Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice

Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Chronic Total Occlusion: A Meta-Analysis

Background/Objectives: Chronic total occlusion (CTO) is a prevalent finding in patients with coronary artery disease and is associated with increased mortality. Prior reports on the efficacy of percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) were controversial. Following the emergence of recently published new evidence, a meta-analysis is warranted. The current meta-analysis assessed the effects of PCI compared to OMT in the treatment of CTO. Methods: A structured literature search was performed. Randomized controlled trials (RCTs) and non-randomized controlled studies of interventions were eligible. The primary outcome was an accumulated composite of cardiac mortality, myocardial infarction and target vessel/lesion revascularization events. Results: Thirty-two studies reporting on 11260 patients were included. Of these, 5712 (50.7%) were assigned to the PCI and 5548 (49.3%) were allocated to the OMT group. The primary outcome occurred in 14.6% of the PCI and 20.1% of the OMT group (12 trials, OR 0.66, 95% CI 0.50 to 0.88, p = 0.005, I2 = 67%). Subgrouping demonstrated a consistent reduction in the primary outcome for the PCI group in RCTs (six trials, OR 0.58, 95% CI 0.33 to 0.99, p = 0.05). The primary outcome reduction was irrespective of the study design, and it was replicable in sensitivity and subgroup analyses. Advantages in other outcomes were rather related to statistical pooling effects and dominated by observational data. Conclusions: CTO-PCI was associated with improved patient-oriented primary outcome compared to OMT in a study-level meta-analysis. This composite outcome effect was mainly driven by target vessel treatment, but a significant reduction in mortality and myocardial infarction was observed, irrespectively. These findings have hypothesis-generating implications. Future RCTs with adequate statistical power are eagerly awaited.

Percutaneous Coronary Intervention Offers Clinical Benefits to Diabetic Patients With Stable Chronic Total Occlusion

Whether percutaneous coronary intervention for chronic total occlusion (CTO-PCI) in diabetic patients offers more benefits compared with initial medical therapy (CTO-MT) is unclear. In this study, diabetic patients with one CTO (clinical manifestations: stable angina or silent ischemia) were enrolled. Consecutively, enrolled patients (n = 1605) were assigned to different groups: CTO-PCI (1044 [65.0%]) and initial CTO-MT (561 [35%]). After a median follow-up of 44 months, CTO-PCI tended to be superior to initial CTO-MT in major adverse cardiovascular events (adjusted hazard-ratio [aHR]: .81, 95% conference-interval: .65-1.02) and significantly superior in cardiac death (aHR: .58 [.39-.87]) and all-cause death (aHR: .678[.473-.970]). Such superiority mainly attributed to a successful CTO-PCI. CTO-PCI tended to be performed in patients with younger age, good collaterals, left anterior descending branch CTO, and right coronary artery CTO. While, those with left circumflex CTO and severe clinical/angiographic situations were more likely to be assigned to initial CTO-MT. However, none of these variables influenced the benefits of CTO-PCI. Thus, we concluded that for diabetic patients with stable CTO, CTO-PCI (mainly successful CTO-PCI) offered patients survival benefits over initial CTO-MT. These benefits were consistent regardless of clinical/angiographic characteristics.

Assessment of Myocardial Viability and Risk Stratification in Coronary Chronic Total Occlusion: A Qualitative and Quantitative Stress Cardiac MRI Study

BACKGROUND

Indicators for assessing myocardial viability and risk stratification in patients with coronary chronic total occlusion (CTO) are still in the research stage.

PURPOSE

To use stress-MRI to assess myocardial function, blood perfusion, and viability and to explore their relationship with collateral circulation.

STUDY TYPE

Prospective.

SUBJECTS

Fifty-one patients with CTO in at least one major artery confirmed by X-ray coronary angiography (male: 46; age 55.2 ± 10.8 years).

FIELD STRENGTH/SEQUENCE

3.0T; TurboFlash, balanced steady-state free precession cine, and phase-sensitive inversion recovery sequences.

ASSESSMENT

Stress-MRI was used to obtain qualitative and quantitative parameters of segmental myocardium. Myocardial segments supplied by CTO target vessels were grouped according to the degree of collateral circulation assessed by radiographic coronary angiography (no/mild, moderate, or good). Depending on qualitative stress perfusion assessment and late gadolinium enhancement (LGE) extent, segments were also categorized as negative, viable, or trans-infarcted.

STATISTICAL TESTS

Independent sample Student's t-test, one-way analysis of variance (ANOVA) test, Mann-Whitney U test, Kruskal-Wallis test, Spearman correlation coefficient (r). P < 0.05 was considered statistically significant.

RESULTS

A total of 334 segments were supplied by CTO target vessels. The radial strain (RS), circumferential strain (CS), longitudinal strain (LS) of the negative, viable, and trans-infarcted regions showed a significant and stepwise impairment. Myocardial blood flow at rest was positively correlated with RS, CS, and LS (r = 0.42, 0.43, 0.38, respectively). Among the different collateral circulation, there were no significant differences in RS, CS, LS, and LGE volume (P = 0.788, 0.562, 0.122, 0.170, respectively), and there were also no statistically significant differences in the proportions of negative, viable, and trans-infarcted regions (P = 0.372).

DATA CONCLUSION

Myocardial perfusion obtained by stress-MRI combined with strain and LGE may comprehensively evaluate myocardial function and viability, and has potential to facilitate risk stratification of CTO.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 1.

Baseline angina burden predicts quality of life and functional improvement in patients with viable myocardium treated for chronic total occlusion

Chronic total occlusion (CTO) is a common finding in patients with known or suspected coronary artery disease and has a distinctive role in these patients' quality of life. However, there is still a lack of evidence of correct patient selection for percutaneous coronary intervention (PCI). From July 2017 to August 2020, 68 patients with successful PCI of a CTO and previous evidence of viability for PCI by cardiovascular magnetic resonance imaging (CMR) were prospectively included in this single-centre observational study. Of these patients, 62 underwent follow-up CMR, and 56 underwent surveys using the Seattle Angina Questionnaire before PCI and 3, 12 and 24 months after PCI. The CMR results were assessed for volumetric, functional and deformation parameters. From the baseline to the follow-up, there was a significant reduction in the left ventricular volumes (all p < 0.001) and an increase in the left ventricular ejection fraction (57.6 ± 11.6% vs. 60.3 ± 9.4%, p = 0.006). Among the deformation parameters, only the left ventricular radial strain showed significant improvement. The SAQ showed an early improvement that emphasised angina stability and frequency as well as a summary score, which persisted after 24 months. A low SAQ summary score before PCI was the best predictive factor of good clinical improvement thereafter. Improvements in myocardial function and quality of life can be achieved with PCI of a CTO. Patient selection for PCI should be performed primarily among relevantly symptomatic patients when evidence of viability for PCI is present. The SAQ can help guide such patient selection.Trial registration ISRCTN, identifier: ISRCTN33203221. Retrospectively registered on 01.04.2020. https://www.isrctn.com/ISRCTN33203221.

Impact of Percutaneous Intervention Compared to Pharmaceutical Therapy on Complex Arrhythmias in Patients With Chronic Total Coronary Occlusion. Rationale and Design of the CTO-ARRHYTHMIA Study

Chronic total coronary occlusions (CTO) occur in up to 50 % of patients with coronary artery disease by angiography. In CTO-patients, clinically significant arrhythmia is potentially important and insufficiently investigated. Therefore, the purpose of the CTO-ARRHYTHMIA study was to investigate the incidence of loop recorder detected clinically significant arrhythmias and the effect on arrhythmias of revascularization by CTO-PCI. The study is an independent sub-study of the NOrdic-Baltic Randomized Registry Study for Evaluation of PCI in Chronic Total Coronary Occlusion (NOBLE-CTO); ClinicalTrials.gov Identifier NCT03392415. NOBLE-CTO prospectively collects procedural data, quality of life measures, echocardiographic and cardiac MRI findings before and after treatment as well as clinical outcomes in all CTO patients that may be treated by PCI.

Impact of impaired renal function on outcomes of chronic total occlusion undergoing revascularization: a systemic review and meta-analysis

PURPOSE

Patients with chronic kidney disease (CKD) have an associated burden of coronary artery disease, including chronic total occlusions (CTO). It is unclear how the presence of CKD affects the outcomes of CTO revascularization. Previous reviews have not taken into account all relevant published studies that examined the association of CKD with outcomes of CTO revascularization.

METHODS

A systematic search was conducted using PubMed, Scopus, and Google Scholar databases for studies investigating patients with or without CKD who also had coronary chronic total occlusion undergoing revascularization procedures Statistical analysis was performed using STATA software. Effect sizes were reported as pooled relative risk (RR).

RESULTS

A total of 13 studies were included. CKD patients showed elevated risk of in-hospital mortality (RR 4.25, 95% CI 2.64, 6.82) and mortality at latest follow-up (RR 3.24, 95% CI 2.56, 4.11), elevated risk of major cardio or cerebrovascular events (RR 1.65, 95% CI 1.38, 1.98), major bleeding (RR 2.85, 95% CI 1.96, 4.13), and contrast-induced acute kidney injury (RR 3.06, 95% CI 1.70, 5.52). CKD patients also showed lower chances of technical success (RR 0.95, 95% CI 0.91, 1.00).

CONCLUSIONS

The presence of CKD increases the risk of mortality, complications and adversely affects the success of CTO revascularization. Patients with CKD undergoing revascularization should have their kidney function comprehensively evaluated and these patients should be carefully monitored.

Predicting Residual Angina After Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the OPEN‐CTO Registry

Background

Given that percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is indicated primarily for symptom relief, identifying patients most likely to benefit is critically important for patient selection and shared decision‐making. Therefore, we identified factors associated with residual angina frequency after CTO PCI and developed a model to predict postprocedure anginal burden.

Methods and Results

Among patients in the OPEN‐CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry, we evaluated the association between patient characteristics and residual angina frequency at 6 months, as assessed by the Seattle Angina Questionnaire Angina Frequency Scale. We then constructed a prediction model for angina status after CTO PCI using ordinal regression. Among 901 patients undergoing CTO PCI, 28% had no angina, 31% had monthly angina, 30% had weekly angina, and 12% had daily angina at baseline. Six months later, 53% of patients had a ≥20‐point increase in Seattle Angina Questionnaire Angina Frequency Scale score. The final model to predict residual angina after CTO PCI included baseline angina frequency, baseline nitroglycerin use frequency, dyspnea symptoms, depressive symptoms, number of antianginal medications, PCI indication, and presence of multiple CTO lesions and had a C index of 0.78. Baseline angina frequency and nitroglycerin use frequency explained 71% of the predictive power of the model, and the relationship between model components and angina improvement at 6 months varied by baseline angina status.

Conclusions

A 7‐component OPEN‐AP (OPEN‐CTO Angina Prediction) score can predict angina improvement and residual angina after CTO PCI using variables commonly available before intervention. These findings have implications for appropriate patient selection and counseling for CTO PCI.

Predictors of angina resolution after percutaneous coronary intervention in stable coronary artery disease

BACKGROUND

Elective percutaneous coronary intervention (PCI) is performed to relieve symptoms of angina. Identifying patients who will benefit symptomatically after PCI would be clinically advantageous but robust predictors of symptom resolution are ill-defined.

METHODS

Prospective indexing of baseline angina status, clinical, and procedural characteristics were collected over a 5-year period in a regional revascularization registry. At 1-year follow-up, angina resolution was assessed. We performed a stepwise selection algorithm to identify predictors of persistent angina at 1 year.

RESULTS

A total of 777 patients were included in the analysis and the median follow-up was 387 days. Mean age of the cohort was 66.6 years, 23.8% were female and 23.3% had baseline Canadian Cardiovascular Society class 3 or 4 angina. Overall, 13.1% had persistent angina. The only predictor of persistent angina was the presence of a residual chronic total occlusion after PCI with odds ratio of 3.06 (95% confidence interval, 1.81-5.17). Residual stenoses 50-69%, 70-89%, and 90-99% were not associated with residual angina after PCI.

CONCLUSION

Most patients achieved symptom resolution with PCI and optimal medical therapy. A residual chronic total occlusion after PCI was associated with persistent angina. Other degrees of stenoses were not associated with persistent angina.

A Novel Classification for Predicting Chronic Total Occlusion Percutaneous Coronary Intervention

Aims

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is characterized by a low success rate and an increase in complications. This study aimed to explore a new and simple classification method based on plaque composition to predict guidewire (GW) crossing within 30 min of CTO lesions.

Methods

This study consecutively enrolled individuals undergoing attempted PCI of CTO who underwent coronary computed tomographic angiography (CCTA) within 2 months. Lesions were divided into soft and hard CTO groups according to the necrotic core proportion.

Results

In this study, 207 lesions were divided into soft (20.3%) and hard CTO (79.7%) groups according to a necrotic core percentage cutoff value of 72.7%. The rate of successful GW crossing within 30 min (57.6 vs. 85.7%, p = 0.004) and final success (73.3 vs. 95.2%, p = 0.001) were much lower in the hard CTO group. For patients with hard CTO, previous failed attempt, proximal side branch, bending > 45 degrees calcium ≥ 50% cross-sectional area (CSA), and distal reference diameter ≤ 2.5 mm were demonstrated to be associated with GW failure within 30 min. For patients with soft CTO, only blunt entry was proved to be an independent predictive factor of GW failure within 30 min.

Conclusions

Grouping CTO lesions according to the proportion of necrotic core is reasonable and necessary in predicting GW crossing within 30 min. A soft CTO with a necrotic core is more likely to be recanalized compared with a hard CTO with fibrous and/or dense calcium. Different plaque types have variable predictive factors.

Retinal Microvasculature Changes in Patients With Coronary Total Occlusion on Optical Coherence Tomography Angiography

Background: Retinal microvasculature has been associated with coronary artery disease (CAD), but the exact contributory role in coronary total occlusion (CTO) is unclear. We aimed to investigate whether retinal vasculature is associated with CTO and could provide incremental value in the assessment of CTO.

Methods: A total of 218 CAD patients including 102 CTO and 116 non-CTO were enrolled. Retinal vasculature was measured by optical coherence tomography angiography (OCTA) for all patients. Receiver operating characteristic (ROC) curve was used to assess the performance of retinal vasculature in differentiating CTO from non-CTO patients.

Results: In non-CTO CAD patients, vessel density (VD) of mean superficial capillary plexus (SCP) and parafovea SCP were 49.85 and 52.56%, respectively; in CTO patients, VD of mean SCP and parafovea SCP were 47.77, and 49.58%, respectively. After multiple adjustment, VD in the SCP was significantly lower in CTO patients compared to non-CTO patients. VD of superior hemi in the parafovea SCP combined with the clinical variates showed the best ability to predict CTO from CAD with an area under the curve (AUC) of 0.812 (specificity of 89.0% and sensitivity of 65.9%).

Conclusions: In CTO patients, retinal VD was significantly decreased, and microvascular damage might specifically target to arterioles than capillaries. Retinal vasculature could thus be a surrogate for detecting the microvascular damage and assist in the assessment of CTO patients. OCTA examination could be suggested to monitor the process of coronary arteries lesions.

In-hospital outcomes of patients with chronic kidney disease undergoing percutaneous coronary intervention for chronic total occlusion: a systematic review and meta-analysis

BACKGROUND

The relative safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in patients with chronic kidney disease (CKD) have not been well defined. We performed a systematic review and meta-analysis of observational studies to assess in-hospital outcomes in this population.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to April 2020 for all clinical trials and observational studies. Five observational studies with a total of 6769 patients met our inclusion criteria. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR <60 ml/min/1.73m2 in CKD group and ≥ 60 ml/min/1.73m2 in non-CKD group). The primary outcome was in-hospital mortality. Secondary outcomes were acute kidney injury, coronary injury (perforation, dissection or tamponade), stroke and procedural success. Mantel-Haenszel random-effects model was used to calculate the odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

In-hospital mortality was significantly higher among patients with CKD undergoing PCI for CTO (OR: 5.16, 95% CI: 2.60-10.26, P < 0.00001). Acute kidney injury (OR: 2.54, 95% CI: 1.89-3.40, P < 0.00001) and major bleeding (OR: 2.58, 95% CI: 1.20-5.54, P < 0.01) were also more common in the CKD group. No significant difference was observed in the occurrence of stroke (OR: 2.36, 95% CI: 0.74-7.54, P < 0.15) or coronary injury (OR: 1.38, 95% CI: 0.98-1.93, P < 0.06) between the two groups. Non-CKD patients had a higher likelihood of procedural success compared to CKD patients (OR: 0.66, 95% CI: 0.57-0.77, P < 0.00001).

CONCLUSION

Patients with CKD undergoing PCI for CTO have a significantly higher risk of in-hospital mortality, acute kidney injury and major bleeding when compared to non-CKD patients. They also have a lower procedural success rate.

Trends and outcomes of chronic coronary total occlusion-related ventricular tachyarrhythmias

Our study aims to establish trends and frequencies of ventricular tachyarrhythmia (VTA) among patients with chronic coronary total occlusion (CCTO). We identified CCTO hospitalizations with and without VTA using the National Inpatient Sample. A total of 911,579 CCTO-related hospitalizations were identified, with 92,450 (10.1%) encounters associated with VTA. The CCTO-VTA cohort showed higher all-cause mortality (adjusted odds ratio [aOR] = 4.45, P <  0.001), longer hospital stays (6.8 vs 4.6 days; P <  0.001), and higher hospital charges ($117,382 vs $75,419; P <  0.001) compared to the CCTO non-VTA group. Rates and odds of cardiogenic shock (aOR = 4.19), venous thromboembolism (aOR = 2.09), respiratory failure (aOR = 2.85), and requirement of mechanical ventilation (aOR = 4.23) were higher in the CCTO-VTA group (P <  0.001). Over time, there was an increase in VTA (9.2% in 2010 to 12.1% in 2014) and all-cause mortality (7.5% in 2010 to 12.4% in 2014; P <  0.001). Trends in VTA among patients with CCTO increased by 4.8% for undergoing percutaneous coronary intervention and by 2.5% for undergoing both percutaneous coronary intervention and coronary artery bypass grafting (P <  0.001). Occurrence of VTA among CCTO patients is associated with worse outcomes and higher resource utilization.

Non-invasive Imaging in Patients With Chronic Total Occlusions of the Coronary Arteries-What Does the Interventionalist Need for Success?

Chronic total occlusion (CTO) of coronary arteries is a common finding in patients with known or suspected coronary artery disease (CAD). Although tremendous advances have been made in the interventional treatment of CTOs over the past decade, correct patient selection remains an important parameter for achieving optimal results. Non-invasive imaging can make a valuable contribution. Ischemia and viability, two major factors in this regard, can be displayed using echocardiography, single-photon emission tomography, positron emission tomography, computed tomography, and cardiac magnetic resonance imaging. Each has its own strengths and weaknesses. Although most have been studied in patients with CAD in general, there is an increasing number of studies with positive preselectional factors for patients with CTOs. The aim of this review is to provide a structured overview of the current state of pre-interventional imaging for CTOs.

[Technical armamentarium for chronic total occlusion of coronary vessels]

Percutaneous revascularization of chronic total occlusion (CTO) of coronary vessels represents a major challenge for contemporary interventional cardiologists. In the last decade there has been an unprecedented effort towards the standardization of revascularization procedures for CTO of coronary vessels. This endeavour has been possible by virtue of the growing interest of various cardiological societies for this patient group. Along with supportive endovascular technologies and percutaneous devices specifically dedicated to this interventional target, the increasing experience of interventionalists enabled continuously growing success for revascularization of CTO of coronary vessels. This review article highlights the currently available tools as well as technologies, techniques and strategies for the percutaneous recanalization of CTO of coronary vessels.

Functional recovery after percutaneous revascularization of coronary chronic total occlusions: insights from cardiac magnetic resonance tissue tracking

To evaluate the effect of percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs) on left ventricular (LV) strain assessed using cardiac magnetic resonance (CMR) tissue tracking. In 150 patients with a CTO, longitudinal (LS), radial (RS) and circumferential shortening (CS) were determined using CMR tissue tracking before and 3 months after successful PCI. In patients with impaired LV strain at baseline, global LS (10.9 ± 2.4% vs 11.6 ± 2.8%; P = 0.006), CS (11.3 ± 2.9% vs 12.0 ± 3.5%; P = 0.002) and RS (15.8 ± 4.9% vs 17.4 ± 6.6%; P = 0.001) improved after revascularization of the CTO, albeit to a small, clinically irrelevant, extent. Strain improvement was inversely related to the extent of scar, even after correcting for baseline strain (B =  − 0.05; P = 0.008 for GLS, B =  − 0.06; P = 0.016 for GCS, B =  − 0.13; P = 0.017 for GRS). In the vascular territory of the CTO, dysfunctional segments showed minor improvement in both CS (10.8 [6.9 to 13.3] % vs 11.9 [8.1 to 15.0] %; P < 0.001) and RS (14.2 [8.4 to 18.7] % vs 16.0 [9.9 to 21.8] %; P < 0.001) after PCI. Percutaneous revascularization of CTOs does not lead to a clinically relevant improvement of LV function, even in the subgroup of patients and segments most likely to benefit from revascularization (i.e. LV dysfunction at baseline and no or limited myocardial scar).

Percutaneous Coronary Intervention for Chronic Total Occlusion in Single Coronary Arteries

We retrospectively compared the results of percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) for chronic total occlusion (CTO) in single coronary arteries to determine whether outcomes depend on the artery involved. From January 2004 through November 2015, a total of 731 patients were treated at our center for CTO in the left anterior descending coronary artery (LAD) (234 patients, 32%), left circumflex coronary artery (LCx) (184, 25.2%), or right coronary artery (RCA) (313, 42.8%). We further classified patients by treatment (PCI or OMT) and compared the cumulative incidence of major adverse cardiac events (MACE) and the composite of total death or myocardial infarction, as well as change in left ventricular ejection fraction from baseline. The 5-year cumulative incidence of MACE was similar between the treatment groups regardless of target vessel. The 5-year cumulative incidence of the composite of total death or myocardial infarction was significantly lower after PCI than after OMT or failed PCI in the LCx (2.6% vs 11.5%; P=0.020; log-rank) and RCA (5.8% vs 17.2%; P=0.002) groups, but not in the LAD group. Cox proportional hazards regression analysis indicated that PCI independently predicted a lower incidence of the composite of total death or myocardial infarction in the LCx group (hazard ratio [HR]=0.184; 95% CI, 0.0035-0.972; P=0.046) and the RCA group (HR=0.316; 95% CI, 0.119-0.839; P=0.021). The artery involved does not appear to affect clinical outcomes of successful PCI for single-vessel CTO. Further investigation in a randomized clinical trial is warranted.

Predictors of unsuccessful endovascular recanalization of coronary chronic total occlusion

The prevalence of endovascular interventions for coronary chronic total occlusion (CTO) remains small worldwide. This is due to the complexity of procedure and the risk of intraoperative complications. In this regard, the search for predictors of unsuccessful endovascular intervention in CTO plays a special role. This will allow for a careful selection of patients with the most favorable expectation effect of the operation. Aim. To identify predictors of unsuccessful endovascular recanalization of CTO.

Material and methods. This retrospective study included 180 patients with chronic coronary artery disease (CAD) in the period from November 2017 to June 2019, who had multivessel lesion in combination with CTO. In all patients, an attempt was made to achieve complete myocardial revascularization. Depending on the success of procedure, the patients were divided into two groups: complete and incomplete myocardial revascularization. The follow-up period was 12 months.

Results. All baseline characteristics of patients in the compared groups were similar. The successful recanalization rate of occlusion was 79,5%. Multivariate regression analysis showed that calcified CTO (p<0,001), baseline SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score >32 (p=0,006), CTO length >30 mm (p=0,046) and CTO of circumflex artery (p<0,01) are significant predictors of unsuccessful endovascular recanalization of CTO. To assess the predictive value of the model, a ROC analysis was carried out, and the area under the curve (AUC) was calculated. The AUC was 0,87, which indicates a high predictive quality of the model. The sensitivity and specificity of the model were 78 and 81%, respectively.

Conclusion. The study showed that the presence of calcified CTO, SYNTAX score >32 points, CTO length >30 mm, and CTO of circumflex artery are significant predictors of unsuccessful CTO recanalization.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Endovascular myocardial revascularization in patients with multivessel coronary artery disease with chronic total occlusion and high surgical risk

The main reason  for incomplete myocardial revascularization is the presence of chronic coronary total occlusion (CTO), which is detected in every fourth patient during coronary angiography. At the same time, a generally accepted approach  to the treatment of CTO has not yet been developed.

Aim. To assess the rationale of complete myocardial revascularization in patients with multivessel coronary artery disease  (CAD) with chronic total occlusion and high surgical risk.

Material and methods. This retrospective,  open-label,  non-randomized clinical trial was carried out included 180 patients multivessel CAD and CTO. The patients  underwent endovascular  surgery for complete myocardial revascularization. Depending on the success of surgery, the patients were divided into groups of complete and incomplete myocardial revascularization. Endpoints were death, acute coronary syndrome, re-revascularization after 1-year follow-up. Left ventricular (LV) contractility and clinical status  of patients  in the study groups after 1 year of observation was assessed.

Results. The median follow-up was 12,1 months. The successful  rate of revascularization was 79,4%. The incidence of main composite endpoint in the group of complete myocardial revascularization was 5,59%, while in the group of incomplete revascularizations — 21,6% (p=0,005).

Conclusion. The study showed  that low incidence  of intraoperative complications and a high successful  rate of revascularization are characteristic of complete myocardial revascularization in patients at high surgical risk with multivessel CAD and CTO. Complete myocardial revascularization leads to a significant decrease in the incidence of major coronary events.

Prognostic impact of coronary chronic total occlusion on recurrences of ventricular tachyarrhythmias and ICD therapies

BACKGROUND

Despite a few studies evaluating the prognostic impact of coronary chronic total occlusion (CTO) in implantable cardioverter defibrillator (ICD) recipients, the impact of CTO on different types of recurrences of ventricular tachyarrhythmias, as well as their predictors has not yet been investigated in CTO patients.

METHODS

A large retrospective registry was used including all consecutive patients with ventricular tachyarrhythmias undergoing coronary angiography at index from 2002 to 2016. Only ICD recipients with CTO were compared to patients without (non-CTO). Kaplan-Meier and Cox regression analyses were applied for the primary end point of first recurrence of ventricular tachyarrhythmias at 5 years. Secondary end points comprised of the different types of recurrences, first appropriate ICD therapy and all-cause mortality at 5 years.

RESULTS

From a total of 422 consecutive ICD recipients with ventricular tachyarrhythmias at index, at least one CTO was present in 25%. CTO was associated with the primary end point of first recurrence of ventricular tachyarrhythmias at 5 years (55% vs. 39%; log rank p = 0.001; HR = 1.665; 95% CI 1.221-2.271; p = 0.001), as well as increased risk of first appropriate ICD therapy (40% vs. 31%; log rank p = 0.039; HR = 1.454; 95% CI 1.016-2.079; p = 0.041) and all-cause mortality at 5 years (26% vs. 16%; log rank p = 0.011; HR = 1.797; 95% CI 1.133-2.850; p = 0.013). Less developed collaterals (i.e., either ipsi- or contralateral compared to bilateral) and a J-CTO score ≥ 3 were strongest predictors of recurrences in CTO patients at 5 years.

CONCLUSION

A coronary CTO even in the presence of less developed collaterals and more complex CTO category is associated with increasing risk of recurrent ventricular tachyarrhythmias at 5 years in consecutive ICD recipients.

Relationship between quality of coronary collateral and myocardial viability in chronic total occlusion: a magnetic resonance study

Revascularization of chronic total occlusion (CTO) is still debated regarding its indications and therapeutic benefits. Guidelines recommend patient selection based on ischemia detection and viability assessment. We aimed to investigate the relationship between the quality of coronary collaterals (CC), graded by Rentrop classification, and myocardial viability assessed by cardiovascular magnetic resonance (CMR). Unselected 100 consecutive patients with a single CTO were prospectively enrolled. CC of Rentrop grade two or three were considered as well-developed. Analyzing late gadolinium enhancement (LGE) images, CTO territories with mean segmental transmural scar extent < 50% were considered viable. Of the 100 patients (70 male, mean age 58.0 ± 6 years), 73 patients (73%) had angiographically visible CC. Based on LGE, patients were classified into viable (n = 50) and non-viable (n = 50) groups. Significant differences between both groups existed regarding frequency of diabetes mellitus (p = 0.044), frequency of congestive heart failure (p = 0.032), presence of pathological Q in CTO territory (p = 0.039); and presence of well-developed CC (p < 0.001). Binary logistic regression and receiver operating characteristic curve showed that presence of well-developed CC could independently (OR 9.4, 95% CI: 2.6-33.6, p < 0.001) predict myocardial viability with a sensitivity and a specificity of 72% and 74%, respectively (AUC: 0.796, 95% CI: 0.708-0.884, P < 0.001). The presence of well-developed CC could independently predict with high accuracy myocardial viability assessed by LGE in territories subtended by CTO vessels. Therefore, search for viable myocardium using different imaging modalities, e.g. CMR, may be recommended in CTO patients with well-developed CC.

The hybrid algorithm in treatment of coronary chronic total occlusions - MSWiA Lublin CTO 5-year registry

INTRODUCTION

Treatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates.

AIM

Our single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients.

MATERIAL AND METHODS

Between January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 - easy, 1 - intermediate, 2 - difficult, ≥ 3 - very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported.

RESULTS

Two hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% - 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis).

CONCLUSIONS

The hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.

Relationship between Coronary Iodine Concentration Determined Using Spectral CT and the Outcome of Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

PURPOSE

To evaluate the feasibility of coronary iodine concentration (CIC) by using spectral CT in the assessment of the outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).

MATERIALS AND METHODS

In total, 50 consecutive patients underwent preprocedural coronary CT angiography with spectral CT prior to their staged PCI for CTO between June 2017 and July 2018. Iodine density maps, referred to as iodine-no-water maps throughout, with spectral CT provided the CIC at proximal CTO (CTO-CIC). Depending on the outcome of PCI, all CTO lesions were divided into two groups: failed PCI and successful PCI. The receiver operating characteristic curve was used to determine the cutoff values of CTO-CIC in the assessment of the outcome of PCI for CTO.

RESULTS

Of the 50 CTO lesions in 50 patients, 34 (68%) and 16 (32%) were assigned to the successful PCI and failed PCI groups, respectively. The mean CTO-CIC was significantly less in the failed PCI group than in the successful PCI group (1.3 mg/mL ± 0.9 [standard deviation] vs 5.2 mg/mL ± 2.5; P < .001). A low CTO-CIC (≤ 2.5 mg/mL) predicted failed PCI with 87% sensitivity, 79% specificity, 79% positive predictive value, and 90% negative predictive value. At multivariable analysis, the low CTO-CIC was significantly associated with the failed PCI (odds ratio, 27.0; 95% confidence interval: 4.9, 147.6; P < .0001).

CONCLUSION

The CTO-CIC determined by using spectral CT may be useful in the assessment of the outcome of staged PCI for CTO.See also the commentary by Rubinshtein and Blankstein in this issue.© RSNA, 2020.

Prompt and consistent improvement of coronary flow velocity reserve following successful recanalization of the coronary chronic total occlusion in patients with viable myocardium

Background

Coronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment, but data on coronary hemodynamic changes in relation to myocardial function are limited. We assessed changes in coronary flow velocity reserve (CFVR) by echocardiography in collateral donor and recanalized artery following successful opening of coronary CTO.

Methods

Our study enrolled 31 patients (60 ± 9 years; 22 male) with CTO and viable myocardium by SPECT scheduled for percutaneous coronary intervention (PCI). Non-invasive CFVR was measured in collateral donor artery before PCI, 24 h and 6 months post-PCI, and 24 h and 6 months in recanalized artery following successful PCI of CTO.

Results

Collateral donor artery showed significant increase in CFVR 24 h after CTO recanalization compared to pre-PCI values (2.30 ± 0.49 vs. 2.71 ± 0.45, p = 0.005), which remained unchanged after 6-months (2.68 ± 0.24). Baseline blood flow velocity of the collateral donor artery significantly decreased 24 h post-PCI compared to pre-PCI (0.28 ± 0.06 vs. 0.24 ± 0.04 m/s), and remained similar after 6 months, with no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24 h and 6 months post-PCI. CFVR of the recanalized coronary artery 24 h post-PCI was 2.55 ± 0.35, and remained similar 6 months later (2.62 ± 0.26, p = NS).

Conclusions

In patients with viable myocardium, prompt and significant CFVR increase in both recanalized and collateral donor artery, was observed within 24 h after successful recanalization of CTO artery, which maintained constant during the 6 months.

Trial registration

ClinicalTrials.gov (Number NCT04060615).

Impact of coronary total occlusion on graft failure and outcomes of coronary artery bypass grafting

OBJECTIVE

The study objective was to assess the impact of chronic total occlusion on long-term graft failure and outcomes in patients who underwent coronary artery bypass grafting.

METHODS

We conducted an observational study involving a single-center subgroup of the CORONARY trial. At 6 to 9 years after coronary artery bypass grafting, all alive patients were invited for coronary computed tomography angiography and clinical follow-up. We assessed the association between chronic total occlusion graft and failing graft showing Fitzgibbon type B or O. Risk factors associated with chronic total occlusion graft failure were assessed. The impact of chronic total occlusion on clinical outcomes was analyzed, including death, myocardial infarction, and repeated revascularization.

RESULTS

A total of 349 patients undergoing coronary artery bypass grafting were enrolled between May 2007 and October 2011. Of 301 alive patients at follow-up time (median, 6.8 years; interquartile range, 6.0-8.0 years), repeat coronary computed tomography angiography was performed in 206 patients (68.4%) with 723 grafts (154 chronic total occlusion grafts and 569 nonchronic total occlusion grafts). Chronic total occlusion graft was significantly associated with an increased risk of long-term graft failure after adjustment for patient- and graft-level characteristics (adjusted odds ratio, 2.27; 95% confidence interval, 1.42-3.62; P < .001). Arterial graft, side-to-side anastomosis, higher graft flow, and antiplatelet therapy at discharge were associated with chronic total occlusion graft patency. The presence of 1 or more chronic total occlusions was not significantly associated with long-term composite of death, myocardial infarction, or repeat revascularization (adjusted hazard ratio, 0.91; 95% confidence interval, 0.54-1.51; P = .707).

CONCLUSIONS

Chronic total occlusion graft was associated with an increased risk of graft failure. Surgical technique and guideline-directed medical therapy should be noted to improve chronic total occlusion graft patency.

Incidence and characteristics of ventricular tachycardia in patients after percutaneous coronary revascularization of chronic total occlusions

Objectives

This study sought to investigate the prevalence of ventricular tachycardia after percutaneous coronary intervention (PCI) of chronic total occlusion (CTO).

Background

PCI of a CTO is associated with improvement of the left ventricular ejection fraction and possibly associated with reduced mortality. However, benefits of CTO-PCI must be weighed against a higher risk of procedure-related complications. The incidence of new-onset ventricular tachycardia after a successful CTO-PCI has not been investigated so far. In this retrospective registry we seek to describe characteristics and predictors of occurrence of post-procedural ventricular tachycardias.

Methods and results

Between 2010 and 2015, 485 patients underwent successful CTO-PCI at Heart Center Leipzig. Of them, 342 had complete follow-up and were further analyzed. Ventricular tachycardias were detected in 9 (2.6%) patients. All of them were monomorphic ventricular tachycardias occurring in median 1 day (interquartile range [IQR] 0.25–4.75 days) after PCI and caused prolongation of the hospital stay. Patients with ventricular tachycardia were older, had worse left ventricular ejection fraction (mean 33.1%, SD 5.9%) and more frequently a CTO of an infarct-related artery. The target vessel was not associated with the occurrence of ventricular arrhythmias. In multivariable analysis, only impaired left ventricular systolic function was an independent predictor for procedure-related ventricular tachycardia. Mortality rates were not different between patients with or without ventricular tachycardia.

Conclusion

Ventricular tachycardia can occur early after CTO-PCI as possible reperfusion arrhythmia and poorer left ventricular ejection fraction is the only independent predictor for onset. Although the occurrence of ventricular tachycardia after CTO-PCI seems not to influence mortality, awareness of this possible complication and longer monitoring may be recommended.

Transcatheter Aortic Valve Replacement in Patients with Coronary Chronic Total Occlusion

INTRODUCTION

Coronary artery disease is a common diagnosis among patients evaluated for transcatheter aortic valve replacement (TAVR). It is unknown whether the presence of coronary artery chronic total occlusion (CTO) has any impact on TAVR post-procedural in-hospital outcomes.

METHODS

The study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for TAVR, coronary CTO and post-procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay, paravalvular leak (PVL), mechanical complications of prosthetic valve, cardiogenic shock, acute myocardial infarction (AMI), acute kidney injury (AKI), need for a permanent pacemaker, and bleeding. Propensity matching was used to extract a matched control (TAVR-M group to TAVR-CTO group).

RESULTS

There were 23,604 TAVR, of whom, 467 discharges were identified in each group. Baseline characteristics and comorbidities were comparable. Mean age was 80.5 years and 45.9% were female. In comparison to TAVR-M, TAVR-CTO was associated with longer length of stay (8.1 versus 5.9 days, p < 0.01), and higher incidence of post-procedural cardiogenic shock (5.1% versus 1.7%, p < 0.01), AMI (5.8% versus 2.8%, p = 0.02), and AKI (18.6% versus 13.9, p = 0.048). There was no significant difference between the two groups in in-hospital all-cause mortality (1.7% versus 2.4%, p = 0.49), PVL (1.3% versus 0.4%, p = 0.16), mechanical complications of prosthetic valve (0.4% versus 0.9%, p = 0.41), permanent pacemaker (11.6% versus 8.1%, p = 0.07), or bleeding (20.6% versus 19.7%, p = 0.74).

CONCLUSIONS

In comparison to TAVR-M, TAVR-CTO was associated with a higher incidence of cardiogenic shock, AMI, and AKI and longer LOS but similar mortality.

Predictors for New Native-Vessel Occlusion in Patients with Prior Coronary Bypass Surgery: A Single-Center Retrospective Research

Objectives

Chronic total occlusion (CTO) is prevalent in patients with prior coronary artery bypass grafting (CABG). However, data available concerning the prevalence of new-onset CTO of native vessels in patients with prior CABG is limited. Therefore, the objective of the study is to determine predictors for new native-vessel occlusion in patients with prior coronary bypass surgery.

Methods

354 patients with prior CABG receiving follow-up angiography are selected and analyzed in the present study, with clinical and angiographic variables being analyzed by logistic regression to determine the predictors of new native-vessel occlusion.

Results

The overall new occlusion rate was 35.59%, with multiple CTOs (42.06%) being the most prevalent (LAD 24.60% and RCA 18.25%, respectively). Additionally, current smoking (OR: 2.67; 95% CI: 2.60 to 2.74; p=0.01), reduced ejection fraction (OR: 1.76; 95% CI: 1.04 to 2.97; p=0.04), severe stenosis (OR: 3.65; 95% CI: 2.55 to 5.24; p=0.01), and diabetes mellitus (OR: 1.86; 95% CI: 1.34 to 2.97; p=0.04) serve as the independent predictors for new native-vessel occlusion.

Conclusion

As to high incidence of postoperative CTO, appropriate revascularization strategies and postoperative management should be taken into careful consideration.

Angiography and Percutaneous Coronary Intervention for Chronic Total Coronary Occlusion in Daily Practice (from a Large French Registry [CARDIO-ARSIF])

The aim of this study was to provide contemporary data on chronic total occlusion (CTO) prevalence and management in a large unselected population representing the daily activity of cathlabs, in the greater Paris area, and to compare percutaneous coronary intervention (PCI) features in patients with and without CTO. Procedures were collected from the CARDIO-ARSIF (Agence Régionale de Santé Ile de France) registry from 2012 to 2015. Patients with acute coronary syndrome or previous coronary artery bypass grafting were excluded. CTO features were assessed and PCIs with and without CTO were compared. Among 128,739 included patients, 10,468 (8.1%) had at least 1 CTO. Cardiovascular risk-factor burden was higher in the CTO group, which had more patients with multivessel disease (74% vs 24%) and with referral for interventional management (59% vs 33%). Of all PCIs during the study period, 5.7% involved a CTO; this proportion increased significantly over the study period. PCI success rate was 75.9% in the CTO group. CTO-PCI volume per center did not correlate with CTO-PCI success rate. In conclusion, CTO is common in patients who underwent scheduled coronary angiography. Invasive management is done more often in patients with than without CTO. The success rate of PCI in CTO is not associated with case volume per center.

Successful revascularization versus medical therapy in diabetic patients with stable right coronary artery chronic total occlusion: a retrospective cohort study

Background

The territory of the right coronary artery (RCA) is smaller than that of the left anterior descending artery. Previous studies have reported conflicting results when considering whether stable RCA-chronic total occlusion (CTO) should be reopened. The coexistence of diabetic and coronary artery diseases represents a severe situation. Therefore, we aimed to determine if stable RCA-CTO in diabetic patients was necessary to be reopened. To our knowledge, no studies have focused on this topic to date.

Methods

We enrolled diabetic patients with RCA-CTO who had clinical presentations of symptomatic stable angina or silent ischemia. RCA-CTO was treated with either successful revascularization (the CTO-SR group) or medical therapy (the CTO-MT group). The primary endpoint was all-cause death. Both Cox regression and propensity score matching analyses were used. Sensitivity analysis was performed based on subgroup populations and relevant baseline variables.

Results

A total of 943 patients were included: 443 (46.98%) patients in the CTO-MT group and 500 (53.02%) patients in the CTO-SR group. After a mid-term follow-up (CTO-SR: 48 months; CTO-MT: 42 months), we found that CTO-SR was superior to CTO-MT in terms of all-cause death (adjusted hazard ratio [HR] [model 1]: 0.429, 95% conference interval [CI] 0.269–0.682; adjusted HR [model 2]: 0.445, 95% CI 0.278–0.714). The superiority of CTO-SR was consistent for cardiac death, possible/definite cardiac death, repeat revascularization, target vessel revascularization (TVR) and repeat nonfatal myocardial infarction. Subgroup analysis confirmed the mortality benefit of CTO-SR by percutaneous coronary intervention (the successful CTO-PCI subgroup, 309 patients in total). While CTO-SR by coronary artery bypass grafting (the CTO-CABG subgroup, 191 patients in total) offered patients more benefit from repeat revascularization and TVR than that offered by successful CTO-PCI.

Conclusions

For stable RCA-CTO patients with diabetes, successful revascularization offered patients more clinical benefits than medical therapy. CTO-CABG might be a more recommended way to accomplish revascularization.

Trial registration This study was not registered in an open access database

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0911-4) contains supplementary material, which is available to authorized users.

Percutaneous Coronary Intervention Versus Medical Therapy for Chronic Total Occlusion of Coronary Arteries: A Systematic Review and Meta-Analysis

Purpose of Review

Chronic total occlusion (CTO) of the coronary arteries is a significant clinical problem and has traditionally been treated by medical therapy or coronary artery bypass grafting. Recent studies have examined percutaneous coronary intervention (PCI) as an alternative option.

Recent Findings

This systematic review and meta-analysis compared medical therapy to PCI for treating CTOs.

Summary

PubMed and Embase were searched from their inception to March 2019 for studies that compared medical therapy and PCI for clinical outcomes in patients with CTOs. Quality of the included studies was assessed by Newcastle–Ottawa scale. The results were pooled by DerSimonian and Laird random- or fixed-effect models as appropriate. Heterogeneity between studies and publication bias was evaluated by I² index and Egger’s regression, respectively. Of the 703 entries screened, 17 studies were included in the final analysis. This comprised 11,493 participants. Compared to PCI, medical therapy including randomized and observational studies was significantly associated with higher risk of all-cause mortality (risk ratio (RR) 1.99, 95% CI 1.38–2.86), cardiac mortality (RR 2.36 (1.97–2.84)), and major adverse cardiac event (RR 1.25 (1.03–1.51)). However, no difference in the rate of myocardial infarction and repeat revascularization procedures was observed between the two groups. Univariate meta-regression demonstrated multiple covariates as independent moderating factors for myocardial infarction and repeat revascularization but not cardiac death and all-cause mortality. However, when only randomized studies were included, there was no difference in overall mortality or cardiac death. In CTO, when considering randomized and observational studies, medical therapy might be associated with a higher risk of mortality and myocardial infarction compared to PCI treatment.

Electronic supplementary material

The online version of this article (10.1007/s11883-019-0804-8) contains supplementary material, which is available to authorized users.

Improvement of left ventricular function assessment by global longitudinal strain after successful percutaneous coronary intervention for chronic total occlusion

The benefit of revascularization of chronic total occlusion (CTO) in percutaneous coronary intervention (PCI) is controversial. On the other hand, left ventricular (LV) global longitudinal strain (GLS) is a more sensitive marker of LV myocardial ischemia and LV function than LV ejection fraction (EF). The purpose of this study was to investigate the impact of revascularization of CTO on LV function using LV GLS. A total of 70 consecutive patients (65.1±8.9 years, 59 males, LVEF 51.0±12.0%) with CTO who had a positive functional ischemia and underwent PCI, were included in this study. Echocardiography was performed before and 9 months after the procedure with conventional assessment including LV end-diastolic and end-systolic volume (LVEDV, LVESV), LVEF, and with 2DSTE analysis of GLS. Successful PCI was obtained in 60 patients (86%). There were no stent thromboses during follow-up. GLS showed a significant improvement 9 months after successful PCI (pre-PCI -12.4±4.1% vs. post-PCI -14.5±4.1%, P< 0.01), whereas in failed PCI group that did not change significantly (pre-PCI -13.2±4.2% vs. post-PCI -14.0±4.7%, P = 0.64). LVEF, LVEDV and LVESV did not change significantly during follow-up in both successful and failed groups. Successful PCI for CTO improved LV function, assessed by LV GLS.

Adverse events in patients with high platelet reactivity following successful chronic total occlusion PCI: The Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents (ADAPT-DES) study

BACKGROUND

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) typically requires a greater number of stents and longer stent length than non-CTO PCI, placing these patients at greater risk for adverse ischemic events. We sought to determine whether the association between high platelet reactivity (HPR) and the risk of ischemic events is stronger after CTO than non-CTO PCI.

METHODS

Patients undergoing successful PCI in the multicenter ADAPT-DES study were stratified according to whether they underwent PCI of a CTO. HPR was defined as VerifyNow platelet reaction units >208. The study primary endpoint was the 2-year risk target vessel failure ([TVF] defined as cardiac death, myocardial infarction, or target lesion revascularization).

RESULTS

CTO PCI was performed in 400 of 8448 patients. HPR was present in 34.5% of CTO PCI patients and 43.1% of non-CTO PCI patients (P = .0007). Patients undergoing CTO PCI with versus without HPR had significantly higher 2-year rates of TVF (15.0% versus 8.3%, P = .04) without significant differences in bleeding. HPR was an independent predictor of 2-year TVF (adjusted HR 1.16, 95% CI 1.02-1.34, P = .03) whereas CTO PCI was not (adjusted HR 0.89, 95% CI 0.65-1.22, P = .48). There was a significant interaction between CTO versus non-CTO PCI and PRU as a continuous variable for 2-year TVF (P_interaction = 0.02).

CONCLUSIONS

In ADAPT-DES, HPR was associated with an increased 2-year risk of TVF after PCI, an association that was at least as strong after CTO PCI compared with non-CTO PCI.

Prevalence of ischaemia in patients with a chronic total occlusion and preserved left ventricular ejection fraction

Aims

Previous studies on invasive assessment of collateral function in patients with a chronic total occlusion (CTO) have displayed only a limited increase in collateral flow and high occurrence of coronary steal during pharmacological stress. This could question the necessity for ischaemia testing prior to revascularization of CTOs in the presence of myocardial viability. The purpose of the present study was to determine the prevalence of perfusion impairments in patients with a CTO as assessed by [15O]H2O positron emission tomography (PET).

Methods and results

Seventy-six consecutive patients (60 men, 62 ± 10 years) with a documented CTO and preserved left ventricular ejection fraction (LVEF) were included. All patients underwent PET to assess (hyperaemic) myocardial blood flow (MBF) and coronary flow reserve (CFR). Collateral connection score was 0 in 7 (9%), 1 in 13 (17%), and 2 in 56 (74%) of the cases, with predominantly a high Rentrop grade (96% ≥2). MBF of the target area during hyperaemia was significantly lower when compared with the remote area (1.37 ± 0.37 vs. 2.63 ± 0.71 mL min-1 g-1, P < 0.001). Target to remote ratio during hyperaemia was on average 0.54 ± 0.13, and 73 (96%) patients demonstrated a significantly impaired target to remote ratio (≤0.75). Only 7 (9%) patients displayed a preserved CFR of ≥2.50, whereas coronary steal (CFR <1.0) was observed in 10 (13%) patients.

Conclusions

Even in the presence of angiographically well-developed collateral arteries, the vast majority of CTO patients with a preserved LVEF showed significantly impaired perfusion. These results suggest that collateral function during increased blood flow demand in viable myocardium is predominantly insufficient.

Percutaneous coronary intervention versus optimal medical therapy for patients with chronic total occlusion: a meta-analysis and systematic review

Background

It was under debate whether chronic total occlusion (CTO) patients could benefit from percutaneous coronary intervention (PCI). We sought to compare clinical outcomes of PCI and optimal medical therapy (OMT) in these patients.

Methods

PubMed, Embase and Cochrane Library were searched for studies enrolling patients with CTO who accepted PCI or OMT. The meta-analysis was performed by using a random-effect model. In addition, subgroup analyses were performed, including patients after propensity-matching and patients with CTO in infarct-related artery (IRA), respectively.

Results

We identified 5 studies enrolling 4,761 participants in this meta-analysis. In the main analysis, when compared with OMT, PCI was associated with significant improvement in all-cause death [risk ratio (RR) 0.41, 95% CI: 0.35-0.48], cardiac death (RR 0.44, 95% CI: 0.35-0.55) and major adverse cardiac events (MACE) (RR 0.64, 95% CI: 0.43-0.97). But there were no differences in myocardial infarction (MI) and stroke. The results of the propensity-matched subgroup were somewhat consistent with those of the main analysis (all-cause death: RR 0.57, 95% CI: 0.26-0.89; MI: RR 0.54, 95% CI: 0.32-0.77; and MACE: RR 0.76, 95% CI: 0.33-1.18). In IRA subgroup, PCI reduced risks of mortality (all-cause death: RR 0.41, 95% CI: 0.34-0.49; cardiac death: RR 0.44, 95% CI: 0.35-0.56) and MACE (RR 0.71, 95% CI: 0.46-1.10). But no difference was observed in MI.

Conclusions

PCI was associated with improved survival and reduced MACE relative to OMT.

Predictors of successful chronic total occlusion percutaneous coronary interventions: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to identify positive and negative predictors of technical and clinical success for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO).

METHODS

We conducted a systematic review and meta-analysis of studies published between 2000 and 2016 analysing rates of CTO PCI success with respect to demographic and angiographic characteristics. Crude ORs and 95% CIs for each predictor were calculated using a random effects model. Predictors of technical and clinical success were assessed among 28 demographic and 31 angiographic variables. Clinical success was defined as technical success without major adverse cardiac events.

RESULTS

A total of 61 studies, totalling 69 886 patients were included in this analysis. The major demographic characteristics associated with a 20% or greater reduction in the odds of technical and clinical success were a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke/transient ischaemic attack and peripheral vascular disease. Angiographic factors were generally stronger predictors of reduced technical and clinical success. Those associated with >20% odds reduction included non-left anterior descending CTOs, multivessel disease, presence of bridging collaterals, moderate-to-severe calcification, >45 degree vessel bending, tortuous vessel, blunt stump and ostial lesions. Of these, novel predictors included prior PCI, prior stroke, peripheral vascular disease, presence of multivessel disease and bridging collaterals.

CONCLUSION

The present study has identified strong negative predictors for clinical success for CTO PCI, which will aid in patient selection for this procedure.

Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of patients with CTOs and to compare the clinical outcomes of CTO lesions with those of non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013, in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for patients with CTOs across hospitals in Ontario (44.9% to 94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of coronary artery bypass grafting over medical therapy was consistent in both patients with CTOs and patients without CTOs, the benefit of percutaneous coronary intervention (PCI) was limited to patients without CTOs (hazard ratio 0.56, 95% confidence interval 0.40- to 0.78), with no difference in patients with CTOs. The CTO lesion, however, was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients.

Gender-based acute outcome in percutaneous coronary intervention of chronic total coronary occlusion

Background

Percutaneous coronary intervention (PCI) of total chronic coronary occlusion (CTO) still remains a major challenge. Insignificant data are reported in the literature about gender differences in CTO-PCI in the era of new drug-eluting stents. In this study we analysed the impact of gender on procedural characteristics, complications and acute results.

Methods

Between 2010–2015 we included 780 consecutive patients. They underwent PCI for at least one CTO. Antegrade and retrograde CTO techniques were applied.

Results

Patients undergoing CTO-PCI were mainly men (84%). Male patients were younger (66.9 years ±10.6 vs. 61.1 years ±10.4; p < 0.001), more often smokers, but less frequently had a history of coronary artery disease (24.4% vs. 32.7%; p = 0.085) compared with female patients. Female patients more often had diabetes mellitus (29.6% vs. 26.7%; p = 0.55) and hypertension (82.7% vs. 80.7%; p = 0.55). There were no differences with respect to the amount of contrast fluid, fluoroscopy time and examination time as well as to the length of the stent or the number of the stents. The stent diameter was slightly smaller in women, which was not surprising because the lumen calibre tends to be smaller in women than in men (3.0 mm (2.5–3) vs. 3.0 mm (3–3.5); p < 0.001). The success rates were 81.0% in women and 80.1% in men. There was no significant interaction between gender and procedural success and complication rates.

Conclusions

Our retrospective study suggests that women and men have a comparable success rate at a low complication rate after recanalisation of CTO.

Retrograde Approach is as Effective and Safe as Antegrade Approach in Contemporary Percutaneous Coronary Intervention for Chronic Total Occlusion: A Taiwan Single-Center Registry Study

BACKGROUND

In percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), most experts regard the antegrade approach as the default initial strategy, reserving the retrograde approach for reattempts following antegrade failure. In this study, we aimed to compare the efficacy and safety between the antegrade and retrograde approaches in CTO PCI.

RESULTS

Between 2012 and 2013, patients that underwent 321 consecutive attempts by high-volume operators (> 75 total CTO PCI cases during the period) in a tertiary university-affiliated hospital were enrolled. The antegrade approach was used in 152 patients, and retrograde in 169 patients. The duration of occlusion was significantly longer and the J-CTO score higher in the retrograde group. Technical success was achieved in 148 patients of the antegrade group (97.4%), and 163 patients in the retrograde group (96.4%) (p = 0.75). A major procedural complication occurred in 3 patients of the antegrade group (2.0%) and in 6 patients of the retrograde group (3.6%) (p = 0.51). In-hospital major adverse cardiac events (MACE) rates (antegrade 0.7%, n = 152; retrograde 0.6%, n = 169) were comparable. The procedure and fluoroscopy times were significantly longer, with more radiation exposure and contrast medium consumption, in the retrograde group. In the retrograde group, similar success, procedural complication and in-hospital MACE rates were achieved in the 3 collateral subgroups.

CONCLUSIONS

In selected cases and with highly experienced operators, retrograde approach in CTO PCI is as effective and safe as antegrade approach at the expense of longer procedure time, more radiation exposure and contrast medium consumption. For retrograde approach, either septal, epicardial or AV groove collaterals can be used with similarly success, complication and in-hospital MACE rates.