Chronic Total Occlusion Patients Research Articles

Predictive value of SYNTAX-Ⅱ score on prognosis of patients with chronic total occlusion undergoing percutaneous coronary intervention

Objective: To investigate the predictive value of SYNTAX-Ⅱ score on long term prognosis of patients diagnosed with chronic total occlusion (CTO) and received percutaneous coronary intervention (PCI). Methods: Patients undergoing CTO-PCI in Fuwai hospital from January 2010 to December 2013 were enrolled in this retrospective analysis. The SYNTAX-Ⅱ score of the patients was calculated. According to SYNTAX-Ⅱ score tertiles, patients were stratified as follows: SYNTAX-Ⅱ≤20, 20<SYNTAX-Ⅱ≤27, SYNTAX-Ⅱ>27. Primary endpoint was major adverse cardiac events (MACCE), including all-cause death, myocardial infarction, stroke and any revascularization. Secondary endpoints included stent thrombosis, heart failure and target lesion failure (TLF). Patients were followed up by outpatient visit or telephone call at 1 month, 6 months and 1 year after PCI, and annually up to 5 years. Multivariate Cox regression model was used to analyze the independent risk factors of all-cause death in patients undergoing CTO-PCI. The predictive value of SYNTAX score with SYNTAX-Ⅱ score for all-cause death was evaluated by the receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results: A total of 2 391 patients with CTO and received PCI were enrolled in this study. The mean age was (57.0±10.5) years, 1 994 (83.40%) patients were male. There were 802 patients in lower tertile group (SYNTAX-Ⅱ≤20), 798 patients in intermediate group (20<SYNTAX-Ⅱ≤27) and 791 patients in upper tertile group (SYNTAX-Ⅱ>27). At the end of 5-year follow-up, the loss to follow-up rate of the three groups was 9.10%(73/802), 10.78%(86/798)and 8.85%(70/791), respectively. The rate of all-cause mortality (1.78% (13/729) vs. 3.65% (26/712) vs. 9.02% (65/721), P<0.001), cardiac death (1.37% (10/729) vs. 2.11% (15/712) vs. 4.85% (35/721), P<0.001), target vessel myocardial infarctions (4.25% (31/729) vs. 4.49% (32/712) vs. 7.07% (51/721), P=0.03), probable stent thrombosis (1.51% (11/729) vs. 2.81% (20/712) vs. 3.61% (26/721), P=0.04) and heart failure (1.78% (13/729) vs. 1.97% (14/712) vs. 5.41% (39/721), P<0.001) increased in proportion to increasing SYNTAX-Ⅱ score (all P<0.05). Multivariable Cox regression analysis indicated that female (HR=2.05, 95%CI 1.12-3.73, P=0.01), left ventricular ejection fraction (HR=0.97, 95%CI 0.95-1.00, P=0.05) and SYNTAX-Ⅱ score (HR=1.07, 95%CI 1.02-1.11,P=0.01) were independent predictors for all-cause mortality in patients undergoing CTO-PCI. The predicted value of the SYNTAX-Ⅱ score for all-cause death was significantly higher than the SYNTAX score (AUC 0.71 vs. 0.60, P=0.003). Conclusion: For CTO patients who underwent percutaneous coronary intervention, SYNTAX-Ⅱ score is an independent predictor for 5-year all-cause death, and SYNTAX-Ⅱ serves as an important predictor for all-cause death in these patients.

Percutaneous coronary intervention improves quality of life of patients with chronic total occlusion and low estimated glomerular filtration rate.

A low estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) is widely recognized as a risk factor for major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, the impact of successful CTO-PCI on quality of life (QOL) of patients with low eGFR remains unknown. The aim of this prospective study was to assess the QOL of CTO patients with low eGFR after successful PCI. Consecutive patients undergoing elective CTO-PCI were prospectively enrolled and subdivided into four groups: eGFR ≥90 mL/min/1.73 m2 (n = 410), 90 > eGFR ≥ 60 mL/min/1.73 m2 (n = 482), 60 > eGFR ≥ 30 mL/min/1.73 m2 (n = 161), and eGFR <30 mL/min/1.73 m2 (n = 23). The primary outcomes included QOL, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, and symptoms, as assessed with the Rose Dyspnea Scale (RDS) and Seattle Angina Questionnaire (SAQ), at 1 month and 1 year after successful PCI. With the decline of eGFR, CTO patients were more likely to present with comorbidities of hypertension, diabetes, hyperuricemia, and previous stroke, in addition to lower hemoglobin levels and left ventricular ejection fraction (p < 0.05). Low eGFR was associated with greater incidences of in-hospital pericardiocentesis, major bleeding, acute renal failure, and subcutaneous hematoma, but not in-hospital MACE (p < 0.05). Symptoms of dyspnea and angina were alleviated in all CTO patients with eGFR ≥30 mL/min/1.73 m2 at 1 month and 1 year after successful CTO-PCI, but only at 1 month for those with eGFR <30 mL/min/1.73 m2 (p < 0.01). Importantly, QOL was markedly improved at 1 month and 1 year after successful PCI (p < 0.01), notably at a similar degree between patients with low eGFR and those with normal eGFR (p > 0.05). Successful PCI effectively improved symptoms and QOL of CTO patients with low eGFR.

The association of collaterals with myocardial ischemia and viability in chronic total occlusions.

Collateral development in chronic total occlusions (CTO) is crucial to perfuse the distal myocardium and its angiographic evaluation is frequently used to assess the need for revascularization. We aimed to analyse the association between the presence of ischemia and hibernating myocardium, evaluated by cardiac [13N]NH3/2-[18F]FDG PET-CT, and the angiographic characterization of the collateral circulation. Prospective study including patients with a CTO who underwent a [13N]NH3 and, when deemed necessary, 2-[18F]FDG PET-CT. Well developed (WD) collaterals were defined as a concomitant angiographic Rentrop grade 3 and Werner collateral connection score 2 or 3, whereas the remaining as poorly developed (PD). 2% thresholds used to identify prognostic benefit of revascularization were applied: ischemia > 10% and hibernating myocardium > 7%. Fifty-nine patients (age 62.9±9.1 years, 58 male) were recruited, WD collaterals were present in 28 (47.5%). No significant differences were found in ischemia (WD 6.4±4.3 vs. PD 7.0±4.1, p = 0.64) and hibernation (WD 1.8±1.9 vs. PD 3.1±3.3, p = 0.18) scores. Most CTO territories demonstrated ischemia, but only 19 (46.3%) were associated with an area > 10% (WD 47.6% vs. PD 45.0%, p = 0.58). Scared non-viable myocardium was limited to 9 (15.3%) patients and was not associated with PD collaterals. Hibernating myocardium was frequent (54.2%), but just 6 (10.2%) CTO patients had an area of > 7% (WD 3.6% vs. PD 16.1%, p = 0.20). Collateral assessment by angiography has a poor association with the ischemic burden and hibernation state of CTO territories. Myocardial viability was present even in most CTO with angiographic PD collaterals.

Benefits of successful percutaneous coronary intervention in chronic total occlusion patients with diabetes

BackgroundDiabetes was commonly seen in chronic total occlusion (CTO) patients but data regarding the impact of successful percutaneous coronary intervention (PCI) on clinical outcome of CTO patients with diabetes was controversial. And importantly, no studies have compared quality of life (QOL) after CTO-PCI in patients with and without diabetes.MethodsConsecutive patients undergoing elective CTO-PCI were prospectively enrolled from Apr. 2018 to May 2021. Patients were subdivided into 2 groups: Diabetes and No Diabetes. Detailed baseline characteristics, assessment of symptoms and QOL, angiographic and procedural details, in-hospital complications, and 1 month and 1 year follow-up data were collected. These data were analyzed accordingly for risk predictors of clinical outcome in patients who have diabetes and received successful CTO-PCI.ResultsA total of 1076 patients underwent CTO-PCI attempts. Diabetes was present in 374 (34.76%) patients, who had more hypertension, previous PCI and stroke. Regarding the coronary lesions, diabetic patients suffered more LCX lesion, multivessel disease, number of lesions per patient, blunt stump, calcification and higher J-CTO score (p < 0.05). In-hospital major adverse cardiac event (MACE) (4.13% vs. 5.35%; p = 0.362) was similar in the two groups. At 1 month and 1 year follow-up after successful CTO-PCI, the incidence of MACE and all-cause mortality were also similar in the two groups (p > 0.05). Number of lesions per patient was an independent risk factor of MACE and all-cause mortality (p < 0.001) 1 year after successful CTO-PCI. Symptom and QOL were markedly improved regardless of diabetes both at 1 month and 1 year follow-up, and importantly, patients with diabetes showed similar degrees of improvement to those without diabetes (P > 0.05).ConclusionsSuccessful CTO-PCI could represent an effective strategy improving clinical outcome, symptoms and QOL in CTO patients with diabetes.

Leveraging Machine Learning Techniques to Forecast Chronic Total Occlusion before Coronary Angiography

Chronic total occlusion (CTO) remains the most challenging procedure in coronary artery disease (CAD) for interventional cardiology. Although some clinical risk factors for CAD have been identified, there is no personalized prognosis test available to confidently identify patients at high or low risk for CTO CAD. This investigation aimed to use a machine learning algorithm for clinical features from clinical routine to develop a precision medicine tool to predict CTO before CAG. Data from 1473 CAD patients were obtained, including 1105 in the training cohort and 368 in the testing cohort. The baseline clinical characteristics were collected. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors that impact the diagnosis of CTO. A CTO predicting model was established and validated based on the independent predictors using a machine learning algorithm. The area under the curve (AUC) was used to evaluate the model. The CTO prediction model was developed with the training cohort using the machine learning algorithm. Eight variables were confirmed as 'important': gender (male), neutrophil percentage (NE%), hematocrit (HCT), total cholesterol (TC), high-density lipoprotein cholesterol (HDL), ejection fraction (EF), troponin I (TnI), and N-terminal pro-B-type natriuretic peptide (NT-proBNP). The model achieved good concordance indices of 0.724 and 0.719 in the training and testing cohorts, respectively. An easy-to-use tool to predict CTO in patients with CAD was developed and validated. More research with larger cohorts are warranted to improve the prediction model, which can support clinician decisions on the early discerning CTO in CAD patients.

Abstract 9961: Benefits of Successful Percutaneous Coronary Intervention in Chinese CTO Patients With Low LVEF

Introduction: Low left ventricular ejection fraction (LVEF) was commonly seen in chronic total occlusion (CTO) patients and was considered as an independent risk factor of poor prognosis of those patients. Yet, data regarding the clinical outcome, symptom and quality of life (QOL) of successful recanalization of CTO in low LVEF patients were scarcely reported. Objectives: This study set out to assess the clinical outcome, symptoms and QOL of CTO treated with percutaneous coronary intervention (CTO-PCI) in Chinese patients with low LVEF. Methods: Patients consecutively undergoing elective CTO-PCI were included and subdivided into 3 groups: LVEF≥50%, 50%&gt;LVEF≥40%, and LVEF&lt;40%. Detailed baseline characteristics, assessment of symptoms and QOL, procedural details, in-hospital complications, and 1 month and 1 year follow-up data were collected. Results: Of 995 CTO patients, LVEF&lt;40% was present in 172 (17.29%), who had more previous MI, multi-CTO lesion and higher SYNTAX score (p&lt;0.001), and their procedural success rate did not drop significantly compared with the other two groups (93.95% vs. 92.31% vs. 88.95%; p=0.078). In-hospital MACCE (2.55% vs. 2.56 vs. 8.14%; p=0.001) was the highest in patients with LVEF&lt;40%. At 1 month and 1 year follow-up, MACE and all-cause mortality were also the highest in patients with LVEF&lt;40% after successful CTO-PCI, while they were markedly lower than those with failed CTO-PCI (p&lt;0.001). LVEF&lt;40% was an independent risk factor of MACE and all-cause mortality 1 year after successful revascularization. Symptoms and QOL were markedly improved regardless of LVEF at 1 month and 1 year follow-up, notably at a similar degree between patients with LVEF&lt;40% and the other two groups (P&gt;0.05). Conclusions: PCI could represent an effective revascularization strategy improving clinical outcome, symptoms and QOL in CTO patients with low LVEF.

Abstract 14495: Impact of Complete Revascularization in Chronic Total Occlusion Patients With Multi-Vessel Disease on Long-Term Clinical Outcomes

Background: This study compares the long-term clinical outcomes between two different treatment strategies: percutaneous coronary intervention (PCI) versus medical therapy (MT) for chronic total occlusion (CTO) in multi-vessel disease (MVD) patients. Methods: The study data obtained from the CTO registry of Korea University Guro Hospital (KUGH), Seoul, South Korea. This trial is a single-center, prospective, all-comer registry designed to reflect “real world” practice since 2004. the study population has been divided into two groups: the CTO-PCI group having 233 patients and the CTO-MT group having 230 patients. A propensity score matching (PSM) analysis had performed to adjust for confounding factors. Results: Following PSM, the two groups comprised the matched individuals from 336 pairs (total N=272 patients). The baseline clinical and angiographic characteristics were well-balanced between the two groups. Up to a 5-year clinical follow-up by Kaplan-Meier survival analysis, the primary endpoint, as defined as the composite of all-cause death or myocardial infarction (MI), occurred more in the CTO-MT group (32.6%) than in the PCI group (2.3%), as did all-cause death (2.3% vs. 8.4%, P=0.042) and MI (4.3% vs. 0.0%, P= 0.023). Target vessel revascularization (TVR) at CTO lesions still occurred more in the CTO-PCI group than in the CTO-MT group (38.3% vs. 6.8%, P=0.009). Conclusions: PCI is shown as a reasonable treatment option compared to MT for CTO lesions in MVD patients; TVR risk is still higher, although.

Abstract 12314: Bivalirudin versus Unfractionated Heparin During Percutaneous Intervention for Chronic Total Occlusion: A Systematic Review and Meta-Analysis

Introduction: Chronic total occlusion (CTO) percutaneous intervention (PCI) is an evolving challenge within interventional cardiology. Anticoagulation during percutaneous intervention remains part of the standard of care for patients undergoing PCI to prevent thrombotic complications peri-procedurally. Unfractionated heparin (UFH) is a commonly used for CTO PCI-related anticoagulation. However, bivalirudin (BV), a synthetic, reversible, direct thrombin inhibitor, has been utilized as an alternative to UFH in CTO patients undergoing PCI. This meta-analysis aims to investigate the efficacy and safety of bivalirudin versus UFH for CTO PCI. Methods: We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases through May 2022 for all studies evaluating efficacy and safety of bivalirudin versus UFH in CTO patients undergoing PCI. The primary outcome was mortality. Secondary outcomes were major adverse cardiac events (MACE), major bleeding events, peri-procedure myocardial infarction (MI), in-stent thrombosis, and unplanned revascularization. Pooled risk ratio (RR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effects model. Heterogeneity was assessed by I2 statistic. Results: A total of 5 studies containing 1347 patients with CTO undergoing PCI on anticoagulation (631 BV versus 716 UFH) were included. No significant difference existed between BV and UFH regarding mortality [RR: 0.54 (95% CI: 0.19-1.56); P 0.26 , I2 0%]. Major bleeding events were significantly lower in BV compared with UFH [RR: 0.33 (95% CI: 0.19-0.66); P 0.001, I2 0%]. MACE [RR: 0.75 (95% CI: 0.55-1.00); P 0.05, I2 2%], peri-procedure MI [RR: 0.80 (95% CI: 0.56-1.15); P 0.24, I2 0%], in-stent thrombosis [RR: 0.68 (95% CI: 0.19-2.39); P 0.55, I2 17%] and unplanned revascularization [OR: 0.77 (95% CI: 0.29-2.07); P 0.61, I2 0%] were similar between the two groups. Conclusions: BV seems to be safer than UFH in preventing major bleeding in anticoagulated patients with CTO undergoing PCI; there is no significant difference between groups in terms of mortality, MACE, peri-procedure MI, in-stent thrombosis, or unplanned revascularization. Future randomized controlled trials are needed.

Predictors and prognosis of PCI-related myocardial injury in chronic total occlusion

BackgroundPeriprocedural myocardial injury (PMI) is associated with major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). However, the incidence predictors and prognosis of PMI in chronic total occlusion (CTO) undergoing PCI remains unclear.MethodTo evaluate the predictors and prognostic impact of PMI following PCI in patients with CTO. We consecutively enrolled 132 individuals and 8 of whom with procedural failure were excluded in this study. Thus, a total of 124 CTO patients successfully received PCI were included in this study. And patients were divided into the PMI group (n = 42) and the non-PMI group (n = 82) according to their c-TnI levels measured after procedure. The baseline and angiographic characteristics of the two groups were compared. The predictors of PMI and the correlation between PMI and MACE were investigated.ResultsOverall, PMI occurred in 42 patients (33.9%). Comparing with control group, PMI group had more diabetes (54.8% vs. 31.7%,P = 0.013) and dyslipidemia (54.8% vs. 13.4%, P＜0.001). Also, there were significant differences between the two groups in left ventricular ejection fraction(43.2 ± 7.2 vs 47.2 ± 8.0, P = 0.027), prior myocardial infarction(54.8%vs43.1%, P = 0.020), prior PCI(57.1% vs 22.0%, P＜0.001) and prior CABG(14.3% vs 2.4%, P = 0.011). Also, patients with PMI had more calcified lesions (52.4% vs 24.4%, P = 0.002) and were more likely to have multivessel disease (71.4% vs 35.4%, P＜0.001). In addition, patients in the PMI group had higher J-CTO scores (3.3 ± 1.0 vs 1.9 ± 0.5, P＜0.001) and were more likely to have wire-crossing difficulties (64.3% vs 37.8%, P = 0.005), require more use of retrograde approach (38.1% vs 7.3%, P＜0.001) and have more procedural complications (19.0% vs 2.4%, P = 0.003). In the multivariate analysis, multivessel artery disease (odd ratio [OR], 4.347;95% confidence interval [CI], 1.601– 11.809;P = 0.004), retrograde approach (OR, 4.036; 95%CI, 1.162– 14.020;P = 0.028) and the presence of procedural complications (OR, 16.480;95%CI, 2.515-107.987;P = 0.003) were predictors of PMI.ConclusionThe incidence of PMI in CTO patients after PCI was 33.9%. Multivessel artery disease, retrograde approach, and the presence of procedural complications were predictors of PMI after CTO-PCI. Patients who develop PMI tend to have a poorer clinical prognosis and more MACE than those who do not develop PMI.

The association of new atherosclerosis markers with coronary collaterals in chronic total occlusion patients

Objectives: In the present study, we investigated the relationship between mentioned markers and chronic total occlusion collateral development. Patients and methods: A total of 243 patients (210 males, 33 females; mean age: 63.3±11.5; range, 51 to 76 years) who underwent coronary angiography due to typical chest pain or myocardial ischemia detected in noninvasive stress tests and diagnosed with ≥1 major coronary artery occlusion between January and September 2020 were included in the cross-sectional observational study. The angiographic collateral index was determined according to the Cohen-Rentrop classification. The patients were divided into two groups according to the sufficiency of collateral development: the well-developed collaterals group (n=155) and the poor-developed collaterals group (n=88). Results: Statistically significant parameters in univariate logistic regression analysis were evaluated with multivariate (stepwise) logistic regression analysis; as a result, presence of chronic total occlusion in left anterior descending artery (odds ratio [OR]=2.447; 95% confidence interval [CI], 1.160-5.162; p=0.019), total number of occlusions (OR=3.503; 95% CI, 1.445-8.494; p=0.006), left ventricular ejection fraction (OR=1.056; 95% CI, 1.022-1.091; p=0.001), and the atherogenic index of plasma (OR=0.017; 95% CI, 1.022-1.091; p&lt;0.001) were independently associated with well-developed collaterals. Although the triglyceride-glucose index had statistical significance in the univariate analysis, it was not detected as an independent variable in the multivariate analysis. The monocyte-lymphocyte ratio was not significant in the univariate analysis. Conclusion: Of the new atherosclerosis markers, only the atherogenic index of plasma had an independent association with poor collateral development.

In-hospital and long-term outcomes of percutaneous coronary interventions for chronic total occlusions in patients with contrast-associated acute kidney injury

Abstract Background The prognostic impact on in-hospital and long-term outcomes of contrast-associated acute kidney injury (CA-AKI) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been limitedly studied. Methods We examined 2707 consecutive procedures performed in a referral CTO center between 2015 and 2019. CA-AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥50% within 48 h post-PCI†. Primary endpoints were major adverse cardiac and cerebrovascular events (MACCE) in-hospital (composite of all-cause death, myocardial infarction [MI], target vessel revascularization [TVR], stroke) and at 1-year of follow-up. Results The overall incidence of CA-AKI was 11.5%, respectively. Patients with CA-AKI (n=312) had more severe comorbidities in comparison with patients without CA-AKI (n=2,395). Technical success was similar across the groups (87.2% vs. 90.5%, p=0.056), whereas procedural success was lower in the CA-AKI group (84.3% vs. 89.7%, p=0.004). In-hospital MACCE was 1.3%, respectively, and were comparable in patients with and without CA-AKI (1.6% vs. 1.3%, p=0.655), however, pericardial tamponade requiring pericardiocentesis occurred more commonly in patients with renal function impairment (2.2% vs. 0.5%, p=0.001). In multivariate analysis, CA-AKI was not associated with higher risk for in-hospital MACCE (adjusted odds ratio [OR] 1.34, confidence intervals [CI] 0.45–3.19, p=0.563). At median follow-up time of 14 months (interquartile range [IQR], 11 to 35 months), the cumulative incidence of 1-year MACCE was significantly higher in patients with versus without CA-AKI (20.8% vs. 12.8%, p&amp;lt;0.001), and CA-AKI was independently associated with an increased risk for 1-year MACCE (adjusted hazard ratio [HR] 1.52, CI 1.05–2.15, p=0.029) following CTO PCI. Patients with CA-AKI had inferior MACCE-free (log-rank p&amp;lt;0.001) survival on Kaplan-Meier analysis (Figure 1), mostly driven by higher rate of target vessel failure (log-rank p&amp;lt;0.001), mortality (log-rank p=0.001), and myocardial infarction (log-rank p=0.042) over time. MACCE-free survivals significantly differed both in successful (Figure 2, Panel A) versus failed (Figure 2, Panel B) CTO PCI, with less favourable outcomes in patients developing CA-AKI post-PCI. Conclusions Contrast-associated acute kidney injury commonly occurs in patients undergoing CTO PCI, that may lead to an increased risk for MACCE 1-year post-PCI, but not immediately after the procedure. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only.

Collateral presence and extent do not predict myocardial viability and ischemia in chronic total occlusions: A stress-CMR study

BackgroundWell-developed collaterals are assumed as a marker of viability and ischemia in chronic total occlusions (CTO). We aim to correlate viability and ischemia with collateral presence and extent in CTO patients by cardiac magnetic resonance (CMR). MethodsMulticentre study of 150 CTO patients undergoing stress-CMR, including adenosine if normal systolic function, high-dose-dobutamine for patients with akinetic/>2 hypokinetic segments and EF ≥35%, otherwise low-dose-dobutamine (LDD); all patients underwent late gadolinium enhancement (LGE) imaging. Viability was defined as mean LGE transmurality ≤50% for adenosine, as functional improvement for dobutamine-stress-test, ischemia as ≥1.5 segments with perfusion defects outside the scar zone. ResultsRentrop 3/CC 2 defined well-developed (WD, n = 74) vs poorly-developed collaterals (PD, n = 76). Viability was equally prevalent in WD vs PD: normo-functional myocardium with ≤50% LGE in 52% vs 58% segments, p = 0.76, functional improvement by LDD in 48% vs 52%, p = 0.12. Segments with none, 1–25%,26–50%,51–75% LGE showed viability by LDD in 90%,84%,81%,61% of cases, whilst in 12% if 76–100% LGE (p < 0.01). There was no difference in WD vs PD for ischemia presence (74% vs 75%, p = 0.99) and extent (2.7 vs 2.8 segments, p = 0.77). ConclusionsIn a large cohort of CTO patients, presence and extent of collaterals did not predict viability and ischemia by stress-CMR. Scar extent up to 75% LGE was still associated with viability, whereas ischemia was undetectable in 25% of patients, suggesting that the assessment of CTO patients with CMR would lead to a more comprehensive evaluation of viability and ischemia to guide revascularization.

TCT-120 Impact of Complete Revascularization in Chronic Total Occlusion Patients With Multivessel Disease on Long-Term Clinical Outcomes

TCT-120 Impact of Complete Revascularization in Chronic Total Occlusion Patients With Multivessel Disease on Long-Term Clinical Outcomes

TCT-122 Revascularization Versus Optimal Medical Therapy on Left Ventricular Ischemia Reduction: Exploring the Associations Between Ischemia, Functional Outcome, and Collaterals in the Treatment of Chronic Total Occlusion Patients: Rationale and Design of the REVISE-CTO Trial

TCT-122 Revascularization Versus Optimal Medical Therapy on Left Ventricular Ischemia Reduction: Exploring the Associations Between Ischemia, Functional Outcome, and Collaterals in the Treatment of Chronic Total Occlusion Patients: Rationale and Design of the REVISE-CTO Trial

ST-segment Yükselmeli Miyokart Enfarktüsünde Kronik Total Oklüzyonu Öngörmede Nötrofil/Lenfosit ve Trombosit/Lenfosit Oranı

Background: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are new systemic inflammation markers and predictor of adverse cardiovascular outcomes. Approximately 10% of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) have chronic total occlusion (CTO) of the non-infarct-related artery. The presence of concurrent CTO is associated with short- and long-term morbidity and mortality. Here, we aimed to investi-gate the relationship of NLR and PLO with coexistent CTO in STEMI patients.Materials and Methods: Ninety consecutive STEMI patients with concurrent CTO were included in the study group and 100 STEMI patients without CTO were included in the control group retrospectively. The relationship between inflammatory markers and concurrent CTO in STEMI was analyzed.Results: STEMI patients with concurrent CTO had increased NLR, PLR, C-reaktive protein and troponin while decreased glomerular filtration rate, left ventricular ejection fraction (LVEF) in comparison with patients without CTO. In multivariate analysis, NLR (p=0.002), PLR (p=0.042), CRP (p=0.002), hypertension (p&amp;lt;0.001), Hyperlipidemia (p=0.002) and LVEF (p=0.012) were found to be the independent predictors for the presence of concurrent CTO. In the ROC (Receiver Operating Characteristic) curve analysis, ≥ 5.6 and ≥ 164 cut-off values were determined for NLR and PLR in detecting concurrent CTO in STEMI.Conclusions: PLR and NLR, simple and easily calculated laboratory parameters, may permit prediction of concurrent CTO in patients with STEMI.Key Words:

Relevance of Chronic Total Occlusion for Outcome of Ventricular Tachycardia Ablation in Ischemic Cardiomyopathy.

Background Catheter ablation of ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) is an effective tool to prevent VT recurrences. Chronic total occlusion (CTO) represents a clinically relevant entity in ICM patients and is an independent predictor of ventricular arrhythmia and mortality. The effects of CTO on the outcome of VT ablation are not well-studied. Objective This analysis aimed to identify the impact of CTO, revascularized, or not revascularized, on the outcome of VT ablation. Methods and Results Of 385 consecutive subjects with ICM-VT who underwent catheter VT ablation for monomorphic VT at Heart Center Leipzig between 2008 and 2017, 108 patients without CTO and 191 patients with CTO were included in the analysis. Within a median follow-up time of 557 days (IQR 149, 1095), VT recurred in 77 (40%) patients in the CTO and 40 (37.0%) in the non-CTO cohort (p = 0.62). In a multivariable model, a 10% stepwise change in LVEF as well as ICD on admission was associated with VT recurrence (HRadj 1.82, 95% CI 1.04–3.18 and HRadj 1.35, 95% CI 1.23–1.61, respectively). Of the CTO cohort before ablation, 45% had received revascularization, which was independently associated with a higher risk for VT recurrence (HR 2.12, 95% CI 1.35–3.34) as compared to nonrevascularized CTO. Conclusion In ICM patients with and without CTO, VT ablation was associated with equal effectiveness with regard to VT recurrence. However, in revascularized CTO patients, the risk of recurrence of VT after ablation was significantly increased.

Impact of Complete Revascularization in Chronic Total Occlusion Patients With Multi-Vessel Disease on Long-Term Clinical Outcomes

Impact of Complete Revascularization in Chronic Total Occlusion Patients With Multi-Vessel Disease on Long-Term Clinical Outcomes

Comparative Analysis of Patient Characteristics in Chronic Total Occlusion Revascularization Studies: Trials vs Real-World Registries.

The few randomized controlled trials (RCTs) on chronic total occlusion (CTO) percutaneous coronary intervention (PCI) are subject to selection bias. The purpose of this study was to evaluate the differences between real-world CTO patients and those enrolled in RCTs. This study performed a meta-analysis of national and dedicated CTO PCI registries and compared patient characteristics and outcomes with those of RCTs that randomized patients to CTO PCI versus medical therapy. Given the large sample size differences between RCTs and registries, the study focused on the absolute numbers and their clinical significance. The study considered a 5% relative difference between groups to be potentially clinically relevant. From 2012 to 2022, 6 RCTs compared CTO PCI versus medical therapy (n=1,047) and were compared with 15 registries (5 national and 10 dedicated CTO PCI registries). Compared with registry patients, RCT patients had fewer comorbidities, including diabetes, hypertension, previous myocardial infarction, and prior coronary artery bypass graft surgery. RCT patients had shorter CTO length (29.6 ± 19.7mm vs 32.6 ± 23.0mm, a relative difference of 9.2%) and lower Japan-Chronic Total Occlusion Score scores (2.0 ± 1.1 vs 2.3 ± 1.2, a relative difference of 13%) compared with those enrolled in dedicated CTO registries. Procedural success was similar between RCTs (84.5%) and dedicated CTO registries (81.4%) but was lower in national registries (63.9%). There is a paucity of randomized data on CTO PCI outcomes (6 RCTs, n=1,047). These patients have lower risk profiles and less complex CTOs than those in real-world registries. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation.

Meta-analysis on efficacy of PCI treatment or conservative treatment among patients with chronic total occlusions

Objective: To compare the efficacy between percutaneous coronary intervention (PCI) and conservative medication treatment in chronic total occlusions (CTO) patients. Methods: It was a meta-analysis.Articles on drug therapy and PCI for complete coronary artery occlusion were retrieved from Pubmed, Embase and Web of Science databases. The search time was from the database construction to May 10, 2020, and the following search criteria were used for the search "chronic total occlusion" "percutaneous coronary intervention" and "medical therapy". References from searched literatures were also searched to identify more eligible studies. Randomized controlled trials (RCT) and cohort studies comparing efficacy of PCI versus oral medication as well as medication as initial therapy option for CTO patients with single or multiple lesions were included. The primary endpoints included all-cause death, cardiac death, recurrent myocardial infarction, re-revascularization, major adverse cardiac events (MACE) and stroke. Data were analyzed with ReviewManager5.3.0 software. Pooled effect size RR and 95%CI were calculated by randomization effect model. Heterogeneity was evaluated by I2. Bege test was used to evaluate publication bias. Subgroup analyses were performed for RCT and cohort studies. Results: A total of 1 079 articles were retrieved and 16 studies (RCT=4, cohort study=12) were included with 12 223 patients. Fourteen publications (RCT=4, cohort study=10) reported all-cause death post PCI and/or drug therapy. Results showed that risk of all-cause death was significantly lower in PCI group than in drug therapy group (RR=0.45,95%CI 0.39-0.53,P<0.001);subgroup analysis showed that risk of all-cause death was significantly lower in PCI group than in drug therapy group from cohort studies (RR=0.44,95%CI 0.38-0.52,P<0.001),but comparable in RCT (P=0.27). Thirteen studies (RCT=3, cohort study=10) reported cardiac death post PCI and/or drug therapy. Results showed that risk of cardiac death was significantly lower in PCI group than in drug therapy group (RR=0.44,95%CI 0.35-0.55,P<0.001);subgroup analysis showed that risk of cardiac death was significantly lower in PCI group than in drug therapy group in cohort studies (RR=0.43,95%CI 0.34-0.54,P<0.001),but not in RCT (P=0.25). Fourteen publications (RCT=4, cohort study=10) reported recurrent myocardial infarction post PCI and/or drug therapy. Results showed that risk of recurrent myocardial infarction was significantly lower in PCI group than in drug therapy group (RR=0.62,95%CI 0.44-0.88,P=0.007);subgroup analysis showed that risk of recurrent myocardial infarction was significantly lower in PCI group than in drug therapy group from cohort studies (RR=0.56,95%CI 0.40-0.78,P=0.000 5),but comparable in RCT (P=0.17). Fourteen publications (RCT=4, cohort study=10) reported re-revascularization post PCI and/or drug therapy. Results showed that risk of re-revascularization was comparable between PCI group and drug therapy group (P=0.91);subgroup analysis showed that risk of re-revascularization was comparable between PCI group and drug therapy group both in cohort study and RCT (P=0.60 and 0.41, respectively). Eleven publications (RCT=3, cohort study=8) reported MACE post PCI and/or drug therapy. Results showed that risk of MACE was significantly lower in PCI group than in drug therapy group (RR=0.74,95%CI 0.59-0.93,P=0.03);subgroup analysis showed that risk of MACE was significantly lower in PCI group than in drug therapy group in cohort studies (RR=0.72,95%CI 0.56-0.93,P=0.01), but not in RCT (P=0.8). Six publications (RCT=2, cohort study=4) reported stroke post PCI and/or drug therapy. Results showed that risk of stroke was comparable between PCI and drug therapy groups (RR=0.62,95%CI 0.32-1.20, P=0.15);subgroup analysis showed that risk of stroke was comparable between PCI and drug therapy groups both in cohort studies and RCT (P=0.48 and 0.32, respectively). Conclusion: Compared with oral drug therapy, PCI may have better efficacy for CTO patients based on results from this cohort study.

Procedural results and in-hospital outcomes of percutaneous coronary intervention for chronic total occlusion in patients with reduced left ventricular ejection fraction: Sub-analysis of the Japanese CTO-PCI Expert Registry.

To evaluate the procedural results and in-hospital outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients with reduced left ventricular ejection fraction (LVEF). While the technical success of general CTO-PCI has improved, CTO-PCI patients with reduced LVEF remain at high-risk for adverse events. The data of 820 patients with LVEF ≤ 35% (Group 1), 1816 patients with LVEF = 35%-50% (Group 2), and 5503 patients with LVEF ≥ 50% (Group 3), registered in the Japanese CTO-PCI Expert Registry from January 2014 to December 2019, were retrospectively analyzed. The primary endpoint was in-hospital major adverse cardiac or cerebrovascular events (MACCEs), including death, myocardial infarction, stent thrombosis, stroke, and emergent revascularization. Secondary endpoints included procedural details, guidewire success, and technical success. There were no differences in guidewire and technical success rates between the groups. In-hospital MACCEs was significantly higher in Group 1 (Group 1 vs. Group 2 vs. Group 3: 3.4% vs. 1.7% vs. 1.5%,p = 0.001) and was especially driven by death (1.3% vs. 0.3% vs. 0.1%,p < 0.001) and stroke (0.7% vs. 0.2% vs. 0.2%,p = 0.007). Multivariate analysis showed that LVEF ≤ 35% (odds ratio[OR];1.58, 95% confidence interval[CI];1.04-2.41,p = 0.03) and New York Heart Association (NYHA)class ≥ 3 (OR; 2.01, 95% CI; 1.03-3.93,p = 0.04) were predictors of in-hospital MACCEs. In-hospital MACCEs were significantly higher in patients with LVEF ≤ 35%. LVEF ≤;35% and NYHA class ≥ 3 were predictors of in-hospital MACCEs after CTO-PCI.