1
|
Sliman H, Sliman RKA, Knaapen P, Nap A, Henriques J, Verouden N, Claessen BE. The role of chronic total occlusions in non-infarct-related arteries in acute coronary syndrome patients: a systematic review. Future Cardiol 2024; 20:581-590. [PMID: 39382445 DOI: 10.1080/14796678.2024.2406651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 09/17/2024] [Indexed: 10/10/2024] Open
Abstract
Aim: This systematic review evaluated the impact of a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) on clinical outcomes in acute coronary syndrome (ACS) patients and assessed the benefits of staged revascularization.Methods: We performed a comprehensive systematic review to provide further insight into the impact of a CTO in a non-IRA on clinical outcomes after ACS. Moreover, we review the currently available evidence on the clinical significance of staged revascularization for a CTO in a non-IRA patients with ACS and propose whether prophylactic CTO percutaneous coronary intervention (PCI) could improve outcomes in patients who subsequently develop an ACS.Results: Our search identified 999 studies, from which 30 were selected and ten were included in the analysis. The results showed a trend of higher all-cause mortality and major adverse cardiac event rates in the culprit-only-PCI group compared with the multivessel (MV)-PC I group in ST elevation myocardial infarction patients, with varying statistical significance across different outcomes.Conclusion: This review highlights the significant impact of non-IRA CTOs in ACS. Successful CTO revascularization may provide benefits, particularly in ST elevation myocardial infarction, but the optimal management approach remains uncertain. The presence of a non-IRA CTO, especially in cardiogenic shock, predicts worse outcomes. Further research is warranted to determine the effective strategies to improve survival.
Collapse
Affiliation(s)
- Hussein Sliman
- Department of Cardiology, Carmel Medical Center, Heart Center, Haifa, Israel
| | - Rim Kasem Ali Sliman
- Department of Pediatrics, Clalit Health Care Organization, Carmel Medical Center, Haifa, Israel
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, 1105 AZ, The Netherlands
| | - Alex Nap
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, 1105 AZ, The Netherlands
| | - Jose Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, 1105 AZ, The Netherlands
| | - Niels Verouden
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, 1105 AZ, The Netherlands
| | - Bimmer Epm Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, 1105 AZ, The Netherlands
| |
Collapse
|
2
|
Saito Y, Kobayashi Y. Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review. Intern Med 2024:4505-24. [PMID: 39343561 DOI: 10.2169/internalmedicine.4505-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2024] Open
Abstract
Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.
Collapse
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| |
Collapse
|
3
|
Cilia L, Megaly M, Davies R, Tehrani BN, Batchelor WB, Truesdell AG. A non-interventional cardiologist's guide to coronary chronic total occlusions. Front Cardiovasc Med 2024; 11:1350549. [PMID: 38380179 PMCID: PMC10876789 DOI: 10.3389/fcvm.2024.1350549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications, and post-procedure management and follow-up unique to patients undergoing this highly specialized intervention. Distinct from other existing topical reviews, the current manuscript focuses on key knowledge relevant to non-interventional cardiologists.
Collapse
Affiliation(s)
- Lindsey Cilia
- Virginia Heart, Falls Church, VA, United States
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Michael Megaly
- Willis Knighton Medical Center, Shreveport, LA, United States
| | | | - Behnam N. Tehrani
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Virginia Heart, Falls Church, VA, United States
- Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| |
Collapse
|
4
|
Megaly M, Zakhour S, Karacsonyi J, Basir MB, Kunkel K, Gupta A, Neupane S, Alqarqaz M, Brilakis ES, Alaswad K. Outcomes of Chronic Total Occlusion Percutaneous Coronary Intervention of the Left Anterior Descending Artery. Am J Cardiol 2023; 193:75-82. [PMID: 36878056 DOI: 10.1016/j.amjcard.2023.01.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/17/2022] [Accepted: 01/27/2023] [Indexed: 03/07/2023]
Abstract
The left anterior descending artery (LAD) subtends a large myocardial territory. The outcomes of LAD chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. We performed a retrospective analysis of all patients who underwent LAD CTO PCI at a high-volume single center. Outcomes included in-hospital and long-term major adverse cardiovascular events (MACEs) and changes in left ventricular ejection fraction (LVEF). We performed a subgroup analysis of patients with ischemic cardiomyopathy, defined as an LVEF of 40% or less. From December 2014 to February 2021, 237 patients underwent LAD CTO PCI. The technical success rate was 97.4%, and the in-hospital MACE rate was 5.4%, A landmark analysis after hospital discharge showed an overall survival of 92% and 85% MACE-free survival at 2 years. There was no difference in overall survival or MACE-free survival between those who had ischemic cardiomyopathy versus those who did not. In patients with ischemic cardiomyopathy, LAD CTO PCI was associated with significant improvement in LVEF (10.9% at 9 months), which was further pronounced when these patients had a proximal LAD CTO and were on optimal medical therapy (14% at 6 months). In a single high-volume center, LAD CTO PCI was associated with 92% overall survival at 2 years, with no difference in survival between patients with or without ischemic cardiomyopathy. LAD CTO PCI was associated with an absolute 10% increase in LVEF at 9 months in patients with ischemic cardiomyopathy.
Collapse
Affiliation(s)
- Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Samer Zakhour
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Judit Karacsonyi
- Department of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Katherine Kunkel
- Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Ankur Gupta
- Department of Cardiology, HonorHealth Heart Group - Shea, Phoenix, Arizona
| | - Saroj Neupane
- Department of Cardiology, WakeMed Hospital, Raleigh, North Carolina
| | | | - Emmanouil S Brilakis
- Department of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | |
Collapse
|
5
|
Sengodan P, Davies RE, Matsuno S, Chan AK, Kearney K, Salisbury A, Grantham JA, Hirai T. Chronic Total Occlusion Interventions in Patients with Reduced Ejection Fraction. Curr Cardiol Rep 2023; 25:43-50. [PMID: 36576680 DOI: 10.1007/s11886-022-01832-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF THE REVIEW The goal of this paper is to review the current evidence surrounding CTO PCI in patients with low EF, the most high-risk population to treat. We also present pertinent case examples and offer practical tips to increase success and lower complications when performing CTO PCI in patients with low EF. RECENT FINDINGS In a prospective randomized control study, greater improvement in angina frequency and quality of life, assessed by the Seattle Angina Questionnaire, was achieved by CTO PCI compared to optimal medical therapy. Furthermore, after successful CTO PCI, improvements in health status were similar in patients with both low and normal EF. CTO PCI can not only ameliorate symptoms of angina in patients with low EF but may also potentially improve EF in carefully selected populations. However, information regarding treatment of this high-risk population is lacking and large-scale studies targeting patients with severely reduced EF remain necessary.
Collapse
Affiliation(s)
| | | | | | - Albert K Chan
- University of Missouri Columbia, One Hospital Drive, Columbia, MO, 65212, USA
| | | | - Adam Salisbury
- St. Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Taishi Hirai
- University of Missouri Columbia, One Hospital Drive, Columbia, MO, 65212, USA.
| |
Collapse
|
6
|
Di Mario C, Mashayekhi KA, Garbo R, Pyxaras SA, Ciardetti N, Werner GS. Recanalisation of coronary chronic total occlusions. EUROINTERVENTION 2022; 18:535-561. [PMID: 36134683 DOI: 10.4244/eij-d-21-01117] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.
Collapse
Affiliation(s)
- Carlo Di Mario
- Structural Interventional Cardiology Division, Department of Clinical & Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Kambis A Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Roberto Garbo
- GVM Care & Research, Maria Pia Hospital, Turin, Italy
| | | | - Niccolò Ciardetti
- Structural Interventional Cardiology Division, Department of Clinical & Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Gerald S Werner
- Department of Cardiology, Klinikum Darmstadt GmbH, Darmstadt, Germany
| |
Collapse
|
7
|
Megaly M, Buda K, Mashayekhi K, Werner GS, Grantham JA, Rinfret S, McEntegart M, Brilakis ES, Alaswad K. Comparative Analysis of Patient Characteristics in Chronic Total Occlusion Revascularization Studies: Trials vs Real-World Registries. JACC Cardiovasc Interv 2022; 15:1441-1449. [PMID: 35863793 DOI: 10.1016/j.jcin.2022.05.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are subject to selection bias. OBJECTIVES The purpose of this study was to evaluate the differences between real-world CTO patients and those enrolled in RCTs. METHODS This study performed a meta-analysis of national and dedicated CTO PCI registries and compared patient characteristics and outcomes with those of RCTs that randomized patients to CTO PCI versus medical therapy. Given the large sample size differences between RCTs and registries, the study focused on the absolute numbers and their clinical significance. The study considered a 5% relative difference between groups to be potentially clinically relevant. RESULTS From 2012 to 2022, 6 RCTs compared CTO PCI versus medical therapy (n = 1,047) and were compared with 15 registries (5 national and 10 dedicated CTO PCI registries). Compared with registry patients, RCT patients had fewer comorbidities, including diabetes, hypertension, previous myocardial infarction, and prior coronary artery bypass graft surgery. RCT patients had shorter CTO length (29.6 ± 19.7 mm vs 32.6 ± 23.0 mm, a relative difference of 9.2%) and lower Japan-Chronic Total Occlusion Score scores (2.0 ± 1.1 vs 2.3 ± 1.2, a relative difference of 13%) compared with those enrolled in dedicated CTO registries. Procedural success was similar between RCTs (84.5%) and dedicated CTO registries (81.4%) but was lower in national registries (63.9%). CONCLUSIONS There is a paucity of randomized data on CTO PCI outcomes (6 RCTs, n = 1,047). These patients have lower risk profiles and less complex CTOs than those in real-world registries. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation.
Collapse
Affiliation(s)
- Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kevin Buda
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Kambis Mashayekhi
- Department of Cardiology, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; Department of Cardiology, MediClin Heartcenter Lahr, Lahr, Germany
| | - Gerald S Werner
- Department of Cardiology, Klinikum Darmstadt, Darmstadt, Germany
| | - J Aaron Grantham
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Stephane Rinfret
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Khaldoon Alaswad
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA.
| |
Collapse
|
8
|
Update on chronic total occlusion percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:27-34. [PMID: 34826426 DOI: 10.1016/j.pcad.2021.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 11/22/2022]
Abstract
Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be challenging to perform. The main indication for CTO PCI is to improve symptoms. Several contemporary studies have reported high CTO PCI success rates at experienced centers but success rates in all-comer registries remain low. Several scores can estimate the difficulty and the likelihood of success of CTO PCI. Dual arterial access and use of CTO crossing algorithms can improve the success and safety of CTO PCI. Intracoronary imaging can optimize stent expansion and minimize adverse cardiovascular events. While complications are more common in CTO PCI, careful planning and prompt diagnosis and treatment can prevent them or minimize their adverse consequences. In this article, we review contemporary data on the indications, safety and efficacy of CTO PCI.
Collapse
|