Abstract 12820: Utilization of Cardiac Magnetic Resonance Imaging for Management of Coronary Chronic Total Occlusions

Abstract

Introduction: Revascularization of coronary chronic total occlusions (CTOs) may be indicated for relief of medically refractory angina. Myocardial viability assessment by cardiac magnetic resonance (CMR) may help select patients for CTO intervention. Real-world practice is not well described. Methods: We identified patients who underwent coronary angiography between 2016-2020 at a large tertiary center and had ≥1 CTO. Patients with prior CABG were excluded. We examined rates of CMR and outcomes including revascularization and MACE. Myocardial segments were attributed to a CTO territory and adjudicated following angiographic review of coronary anatomy. Significant CMR viability was defined as <50% transmural delayed enhancement in the CTO territory. Results: We identified 1279 patients (74.1% male, 28.1% Black) who met inclusion criteria. Of these, 36.0% had type 2 diabetes mellitus and 54.9% reported angina pectoris. Over half of patients had CTO of the RCA (56.5%), and 18.5% of patients had CTO in >1 vessel. Non-invasive testing was performed in 38.4% of patients; 10.8% had CMR. Rates of CMR were higher in patients with severely reduced EF (≤35%) compared to those with normal EF (≥55%) (22.1% vs 11.1%; p<0.001). Among those who had CMR, 84.8% of patients showed significant viability in the CTO territory (Fig). CTO PCI was performed in 12.5% of patients, CABG was performed in 24.9%, and 63.2% were managed medically. Patients who had CTO PCI had higher rates of angina versus those without CTO PCI (70.0% vs 52.8%; p<0.001) and were more likely to be on ≥2 anti-anginal medications (30.6% vs 18.9%; p<0.001). CTO PCI technical success was achieved in 69.5% of patients and MACE occurred in 2.3% of cases. Conclusions: Patients with coronary CTOs demonstrate high rates of viability in CTO territories based on CMR. Rates of viability testing and CTO revascularization remain low. Further work is needed to determine the role of CMR and other non-invasive testing in CTO management.