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Assaf A, Sakhi R, Diletti R, Hirsch A, Allaart CP, Bhagwandien R, Firouzi M, Smits PC, Hoogendijk MG, Theuns DA, Yap SC. Incidence of ventricular arrhythmias in patients with chronic total coronary occlusion: Results of the VACTOR study. IJC HEART & VASCULATURE 2024; 50:101323. [PMID: 38188347 PMCID: PMC10768522 DOI: 10.1016/j.ijcha.2023.101323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 01/09/2024]
Abstract
Background A chronic total coronary occlusion (CTO) is associated with ventricular arrhythmias (VA) in patients with an implantable cardioverter-defibrillator (ICD). Limited data is available on the incidence of VA in CTO patients without an ICD. Objectives To investigate the incidence of sustained VA in CTO patients after successful CTO revascularization and in patients with untreated CTO or failed CTO revascularization. Methods Prospective, multicenter observational pilot study including CTO patients who were not eligible for an ICD and had a left ventricular ejection fraction >35 %. We enrolled patients with a successful CTO revascularization (group A) and patients with untreated CTO or failed CTO revascularization (group B). All patients received an implantable loop recorder with remote monitoring. The primary endpoint was sustained VA. Results Ninety patients were enrolled (mean age 63 ± 10 years, 83.3 % man, mean LVEF 55 ± 8 %). Group A (n = 45) had a higher prevalence of CTO in the left anterior descending artery in comparison to group B (n = 45) (28.9 % versus 4.4 %, P = 0.002). Other baseline characteristics were similar. During a median follow-up time of 26 months (IQR, 19-35), five patients (5.6 %) had a sustained VA. There was no difference in the incidence of sustained VA between groups (3-year cumulative event rate: 8.8 % (group A) versus 4.5 % (Group B), log-rank P = 0.71). Conclusion Patients with an CTO, who do not qualify for an ICD, have a substantial risk of sustained VA. In our study the incidence was not different between patients with revascularized and those with untreated CTO.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rafi Sakhi
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alexander Hirsch
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Cornelis P. Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rohit Bhagwandien
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mehran Firouzi
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Mark G. Hoogendijk
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dominic A.M.J. Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Cojocaru C, Nastasa A, Bogdan S, Iorgulescu C, Deaconu A, Onciul S, Vatasescu R. Non-revascularized chronic total occlusions impact on substrate and post-ablation results in drug-refractory electrical storm. Front Cardiovasc Med 2023; 10:1258373. [PMID: 37808884 PMCID: PMC10552148 DOI: 10.3389/fcvm.2023.1258373] [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: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Background and aims There is limited data concerning the effect of non-revascularized chronic total occlusions (NR-CTOs) after VT ablation. This study sought to evaluate the impact of NR-CTOs after ablation for electrical storm (ES). Methods Post-hoc retrospective analysis of data regarding 64 consecutive post-myocardial infarction patients (out of which 12 patients with NR-CTOs and 52 without NR-CTOs) undergoing substrate ablation for ES with an available median follow-up of 37.53 (7.25-64.65) months. Ablation result was assessed by inducibility of sustained monomorphic VT (SMVT) during final programmed ventricular stimulation (PVS). The primary endpoints were all-cause mortality and VT/VF recurrences after ablation, respectively, stratified by the presence of NR-CTOs. The secondary endpoint was to assess the predictive effect of NR-CTOs on all-cause mortality and VT/VF recurrences in relation to other relevant prognostic factors. Results At baseline, the presence of NR-CTOs was associated with higher bipolar BZ-to-total scar ratio (72.4% ± 17.9% vs. 52% ± 37.7%, p = 0.022) and more failure to eliminate the clinical VT (25% (3) vs. 0% (0), p < 0.001). During follow-up, overall all-cause mortality and recurrences were more frequent in the NR-CTO subgroup (75% (9) vs. 19.2% (10), log rank p = 0.003 and 58.3% vs. 23.1% (12), log rank p = 0.042 respectively). After adjusting for end-procedural residual SMVT inducibility, NR-CTOs predicted death during follow-up (HR 3.380, p = 0.009) however not recurrence (HR 1.986, p = 0.154). Conclusions NR-CTO patients treated by RFCA for drug-refractory ES demonstrated a higher ratio of BZ-to-total-scar area. In this analysis, NR-CTO was associated with worse acute procedural results and may as well impact long-term outcomes which should be further assessed in larger patient populations.
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Affiliation(s)
- Cosmin Cojocaru
- Department of Cardiothoracic Pathology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Emergency Clinical Hospital Bucharest, Bucharest, Romania
| | | | - Stefan Bogdan
- Department of Cardiothoracic Pathology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Elias University Hospital, Bucharest, Romania
| | - Corneliu Iorgulescu
- Department of Cardiology, Emergency Clinical Hospital Bucharest, Bucharest, Romania
| | - Alexandru Deaconu
- Department of Cardiothoracic Pathology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Emergency Clinical Hospital Bucharest, Bucharest, Romania
| | - Sebastian Onciul
- Department of Cardiothoracic Pathology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Emergency Clinical Hospital Bucharest, Bucharest, Romania
| | - Radu Vatasescu
- Department of Cardiothoracic Pathology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Cardiology, Emergency Clinical Hospital Bucharest, Bucharest, Romania
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Faga V, Anguera I, Oloriz T, Nombela-Franco L, Teruel L, Dallaglio P, Guerrero AP, Salazar CH, Escaned J, Abadía AA, Hospital JAG, García JR, García MR, Colet JC, Di Marco A. Improved prediction of electrical storm in patients with prior myocardial infarction and implantable cardioverter defibrillator. Int J Cardiol 2022; 355:9-14. [PMID: 35176405 DOI: 10.1016/j.ijcard.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 12/12/2022]
Abstract
AIMS To evaluate predictors of electrical storm (ES), including chronic total occlusion in an infarct-related coronary artery (infarct-related artery CTO, IRACTO), in a cohort of patients with prior myocardial infarction (MI) and implantable cardioverter-defibrillators (ICD). METHODS Multicenter observational cohort study including 643 consecutive patients with prior MI and a first ICD implanted between 2005 and 2018 at three tertiary hospitals. All the patients included in the study had undergone a diagnostic coronary angiography before ICD implantation. The variable prior ventricular arrhythmias (VA+) was positive in patients with secondary prevention ICDs and in those with at least one appropriate ICD therapy after primary prevention implantation. RESULTS During a median follow-up of 42 months 59 patients (9%) suffered ES. The presence of at least one IRACTO not revascularized (IRACTO-NR) was associated with a significantly higher cumulative incidence of ES (14.5% vs 4.8%, p < 0.001). IRACTO-NR maintained a significant association with ES after adjustment for potential confounders (HR 2.3, p = 0.005) and was an independent predictor of ES together with VA+ and LVEF. The best cut-off of LVEF to predict ES was ≤38%. A risk-prediction model based on IRACTO-NR, VA+ and LVEF≤38% identified three categories of ES risk (low, intermediate and high), with progressively increasing cumulative incidence of ES (2.2%, 9% and 20%). CONCLUSION In a cohort of patients with prior MI and ICD, IRACTO-NR is an independent predictor of ES. A new risk-prediction model allowed the identification of three categories of risk, with potentially important clinical implications.
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Affiliation(s)
- Valentina Faga
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Ignasi Anguera
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Teresa Oloriz
- Cardiology Department, Hospital Miguel Servet, Zaragoza, Spain
| | | | - Luis Teruel
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Paolo Dallaglio
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | | | | | - Javier Escaned
- Cardiology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Joan Antoni Gomez Hospital
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Julián Rodriguez García
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Marcos Rodriguez García
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Josep Comin Colet
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, School of Medicine, University of Barcelona, Spain
| | - Andrea Di Marco
- Cardiology Department, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain; BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain.
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Assaf A, Diletti R, Hoogendijk MG, van der Graaf M, Zijlstra F, Szili-Torok T, Yap SC. Vulnerability for ventricular arrhythmias in patients with chronic coronary total occlusion. Expert Rev Cardiovasc Ther 2020; 18:487-494. [PMID: 32684000 DOI: 10.1080/14779072.2020.1793671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The presence of a chronic total occlusion (CTO) is associated with an increased risk of ventricular arrhythmias. AREAS COVERED This review provides an overview of the relationship between CTO and ventricular arrhythmias, arrhythmogenic mechanisms, and the effect of revascularization. EXPERT OPINION Studies in recipients of an implantable cardioverter-defibrillator (ICD) have shown that a CTO is an independent predictor of appropriate ICD therapy. The myocardial territory supplied by a CTO is a pro-arrhythmogenic milieu characterized by scar tissue, large scar border zone, hibernating myocardium, residual ischemia despite collaterals, areas of slow conduction, and heterogeneity in repolarization. Restoring coronary flow by revascularization might be associated with electrical homogenization as reflected by a decrease in QT(c) dispersion, decrease in T wave peak-to-end interval, reduction of late potentials, and decrease in scar border zone area. Future research should explore whether CTO revascularization results in a lower burden of ventricular arrhythmias. Furthermore, risk stratification of CTO patients without severe LV dysfunction is interesting to identify potential ICD candidates. Potential tools for risk stratification are the use of electrocardiographic parameters, body surface mapping, electrophysiological study, and close rhythm monitoring using an insertable cardiac monitor.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Mark G Hoogendijk
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Marisa van der Graaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
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5
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Di Marco A, Anguera I, Nombela‐Franco L, Oloriz T, Teruel L, Rodriguez Mañero M, Toquero J, León V, Dallaglio P, Perez Guerrero A, Salazar CH, Escaned J, Asso Abadía A, Gomez Hospital JA, Cequier A. Revascularization of coronary chronic total occlusions in an infarct‐related artery and recurrence of ventricular arrhythmias among patients with secondary prevention implantable cardioverter defibrillator. Catheter Cardiovasc Interv 2020; 97:E1-E11. [DOI: 10.1002/ccd.28915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/27/2020] [Accepted: 04/04/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Andrea Di Marco
- Cardiology Department Bellvitge University Hospital Barcelona Spain
| | - Ignasi Anguera
- Cardiology Department Bellvitge University Hospital Barcelona Spain
| | | | - Teresa Oloriz
- Cardiology Department Hospital Miguel Servet Zaragoza Spain
| | - Luis Teruel
- Cardiology Department Bellvitge University Hospital Barcelona Spain
| | - Moisés Rodriguez Mañero
- Cardiology Department Hospital Universitario Santiago de Compostela Santiago de Compostela Spain
| | - Jorge Toquero
- Cardiology Department Hospital Puerta del Hierro, Majadahonda Madrid Spain
| | - Valentina León
- Cardiology Department Bellvitge University Hospital Barcelona Spain
| | - Paolo Dallaglio
- Cardiology Department Bellvitge University Hospital Barcelona Spain
| | | | | | - Javier Escaned
- Cardiology Department Hospital Clínico San Carlos Madrid Spain
| | | | | | - Angel Cequier
- Cardiology Department Bellvitge University Hospital Barcelona Spain
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Yamashita K, Igawa W, Ono M, Kido T, Okabe T, Isomura N, Araki H, Ochiai M. Impact of recanalization of chronic total occlusion on left ventricular electrical remodeling. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:712-721. [PMID: 30963616 PMCID: PMC6849561 DOI: 10.1111/pace.13691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 11/29/2022]
Abstract
Background Successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is associated with reduction of cardiac mortality, as well as reducing fatal ventricular arrhythmias. The aim of this study was to evaluate the effect of recanalization of CTO on endocardial left ventricular voltages by paired electrophysiological studies. Methods Sixteen consecutive patients who underwent PCI for de novo CTO lesions were included. High‐density mapping was performed during sinus rhythm before and 8 months after PCI. According to the amplitude of bipolar electrograms, the left ventricular endocardium was classified into a preserved normal voltage (>1.5 mV), border zone (0.5–1.5 mV), and dense scar areas (<0.5 mV). Results The border zone area had a significant positive correlation with CTO length, as well as a significant negative correlation observed in the preserved voltage region. In the successful PCI patient, the median dense scar area did not change significantly (reported as [median difference: 95% confidence interval]) between baseline and after PCI (0.1 cm2: –2.8 to 2.9). However, the area of the border zone decreased (–10.5 cm2: –16.8 to –4.1) and the preserved voltage area increased significantly (19.2 cm2: 7.7–30.6). In addition, successful PCI was related to slight, but significant, increase in the amplitude of unipolar and bipolar voltage (1.55 mV: 0.88–3.33, 0.23 mV: 0.08–0.36). Conclusions Recanalization of CTO may promote reverse electrical remodeling in the border zone of the left ventricle, without affecting the dense scar tissue.
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Affiliation(s)
- Kennosuke Yamashita
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Wataru Igawa
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Morio Ono
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Takehiko Kido
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Toshitaka Okabe
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Naoei Isomura
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Hiroshi Araki
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Masahiko Ochiai
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan
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