 01/21/2023] Open
Abstract
Background There is evidence that the benefit of a primary prophylactic ICD therapy is not equal in all patients. Purpose To evaluate risk factors of appropriate shocks and all- cause mortality in patients with a primary prophylactic ICD regarding contemporary studies. Data source PubMed, LIVIVO, Cochrane CENTRAL between 2010 and 2016. Study selection Studies were eligible if at least one of the endpoints of interest were reported. Data extraction All abstracts were independently reviewed by at least two authors. The full text of all selected studies was then analysed in detail. Data synthesis Our search strategy retrieved 608 abstracts. After exclusion of unsuitable studies, 36 papers with a total patient number of 47282 were included in our analysis. All-cause mortality was significantly associated with increasing age (HR 1.41, CI 1.29–1.53), left ventricular function (LVEF; HR 1.21, CI 1.14–1.29), ischemic cardiomyopathy (ICM; HR 1.37, CI 1.14–1.66) and co-morbidities such as impaired renal function (HR 2.30, CI 1.97–2.69). Although, younger age (HR 0.96, CI 0.85–1.09), impaired LVEF (HR 1.26, CI 0.89–1.78) and ischemic cardiomyopathy (HR 2.22, CI 0.83–5.93) were associated with a higher risk of appropriate shocks, none of these factors reached statistical significance. Limitations Individual patient data were not available for most studies. Conclusion In this meta-analysis of contemporary clinical studies, all-cause mortality is predicted by a variety of clinical characteristics including LVEF. On the other hand, the risk of appropriate shocks might be associated with impaired LVEF and ischemic cardiomyopathy. Further prospective studies are required to verify risk factors for appropriate shocks other than LVEF to help select appropriate patients for primary prophylactic ICD-therapy.
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MESH Headings
- Age Factors
- Aged
- Cardiomyopathy, Dilated/complications
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Dilated/mortality
- Cardiomyopathy, Dilated/therapy
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Female
- Humans
- Male
- Middle Aged
- Myocardial Ischemia/complications
- Myocardial Ischemia/diagnosis
- Myocardial Ischemia/mortality
- Myocardial Ischemia/therapy
- Primary Prevention
- Prognosis
- Prospective Studies
- Risk Factors
- Survival Analysis
- Ventricular Function, Left
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Affiliation(s)
- Leonard Bergau
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias Tichelbäcker
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Barbora Kessel
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Lars Lüthje
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas H. Fischer
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Markus Zabel
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- * E-mail:
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Råmunddal T, Hoebers LP, Henriques JPS, Dworeck C, Angerås O, Odenstedt J, Ioanes D, Olivecrona G, Harnek J, Jensen U, Aasa M, Albertsson P, Wedel H, Omerovic E. Prognostic Impact of Chronic Total Occlusions: A Report From SCAAR (Swedish Coronary Angiography and Angioplasty Registry). JACC Cardiovasc Interv 2017; 9:1535-44. [PMID: 27491603 DOI: 10.1016/j.jcin.2016.04.031] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 03/28/2016] [Accepted: 04/21/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to determine the prognostic impact of chronic total occlusion (CTO) on long-term mortality in a large prospective cohort. BACKGROUND CTO is present in many patients with coronary artery disease and is difficult to treat with percutaneous coronary intervention. METHODS The study population consisted of all consecutive patients who underwent coronary angiography in Sweden between January 1, 2005 and January 1, 2012, who were registered in SCAAR (Swedish Coronary Angiography and Angioplasty Registry). The patient population was heterogeneous with regard to indication for angiography (stable angina, ST-segment elevation myocardial infarction [STEMI], unstable angina or non-STEMI, and other) and treatment options. The long-term mortality rates of patients with and without CTO were compared by using shared frailty Cox proportional hazards regression adjusted for confounders. Tests were conducted for interactions between CTO and several pre-specified characteristics: indication for angiography and percutaneous coronary intervention (stable angina, STEMI, unstable angina or non-STEMI, and other), severity of coronary artery disease (1-, 2-, and 3-vessel and/or left main coronary artery disease), age, sex, and diabetes. RESULTS During the study period, 14,441 patients with CTO and 75,431 patients without CTO were registered in SCAAR. CTO was associated with higher mortality (hazard ratio: 1.29; 95% confidence interval: 1.22 to 1.37; p < 0.001). In subgroup analyses, the risk attributable to CTO was lowest in patients with stable angina and highest in those with STEMI. In addition, CTO was associated with highest risk in patients under 60 years of age and with lowest risk in octogenarians. There was no interaction between CTO and either diabetes or sex, suggesting an equally adverse effect in both groups. CONCLUSIONS In this large prospective observational study of patients with coronary artery disease, CTO was associated with increased mortality. This association was most prominent in younger patients and in those with acute coronary syndromes.
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Affiliation(s)
- Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Loes P Hoebers
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Olivecrona
- Department of Coronary Heart Disease, Skåne University Hospital, Lund, Sweden
| | - Jan Harnek
- Department of Coronary Heart Disease, Skåne University Hospital, Lund, Sweden
| | - Ulf Jensen
- Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Mikael Aasa
- Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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70
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Weeraman D, Mannakkara NN, Gerber RT. Contemporary Evidence, Treatment Strategies, and Indications for Chronic Total Occlusion-Percutaneous Coronary Intervention. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Chronic total occlusions (CTOs) are detected incidentally in ˜20% of patients undergoing coronary angiography and are often associated with significant morbidity and mortality. CTOs can manifest with worsening symptoms, reduced left ventricular function, and increased incidence of ventricular arrhythmias. Despite this, according to USA, Italian, and Japanese national registry data, only ~5–22% of CTO lesions are treated by percutaneous coronary intervention (PCI). CTO-PCI is a particularly challenging technique for this subset of lesions and has traditionally been associated with increased risks and complications compared to conventional PCI. However, increased experience, the development of novel techniques, and dedicated equipment have revolutionised CTO-PCI. USA, Italian, and Japanese registry data have shown success rates of between 85% and 90%, with diminishing complication rates when performed by experienced operators. Moreover, observational studies have suggested that there are significant benefits of using CTO-PCI, including fewer symptoms, improved quality of life, reduced need for coronary artery bypass surgery, and reduction in ischaemic burden and mortality. In addition, when there is demonstrable ischaemia and viable myocardium in the CTO territory, there is further potential prognostic benefit from complete revascularisation. However, there has so far been a relative lack of randomised trial data to support the routine use of CTO-PCI. This paper reviews the current evidence surrounding this subject and discusses the arguments for and against CTO-PCI. It includes an exploration of the interventionalist’s ‘toolbox’ and the techniques used in CTO-PCI, including a section on ‘tips and tricks’ for the most challenging cases. Finally, there is a discussion on the future of CTO-PCI including promising ongoing clinical trials and novel equipment that may improve outcomes and help to establish a more widespread adoption of CTO-PCI.
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Affiliation(s)
- Deshan Weeraman
- Department of Cardiology, Eastbourne District General Hospital, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | - Nilanka N. Mannakkara
- Department of Cardiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
| | - Robert T. Gerber
- Department of Cardiology, Eastbourne District General Hospital, East Sussex Healthcare NHS Trust, Eastbourne, UK; Department of Cardiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
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71
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Di Marco A, Anguera I, Teruel L, Muntane G, Campbell NG, Fox DJ, Brown B, Skene C, Davidson N, Leon V, Dallaglio P, Elzein H, Garcia-Romero E, Gomez-Hospital JA, Cequier A. Chronic total occlusion in an infarct-related coronary artery and the risk of appropriate ICD therapies. J Cardiovasc Electrophysiol 2017; 28:1169-1178. [DOI: 10.1111/jce.13290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/08/2017] [Accepted: 05/22/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Andrea Di Marco
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Ignasi Anguera
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Luis Teruel
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Guillem Muntane
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Niall G. Campbell
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | - David J. Fox
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | - Benjamin Brown
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | - Chris Skene
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | - Neil Davidson
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | - Valentina Leon
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Paolo Dallaglio
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
| | - Hind Elzein
- Department of Cardiology; University Hospital of South Manchester; Manchester United Kingdom
| | | | | | - Angel Cequier
- Heart Diseases Institute; Bellvitge University Hospital; Barcelona Spain
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72
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Bennett J, Kayaert P, Bataille Y, Dens J. Percutaneous coronary interventions of chronic total -occlusions; a review of clinical indications, treatment strategy and current practice. Acta Cardiol 2017; 72:357-369. [PMID: 28705045 DOI: 10.1080/00015385.2017.1335080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to the perception of limited clinical benefit, high complexity and cost of intervention, and perceived risk of complications. Numerous observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit remains debated. Nevertheless, over the past decade the interest in CTO-PCI has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. A number of factors must be taken into consideration in selecting patients for CTO-PCI, including presence of symptoms attributable to the CTO, extent of ischaemia distal to the occlusion, and degree of myocardial viability. In this review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection. Data regarding efficacy and safety of recent advances in PCI-CTO techniques will be discussed. Steps involved in setting up a dedicated CTO program will be outlined and the current CTO landscape in Belgium will be briefly highlighted. The overall aim of this review is to promote a more balanced approach to management of patients with a CTO.
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Affiliation(s)
- Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Kayaert
- Department of Cardiology, University Hospital Brussels, Brussels, Belgium
| | | | - Jo Dens
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium
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73
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Elias J, van Dongen IM, Hoebers LP, Ouweneel DM, Claessen BEPM, Råmunddal T, Laanmets P, Eriksen E, van der Schaaf RJ, Ioanes D, Nijveldt R, Tijssen JG, Hirsch A, Henriques JPS. Improved recovery of regional left ventricular function after PCI of chronic total occlusion in STEMI patients: a cardiovascular magnetic resonance study of the randomized controlled EXPLORE trial. J Cardiovasc Magn Reson 2017; 19:53. [PMID: 28724418 PMCID: PMC5517806 DOI: 10.1186/s12968-017-0369-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/29/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) trial did not show a significant benefit of percutaneous coronary intervention (PCI) of the concurrent chronic total occlusion (CTO) in ST-segment elevation myocardial infarction (STEMI) patients on global left ventricular (LV) systolic function. However a possible treatment effect will be most pronounced in the CTO territory. Therefore, we aimed to study the effect of CTO PCI compared to no-CTO PCI on the recovery of regional LV function, particularly in the CTO territory. METHODS Using cardiovascular magnetic resonance (CMR) we studied 180 of the 302 EXPLORE patients with serial CMR (baseline and 4 months follow-up). Segmental wall thickening (SWT) was quantified on cine images by an independent core laboratory. Dysfunctional segments were defined as SWT < 45%. Dysfunctional segments were further analyzed by viability (transmural extent of infarction (TEI) ≤50%.). All outcomes were stratified for randomization treatment. RESULTS In the dysfunctional segments in the CTO territory recovery of SWT was better after CTO PCI compared to no-CTO PCI (ΔSWT 17 ± 27% vs 11 ± 23%, p = 0.03). This recovery was most pronounced in the dysfunctional but viable segments(TEI < 50%) (ΔSWT 17 ± 27% vs 11 ± 22%, p = 0.02). Furthermore in the CTO territory, recovery of SWT was significantly better in the dysfunctional segments in patients with Rentrop grade 2-3 collaterals compared to grade 0-1 collaterals to the CTO (16 ± 26% versus 11 ± 24%, p = 0.04). CONCLUSION CTO PCI compared with no-CTO PCI is associated with a greater recovery of regional systolic function in the CTO territory, especially in the dysfunctional but viable segments. Further research is needed to evaluate the use of CMR in selecting post-STEMI patients for CTO PCI and the effect of regional LV function recovery on clinical outcome. TRIAL REGISTRATION Trialregister.nl NTR1108 , Date registered NTR: 30-okt-2007.
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Affiliation(s)
- Joëlle Elias
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
| | - Ivo M. van Dongen
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
| | - Loes P. Hoebers
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
| | - Dagmar M. Ouweneel
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
| | | | | | | | | | | | - Dan Ioanes
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Jan G. Tijssen
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
| | | | - José P. S. Henriques
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiology, Academic Medical Center - University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - on behalf of the EXPLORE investigators
- Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands
- Sahlgrenska University Hospital, Gothenburg, Sweden
- North Estonia Medical Center, Tallinn, Estonia
- Haukeland University Hospital, Bergen, Norway
- Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
- VU Medical Center, Amsterdam, the Netherlands
- Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Cardiology, Academic Medical Center - University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Nishikawa T, Fujino M, Nakajima I, Asaumi Y, Kataoka Y, Anzai T, Kusano K, Noguchi T, Goto Y, Nishimura K, Miyamoto Y, Kiso K, Yasuda S. Prognostic impact of chronic total coronary occlusion on long-term outcomes in implantable cardioverter-defibrillator recipients with ischaemic heart disease. Europace 2017; 19:1153-1162. [PMID: 27738062 DOI: 10.1093/europace/euw213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/20/2016] [Indexed: 11/15/2022] Open
Abstract
Aims The prognostic impact of chronic total coronary occlusion (CTO) on implantable cardioverter-defibrillator (ICD) recipients remains unclear. Methods and results Eighty-four consecutive patients with ischaemic heart disease who received ICD therapy for primary or secondary prevention were analysed. We investigated all-cause mortality and major adverse cardiac events (MACEs) including cardiac death, appropriate device therapy, hospitalization for heart failure, and ventricular assist device implantation. Of the study patients (mean age 70 ± 8 years; 86% men), 34 (40%) had CTO. There were no significant differences in age, left ventricular ejection fraction (LVEF), New York Heart Association functional class III or IV status, and proportion who underwent secondary prevention between patients with CTO (CTO group) and without CTO (non-CTO group). During a median follow-up of 3.8 years (interquartile range 2.7-5.4 years), the CTO group tended to have a higher MACE rate (log-rank P = 0.054) than the non-CTO group. Within the CTO group, there was no difference in the MACE rate between patients with and without viable myocardium. In patients with ICD for secondary prevention (n = 47), 16 patients (34%) with CTO had a higher MACE rate than patients without CTO (log-rank P < 0.01). Cox proportional hazards regression analysis showed that the presence of CTO, but not LVEF, was associated with a higher MACE rate. Multivariate analysis showed that the presence of CTO was a predictor of MACE (P < 0.05). Conclusion In patients with ischaemic heart disease receiving ICD implantation, the presence of CTO has an adverse impact on long-term prognosis, especially as secondary prevention.
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MESH Headings
- Aged
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/mortality
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/prevention & control
- Chi-Square Distribution
- Chronic Disease
- Coronary Occlusion/complications
- Coronary Occlusion/mortality
- Coronary Occlusion/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/adverse effects
- Electric Countershock/instrumentation
- Electric Countershock/mortality
- Female
- Heart Failure/etiology
- Heart Failure/therapy
- Heart-Assist Devices
- Hospitalization
- Humans
- Kaplan-Meier Estimate
- Male
- Middle Aged
- Multivariate Analysis
- Primary Prevention/instrumentation
- Proportional Hazards Models
- Retrospective Studies
- Risk Factors
- Secondary Prevention/instrumentation
- Stroke Volume
- Time Factors
- Treatment Outcome
- Ventricular Function, Left
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Affiliation(s)
- Tatsuya Nishikawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
- Department of Pathophysiology Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ikutaro Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Keisuke Kiso
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Leibundgut G, Kaspar M. Chronic Total Occlusions. Interv Cardiol 2017. [DOI: 10.5772/68067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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76
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Behnes M, Mashayekhi K. Chronic Total Occlusion (CTO): Scientific Benefit and Principal Interventional Approach. Interv Cardiol 2017. [DOI: 10.5772/intechopen.68303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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77
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Nombela-Franco L, Iannaccone M, Anguera I, Amat-Santos IJ, Sanchez-Garcia M, Bautista D, Calvelo MN, Di Marco A, Moretti C, Pozzi R, Scaglione M, Cañadas V, Sandin-Fuentes M, Arenal A, Bagur R, Perez-Castellano N, Fernandez-Perez C, Gaita F, Macaya C, Escaned J, Fernández-Lozano I. Impact of Chronic Total Coronary Occlusion on Recurrence of Ventricular Arrhythmias in Ischemic Secondary Prevention Implantable Cardioverter-Defibrillator Recipients (VACTO Secondary Study). JACC Cardiovasc Interv 2017; 10:879-888. [DOI: 10.1016/j.jcin.2017.02.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 01/14/2023]
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78
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Gao L, Wang Y, Liu Y, Cao F, Chen Y. Long-term clinical outcomes of successful revascularization with drug-eluting stents for chronic total occlusions: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2017; 89:574-581. [PMID: 28318134 DOI: 10.1002/ccd.26934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/04/2017] [Accepted: 01/07/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine whether successful percutaneous coronary intervention (PCI) using drug-eluting stents (DESs) have beneficial effects on long-term outcomes in patients with chronic total occlusions (CTOs) compared with failed PCIs for CTOs. BACKGROUND Several observational studies have evaluated the long-term clinical outcomes of successful PCIs using DESs for CTOs. However, the results of these studies were inconsistent and inconclusive. METHODS We searched five online electronic databases to identify all the publications assessing the long-term outcomes of successful and failed PCIs using DESs for CTOs. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by STATA software. RESULTS A total of nine studies involving 5958 CTO patients who underwent successful PCI and 1511 CTO patients who underwent failed PCI were included in this meta-analysis. The results of the analysis indicated that successful CTO PCIs using DESs were associated with lower long-term all-cause mortality(OR = 0.55, 95% CI = 0.45-0.67, P < 0.001), lower risk of myocardial infarction (OR = 0.45, 95% CI = 0.23-0.74, P = 0.002), lower risk of major adverse cardiac events (MACEs, OR = 0.44, 95% CI = 0.27-0.72, P = 0.001), and less incidence of subsequent coronary artery bypass grafting (OR = 0.10, 95% CI = 0.05-0.21, P < 0.001) than failed CTO PCIs. However, there was no difference in the incidence of target vessel revascularization (OR = 1.06, 95% CI = 0.17-6.60, P > 0.05) between the two groups. CONCLUSION Successful CTO PCI using DESs can reduce long-term all-cause mortality and the risks of MI, MACEs, and CABG in patients with CTOs. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Lei Gao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yabin Wang
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yuqi Liu
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Feng Cao
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, 100853, China
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Azzalini L, Torregrossa G, Puskas JD, Brilakis ES, Lombardi WL, Karmpaliotis D, Nakamura S, Colombo A, Carlino M. Percutaneous revascularization of chronic total occlusions: Rationale, indications, techniques, and the cardiac surgeon's point of view. Int J Cardiol 2017; 231:90-96. [DOI: 10.1016/j.ijcard.2017.01.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/03/2017] [Indexed: 11/24/2022]
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80
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Impact of revascularization of coronary chronic total occlusion on left ventricular function and electrical stability: analysis by speckle tracking echocardiography and signal-averaged electrocardiogram. Int J Cardiovasc Imaging 2017; 33:815-823. [DOI: 10.1007/s10554-017-1064-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/03/2017] [Indexed: 01/08/2023]
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81
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Mashayekhi K, Valuckiene Z, Neuser H, Walter M, Gappmaier W, Kaiser T, Neumann FJ, Akin I, Behnes M. "Spiral stenting"-creating a subintimal neo-luminal helix around a massively calcified ostial chronic total occlusion of the right coronary artery in a patient with recurrent ventricular tachycardia. J Thorac Dis 2017; 8:E1564-E1569. [PMID: 28066662 DOI: 10.21037/jtd.2016.11.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This case report describes a successful percutaneous coronary intervention (PCI) of a severely calcified aorto-ostial chronic total occlusion (CTO) of the right coronary artery (RCA). The lesion was treated by a retrograde approach implementing long spiral subintimal wire tracking and final coronary stenting creating a subintimal neo-luminal helix around the natively occluded RCA. After 6 months of follow-up valuable angiographic results were proven.
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Affiliation(s)
- Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Zivile Valuckiene
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Hans Neuser
- Internal Medicine Clinic II, Helios Vogtland Klinikum Plauen, Plauen, Germany
| | - Marlon Walter
- Institute of Interventional Cardiology, Landeskrankenhaus Feldkirch, Academic Teaching Hospital of Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang Gappmaier
- Institute of Interventional Cardiology, Landeskrankenhaus Feldkirch, Academic Teaching Hospital of Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Kaiser
- Internal Medicine Clinic II, Helios Vogtland Klinikum Plauen, Plauen, Germany
| | - Franz-Josef Neumann
- Division of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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82
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Bijuklic K, Schwencke C, Schofer J. Long-term major adverse cardiac and cerebrovascular events (MACCE) rate. Wien Klin Wochenschr 2016; 129:243-250. [DOI: 10.1007/s00508-016-1148-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
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83
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[Chronic coronary occlusions : When and how should revascularization be performed?]. Herz 2016; 41:585-590. [PMID: 27484494 DOI: 10.1007/s00059-016-4464-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] [Indexed: 10/21/2022]
Abstract
Chronic occlusion of coronary arteries also known as chronic total occlusions (CTO) are found in approximately 20 % of patients undergoing percutaneous coronary interventions (PCI) and in approximately 50 % of patients after coronary artery bypass grafts (CABG). As a result of technical advancements in retrograde recanalization techniques specialized centers can now achieve success rates of over 85 %, regardless of the CTO anatomy. Given the complexity of retrograde CTO techniques, a consensus paper issued by the Euro CTO Club requires interventional cardiologists to have sufficient experience in antegrade approaches (>300 antegrade CTO cases and >50 per year) with an additional training program (25 retrograde cases each as first and second operating surgeon) before becoming a qualified independent retrograde surgeon. The increased investment in time and technical resources can only be justified if the patient has a clear clinical benefit. This technical advancement and the progressively clearer evidence that complete revascularization can be achieved in patients with multivessel coronary artery disease have attracted growing interest in recent years from interventional cardiologists in the recanalization of CTO.
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84
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Di Marco A, Anguera I, Teruel L, Dallaglio P, González-Costello J, León V, Nuñez E, Manito N, Gómez-Hospital JA, Sabaté X, Cequier Á. Chronic total occlusion of an infarct-related artery: a new predictor of ventricular arrhythmias in primary prevention implantable cardioverter defibrillator patients. Europace 2016; 19:267-274. [DOI: 10.1093/europace/euw009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/06/2016] [Indexed: 01/09/2023] Open
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85
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Claessen BE, Hoebers LP, Elias JE, van Dongen IM, Henriques JPS. Meta-analyses and randomized trials investigating percutaneous coronary intervention of chronic total occlusions: what is left to explore? J Thorac Dis 2016; 8:E1100-E1102. [PMID: 27747075 DOI: 10.21037/jtd.2016.08.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Bimmer E Claessen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Loes P Hoebers
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Joelle E Elias
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Ivo M van Dongen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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86
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Nombela-Franco L, Ryan N. Ischemic Cardiomyopathy and Chronic Total Occlusions. JACC Cardiovasc Interv 2016; 9:1798-800. [DOI: 10.1016/j.jcin.2016.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/30/2016] [Indexed: 12/12/2022]
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87
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Tajstra M, Pyka Ł, Gorol J, Pres D, Gierlotka M, Gadula-Gacek E, Kurek A, Wasiak M, Hawranek M, Zembala MO, Lekston A, Poloński L, Bryniarski L, Gąsior M. Impact of Chronic Total Occlusion of the Coronary Artery on Long-Term Prognosis in Patients With Ischemic Systolic Heart Failure. JACC Cardiovasc Interv 2016; 9:1790-7. [DOI: 10.1016/j.jcin.2016.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/16/2016] [Accepted: 06/02/2016] [Indexed: 12/16/2022]
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88
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Koenig S, Arya A, Hindricks G, Dinov B. Catheter ablation of ventricular tachycardia in the setting of electrical storm after revascularization of a chronic total occlusion of the right coronary artery: An uncommon presentation of reperfusion arrhythmia. HeartRhythm Case Rep 2016; 2:462-464. [PMID: 28491737 PMCID: PMC5419978 DOI: 10.1016/j.hrcr.2016.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sebastian Koenig
- Department of Cardiac Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Cardiac Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Cardiac Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
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89
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Hoebers LP, Elias J, van Dongen IM, Ouweneel DM, Claessen BE, Piek JJ, Henriques JP. The impact of the location of a chronic total occlusion in a non-infarct-related artery on long-term mortality in ST-elevation myocardial infarction patients. EUROINTERVENTION 2016; 12:423-30. [DOI: 10.4244/eijv12i4a75] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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90
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Survival after percutaneous coronary intervention for chronic total occlusion. Clin Res Cardiol 2016; 105:921-929. [DOI: 10.1007/s00392-016-1000-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/27/2016] [Indexed: 11/25/2022]
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91
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Brilakis ES, Karmpaliotis D, Vo MN, Carlino M, Galassi AR, Boukhris M, Alaswad K, Bryniarski L, Lombardi WL, Banerjee S. Update on Coronary Chronic Total Occlusion Percutaneous Coronary Intervention. Interv Cardiol Clin 2016; 5:177-186. [PMID: 28582202 DOI: 10.1016/j.iccl.2015.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved during recent years. High success rates are being achieved by experienced centers and operators, but not at less-experienced centers. Use of CTO crossing algorithms can help improve the success and efficiency of these potentially lengthy procedures. There is a paucity of clinical trial data examining clinical outcomes of CTO PCI, which is critical for further adoption and refinement of the procedure. We provide a detailed overview of the clinical evidence and current available crossing strategies, with emphasis on recent developments and techniques.
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Affiliation(s)
- Emmanouil S Brilakis
- Department of Cardiovascular Diseases, VA North Texas Healthcare System, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
| | - Dimitri Karmpaliotis
- Department of Cardiovascular Diseases, NYP Columbia University, New York, NY, USA
| | - Minh N Vo
- St Boniface Hospital Cardiac Science Program, University of Manitoba, Winnipeg, Canada
| | - Mauro Carlino
- Department of Cardiovascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Alfredo R Galassi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Department of Cardiovascular Diseases, University of Zurich, Zurich, Switzerland
| | - Marouane Boukhris
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Khaldoon Alaswad
- Department of Cardiovascular Diseases, Henry Ford Hospital, Detroit, MI, USA
| | - Leszek Bryniarski
- Department of Cardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Subhash Banerjee
- Department of Cardiovascular Diseases, VA North Texas Healthcare System, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
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92
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Sianos G, Konstantinidis NV, Di Mario C, Karvounis H. Theory and practical based approach to chronic total occlusions. BMC Cardiovasc Disord 2016; 16:33. [PMID: 26860695 PMCID: PMC4746803 DOI: 10.1186/s12872-016-0209-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/21/2022] Open
Abstract
Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.
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Affiliation(s)
- Georgios Sianos
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Nikolaos V Konstantinidis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Carlo Di Mario
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
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93
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Myths to Debunk to Improve Management, Referral, and Outcomes in Patients With Chronic Total Occlusion of an Epicardial Coronary Artery. Am J Cardiol 2015; 116:1774-80. [PMID: 26434510 DOI: 10.1016/j.amjcard.2015.08.050] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 02/05/2023]
Abstract
A chronic total occlusion (CTO) is defined as an occlusive (100% stenosis) coronary lesion with anterograde Thrombolysis In Myocardial Infarction 0 flow for at least 3 months. CTOs are common in patients referred for coronary angiography (up to 33%) and are associated with angina, impaired quality of life, and reduced survival. Unfortunately, CTO percutaneous coronary intervention continues to be underperformed worldwide (10% to 15% at most institutions, ∼30% where expert operators are available). The aim of this study was to address common fallacies pertaining to CTOs among cardiologists by providing a concise review of pertinent previously published reports along with an update on safety and efficacy of state-of-the-art CTO percutaneous coronary intervention techniques.
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94
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Impact of Chronic Total Occlusions and Coronary Revascularization on All-Cause Mortality and the Incidence of Ventricular Arrhythmias in Patients With Ischemic Cardiomyopathy. Am J Cardiol 2015; 116:1358-62. [PMID: 26341182 DOI: 10.1016/j.amjcard.2015.07.057] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 12/22/2022]
Abstract
Coronary chronic total occlusions (CTOs) have been associated with higher mortality in patients with ischemic cardiomyopathy and implantable cardioverter defibrillators (ICDs); yet the impact of CTO revascularization on subsequent clinical outcomes has not been studied. We evaluated the clinical characteristics and outcomes of patients with ischemic cardiomyopathy who also received an ICD for primary prevention of sudden death at the Dallas VA Medical Center from January 2002 to December 2013. On the basis of coronary angiography performed before device implantation, patients were divided into 3 groups: no CTOs, revascularized CTOs (with percutaneous coronary intervention or surgery), and unrevascularized CTOs. Primary and secondary outcomes were all-cause mortality and appropriate ICD therapy for sustained ventricular arrhythmias. A total of 307 patients (mean age 64.3 ± 8.1 years, 100% men) were included in the study. At least 1 CTO was present in 213 patients (69%) and was revascularized in 99 patients (32%). During a median follow-up of 4.1 years, 51 patients (17%) died and 98 (32%) had at least 1 episode of sustained ventricular arrhythmia. Mortality and incidence of ventricular arrhythmias were similar in the 3 study groups in both univariate and multivariate analyses. In conclusion, CTOs are commonly found in patients with ischemic cardiomyopathy. In contrast to previous studies, the presence of a CTO was not associated with higher mortality or incidence of ventricular arrhythmias. In addition, revascularization of CTOs was not associated with improved outcomes in this high-risk cohort.
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95
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Baker WL, Kluger J, Coleman CI, White CM. Impact of Magnesium L-Lactate on Occurrence of Ventricular Arrhythmias in Patients with Implantable Cardioverter Defibrillators: A Randomized, Placebo-Controlled Trial. Open Cardiovasc Med J 2015; 9:83-8. [PMID: 27006710 PMCID: PMC4768635 DOI: 10.2174/1874192401509010083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 03/20/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
Background: We evaluated the antiarrhythmic efficacy and quality of life (QoL) impact of oral magnesium Llactate
on patients with an implantable cardioverter defibrillator (ICD). Methods: This prospective, double-blind, placebo-controlled trial randomized 70 patients with an ICD to receive oral
magnesium L-lactate 3 tablets twice daily (504mg elemental magnesium daily) or matching placebo for 12 months. Patients
were seen at baseline, 12, 24, 36, and 52 weeks. The primary endpoints were the cumulative occurrence of ICD
therapy [either shock or anti-tachycardia pacing (ATP)] or QoL between the groups. Results: Among the 70 randomized patients with a mean ± SD follow-up of 6.4 ± 4.1 months, 10 patients in the placebo
group and 8 in the magnesium group experienced either ICD shock or ATP [HR 0.84, 95% CI 0.33 to 2.12; p=0.706].
Without significant arrhythmia suppression, only minimal effects on QoL were seen. Eighty six percent of all patients had
serum intracellular magnesium deficiency. Conclusion: In our underpowered trial, patients with ICDs had intracellular magnesium deficiency but oral magnesium Llactate
only nonsignificantly reduced the occurrence of ICD therapies and had little impact on HrQoL.
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Affiliation(s)
- William L Baker
- University of Connecticut, Schools of Pharmacy, Hartford CT, USA; Storrs and Farmington, Hartford Hospital, Division of Pharmacy, Hartford CT, USA
| | - Jeffrey Kluger
- University of Connecticut, Schools of Medicine, Hhartford CT, USA; Storrs and Farmington, Hartford Hospital, Division of Cardiology, Hartford CT, USA
| | - Craig I Coleman
- University of Connecticut, Schools of Pharmacy, Hartford CT, USA; Storrs and Farmington, Hartford Hospital, Division of Pharmacy, Hartford CT, USA
| | - C Michael White
- University of Connecticut, Schools of Pharmacy, Hartford CT, USA; Storrs and Farmington, Hartford Hospital, Division of Pharmacy, Hartford CT, USA
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96
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Rodríguez-Reyes H, Muñoz Gutiérrez M, Márquez MF, Pozas Garza G, Asensio Lafuente E, Ortíz Galván F, Lara Vaca S, Mariona Montero VA. [Sudden cardiac death. Risk stratification, prevention and treatment]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 85:329-36. [PMID: 26253348 DOI: 10.1016/j.acmx.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Manlio F Márquez
- Servicio de Electrocardiología, Instituto Nacional de Cardiología Ignacio Chávez, México, México
| | - Gerardo Pozas Garza
- Servicio de Cardiología, Hospital San José Tecnológico de Monterrey, Monterrey, México
| | | | - Fernando Ortíz Galván
- Centro Universitario del Sur (CUSUR), Universidad de Guadalajara, Cd. Guzmán, Jalisco, México
| | - Susano Lara Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
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97
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Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani DJ, Vo M, Luna M, Alaswad K, Karmpaliotis D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol 2015; 115:1367-75. [PMID: 25784515 DOI: 10.1016/j.amjcard.2015.02.038] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 12/11/2022]
Abstract
Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.
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Affiliation(s)
- Georgios E Christakopoulos
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Georgios Christopoulos
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Mauro Carlino
- Department of Cardiovascular Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Omar M Jeroudi
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Michele Roesle
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Bavana V Rangan
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Shuaib Abdullah
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Jerrold Grodin
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Dharam J Kumbhani
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Minh Vo
- Department of Cardiovascular Diseases, University of Manitoba, Manitoba, Canada
| | - Michael Luna
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Khaldoon Alaswad
- Department of Cardiovascular Diseases, Henry Ford Hospital, Detroit, Michigan
| | | | - Stephane Rinfret
- Department of Cardiovascular Diseases, Institut universitaire de cardiologie et de pneumologie de Québec (Quebec Heart and Lung Institute), Laval University, Quebec City, Quebec, Canada
| | - Santiago Garcia
- Department of Cardiovascular Diseases, Minneapolis VA Healthcare System and University of Minnesota, Minneapolis, Minnesota
| | - Subhash Banerjee
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
| | - Emmanouil S Brilakis
- Department of Cardiovascular Diseases, VA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas.
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98
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Mixon TA. Ventricular tachycardic storm with a chronic total coronary artery occlusion treated with percutaneous coronary intervention. Proc (Bayl Univ Med Cent) 2015; 28:196-9. [PMID: 25829653 DOI: 10.1080/08998280.2015.11929228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
A 66-year-old man with a history of coronary artery disease was evaluated due to ventricular tachycardic (VT) storm. The patient continued to have frequent recurrences of VT despite treatment with amiodarone and lidocaine. Since the ventricular arrhythmia could be related to myocardial ischemia related to a chronic total occlusion (CTO) of the right coronary artery, the patient underwent successful percutaneous coronary intervention of the CTO, followed by implantable cardioverter defibrillator implantation. He had no further episodes of VT during his hospital stay. After 9 months of follow-up, he had no further chest pain or clinically apparent recurrent ischemia. Interrogation of his defibrillator has shown brief nonsustained episodes of ventricular tachycardia, but the patient has not required delivery of a shock. The temporal association between treatment of the CTO and resolution of the VT, as well as the lack of recurrence of sustained VT, suggest a causative link between underlying ischemia produced by a chronically occluded coronary artery and provocation of VT and lend supportive evidence to this treatment approach.
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Affiliation(s)
- Timothy A Mixon
- Department of Internal Medicine, Division of Cardiology, Texas A&M College of Medicine, Baylor Scott & White Health, Temple, Texas
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99
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Hoebers LP, Claessen BE, Elias J, Dangas GD, Mehran R, Henriques JPS. Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome. Int J Cardiol 2015; 187:90-6. [PMID: 25828320 DOI: 10.1016/j.ijcard.2015.03.164] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 03/07/2015] [Accepted: 03/15/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) may have a beneficial effect on survival through a better-preserved or improved LVEF. Current literature consists of small observational studies therefore we performed a weighted meta-analysis on the impact of revascularization of CTOs on left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and long-term mortality. METHODS We conducted a meta-analysis evaluating LVEF before and after CTO PCI and long-term mortality. No language or time restrictions were applied. References from the identified articles and reviews were examined to find additional relevant manuscripts. RESULTS Of the 812 citations, 34 studies performed between 1987-2014 in 2243 patients were eligible for LVEF and 27 studies performed between 1990-2013 in 11,085 patients with success and 4347 patients that failed CTO PCI were eligible for long-term mortality. After successful CTO PCI, LVEF increased with 4.44% (95% CI: 3.52-5.35, p<0.01) compared to baseline. In a small cohort of ~70 patients, no significant difference in LVEF was observed after non-successful CTO PCI or reocclusion. Additionally, 8 studies reported the change in left ventricular end-diastolic volume (LVEDV) in a total of 412 patients. LVEDV decreased with 6.14 ml/m(2) (95% CI: -9.31 to -2.97, p<0.01). Successful CTO PCI was also associated with reduced mortality in comparison with failed CTO PCI (OR: 0.52, 95% CI: 0.43-0.62, p-value<0.01). CONCLUSIONS The current meta-analysis revealed that successful recanalization of a CTO resulted in an overall improvement of 4.44% absolute LVEF points, reduced adverse remodeling and an improvement of survival (OR: 0.52).
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Affiliation(s)
- Loes P Hoebers
- Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Joelle Elias
- Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Roxana Mehran
- Mount Sinai Medical Center, New York, NY, United States
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100
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Di Marco A, Paglino G, Oloriz T, Maccabelli G, Baratto F, Vergara P, Bisceglia C, Anguera I, Sala S, Sora N, Dallaglio P, Marzi A, Trevisi N, Mazzone P, Della Bella P. Impact of a chronic total occlusion in an infarct-related artery on the long-term outcome of ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2015; 26:532-9. [PMID: 25598359 DOI: 10.1111/jce.12622] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/01/2015] [Accepted: 01/12/2015] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In patients with a prior myocardial infarction (MI), angiographic predictors of ventricular tachycardia (VT) recurrence after ablation are lacking. Recently, a proarrhythmic effect of a chronic total occlusion (CTO) in a coronary artery has been suggested. METHODS AND RESULTS A total of 191 patients with prior MI were referred to our Hospital between 2010 and June 2013 for a first ablation of VT. Of these, 84 patients (44%) with stable coronary artery disease that underwent a coronary angiography during the index hospitalization were included in this study. A CTO in an infarct-related artery (IRA-CTO) was present in 47 patients (56%). Patients with and without IRA-CTO did not differ in terms of comorbidities, severity of heart failure, presentation of VT or acute outcome of ablation, that was completely successful in 93% of cases. At electroanatomic mapping, IRA-CTO was associated with greater scar and especially with greater area of border zone (34 cm(2) vs. 19 cm(2) , P = 0.001). Median follow-up was 19 months (IQR 18). At follow-up, patients with IRA-CTO had a significantly higher rate of VT recurrence (47% vs. 16%, P = 0.003). At multivariate analysis, IRA-CTO resulted to be an independent predictor of VT recurrence after ablation (HR 4.05, P = 0.004). CONCLUSIONS IRA-CTO is an independent predictor of VT recurrence after ablation and identifies a subgroup of patients with high recurrence rate despite a successful procedure. IRA-CTO is associated with greater scars and border zone area; however, this association does not completely justify its proarrhythmic effect.
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Affiliation(s)
- Andrea Di Marco
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy.,Arrhythmia Unit, Heart Diseases Institute, Bellvitge Universisty Hospital, Barcelona, Spain
| | - Gabriele Paglino
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Teresa Oloriz
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Giuseppe Maccabelli
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Francesca Baratto
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Caterina Bisceglia
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Ignasi Anguera
- Arrhythmia Unit, Heart Diseases Institute, Bellvitge Universisty Hospital, Barcelona, Spain
| | - Simone Sala
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicoleta Sora
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Paolo Dallaglio
- Arrhythmia Unit, Heart Diseases Institute, Bellvitge Universisty Hospital, Barcelona, Spain
| | - Alessandra Marzi
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicola Trevisi
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Patrizio Mazzone
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
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