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

Prognostic Value of Different Levels of Uric Acid in Patients with Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Recent data suggest that uric acid (UA) might be an independent predictor of clinical outcomes following percutaneous coronary intervention (PCI). The predictive value of uric acid in patients undergoing PCI for chronic total occlusions (CTO) is unknown. We included patients with CTO who underwent PCI at our center in 2005 and 2012, with available uric acid levels before angiography. Subjects were divided into groups according to uric acid tertiles (<5.5 mg/dL, 5.6-6.9 mg/dL, and >7.0 mg/dL), and outcomes were compared among the groups. Out of the 1963 patients (mean age 65.2 ± 11 years), 34.7% (n = 682) had uric acid concentrations in the first tertile, 34.3% (n = 673) in the second tertile, and 31% (n = 608) in the third tertile. Median follow-up was 3.0 years. Uric acid levels in the first tertile were associated with significantly lower all-cause mortality, as compared to the third tertile, with an adjusted hazard ratio (HR) of 0.67 (95% confidence interval (CI): 0.49 to 0.92; p = 0.012). No significant differences regarding all-cause mortality were found between patients in the first and second tertiles (HR: 0.96 [95% CI: 0.71 to 1.3; p = 0.78]). High levels of uric acid emerged as an independent predictor of all-cause mortality in patients with chronic total occlusion treated with PCI. Hence, uric acid levels should be incorporated into the risk assessment of patients with CTO.

Infarct-Related Artery as a Donor of Collaterals in ST-Segment-Elevation Myocardial Infarction With Concomitant Chronic Total Occlusion: Challenge of the Double-Jeopardy Thesis

BACKGROUND In ST-segment-elevation myocardial infarction (STEMI), a concomitant chronic total occlusion (CTO) in a non-infarct-related artery (NIRA) is associated with adverse outcome. In the case of the infarct-related artery (IRA) as a donor vessel for collaterals to the CTO, the IRA occlusion may lead to an acute threat to both the immediate IRA and the collaterally supplied CTO area, which has been described as a double-jeopardy effect. METHODS AND RESULTS We investigated the role of preformed intercoronary collaterals to the CTO originating from either the IRA or NIRA. Data were obtained from 2 hospitals participating in the prospective FITT-STEMI (Feedback Intervention and Treatment Times in ST-Segment Elevation Myocardial Infarction) study. From a total cohort of 2102 patients with acute STEMI, 93 patients had single-vessel CTO in an NIRA and well-developed intercoronary collaterals to the CTO. In-hospital mortality differed significantly with respect to the origin of the collaterals. Mortality was 15.2% with collaterals originating from the NIRA, 29.4% with a collateral origin from the IRA proximal to the acute STEMI occlusion, and 3.3% with a collateral origin from the IRA distal to the acute occlusion (P=0.044). A multivariate regression model confirmed that a proximal collateral origin had a significant higher mortality compared with a branching in the distal position from the acute STEMI occlusion (P=0.027; odds ratio = 20.8 [95% CI, 1.4-304.1]). CONCLUSIONS In STEMI with CTO in an NIRA, a CTO collateralization from the IRA distal to the acute occlusion is associated with a better prognosis. This finding challenges the double-jeopardy assumption as the main cause of adverse outcome in STEMI with CTO in an NIRA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00794001.

Prevalence and associated factors of mortality after percutaneous coronary intervention for adult patients with ST-elevation myocardial infarction: A systematic review and meta-analysis

Background

There is a paucity of systematic reviews on the associated factors of mortality among ST-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention (PCI). This meta-analysis was designed to synthesize available evidence on the prevalence and associated factors of mortality after PCI for adult patients with STEMI.

Materials and Methods

Databases including the Cochrane Library, PubMed, Web of Science, Embase, Ovid, Scopus, ProQuest, MEDLINE, and CINAHL Complete were searched systematically to identify relevant articles published from January 2008 to March 2020 on factors affecting mortality after PCI in STEMI patients. Meta-analysis was conducted using Stata 12.0 software package.

Results

Our search yielded 91 cohort studies involving a total of 199, 339 participants. The pooled mortality rate for STEMI patients after PCI was 10%. After controlling for grouping criteria or follow-up time, the following 17 risk factors were significantly associated with mortality for STEMI patients after PCI: advanced age (odds ratio [OR] = 3.89), female (OR = 2.01), out-of-hospital cardiac arrest (OR = 5.55), cardiogenic shock (OR = 4.83), renal dysfunction (OR = 3.50), admission anemia (OR = 3.28), hyperuricemia (OR = 2.71), elevated blood glucose level (OR = 2.00), diabetes mellitus (OR = 1.8), chronic total occlusion (OR = 2.56), Q wave (OR = 2.18), without prodromal angina (OR = 2.12), delay in door-to-balloon time (OR = 1.72), delay in symptom onset-to-balloon time (OR = 1.43), anterior infarction (OR = 1.66), ST-segment resolution (OR = 1.40), and delay in symptom onset-to-door time (OR = 1.29).

Conclusion

The pooled prevalence of mortality after PCI for STEMI patients was 10%, and 17 risk factors were significantly associated with mortality for STEMI patients after PCI.

SerpinG1: A Novel Biomarker Associated With Poor Coronary Collateral in Patients With Stable Coronary Disease and Chronic Total Occlusion

Background This study aimed to explore predictive biomarkers of coronary collateralization in patients with chronic total occlusion. Methods and Results By using a microarray expression profiling program downloaded from the Gene Expression Omnibus database, weighted gene coexpression network analysis was constructed to analyze the relationship between potential modules and coronary collateralization and screen out the hub genes. Then, the hub gene was identified and validated in an independent cohort of patients (including 299 patients with good arteriogenic responders and 223 patients with poor arteriogenic responders). Weighted gene coexpression network analysis showed that SERPING1 in the light-cyan module was the only gene that was highly correlated with both the gene module and the clinical traits. Serum levels of serpinG1 were significantly higher in patients with bad arteriogenic responders than in patients with good arteriogenic responders (472.53±197.16 versus 314.80±208.92 μg/mL; P<0.001) and were negatively associated with the Rentrop score (Spearman r=-0.50; P<0.001). Receiver operating characteristic curve analysis indicated that the area under the curve was 0.77 (95% CI, 0.72-0.81; P<0.001) for serum serpinG1 in prediction of bad arteriogenic responders. After adjusting for traditional cardiovascular risk factors, serum serpinG1 levels (per SD) remained an independent risk factor for bad arteriogenic responders (odds ratio, 2.20 [95% CI, 1.76-2.74]; P<0.001). Conclusions Our findings illustrate that SERPING1 screened by weighted gene coexpression network analysis was associated with poor collateralization in patients with chronic total occlusion.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization

Background

Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures.

Methods

From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time).

Results

A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm² vs. 1,300 mGy×cm², p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35).

Conclusion

Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Chronic total occlusion revascularization: A complex piece to "complete" the puzzle

Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of “contemporary” strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a “complex” piece to “complete” the puzzle.

A comparison of long-term clinical outcomes between percutaneous coronary intervention (PCI) and medical therapy in patients with chronic total occlusion in noninfarct-related artery after PCI of acute myocardial infarction

BACKGROUND

Chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is one of the risk factors for mortality after acute myocardial infarction (AMI). However, there are limited data comparing the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with patients having medical therapy (MT) in CTO lesion after AMI PCI.

METHODS

We retrospectively enrolled 330 patients (successful CTO PCI in 166 patients, failed CTO PCI in 32 patients, MT in 132 patients) with non-IRA CTO from a total of 4372 patients who underwent PCI after AMI in our center. Propensity score matching (PSM) was used to adjust for baseline differences.

RESULTS

The primary analysis is based on the intention-to-treat population. During a median follow-up period of 946 days, patients in the PCI group (n = 198) had significantly higher cardiac death-free survival (96.6% vs. 82.8%, p = .004) compared with patients in MT group (n = 132). However, no significant difference in the occurrence of cardiac death was observed after PSM. The analysis based on the per-protocol population demonstrated significantly higher cardiac death-free survival in the successful CTO PCI group (n = 166) compared with the occluded CTO group (n = 164) both before and after PSM. In subgroup analysis, successful CTO PCI was associated with less cardiac death in patients over 65 years old, with LVEF < 50%, left anterior descending (LAD) IRA, and non-LAD CTO lesion compared with occluded CTO group.

CONCLUSIONS

Patients undergoing successful revascularization of non-IRA CTO after AMI might have a better long-term prognosis. Moreover, patients with LVEF < 50% may benefit from successful non-IRA CTO PCI after AMI.

Plasma Heat Shock Protein 70 Is Associated With the Onset of Acute Myocardial Infarction and Total Occlusion in Target Vessels

Background: Whether the role of plasma heat shock protein 70 (HSP70) in acute myocardial infarction (AMI) is protective or detrimental remains debated, and the relationship between HSP70 and total occlusion remains elusive.

Methods: A total of 112 patients with primary diagnosis of AMI and 52 patients with chronic coronary syndrome (CCS) were enrolled into the study. Plasma HSP70 level was determined by ELISA on day 1 and day 7 after the onset of AMI and was examined before angiography in patients with CCS. Peak NT-proBNP, high-sensitivity C-reactive protein (CRP), troponin T (cTnT), and left ventricular ejection fraction were measured.

Results: Plasma HSP70 was significantly higher in CCS than AMI (P < 0.0001), and it showed a significant decrease from day 1 to day 7 after AMI (P < 0.01). Elevated HSP70 was associated with decreased levels of LDL-C (P < 0.05), peak cTnT (R = −0.3578, P < 0.0001), peak NT-proBNP (R = −0.3583, P < 0.0001), and peak CRP (R = −0.3539, P < 0.0001) and a lower diagnosis of AMI (R = −0.4016, P < 0.0001) and STEMI (R = −0.3675, P < 0.0001), but a higher diagnosis of total occlusion in target vessels (R = 0.1702, P < 0.05). HSP70 may provide certain predictive value for the diagnosis of AMI, STEMI, and total occlusion in target vessels, and the area under the receiver operating characteristic curves were 0.7660, 0.7152, and 0.5984, respectively. HSP70 was also negatively associated with in-hospital stay (P < 0.001) and positively correlated with left ventricular ejection fraction (LVEF) at 1-year follow-up (P < 0.05), despite no association with in-hospital major adverse cardiovascular events (MACE).

Conclusion: Plasma HSP70 level was found to decrease from day 1 to day 7 post-AMI, but the overall level of patients with AMI was lower than that of patients with CCS. However, the ability of HSP70 to identify clinically significant AMI and STEMI was moderate, and the predictive value to total occlusion was slight.

Shockwave intravascular lithotripsy as a novel strategy for balloon undilatable heavily calcified chronic total occlusion lesions

BACKGROUND

The successful percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) improves the long-term outcome in patients with coronary artery disease (CAD). Heavy calcification remains one of the strongest predictors of an unfavorable outcome of PCI. In this case series study, shockwave intravascular lithotripsy (S-IVL)-a novel balloon-based coronary system facilitating modification of calcified coronary lesions was evaluated.

METHODS

The study population consisted of five heavily calcified, undilatable-CTOs lesions treated with S-IVL selected out of all consecutive CTO-PCI patients performed at two high-volume cardiac centers.

RESULTS

The registry included 5 patients successful CTO - S-IVL procedures with an average J-CTO of 2.6 points. In the short-term follow-up period, including the first 30 days, no cases of acute in-stent thrombosis, target lesion failure, or major adverse cardiac and cerebrovascular events were noted.

CONCLUSIONS

The present data suggest that this approach can be safe and useful in the treatment of complex calcified CTO lesions.