Abstract
Background: Concomitant left main coronary artery (LMCA) disease in patients with chronic total occlusions (CTO) commonly results in referral for coronary artery bypass grafting, although the impact of LMCA in CTO patients remains largely unknown. Nevertheless, patient selection for percutaneous coronary intervention of CTOs (CTO-PCI) or alternative revascularization strategies should be based on precise evaluation of the coronary anatomy to anticipate those patients that most likely benefit from a procedure and not on strict adherence to perpetual clinical practice. Therefore, the aim of this study was to assess the impact of LMCA disease on long-term outcomes in patients undergoing percutaneous coronary intervention for CTO. Methods: We enrolled 3860 consecutive patients undergoing PCI for at least one CTO lesion and investigated the predictive value of concomitant LMCA disease. All-cause mortality was defined as the primary study endpoint. Results: We observed that LMCA disease is significantly associated with mortality. In the Cox regression analysis, we observed a crude hazard ratio (HR) 1.59 (95% confidence interval (CI) 1.23–2.04, p < 0.001) for patients with LMCA disease as compared to patients without. Results remained unchanged after bootstrap- or clinical confounder-based adjustment. Conclusion: LMCA disease is associated with excess mortality in CTO patients. Specifically, anatomical features such as CTO of the circumflex artery represent a high risk patient population.
Highlights
Coronary artery chronic total occlusions (CTO) represent the most advanced form of coronary artery disease (CAD), which are defined by coronary arteries with absent anterograde blood flow for more than 3 months [1]
Concomitant right coronary artery (RCA) disease was present in 1800 patients (47%), a history of coronary artery bypass graft (CABG) in 594 patients (15%), and a history of previous percutaneous coronary intervention (PCI) in 645 patients (17%)
We found that left main coronary artery (LMCA) is a strong and independent risk factor for unfavorable outcome, but that excess mortality is largely driven by anatomical features i.e., CTO of the circumflex artery
Summary
Coronary artery chronic total occlusions (CTO) represent the most advanced form of coronary artery disease (CAD), which are defined by coronary arteries with absent anterograde blood flow for more than 3 months [1]. The prognostic significance of concomitant LMCA in CTO-PCI is unknown, the presence of LMCA disease in CTO patients—in accordance with current guidelines—leads commonly to referral for coronary artery bypass graft (CABG) surgery, significance of concomitant LM lesions remains unknown [8]. For this purpose, we sought to define clearly the impact of concomitant left main coronary artery diseases on outcome in CTO-PCI in order to guide clinical decision making. Anatomical features such as CTO of the circumflex artery represent a high risk patient population
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