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Gikandi A, Stock EM, Dematt E, Quin J, Hirji S, Biswas K, Zenati MA. Chronic total occlusions and coronary artery bypass grafting outcomes. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00700-1. [PMID: 39173708 DOI: 10.1016/j.jtcvs.2024.08.016] [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] [Received: 03/26/2024] [Revised: 07/29/2024] [Accepted: 08/07/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVE To investigate the association between the presence and grafting of chronic total occlusions (CTOs) and coronary artery bypass grafting (CABG) outcomes. METHODS This was a post hoc analysis of the Randomized Endograft vs Open Prospective (REGROUP) trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified on the basis of the presence of at least 1 CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months) and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. RESULTS At least 1 CTO was present in 453 of 1149 patients (39.4%). Over a median follow-up of 4.7 years (interquartile range, 3.84-5.45), MACE rates were 23.4% versus 22.2% for the CTO versus no CTO group, respectively (adjusted hazard ratio [aHR], 0.92; 95% confidence interval [CI], 0.70-1.20). MACE rates for patients with complete CTO grafting versus not were 23.1% versus 25.0%, respectively (aHR, 0.95; 95% CI, 0.57-1.57). In patients with right coronary dominance undergoing left anterior descending artery grafting, bypassing a right coronary artery CTO was associated with significantly lower rates of all-cause mortality (aHR, 0.38; 95% CI, 0.17-0.83). CONCLUSIONS In this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels was associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside left anterior descending artery grafting warrants additional study.
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Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Eileen M Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Ellen Dematt
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Jacquelyn Quin
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass
| | - Sameer Hirji
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Md
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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2
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Sahu AK, Kazmi DH, Kaushik A. Is it Worthy Enough to Revascularize Chronically Occluded Coronaries? Cardiol Rev 2024; 32:338-347. [PMID: 36912530 DOI: 10.1097/crd.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.
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Affiliation(s)
- Ankit Kumar Sahu
- From the Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
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3
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Kyaw H, Giustino G, Kumar S, Sartori S, Qiu H, Feng Y, Iruvanti S, Kini A, Mehran R, Sharma SK. Gender-Based Differences in Outcomes After Percutaneous Coronary Intervention of Chronic Total Occlusions (Insights from a Large Single-Center Registry). Am J Cardiol 2023; 207:108-113. [PMID: 37734299 DOI: 10.1016/j.amjcard.2023.08.134] [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] [Received: 10/02/2022] [Revised: 07/28/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Abstract
Patients who undergo percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are at a high risk for both periprocedural and post-procedural adverse events. Whether gender-differences in outcomes exist after PCI of CTO remain unclear. Therefore, we sought to investigate gender-based differences in outcomes after CTO-PCI. All patients who underwent elective CTO intervention from January 2012 to December 2017 at The Mount Sinai Hospital (New York, New York) were included. The primary end point of interest was major adverse cardiac events defined as the composite of death, myocardial infarction, and target vessel revascularization at 1 year of follow-up. A total 1,897 patients were included, of which 368 were women (19.4%). Mean follow-up time was 174 days. Women were older (66.8 ± 11.3 years vs 62.6 ± 10.9 years) and had a higher prevalence of co-morbidities including diabetes and chronic kidney disease. There were no significant differences in the rate of successful CTO-PCI between groups (73.5% vs 73.2%, p = 0.91). Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding (4.1% vs 1.8%, p = 0.009) and acute vessel closure (1.36% vs 0.2%, p = 0.009). In multivariable-adjusted analysis, female gender was associated with higher risk of major adverse cardiac event and target vessel revascularization at 1 year. In conclusion, in this large single-center study, women who underwent percutaneous CTO revascularization experienced higher rates of periprocedural complications and worse clinical outcomes at 1 year compared with men. Further research is needed to address disparities in gender-specific outcomes of CTO-PCI.
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Affiliation(s)
- Htoo Kyaw
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suwen Kumar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hanbo Qiu
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yihan Feng
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suvruta Iruvanti
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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4
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Kucukseymen S, Iannaccone M, Grantham JA, Sapontis J, Juricic S, Ciardetti N, Mattesini A, Stojkovic S, Strauss BH, Wijeysundera HC, Werner GS, D'Ascenzo F, Di Mario C. Association of Successful Percutaneous Revascularization of Chronic Total Occlusions With Quality of Life: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2324522. [PMID: 37471086 PMCID: PMC10359963 DOI: 10.1001/jamanetworkopen.2023.24522] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Importance Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is not usually offered because of skepticism about long-term clinical benefits. Objective To assess the association of successful CTO-PCI with quality of life by analyzing the relevant domains of the Seattle Angina Questionnaire (SAQ). Data Sources PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane databases were searched to identify randomized trials and observational studies specifically addressing quality of life domains of SAQ from January 2010 to June 2022. Study Selection Studies included reporting SAQ metrics such as angina frequency, physical limitation, and quality of life, before and after CTO-PCI. Data Extraction and Synthesis The present study was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements, in which fixed-effect or random-effect models with generic inverse-variance weighting depending on statistical homogeneity were applied. Data were extracted by 3 independent reviewers. Outcomes and Measures The primary outcome was angina frequency; physical limitation and quality of life were assessed as secondary outcomes. Results Seven prospective randomized or observational studies (2500 patients) were included, with a mean (SD) participant age of 61.2 (2.1) years. CTO-PCI was associated with significantly improved quality-of-life metrics during a mean (SD) follow-up of 14.8 (16.3) months. In patients with successful procedures, angina episodes became less frequent (mean [SD] difference for SAQ angina frequency of 12.9 [3.1] survey points [95% CI, 7.1-19.8 survey points]; standardized mean difference was 0.54 [95% CI, 0.21-0.92]; P = .002; I2 = 86.4%) and they experienced less physical activity limitation (mean [SD] difference for SAQ physical limitation of 9.7 [6.2] survey points [95% CI, 3.5-16.2 survey points]; standardized mean difference was 0.42 [95% CI, 0.24-0.55]; P < .001; I2 = 20.9%), and greater quality-of-life domain (mean [SD] difference for SAQ quality of life of 14.9 [3.5] survey points [95% CI, 7.7-22.5 survey points]; standardized mean difference was 0.41 [95% CI, 0.25-0.61]; P < .001; I2 = 58.8%) compared with patients with optimal medical therapy or failed procedure. Furthermore, follow-up duration (point estimate, 0.03; 95% CI, 0.01-0.04; P = .01) was associated with a significant decrease in angina frequency in meta-regression analysis. Conclusions and Relevance In this systematic review and meta-analysis examining quality of life following CTO-PCI, successful procedures were associated with improved quality-of-life parameters compared with patients on optimal medical therapy or after failed CTO-PCI. These findings suggest support for using PCI to treat CTOs in symptomatic patients unresponsive to medical treatment.
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Affiliation(s)
- Selcuk Kucukseymen
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Mario Iannaccone
- Cardiology Department, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - James A Grantham
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Stefan Juricic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Niccolò Ciardetti
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
| | - Sinisa Stojkovic
- Clinic for Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bradley H Strauss
- Schulich Heart Program, Division of Cardiology, University of Toronto, Ontario, Canada
| | | | - Gerald S Werner
- Medizinische Klinik I, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science, University of Turin, Turin, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
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5
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Guo L, Lv H, Yin X. Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Graft: Current Evidence and Future Perspectives. Front Cardiovasc Med 2022; 9:753250. [PMID: 35479272 PMCID: PMC9037955 DOI: 10.3389/fcvm.2022.753250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary chronic total occlusion (CTO), which occurs in 18. 4-52% of all patients referred for coronary angiography, represents one of the last barriers in coronary intervention. Approximately half of all patients with prior coronary artery bypass graft (CABG), who undergo coronary angiography, are diagnosed with coronary CTO. In fact, these patients often develop recurrent symptoms and events, necessitating revascularization. Currently, there is neither a consensus nor developed guidelines for the treatment of CTO patients with prior CABG, and the prognosis of these patients remains unknown. In this review, we discuss current evidence and future perspectives on CTO revascularization in patients with prior CABG, with special emphasis on clinical and lesion characteristics, procedural success rates, periprocedural complications, and long-term outcomes.
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Affiliation(s)
| | | | - Xiaomeng Yin
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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6
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Hu YY, Cai YJ, Jiang X, Mao FY, Zhang J, Liu L, Wu Q, Wang XH. Relationship between dynamic changes of peri-procedure anxiety and short-term prognosis in patients undergoing elective percutaneous coronary intervention for coronary heart disease: A single-center, prospective study. PLoS One 2022; 17:e0266006. [PMID: 35363813 PMCID: PMC8974971 DOI: 10.1371/journal.pone.0266006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Patients with coronary heart disease (CHD) often experience anxiety, but the current studies on anxiety mostly focused on a certain point in time. Therefore, this study aimed to investigate the dynamic changes of peri-procedure anxiety, status of post-procedure quality of life, and cardiovascular readmission rates in patients with CHD who undergoing elective percutaneous coronary intervention (PCI), and to analyze the influence of peri-procedure anxiety on quality of life and readmission rate after PCI.
Methods
This prospective study was conducted at Changshu NO.1 People’s Hospital. A total of 220 patients with CHD undergoing elective PCI were selected as study subjects. The general information, clinical data, anxiety, quality of life and readmission of patients were collected. Multivariate linear regression was used to examine the effect of peri-procedure anxiety on quality of life, and multivariate logistic regression was used to analyze the influence of peri-procedure anxiety on readmission rate.
Results
This study showed the anxiety scores at hospitalization appointment(T1), 3 days before procedure(T2), 1 day before procedure(T3), 1 day after procedure(T4) were 57(55,61),64(61,68),54(51.58), and 54(50,60), respectively. And, at 3 months and 6 months after PCI, the scores of Seattle Angina Questionnaire (SAQ) were 346.61(319.06,366.52) and 353.34(334.18,372.84) respectively. During 6 months follow-up, 54 cases were readmitted, with a readmission rate of 25.5%. Statistical analysis showed that T1 with anxiety (P = 0.002) and T2 with anxiety (P = 0.024) were independent risk factors for treatment satisfaction at 3 months after PCI. Anxiety in T4 (P = 0.005) was an independent risk factor on the angina frequency at 6 months after PCI. T2 with anxiety (B = 1.445, P = 0.010, 95%CI:1.409–12.773) and T4 without anxiety (B = -1.587, P = 0.042, 95%CI:-0.044–0.941) were risk factors affecting readmission for cardiovascular reasons within 6 months.
Conclusion
Patient anxiety at T1 and T2 affects the treatment satisfaction dimension of the SAQ at 3 months after PCI, and anxiety at T4 affects the angina frequency dimension of the SAQ at 6 months after PCI. Anxiety at T2 and no anxiety at T4 increase short-term readmission rates. In the future, interventions should be strengthened at various time points in the peri-procedure period to improve post-procedure rehabilitation effect.
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Affiliation(s)
- Yao-yao Hu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, P.R, China
| | - Ya-jing Cai
- Department of Cardiology, Changshu NO.1 People’s Hospital, Suzhou, Jiangsu Province, P.R, China
| | - Xin Jiang
- Nursing Department, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, Jiangsu Province, P.R, China
| | - Fang-ying Mao
- School of Nursing, Soochow University, Suzhou, Jiangsu Province, P.R, China
| | - Jing Zhang
- School of Nursing, Soochow University, Suzhou, Jiangsu Province, P.R, China
| | - Lin Liu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, P.R, China
| | - Qing Wu
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, P.R, China
- * E-mail: (QW); (XW)
| | - Xiao-hua Wang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, P.R, China
- * E-mail: (QW); (XW)
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7
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Strauss BH, Knudtson ML, Cheema AN, Galbraith PD, Elbaz-Greener G, Abuzeid W, Henning KA, Qiu F, Wijeysundera HC. Canadian Multicenter Chronic Total Occlusion Registry: Ten-Year Follow-Up Results of Chronic Total Occlusion Revascularization. Circ Cardiovasc Interv 2021; 14:e010546. [PMID: 34932391 DOI: 10.1161/circinterventions.121.010546] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic total occlusions (CTO) occur in nearly 20% of coronary angiograms. CTO revascularization, either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting surgery (CABG), is infrequently performed, approximately one-third of cases. Long-term outcomes are unknown. The objective of the study was to determine whether early CTO revascularization of patients, either by CABG or PCI, was associated with improved clinical outcomes. METHODS One thousand six hundred twenty-four patients from the Canadian CTO registry were followed for at least 9.75 years. Revascularization was performed according to routine clinical practice. Patients were grouped according to CTO revascularization status (PCI or CABG of CTO vessel, CTO revasc) or no CTO revasc (medical therapy only, or PCI/CABG of non-CTO vessels only), within 3 months of initial angiogram. Patients were followed for mortality, revascularization procedures (PCI and CABG), and hospitalizations for acute coronary syndromes and heart failure. RESULTS Early CTO revasc was performed in 28.2% of patients (17.5% CABG, 10.7% PCI). The CTO revasc group was younger, with more males and generally fewer comorbidities. There was a significantly lower mortality probability at 10 years in the CTO revascularization group (22.7% [95% CI, 19.0%-26.9%]) compared with the no CTO revasc group (36.6% [95% CI, 33.8%-39.5%]). At 10 years, revascularization rates (14.0% versus 22.8%) and acute coronary syndrome hospitalization rates (10.0% versus 16.6%) were significantly lower in the CTO revasc group. Baseline-adjusted analysis showed CTO revasc was associated with significantly lower all-cause mortality (hazard ratio, 0.67 [95% CI, 0.54-0.84]). In both landmark and time varying analyses, association with lower mortality was particularly robust for CTO revascularization by CABG (hazard ratio 0.56 and 0.60, respectively), with a marginally significant result for PCI in the time varying analysis (hazard ratio 0.711 [95% CI, 0.51-0.998]). CONCLUSIONS Early CTO revascularization was associated with significantly lower all-cause mortality, revascularization rates, and hospitalization for acute coronary syndrome at 10 years, and mainly driven by outcomes in patients with CABG.
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Affiliation(s)
- Bradley H Strauss
- Schulich Heart Program, Sunnybrook Health Sciences Centre (B.H.S., G.E.-G., W.A., H.C.W.).,University of Toronto, Ontario, Canada (B.H.S., A.N.C., K.A.H., F.Q., H.C.W.)
| | - Merril L Knudtson
- Libin Cardiovascular Institute of Alberta, Calgary, Canada (M.L.K., P.D.G.)
| | - Asim N Cheema
- Terrence Donnelly Heart Center, St. Michael's Hospital (A.N.C.).,University of Toronto, Ontario, Canada (B.H.S., A.N.C., K.A.H., F.Q., H.C.W.)
| | - P Diane Galbraith
- Libin Cardiovascular Institute of Alberta, Calgary, Canada (M.L.K., P.D.G.)
| | - Gabby Elbaz-Greener
- Schulich Heart Program, Sunnybrook Health Sciences Centre (B.H.S., G.E.-G., W.A., H.C.W.).,Now with Hadassah Medical Center, Hebrew University, Jerusalem, Israel (G.E.-G.)
| | - Wael Abuzeid
- Schulich Heart Program, Sunnybrook Health Sciences Centre (B.H.S., G.E.-G., W.A., H.C.W.).,Now with Kingston General Hospital, Queen's University, Kingston, Ontario, Canada (W.A.)
| | - Kayley A Henning
- University of Toronto, Ontario, Canada (B.H.S., A.N.C., K.A.H., F.Q., H.C.W.).,ICES, Toronto, Ontario (K.A.H., F.Q., H.C.W.)
| | - Feng Qiu
- University of Toronto, Ontario, Canada (B.H.S., A.N.C., K.A.H., F.Q., H.C.W.).,ICES, Toronto, Ontario (K.A.H., F.Q., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre (B.H.S., G.E.-G., W.A., H.C.W.).,University of Toronto, Ontario, Canada (B.H.S., A.N.C., K.A.H., F.Q., H.C.W.).,ICES, Toronto, Ontario (K.A.H., F.Q., H.C.W.)
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8
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Abunassar J, Dave P, Alturki M, Abuzeid W. Preprocedural computed tomography angiography in differentiating chronic total from subtotal coronary occlusions. J Cardiovasc Med (Hagerstown) 2021; 22:371-377. [PMID: 32941329 DOI: 10.2459/jcm.0000000000001113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Differentiation of chronic total occlusion (CTO) from subtotal coronary occlusions (STOs) is often difficult to make from coronary angiography. These differences are very important, as the technical expertise and tools required are significantly different for revascularization of these lesions. We sought to determine if preprocedural computed tomography angiography (CTA) can help better diagnose and differentiate CTO from STO. METHODS We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from 1 January 1946 to 1 March 2019. Studies reporting on the use of computed tomography (CT) to aid in CTO revascularization were included. Case reports and case series were excluded. RESULTS We identified 577 articles, and using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method, 4 articles met prespecified inclusion criteria. A total of 669 patients were included. The statistically significant CT-derived parameters determined to help differentiate CTO from STO were found to include longer lesion length (four out of four studies), larger contrast density difference (one out of four studies), presence of collaterals (two out of four studies) and the presence of the reverse attenuation gradient sign (two out of four studies). CONCLUSION This systematic review shows the utility of preprocedural CTA to help differentiate CTO from STO using a number of CT-derived parameters as above. Further, this study highlights the need for further research to develop specific validated parameters for differentiation of CTO and STO.
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Affiliation(s)
- Joseph Abunassar
- Division of Cardiology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | | | - Mohammad Alturki
- Division of Cardiology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Wael Abuzeid
- Division of Cardiology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
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9
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Allahwala UK, Kiat H, Ekmejian A, Mughal N, Bassin L, Ward M, Weaver JC, Bhindi R. Both surgical and percutaneous revascularization improve prognosis in patients with a coronary chronic total occlusion (CTO) irrespective of collateral robustness. Heart Vessels 2021; 36:1653-1660. [PMID: 33914092 DOI: 10.1007/s00380-021-01859-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/16/2021] [Indexed: 11/29/2022]
Abstract
The impact of surgical or percutaneous coronary revascularization on prognosis in patients with a chronic total occlusion (CTO) remains uncertain. Particularly, whether revascularization of those with robust coronary collaterals improves prognosis is unknown. The objective of this study was to determine the predictors and prognostic impact of revascularization of a CTO, and to determine the clinical impact of robust coronary collaterals. Patients with a CTO diagnosed on coronary angiography between Jul 2010 and Dec 2019 were included in this study. Management strategy of the CTO was defined as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical management. The degree of collateral robustness was determined by the Rentrop grading classification. Demographic, angiographic and clinical outcomes were recorded. A total of 954 patients were included in the study, of which 186 (19.5%) patients underwent CTO PCI, 296 (31.0%) patients underwent CABG and 472 (49.5%) patients underwent medical management of the CTO. 166 patients (17.4%) had Rentrop grade zero or one collaterals, 577 (60.5%) patients had Rentrop grade two and 211 (22.1%) had Rentrop grade three collaterals. The independent predictors of medical management of the CTO were older age, greater stenosis in the donor vessel, an emergent indication for angiography, a non-LAD CTO and female sex. The degree of collateral robustness was not associated with long-term mortality, while patients who were revascularized either through CABG or PCI had a significantly lower mortality compared to medical management alone (p < 0.0001). In patients with a CTO, the presence of robust collaterals is not associated with prognosis, while both surgical and percutaneous revascularization is associated with improved prognosis. Further research into the optimal revascularization strategy for a CTO is required.
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Affiliation(s)
- Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, 2065, Australia. .,The University of Sydney, Sydney, Australia.
| | - Hosen Kiat
- Faculty of Medicine and Health Sciences, Macquarie University, Marsfield, Australia.,Faculty of Medicine, University of New South Wales, Kensington, Australia
| | - Avedis Ekmejian
- Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, 2065, Australia
| | - Nadeem Mughal
- Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, 2065, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Michael Ward
- Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, 2065, Australia.,The University of Sydney, Sydney, Australia
| | - James C Weaver
- The University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney, 2065, Australia.,The University of Sydney, Sydney, Australia
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10
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Meng S, Qiu L, Wu J, Huang R, Wang H. Two-year left ventricular systolic function of percutaneous coronary intervention vs optimal medical therapy for patients with single coronary chronic total occlusion. Echocardiography 2021; 38:368-373. [PMID: 33475185 DOI: 10.1111/echo.14976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/29/2020] [Indexed: 01/05/2023] Open
Abstract
In this study, two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE) were applied to compare the changes of left ventricular systolic function associated with percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with single chronic total occlusion (CTO). 63 single CTO patients (age 61.88 ± 8.86 years) were examined by echocardiography and were divided into the PCI group (n = 27) and OMT group (n = 36) according to the initial treatment strategy. Two-dimensional left ventricular ejection fraction (2D-LVEF), two-dimensional indexed left ventricular end-systolic volume (2D-LVESVI), and two-dimensional indexed left ventricular end-diastolic volume (2D-LVEDVI) were measured using two-dimensional echocardiography (2DE). Three-dimensional left ventricular ejection fraction (3D-LVEF), three-dimensional indexed left ventricular end-systolic volume (3D-LVESVI), and three-dimensional indexed left ventricular end-diastolic volume (3D-LVEDVI) were measured using RT-3DE. Global circumferential strain (GCS) and global longitudinal strain (GLS) were measured using 2D-STE. After 2 years of follow-up, there were no significant differences in the 2D-LVEF, 2D-LVESVI, 3D-LVEF, 3D-LVESVI, 3D-LVEDVI, and GCS, except for GLS (P = .001) between the CTO-PCI and CTO-OMT groups. GLS decreased significantly in OMT group (P = .016) in contrast with PCI group in which GLS increased significantly (P = .007). Left ventricular systolic function assessment using 2D-STE showed a significant difference in GLS between CTO-PCI and CTO-OMT. And the patients who chose PCI revascularization at the 2-year follow-up had better left ventricular systolic function improvement than those who were conservatively treated with OMT.
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Affiliation(s)
- Shuang Meng
- Department of Ultrasound, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Lin Qiu
- Department of Ultrasound, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Rongchong Huang
- Cardiac Center/Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing City, China
| | - Hui Wang
- Department of Ultrasound, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
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11
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Ybarra LF, Buller CE, Rinfret S. The Canadian Contribution to Science, Techniques, Technology, and Education in Chronic Total Occlusion Percutaneous Coronary Intervention. CJC Open 2021; 3:22-27. [PMID: 33458629 PMCID: PMC7801209 DOI: 10.1016/j.cjco.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/02/2020] [Indexed: 12/29/2022] Open
Abstract
Chronic total occlusions are considered the most complex coronary lesions in interventional cardiology. This article reviews the Canadian clinical and academic contributions to this field, including innovative procedural techniques, teaching and proctoring, clinical research, and the development of novel tools and therapies.
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Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | - Stéphane Rinfret
- Division of Cardiology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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12
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Hirai T, Grantham JA. Indications and Patient Selection for Percutaneous Coronary Intervention of Chronic Total Occlusions. Interv Cardiol Clin 2021; 10:1-5. [PMID: 33223098 DOI: 10.1016/j.iccl.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The most common indication for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is angina relief, which translates into improved physical function and quality of life. As the risk of the procedure is higher compared with non CTO PCI, it is important for operators to understand the current state of literature and have a detailed discussion with patients regarding risks and benefits prior to the procedure. This article discusses indications for the procedure and how to appropriately select patients for CTO PCI, in hopes of inspiring the reader to consistently offer this approach to indicated patients regardless of anatomic complexity.
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Affiliation(s)
- Taishi Hirai
- University of Missouri, One Hospital Drive, Columbia, MO 65212, USA.
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, 4330 Wornall Road, Kansas City, MO 64111, USA; University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
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13
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Guo L, Ding H, Lv H, Zhang X, Zhong L, Wu J, Xu J, Zhou X, Huang R. Impact of Renal Function on Long-Term Clinical Outcomes in Patients With Coronary Chronic Total Occlusions: Results From an Observational Single-Center Cohort Study During the Last 12 Years. Front Cardiovasc Med 2020; 7:550428. [PMID: 33304926 PMCID: PMC7701052 DOI: 10.3389/fcvm.2020.550428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022] Open
Abstract
Background: The number of coronary chronic total occlusion (CTO) patients with renal insufficiency is huge, and limited data are available on the impact of renal insufficiency on long-term clinical outcomes in CTO patients. We aimed to investigate clinical outcomes of CTO percutaneous coronary intervention (PCI) vs. medical therapy (MT) in CTO patients according to baseline renal function. Methods: In the study population of 2,497, 1,220 patients underwent CTO PCI and 1,277 patients received MT. Patients were divided into four groups based on renal function: group 1 [estimated glomerular filtration rate (eGFR) ≥ 90 ml/min/1.73 m2], group 2 (60 ≤ eGFR <90 ml/min/1.73 m2), group 3 (30 ≤ eGFR <60 ml/min/1.73 m2), and group 4 (eGFR <30 ml/min/1.73 m2). Major adverse cardiac event (MACE) was the primary end point. Results: Median follow-up was 2.6 years. With the decline in renal function, MACE (p < 0.001) and cardiac death (p < 0.001) were increased. In group 1 and group 2, MACE occurred less frequently in patients with CTO PCI, as compared to patients in the MT group (15.6% vs. 22.8%, p < 0.001; 15.6% vs. 26.5%, p < 0.001; respectively). However, there was no significant difference in terms of MACE between CTO PCI and MT in group 3 (21.1% vs. 28.7%, p = 0.211) and group 4 (28.6% vs. 50.0%, p = 0.289). MACE was significantly reduced for patients who received successful CTO PCI compared to patients with MT (16.7% vs. 22.8%, p = 0.006; 16.3% vs. 26.5%, p = 0.003, respectively) in group 1 and group 2. eGFR < 30 ml/min/1.73 m2, age, male gender, diabetes mellitus, heart failure, multivessel disease, and MT were identified as independent predictors for MACE in patients with CTOs. Conclusions: Renal impairment is associated with MACE in patients with CTOs. For treatment of CTO, compared with MT alone, CTO PCI may reduce the risk of MACE in patients without chronic kidney disease (CKD). However, reduced MACE from CTO PCI among patients with CKD was not observed. Similar beneficial effects were observed in patients without CKD who underwent successful CTO procedures.
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Affiliation(s)
- Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Haichen Lv
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyan Zhang
- Department of Radiology, Fuyang Hospital of Anhui Medical University, Fuyang, China
| | - Lei Zhong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiaying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuchen Zhou
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Rongchong Huang
- Department of Cardiology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
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14
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Abuzeid W, Zivkovic N, Elbaz-Greener G, Yaranton B, Patel V, Strauss B, Wijeysundera HC. Association Between Revascularization and Quality of Life in Patients With Coronary Chronic Total Occlusions: A Systematic Review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 25:47-54. [PMID: 33132085 DOI: 10.1016/j.carrev.2020.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/20/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Percutaneous revascularization of coronary chronic total occlusions (CTO) has increased due to advances in technology and operator expertise. Quality of life (QoL) remains an important but understudied outcome following CTO revascularization. Our aim is to conduct a systematic review of the impact of CTO revascularization on QoL. METHODS We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from January 1st, 1990 to May 17th, 2020. Studies reporting on the following QoL metrics post CTO revascularization were included: QoL subscale of the Seattle Angina Questionnaire (SAQ-QoL). The ROBINS-I tool and Cochrane risk of bias tool were used to critically assess for risk of bias. RESULTS We identified 1476 articles, of which 21 articles met inclusion criteria. Three categories of studies were identified with distinct patient populations. In the first category (1 study), CTO patients treated with either PCI or CABG compared to medical therapy had a significant improvement in SAQ-QoL compared to baseline (PCI 54.2 to 74.3; CABG 56.1 to 78.0; p < 0.05). In the second category (1 study), CTO patients compared to non-CTO patients had similar improvements in SAQ-QoL post PCI (CTO baseline 53.2 to 80.3; non-CTO baseline 56.5 to 80.6; p < 0.05). Finally, a third category with only CTO patients treated with PCI to the CTO vessel included 19 studies, all of which on average showed a significant improvement in SAQ-QoL post successful PCI, compared to non-successful PCI. CONCLUSION Despite the limited literature, revascularization of CTO vessel was generally associated with improvement in QoL. BRIEF SUMMARY Quality of life (QoL) is an important but understudied outcome following CTO revascularization. We conducted a systematic review of the impact of CTO revascularization on QoL. Despite the limitations of a lack of enough randomized control trials and the small number of studies, our systematic review highlights a trend of improvement in QoL indices after revascularization of CTO.
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Affiliation(s)
- Wael Abuzeid
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Division of Cardiology, Kingston Health Sciences Center, Queen's University, Ontario, Canada.
| | - Nevena Zivkovic
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Gabby Elbaz-Greener
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Brynne Yaranton
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Vaidehi Patel
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Bradley Strauss
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada
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15
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Kandzari DE, Lembo NJ, Carlson HD, Kalynych A, Spertus JA, Gibson CM, Chi G, Morgan J, Rinehart S, Yehya A, Qian Z, Ajose B, Karmpaliotis D. Procedural, clinical, and health status outcomes in chronic total coronary occlusion revascularization: Results from the PERSPECTIVE study. Catheter Cardiovasc Interv 2020; 96:567-576. [PMID: 31512377 DOI: 10.1002/ccd.28494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Limited research has detailed the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with independent core laboratory and event adjudication. This study examined procedural, clinical, and patient-reported health status outcomes among patients undergoing CTO PCI with specific focus on outcomes for those treated with zotarolimus-eluting stents (ZES). METHODS Among 500 consecutive patients undergoing attempted CTO PCI, procedural and in-hospital clinical outcomes were examined in addition to the 1-year composite endpoint of death, myocardial infarction, and target lesion revascularization (major adverse cardiac events, MACE). In a pre-specified cohort of 250 patients, health status measures were ascertained at baseline and 1 year. A powered secondary endpoint was 1-year MACE among patients treated with ZES compared with a performance goal. RESULTS Demographic, lesion, and procedural characteristics for the overall population included prior bypass surgery, 29.8%; diabetes, 35.2%; occlusion length >20 mm, 71.3%; J-CTO score, 2.5 ± 1.1; and primary retrograde strategy, 30.8%. Overall guidewire crossing was 90.9%; clinical success following guidewire crossing, 94.3%; and 1-year MACE rate, 12.1%. One-year health status significantly improved from baseline with successful CTO-PCI (angina frequency, 72.7 ± 26.5 at baseline to 96.0 ± 10.8, p < .0001). Compared with a performance goal derived from prior CTO DES trials (1-year hierarchal MACE, 25.2%), treatment with ZES was associated with significantly lower MACE (18.2%, one-sided upper CI, 23.6%, p = .017). CONCLUSIONS Favorable procedural success, health status improvements and late-term clinical outcomes inform the relative risks and benefits of CTO PCI when performed in a clinically indicated, complex patient population representative of those treated in clinical practice.
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Affiliation(s)
- David E Kandzari
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Nicholas J Lembo
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Harold D Carlson
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Anna Kalynych
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - John A Spertus
- Cardiovascular Research, Department of Biomedical and Health Informatics, Saint Luke's Mid America Heart Institute/UMKC, Kansas City, Missouri
| | - C Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gerald Chi
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jayne Morgan
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Sarah Rinehart
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Amin Yehya
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Zhen Qian
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
| | - Bola Ajose
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
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16
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Khanra D, Mishra V, Jain B, Soni S, Bahurupi Y, Duggal B, Rathore S, Guha S, Agarwal S, Aggarwal P, Sinha S, Himanshu K. Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis. Indian Heart J 2020; 72:225-231. [PMID: 32861374 PMCID: PMC7474112 DOI: 10.1016/j.ihj.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/21/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
AIMS Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. METHODS AND RESULTS PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I2 = 88%). CONCLUSION PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.
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Affiliation(s)
| | - Vikas Mishra
- Department of Cardiology, Super-Speciality Hospital, NSCB Medical College, Jabalpur, MP, India.
| | - Bhavna Jain
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Shishir Soni
- Department of Cardiology, All India Institution of Medical Sciences (AIIMS), Rishikesh, India.
| | - Yogesh Bahurupi
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India.
| | - Bhanu Duggal
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India.
| | - Sudhir Rathore
- Frimley Health NHS Foundation Trust, Camberley, Surrey, UK.
| | - Santanu Guha
- Cardiology, Medical College Kolkata, West Bengal, India.
| | | | - Puneet Aggarwal
- Department of Cardiology, ABVIMS and Dr. RML Hospital, New Delhi, India.
| | - SantoshKumar Sinha
- Department of Cardiology, LPS Institution of Cardiology, Kanpur, Uttar Pradesh, India.
| | - Kumar Himanshu
- Department of Cardiology, LPS Institution of Cardiology, Kanpur, Uttar Pradesh, India.
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17
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Guo L, Zhang X, Lv H, Zhong L, Wu J, Ding H, Xu J, Zhou X, Huang R. Long-Term Outcomes of Successful Revascularization for Patients With Coronary Chronic Total Occlusions: A Report of 1,655 Patients. Front Cardiovasc Med 2020; 7:116. [PMID: 32793636 PMCID: PMC7393438 DOI: 10.3389/fcvm.2020.00116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background: To date, the benefit of successful revascularization of chronic total occlusions (CTOs) on prognosis remains uncertain, and there is a paucity of data on the impact of successful revascularization for CTO patients on long-term cardiovascular survival. This study aimed to investigate the long-term cardiovascular survival for patients with successful and unsuccessful CTO revascularization in a large cohort of patients. Methods: There were 1,655 consecutive patients with at least one CTO included and were grouped into successful revascularization (n = 591) and unsuccessful revascularization (n = 1,064). Propensity score matching (PSM) was carried out to balance the clinical and the angiographic characteristics. Cardiac mortality was defined as the primary endpoint. Major adverse cardiac event (MACE) was assessed as a “secondary endpoint.” Results: After 3.6 years of follow-up, there was no significant difference between the successful and the unsuccessful revascularization groups in the rate of cardiac mortality [adjusted hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.59–1.58, p = 0.865]. After the PSM analysis (371 pairs) between the two groups, the cardiac mortality rate values (HR 0.51, 95% CI 0.23–1.15, p = 0.104) were equivalent, whereas the adjusted risk of MACE (HR 0.43, 95% CI 0.32–0.58, p = 0.001) and target-vessel revascularization (HR 0.41, 95% CI 0.29–0.58, p < 0.001) were significantly higher in patients with unsuccessful revascularization. Conclusion: For the treatment of CTO patients, successful revascularization was not associated with a lesser risk for cardiac mortality as compared with unsuccessful revascularization. However, successful revascularization reduced MACE and target-vessel revascularization.
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Affiliation(s)
- Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyan Zhang
- Department of Radiology, Fuyang Hospital of Anhui Medical University, Fuyang, China
| | - Haichen Lv
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lei Zhong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiaying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xuchen Zhou
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Rongchong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Cardiology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
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18
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Dobric M, Beleslin B, Tesic M, Djordjevic Dikic A, Stojkovic S, Giga V, Tomasevic M, Jovanovic I, Petrovic O, Rakocevic J, Boskovic N, Sobic Saranovic D, Stankovic G, Vukcevic V, Orlic D, Simic D, Nedeljkovic MA, Aleksandric S, Juricic S, Ostojic M. Prompt and consistent improvement of coronary flow velocity reserve following successful recanalization of the coronary chronic total occlusion in patients with viable myocardium. Cardiovasc Ultrasound 2020; 18:29. [PMID: 32693812 PMCID: PMC7374915 DOI: 10.1186/s12947-020-00211-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022] Open
Abstract
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).
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Affiliation(s)
- Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia. .,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia.
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Ana Djordjevic Dikic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Sinisa Stojkovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Miloje Tomasevic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, 69 Svetozara Markovica Street, Kragujevac, 34000, Serbia
| | - Ivana Jovanovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Olga Petrovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia
| | - Jelena Rakocevic
- Institute of Histology and Embryology, Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Nikola Boskovic
- Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dragana Sobic Saranovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Goran Stankovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Vladan Vukcevic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dejan Orlic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dragan Simic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Milan A Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Srdjan Aleksandric
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Stefan Juricic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia
| | - Miodrag Ostojic
- Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
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19
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Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, di Mario C, Hovasse T, Teruel L, Bufe A, Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH, Galassi AR, Louvard Y. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J 2019; 39:2484-2493. [PMID: 29722796 DOI: 10.1093/eurheartj/ehy220] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 04/04/2018] [Indexed: 12/13/2022] Open
Abstract
Aims The clinical value of percutaneous coronary intervention (PCI) for chronic coronary total occlusions (CTOs) is not established by randomized trials. This study should compare the benefit of PCI vs. optimal medical therapy (OMT) on the health status in patients with at least one CTO. Method and results Three hundred and ninety-six patients were enrolled in a prospective randomized, multicentre, open-label, and controlled clinical trial to compare the treatment by PCI with OMT with a 2:1 randomization ratio. The primary endpoint was the change in health status assessed by the Seattle angina questionnaire (SAQ) between baseline and 12 months follow-up. Fifty-two percent of patients have multi-vessel disease in whom all significant non-occlusive lesions were treated before randomization. An intention-to-treat analysis was performed including 13.4% failed procedures in the PCI group and 7.3% cross-overs in the OMT group. At 12 months, a greater improvement of SAQ subscales was observed with PCI as compared with OMT for angina frequency [5.23, 95% confidence interval (CI) 1.75; 8.71; P = 0.003], and quality of life (6.62, 95% CI 1.78-11.46; P = 0.007), reaching the prespecified significance level of 0.01 for the primary endpoint. Physical limitation (P = 0.02) was also improved in the PCI group. Complete freedom from angina was more frequent with PCI 71.6% than OMT 57.8% (P = 0.008). There was no periprocedural death or myocardial infarction. At 12 months, major adverse cardiac events were comparable between the two groups. Conclusion Percutaneous coronary intervention leads to a significant improvement of the health status in patients with stable angina and a CTO as compared with OMT alone. Trial registration NCT01760083.
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Affiliation(s)
- Gerald S Werner
- Klinikum Darmstadt GmbH, Medizinische Klinik I, Grafenstrasse 9, Darmstadt, Germany
| | | | - David Hildick-Smith
- Royal Sussex County Hospital, Sussex Cardiac Centre, Eastern Road, Brighton, UK
| | - Nicolas Boudou
- Hopital de Rangueil CHU Toulouse, Department of Cardiology, 1 avenue Jean Poulhès, Toulouse Cedex 9, France
| | - Georgios Sianos
- AHEPA University Hospital, 1st Department of Cardiology, Stilponos Kyriakidi 1, Thessaloniki, Greece
| | - Valery Gelev
- Cardiology Clinic, MHAT "Tokuda Hospital Sofia", 51B Nikola Vaptsarov Blvd., Sofia, Bulgaria
| | - Jose Ramon Rumoroso
- Hospital Galdakao-Usansolo, Sección de Hemodinámica, barrio de labeaga s/n, Galdakao, Spain
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Institute of Cardiology and Regenerative Medicine, 13 Pilsonu street, Riga, Latvia
| | | | - Javier Escaned
- Hospital Clinico San Carlos, Unidad de Cardiología Intervencionista, Profesor Martin Lagos s/n, Madrid, Spain
| | - Carlo di Mario
- University Hospital Careggi, Division of Structural Interventional Cardiology, Largo Brambilla 3, Florence, Italy
| | - Thomas Hovasse
- Institut Jacques Cartier, 6 avenue Noyer Lambert, Massy, France
| | - Luis Teruel
- Bellvitge University Hospital, Unidad de Hemodinàmica y Cardiologia, C/ Feixa Llarga s/n, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alexander Bufe
- HELIOS Klinik Krefeld, Medizinische Klinik I, Lutherplatz 40, Krefeld, Germany
| | - Bernward Lauer
- Zentralklinik Bad Berka, Klinik für Kardiologie, Robert-Koch-Allee 9, Bad Berka, Germany
| | - Kris Bogaerts
- Leuven Biostatistics and Statistical Bioinformatics Centre, L-BioStat. Kapucijnenvoer 35, Leuven, Belgium
| | - Javier Goicolea
- Hospital Universitario Puerta de Hierro, Servicio de hemodinamica y arritmias, Joaquin Rodrigo, 2, Majadahonda, Spain
| | - James C Spratt
- Royal Infirmary of Edinburgh, Department of Cardiology, 51 Little France Crescent, Edinburgh, UK
| | - Anthony H Gershlick
- Glenfield Hospital, Leicester Cardiovascular Biomedical Research Unit, Groby Road, Leicester, UK
| | - Alfredo R Galassi
- Department of Clinical and Experimental Medicine, University of Catania, Via Antonello da Messina 75, Catania, Italy
| | - Yves Louvard
- Institut Jacques Cartier, 6 avenue Noyer Lambert, Massy, France
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20
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Khariton Y, Airhart S, Salisbury AC, Spertus JA, Gosch KL, Grantham JA, Karmpaliotis D, Moses JW, Nicholson WJ, Cohen DJ, Lombardi W, Sapontis J, McCabe JM. Health Status Benefits of Successful Chronic Total Occlusion Revascularization Across the Spectrum of Left Ventricular Function: Insights From the OPEN-CTO Registry. JACC Cardiovasc Interv 2019; 11:2276-2283. [PMID: 30466826 DOI: 10.1016/j.jcin.2018.07.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/02/2018] [Accepted: 07/24/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to describe the association between chronic total occlusion (CTO) revascularization (CTO percutaneous coronary intervention [PCI]) and health status in patients with and without cardiomyopathy. BACKGROUND Prior PCI trials for cardiomyopathy have excluded CTO patients. Whether patients with reduced left ventricular ejection fraction (LVEF) receive similar health status benefit from CTO-PCI compared with patients with normal LVEF is unclear. METHODS We assessed health status change, using the Seattle Angina Questionnaire (SAQ) Summary, SAQ Angina Frequency, and Rose Dyspnea Scale scores, among patients undergoing successful CTO PCI in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) Registry. Participants were classified by LVEF (normal, ≥50%; mild-moderate, 30% to 49%; and severe, <30%), with higher SAQ and lower Rose Dyspnea Scale scores indicating better health status. Differences in 1-year outcomes were compared using hierarchical multivariable regression. RESULTS Of 762 patients, 506 (66.4%), 193 (25.3%), and 63 (8.3%) had normal, mild-moderate, and severely reduced LVEF. SAQ Summary score improvements were observed in each group (27.1 ± 20.4, 26.7 ± 21.2, and 20.3 ± 18.1, respectively). Compared with patients with LVEF ≥50%, those with LVEF <30% had less improvement in SAQ Summary Score (-5.2 points; 95% confidence interval: -9.0 to -1.5; p = 0.01) and Rose Dyspnea Scale (+0.5 points; 95% confidence interval: 0.1 to 0.8; p = 0.01), with no difference in odds of angina (odds ratio: 1.3; 95% confidence interval: 0.6 to 3.0; p = 0.48). Health status improvement was similar between patients with LVEF ≥50% and LVEF 30% to 49%. CONCLUSIONS Although health status improvement was less in patients with severely reduced LVEF compared with those with normal LVEF, each group experienced large health status improvements after CTO-PCI.
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Affiliation(s)
- Yevgeniy Khariton
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | | | - Adam C Salisbury
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | | | - Jeffrey W Moses
- Columbia University Medical Center, New York Presbyterian Hospital, New York, New York
| | | | - David J Cohen
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | | | - James Sapontis
- The Avenue Hospital and Monash Medical Center, Windsor, Victoria, Australia
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21
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Iannaccone G, Scarparo P, Wilschut J, Daemen J, Den Dekker W, De Jaegere P, Zijlstra F, Van Mieghem NM, Diletti R. Current approaches for treatment of coronary chronic occlusions. Expert Rev Med Devices 2019; 16:941-954. [PMID: 31594416 DOI: 10.1080/17434440.2019.1676729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Coronary chronic total occlusions (CTO) represent a challenging subset in interventional cardiology.Areas covered: During the last decade, improvements in materials, techniques, and meticulous pre-procedural lesion assessment have increased the success rate in CTO lesions. Several scores have been developed to address overall lesion evaluation and help select the most appropriate treatment strategy. In addition, specific algorithms such as the hybrid algorithm have been introduced to provide a framework for CTO operators and a rapid management of the various challenging aspects of the procedure. The hybrid approach requires operator's ability to switch from one treatment strategy to another when the first one appears to be unsuccessful. Adequate training and operators' experience remain crucial to improve the likelihood of success.Expert opinion: The aim of this review is to provide insights and guidance for operators on current approaches for treatment of CTO and complication management.
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Affiliation(s)
- Giulia Iannaccone
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wijnand Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Peter De Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
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22
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Guo L, Zhang S, Wu J, Zhong L, Ding H, Xu J, Zhou X, Huang R. Successful recanalisation of coronary chronic total occlusions is not associated with improved cardiovascular survival compared with initial medical therapy. SCAND CARDIOVASC J 2019; 53:305-311. [PMID: 31315453 DOI: 10.1080/14017431.2019.1645351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective. To compare the clinical outcomes associated with successful percutaneous coronary intervention (PCI) versus initial medical therapy (MT) in patients with coronary chronic total occlusions (CTOs). Methods. Between January 2007 and December 2016, a total of 1702 patients with ≥1 CTO were enrolled. Patients who had a failed CTO-PCI were excluded. After exclusion, 1294 patients with 1520 CTOs were divided into the MT group initially (did not undergo a CTO-PCI attempt) (n = 800) and successful PCI group (n = 494). Propensity-score matching was also performed to adjust for baseline characteristics. The primary outcome was cardiac death. Results. The median overall follow-up duration was 3.6 (IQR, 2.1-5.0) years, there was no significant difference between the two groups with respect to the prevalence of cardiac death (MT vs. successful PCI: 6.6 vs. 3.8%, adjusted hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.41-2.14, p = .867). In the propensity-matched population (286 pairs), there were no significant differences in the prevalence of cardiac death (MT vs. successful PCI: 5.9% vs. 3.1%, HR 0.51, 95% CI 0.23-1.15, p = .104) and major adverse cardiovascular events (MACE) (HR 0.76, 95% CI 0.53-1.09, p = .130) between the two groups. Conclusion. In the treatment of patients with CTOs, successful PCI is not associated with improved long-term cardiovascular survival or reduced the risk of MACE compared with MT alone initially.
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Affiliation(s)
- Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Shanfeng Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Lei Zhong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Jiaying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Xuchen Zhou
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
| | - Rongchong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, People's Republic of China
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23
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Sajobi TT, Wang M, Awosoga O, Santana M, Southern D, Liang Z, Galbraith D, Wilton SB, Quan H, Graham MM, James MT, Ghali WA, Knudtson ML, Norris C. Trajectories of Health-Related Quality of Life in Coronary Artery Disease. Circ Cardiovasc Qual Outcomes 2019; 11:e003661. [PMID: 29545392 DOI: 10.1161/circoutcomes.117.003661] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 01/10/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD. METHODS AND RESULTS Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups. CONCLUSIONS This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.
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Affiliation(s)
- Tolulope T Sajobi
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada.
| | - Meng Wang
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Oluwagbohunmi Awosoga
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Maria Santana
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Danielle Southern
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Zhiying Liang
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Diane Galbraith
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Stephen B Wilton
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Hude Quan
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Michelle M Graham
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Matthew T James
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - William A Ghali
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Merrill L Knudtson
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
| | - Colleen Norris
- From the Department of Community Health Sciences, O'Brien Institute for Public Health (T.T.S., M.W., M.S., D.S., Z.L., D.G., H.Q., M.T.J., W.A.G.), Department of Cardiac Sciences (D.G., S.B.W., M.L.K.), and Department of Medicine (S.B.W., M.T.J., W.A.G., M.L.K.), University of Calgary, Canada; Faculty of Health Sciences, University of Lethbridge, Canada (O.A.); and Faculty of Medicine & Dentistry (M.M.G.) and Faculty of Nursing (C.N.), University of Alberta, Edmonton, Canada
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24
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Guo L, Wu J, Zhong L, Ding H, Xu J, Zhou X, Huang R. Two-year clinical outcomes of medical therapy vs. revascularization for patients with coronary chronic total occlusion. Hellenic J Cardiol 2019; 61:264-271. [PMID: 30951874 DOI: 10.1016/j.hjc.2019.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/17/2019] [Accepted: 03/27/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES There are little data on the long-term clinical outcomes of medical therapy (MT) compared with revascularization in patients with chronic total occlusions (CTOs). METHODS Between January 2007 and December 2016, a total of 1655 patients with ≥1 CTO were enrolled in our center and were divided into the MT group (n = 800) and revascularization group (n = 855) according to the initial treatment strategy. Propensity score matching was also performed to adjust for baseline characteristics. The primary outcome was cardiac death. RESULTS After 2 years of follow-up, there was no significant difference between the two groups with regard to the prevalence of cardiac death (MT vs. revascularization: 6.6% vs. 4.2%, adjusted hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.60-1.49, p = 0.820). In the propensity-matched population (406 pairs), there were no significant differences in the prevalence of cardiac death (MT vs. revascularization: 5.4% vs. 4.7%, HR 0.88, 95% CI 0.48-1.63, p = 0.694), except for target vessel revascularization (TVR) (0.44, 0.31-0.63, <0.001) and major adverse cardiovascular events (MACE) (0.51, 0.38-0.68, <0.001), between the two groups. There were also no significant differences in the prevalence of cardiac death (MT vs. successful CTO-PCI: 6.6% vs. 4.0%, HR 0.94, 95% CI 0.41-2.15, p = 0.881) between the MT and successful CTO-PCI groups. CONCLUSION As an initial management strategy in patients with CTOs, revascularization did not reduce the risk of cardiac death compared with treatment with medical therapy alone. However, revascularization was associated with reduction in the prevalence of TVR and MACE. Furthermore, successful CTO-PCI was also not associated with improved long-term survival compared with MT alone.
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Affiliation(s)
- Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Lei Zhong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Jiaying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Xuchen Zhou
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China
| | - Rongchong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian City, China.
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Hirai T, Grantham JA, Sapontis J, Cohen DJ, Marso SP, Lombardi W, Karmpaliotis D, Moses J, Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Nugent K, Gosch KL, Spertus JA, Salisbury AC. Quality of Life Changes After Chronic Total Occlusion Angioplasty in Patients With Baseline Refractory Angina. Circ Cardiovasc Interv 2019; 12:e007558. [DOI: 10.1161/circinterventions.118.007558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Taishi Hirai
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | - J. Aaron Grantham
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | | | - David J. Cohen
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | | | | | | | - Jeffrey Moses
- Columbia University, New York Presbyterian Hospital (D.K., J.M.)
| | | | - Ashish Pershad
- Banner Good Samaritan Medical Center, Phoenix, AZ (A.P.)
- Banner Heart, Mesa, AZ (A.P.)
| | | | | | - Stephen Cook
- Peacehealth Sacred Heart Medical Center, Springfield, OR (S.C.)
| | - Parag Doshi
- Alexian Brothers Medical Center, Chicago, IL (P.D.)
| | | | - Karen Nugent
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
| | - Kensey L. Gosch
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
| | - Adam C. Salisbury
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (T.H., J.A.G., D.J.C., K.N., K.L.G., J.A.S., A.C.S.)
- University of Missouri Kansas City (T.H., J.A.G., D.J.C., J.A.S., A.C.S.)
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Goleski PJ, Nakamura K, Liebeskind E, Salisbury AC, Grantham JA, McCabe JM, Lombardi WL. Revascularization of coronary chronic total occlusions with subintimal tracking and reentry followed by deferred stenting: Experience from a high‐volume referral center. Catheter Cardiovasc Interv 2018; 93:191-198. [DOI: 10.1002/ccd.27783] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/18/2018] [Accepted: 06/24/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Patrick J. Goleski
- Saint Luke's Mid America Heart Institute Kansas City Missouri
- Department of Internal Medicine Section of Cardiovascular DiseaseUniversity of Missouri Kansas City Kansas City Missouri
| | - Kenta Nakamura
- Department of Medicine Division of CardiologyUniversity of Washington Seattle Washington
| | - Emily Liebeskind
- Department of Medicine Division of CardiologyUniversity of Washington Seattle Washington
| | - Adam C. Salisbury
- Saint Luke's Mid America Heart Institute Kansas City Missouri
- Department of Internal Medicine Section of Cardiovascular DiseaseUniversity of Missouri Kansas City Kansas City Missouri
| | - J. Aaron Grantham
- Saint Luke's Mid America Heart Institute Kansas City Missouri
- Department of Internal Medicine Section of Cardiovascular DiseaseUniversity of Missouri Kansas City Kansas City Missouri
| | - James M. McCabe
- Department of Medicine Division of CardiologyUniversity of Washington Seattle Washington
| | - William L. Lombardi
- Department of Medicine Division of CardiologyUniversity of Washington Seattle Washington
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27
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Abouzaki NA, Exaire JE, Guzmán LA. Role of Percutaneous Chronic Total Occlusion Interventions in Patients with Ischemic Cardiomyopathy and Reduced Left Ventricular Ejection Fraction. Curr Cardiol Rep 2018; 20:124. [PMID: 30276495 DOI: 10.1007/s11886-018-1066-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine current evidence on the benefit of chronic total occlusion (CTO) revascularization in patients with ischemic cardiomyopathy and propose a systematic approach on how and when to accomplish revascularization in these patients. RECENT FINDINGS Coronary revascularization in patients with reduced ejection fraction (EF) is advocated for to improve left ventricular function and consequently clinical outcomes. Approximately 16-31% of angiograms in patients with advanced CAD are noted to have a concomitant coronary CTO. Its presence is a main predictor of worse outcomes. Over the past 15 years, advancements in interventional technologies and techniques have made it possible to treat CTO lesions percutaneously with success rates exceeding 90%. Different revascularization techniques have been organized into widely used algorithms for systematic CTO lesion crossing and treatment. Patients with reduced EF can be revascularized percutaneously with goal of complete functional revascularization. However, randomized prospective data is needed to justify the increased patient risks and healthcare costs associated with these procedures.
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Affiliation(s)
- Nayef A Abouzaki
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.,Hunter Holmes McGuire Richmond VA Medical Center, Richmond, VA, 23249, USA
| | - Jose E Exaire
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.,Hunter Holmes McGuire Richmond VA Medical Center, Richmond, VA, 23249, USA
| | - Luis A Guzmán
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.
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Ma Y, Li D, Li J, Li Y, Bai F, Qin F, Zhou S, Liu Q. Percutaneous coronary intervention versus optimal medical therapy for patients with chronic total occlusion: a meta-analysis and systematic review. J Thorac Dis 2018; 10:2960-2967. [PMID: 29997962 DOI: 10.21037/jtd.2018.04.140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Yingxu Ma
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Dongping Li
- Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Jiayi Li
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Yixi Li
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Fan Bai
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Fen Qin
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Shenghua Zhou
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Qiming Liu
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
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Elbaz-Greener G, Wijeysundera HC. Coronary Chronic Total Occlusions: Time to Abandon a Culture of Therapeutic Nihilism? Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.004295. [PMID: 29237747 DOI: 10.1161/circoutcomes.117.004295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gabby Elbaz-Greener
- From the Division of Cardiology and Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Ontario, Canada (G.E.G., H.C.W.); University of Toronto, Ontario, Canada (G.E.G., H.C.W.); Institute for Clinical Evaluative Sciences, Ontario, Canada (H.C.W.); and Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (H.C.W.)
| | - Harindra C Wijeysundera
- From the Division of Cardiology and Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Ontario, Canada (G.E.G., H.C.W.); University of Toronto, Ontario, Canada (G.E.G., H.C.W.); Institute for Clinical Evaluative Sciences, Ontario, Canada (H.C.W.); and Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (H.C.W.).
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31
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Balter S, Brinkman M, Kalra S, Nazif T, Parikh M, Kirtane A, Moses J, Leon M, Feri A, Green P, Ali Z, Liao M, Karmpaliotis D. Novel radiation dose reduction fluoroscopic technology facilitates chronic total occlusion percutaneous coronary interventions. EUROINTERVENTION 2017; 13:e1468-e1474. [DOI: 10.4244/eij-d-16-00216] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Midterm Angina-Related Quality of Life Benefits After Percutaneous Coronary Intervention of Chronic Total Occlusions. Can J Cardiol 2017; 33:1668-1674. [DOI: 10.1016/j.cjca.2017.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/28/2017] [Accepted: 08/15/2017] [Indexed: 01/08/2023] Open
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Stähli BE, Gebhard C, Gick M, Ferenc M, Mashayekhi K, Buettner HJ, Neumann FJ, Toma A. Impact of anemia on long-term outcomes after percutaneous coronary intervention for chronic total occlusion. Catheter Cardiovasc Interv 2017; 91:226-233. [DOI: 10.1002/ccd.27412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/25/2017] [Accepted: 10/14/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Barbara E. Stähli
- Department of Cardiology; Charité Berlin - University Medicine, Campus Benjamin Franklin; Berlin Germany
| | - Cathérine Gebhard
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Michael Gick
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Miroslaw Ferenc
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Heinz Joachim Buettner
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Franz-Josef Neumann
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
| | - Aurel Toma
- Division of Cardiology and Angiology II; University Heart Center Freiburg - Bad Krozingen; Germany
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Hirai T, Grantham JA, Sapontis J, Cohen DJ, Marso SP, Lombardi W, Karmpaliotis D, Moses J, Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Nugent K, Gosch KL, Spertus JA, Salisbury AC. Impact of subintimal plaque modification procedures on health status after unsuccessful chronic total occlusion angioplasty. Catheter Cardiovasc Interv 2017; 91:1035-1042. [DOI: 10.1002/ccd.27380] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/19/2017] [Accepted: 09/28/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Taishi Hirai
- University of Chicago Medical Center; Chicago Illinois
| | - J. Aaron Grantham
- Saint Luke's Mid America Heart Institute; Kansas City Missouri
- University of Missouri Kansas City; Kansas City Missouri
| | | | - David J. Cohen
- Saint Luke's Mid America Heart Institute; Kansas City Missouri
- University of Missouri Kansas City; Kansas City Missouri
| | | | | | | | - Jeffrey Moses
- Columbia University, New York Presbyterian Hospital; New York New York
| | | | - Ashish Pershad
- Banner Good Samaritan Medical Center, Phoenix, AZ and Banner Heart; Mesa Arizona
| | | | | | - Stephen Cook
- Peacehealth Sacred Heart Medical Center; Springfield Oregon
| | - Parag Doshi
- Alexian Brothers Medical Center; Chicago Illinois
| | | | - Karen Nugent
- University of Missouri Kansas City; Kansas City Missouri
| | | | - John A. Spertus
- Saint Luke's Mid America Heart Institute; Kansas City Missouri
- University of Missouri Kansas City; Kansas City Missouri
| | - Adam C. Salisbury
- Saint Luke's Mid America Heart Institute; Kansas City Missouri
- University of Missouri Kansas City; Kansas City Missouri
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Galassi AR, Boukhris M, Toma A, Elhadj ZI, Laroussi L, Gaemperli O, Behnes M, Akin I, Lüscher TF, Neumann FJ, Mashayekhi K. Percutaneous Coronary Intervention of Chronic Total Occlusions in Patients With Low Left Ventricular Ejection Fraction. JACC Cardiovasc Interv 2017; 10:2158-2170. [PMID: 29055762 DOI: 10.1016/j.jcin.2017.06.058] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The study sought to assess the outcome of percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) in patients with low left ventricular ejection fraction (LVEF) (≤35%). BACKGROUND Data regarding the outcome of PCI in patients with low LVEF affected by CTO are scarcely reported. METHODS The authors performed a prospective longitudinal multicenter study including consecutive patients undergoing elective PCI of CTOs. Patients were subdivided into 3 groups: group 1 (LVEF ≥50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF ≤35%). RESULTS A total of 839 patients (mean 64.6 ± 10.5 years of age, 87.7% men) underwent CTO PCI attempts. Baseline LVEF ≤35% was present in 72 (8.6%) patients. The angiographic success was high (overall 93.6%) and similar among the 3 groups (93.5% vs. 94.4% vs. 91.7%, respectively; all p = NS). In group 3, no periprocedural complications of CTO PCI were observed. Mean clinical follow-up of 16.3 ± 8.2 months duration was available in 781 (93.1%) patients including those with LVEF ≤35%. At 2 years, major cardiac and cerebrovascular events (MACCE) free survival was similar in the 3 groups (86% vs. 82.8% vs. 75.2%; all p = NS). In patients with LVEF ≤35%, LVEF improved significantly in the presence of a successful CTO PCI from 29.1 ± 3.4% to 41.6 ± 7.9% (p < 0.001). CONCLUSIONS In CTO patients with low LVEF, PCI could represent a safe and effective revascularization strategy achieving good midterm outcome and LVEF improvement.
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Affiliation(s)
- Alfredo R Galassi
- Department of Experimental and Clinical Medicine, University of Catania, Catania, Italy; University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
| | - Marouane Boukhris
- Department of Experimental and Clinical Medicine, University of Catania, Catania, Italy; Cardiology Department, Abderrhamen Mami Hospital, Ariana, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Aurel Toma
- Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Zied Ibn Elhadj
- Cardiology Department, Abderrhamen Mami Hospital, Ariana, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Lobna Laroussi
- Cardiology Department, Abderrhamen Mami Hospital, Ariana, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Oliver Gaemperli
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas F Lüscher
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Franz J Neumann
- Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
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Shuvy M, Qiu F, Chee-A-Tow A, Graham JJ, Abuzeid W, Buller C, Strauss BH, Wijeysundera HC. Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy. Am J Cardiol 2017; 120:759-764. [PMID: 28716335 DOI: 10.1016/j.amjcard.2017.05.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 01/24/2023]
Abstract
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.
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Bennett J, Kayaert P, Bataille Y, Dens J. Percutaneous coronary interventions of chronic total -occlusions; a review of clinical indications, treatment strategy and current practice. Acta Cardiol 2017; 72:357-369. [PMID: 28705045 DOI: 10.1080/00015385.2017.1335080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to the perception of limited clinical benefit, high complexity and cost of intervention, and perceived risk of complications. Numerous observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit remains debated. Nevertheless, over the past decade the interest in CTO-PCI has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. A number of factors must be taken into consideration in selecting patients for CTO-PCI, including presence of symptoms attributable to the CTO, extent of ischaemia distal to the occlusion, and degree of myocardial viability. In this review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection. Data regarding efficacy and safety of recent advances in PCI-CTO techniques will be discussed. Steps involved in setting up a dedicated CTO program will be outlined and the current CTO landscape in Belgium will be briefly highlighted. The overall aim of this review is to promote a more balanced approach to management of patients with a CTO.
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Affiliation(s)
- Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Kayaert
- Department of Cardiology, University Hospital Brussels, Brussels, Belgium
| | | | - Jo Dens
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium
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Abstract
Chronic total occlusions (CTOs) are routinely encountered during coronary angiography, but subsequent revascularization rates are low. This has likely been driven by a historical belief that there is minimal clinical benefit and poor success rates with a percutaneous coronary intervention (PCI). However, in the current era, with the development of new techniques and tools, experienced operators can perform CTO-PCI successfully in the majority of patients. The current indications and benefit of CTO-PCI remain a topic of controversy and debate. There is a growing body of predominantly nonrandomized studies reporting both short-term and long-term outcomes of CTO-PCI. Recent and upcoming randomized-controlled trials in this area will also potentially expand indications in both stable and patients with acute coronary syndrome. In this review, we will discuss the current evidence for CTO-PCI and also future directions in this field.
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39
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Karjalainen PP, Nammas W. Percutaneous revascularization of coronary chronic total occlusion: Toward a reappraisal of the available evidence. J Cardiol 2017; 69:799-807. [DOI: 10.1016/j.jjcc.2016.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/29/2016] [Accepted: 12/08/2016] [Indexed: 12/19/2022]
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40
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Karatasakis A, Danek BA, Karmpaliotis D, Alaswad K, Vo M, Carlino M, Patel MP, Rinfret S, Brilakis ES. Approach to CTO Intervention: Overview of Techniques. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:1. [PMID: 28105600 DOI: 10.1007/s11936-017-0501-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OPINION STATEMENT Successful percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) has been associated with significant clinical benefits, but remains technically demanding. Failure to cross the CTO with a guidewire is the most common cause of CTO PCI failure. CTO crossing can be achieved in the antegrade or retrograde direction and can be accomplished by maintaining true lumen position throughout or via subintimal dissection/reentry techniques. A procedural plan should be created prior to the procedure through careful angiographic review of four key parameters: (a) morphology of the proximal occlusion cap; (b) length of the occlusion; (c) quality of the distal vessel and presence of bifurcation at the distal cap; and (d) suitability of collateral circulation for retrograde crossing. Dual coronary injection is recommended in all cases with contralateral collaterals for detailed characterization of the lesion. If one approach fails to progress, a quick transition to the next approach is encouraged to maximize efficacy and efficiency. Procedural complications, including vessel perforation, may occur more frequently in CTO as compared with non-CTO PCI; hence, availability of necessary equipment and expertise in treating such complications are essential.
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Affiliation(s)
- Aris Karatasakis
- University of Texas Southwestern Medical Center, Dallas, TX, USA.,VA North Texas Health Care System, Dallas, TX, USA
| | - Barbara Anna Danek
- University of Texas Southwestern Medical Center, Dallas, TX, USA.,VA North Texas Health Care System, Dallas, TX, USA
| | | | | | - Minh Vo
- Mazankowski Heart Institute, Edmonton, AB, Canada
| | | | - Mitul P Patel
- VA San Diego Healthcare System/University of California San Diego, La Jolla, CA, USA
| | | | - Emmanouil S Brilakis
- University of Texas Southwestern Medical Center, Dallas, TX, USA. .,VA North Texas Health Care System, Dallas, TX, USA. .,Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN, 55407, USA.
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Talanas G, Garbo R. Reply: More Stents, More Troubles. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:76. [DOI: 10.1016/j.carrev.2016.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
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Weintraub WS, Garratt KN. Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting? Chronic Total Occlusion Should Not Routinely Be Treated With Coronary Artery Bypass Grafting. Circulation 2016; 133:1818-25. [PMID: 27143549 DOI: 10.1161/circulationaha.115.017798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hwang JK, Yang JH, Hwang JW, Jang WJ, Song YB, Hahn JY, Choi JH, Lee SH, Gwon HC, Choi SH. Association of β-blocker therapy with long-term clinical outcomes in patients with coronary chronic total occlusion. Medicine (Baltimore) 2016; 95:e4300. [PMID: 27472704 PMCID: PMC5265841 DOI: 10.1097/md.0000000000004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There are limited data regarding the efficacy of β-blockers for secondary prevention in patients with coronary chronic total occlusion (CTO). Therefore, we investigated the association of β-blocker therapy with long-term clinical outcomes in CTO patients. From March 2003 to February 2012, a total of 2024 CTO patients treated with either medical therapy alone or revascularization were enrolled in the study. We assessed 1596 patients with stable ischemic heart disease and divided them into the β-blocker group (n = 932) and the no-β-blocker group (n = 664). The primary outcome was all-cause death. The median follow-up duration was 3.9 (interquartile range: 2.0-6.2) years. All-cause death occurred in 11.6% patients in the β-blocker group and 13.6% patients in the no-β-blocker group (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.61-1.08; P = 0.15). In the propensity score-matched population (570 pairs), all-cause death occurred in 12.3% patients in the β-blocker group and 12.8% patients in the no-β-blocker group (HR: 0.93, 95% CI: 0.67-1.29; P = 0.66). In subgroup analysis, β-blocker therapy was associated with better outcome, in terms of all-cause death, in patients with CTO of the left anterior descending coronary artery and Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) score ≥23 (P for interaction = 0.01 and 0.02, respectively). In conclusion, β-blocker therapy was not associated with favorable long-term clinical outcomes in stable CTO patients, regardless of treatment strategy. However, β-blocker therapy might be beneficial in a highly selective group of CTO patients with a high ischemic burden.
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Affiliation(s)
- Jin Kyung Hwang
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Ji-won Hwang
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Woo Jin Jang
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Sang Hoon Lee
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
- Correspondence: Seung-Hyuk Choi, Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea (e-mail: )
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Survival after percutaneous coronary intervention for chronic total occlusion. Clin Res Cardiol 2016; 105:921-929. [DOI: 10.1007/s00392-016-1000-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/27/2016] [Indexed: 11/25/2022]
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McEntegart MB, Badar AA, Ahmad FA, Shaukat A, MacPherson M, Irving J, Strange J, Bagnall AJ, Hanratty CG, Walsh SJ, Werner GS, Spratt JC. The collateral circulation of coronary chronic total occlusions. EUROINTERVENTION 2016; 11:e1596-603. [PMID: 27056120 DOI: 10.4244/eijv11i14a310] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Despite advances in understanding the physiological role of collaterals in coronary chronic total occlusions (CTOs), collateral anatomy remains poorly defined. Our aim was to define the anatomy and interventional utility of collaterals within a large population of patients with CTOs. METHODS AND RESULTS We studied the coronary angiograms of 481 patients with 519 CTOs at six centres in the U.K. over four years. Detailed angiographic analysis was performed by interventional cardiologists specialising in CTO percutaneous coronary intervention (PCI). All visible collaterals with a collateral connection (CC) grade ≥1 were recorded. A subgroup of CTOs (n=277) was assessed for interventional capability, defined as whether the collateral supply was able to facilitate retrograde access. We described 45 different collateral patterns: 20 in right coronary artery (RCA), 13 in left anterior descending (LAD), and 12 in circumflex artery CTOs. Septal collaterals from the LAD to the right posterior descending artery (RPDA), and from the posterior descending artery to the LAD were most common, and most often considered as having "interventional capability". CONCLUSIONS This is the largest analysis of collateral circulation anatomy in a population of patients with CTOs. We anticipate that these data will be of significant benefit in angiographic analysis and procedure planning for CTO PCI.
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Assessment of Inducible Myocardial Ischemia, Quality of Life, and Functional Status After Successful Percutaneous Revascularization in Patients With Chronic Total Coronary Occlusion. Am J Cardiol 2016; 117:720-6. [PMID: 26747733 DOI: 10.1016/j.amjcard.2015.12.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 01/22/2023]
Abstract
The benefits of chronic total coronary occlusion (CTO) revascularization are not well established. In this prospective cohort study, 47 consecutive patients with successful percutaneous recanalization of CTO underwent adenosine stress cardiac magnetic resonance (CMR), 6-minute walk test (6MWT), and the Short Form-36 Health Survey before and 6 months after the procedure. Successful recanalization of a CTO was followed by significant improvement of (1) global physical and mental health status; (2) the distance walked in the 6MWT; (3) the incidence of chest pain at the end of the 6MWT; and (4) the score of a novel CMR ischemic burden index on the basis of the characteristics of adenosine stress perfusion defects (extension, persistence, transmurality, and induced contractile regional dysfunction). Patients with greater CMR ischemic index before percutaneous revascularization showed better improvement in the 6MWT. In conclusion, successful recanalization of a CTO leads to a concurrent improvement in ischemic burden, exercise tolerance, angina frequency, and quality of life scores. Patients with a high ischemic CMR score before CTO recanalization showed the better improvement in exercise tolerance.
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47
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Sianos G, Konstantinidis NV, Di Mario C, Karvounis H. Theory and practical based approach to chronic total occlusions. BMC Cardiovasc Disord 2016; 16:33. [PMID: 26860695 PMCID: PMC4746803 DOI: 10.1186/s12872-016-0209-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/21/2022] Open
Abstract
Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.
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Affiliation(s)
- Georgios Sianos
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Nikolaos V Konstantinidis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Carlo Di Mario
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
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Affiliation(s)
- Yaron Arbel
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Bradley H Strauss
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Wolff R, Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Sparkes JD, Wright GA, Wijeysundera HC, Strauss BH. Gender differences in the prevalence and treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2015; 87:1063-70. [DOI: 10.1002/ccd.26330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 10/24/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Rafael Wolff
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
| | - Paul Fefer
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
- Department of Cardiology; Sheba Medical Center, Tel Aviv University; Tel Aviv Israel
| | - Merril L. Knudtson
- Division of Cardiology; Libin Cardiovascular Institute of Alberta; Calgary Alberta Canada
| | - Asim N. Cheema
- Division of Cardiology; St. Michael's Hospital; Toronto Ontario Canada
- Department of Medicine; University of Toronto, Division of Cardiology; Toronto Ontario Canada
| | - P. Diane Galbraith
- Division of Cardiology; Libin Cardiovascular Institute of Alberta; Calgary Alberta Canada
| | - John D. Sparkes
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
| | - Graham A. Wright
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
| | - Harindra C. Wijeysundera
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
- Department of Medicine; University of Toronto, Division of Cardiology; Toronto Ontario Canada
- Management and Evaluation (IHPME); University of Toronto, Institute of Health Policy; Toronto, Ontario Canada
- Institute for Clinical Evaluative Sciences (ICES); Toronto Ontario Canada
| | - Bradley H. Strauss
- Division of Cardiology; Schulich Heart Program, Sunnybrook Health Sciences Centre; Toronto, Ontario Canada
- Department of Medicine; University of Toronto, Division of Cardiology; Toronto Ontario Canada
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50
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Galassi AR, Brilakis ES, Boukhris M, Tomasello SD, Sianos G, Karmpaliotis D, Di Mario C, Strauss BH, Rinfret S, Yamane M, Katoh O, Werner GS, Reifart N. Appropriateness of percutaneous revascularization of coronary chronic total occlusions: an overview. Eur Heart J 2015; 37:2692-700. [DOI: 10.1093/eurheartj/ehv391] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/26/2015] [Indexed: 01/24/2023] Open
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