Successful Chronic Total Occlusion Research Articles

Comparison of successful versus failed percutaneous coronary intervention in patients with chronic total occlusion: A systematic review and meta-analysis.

The optimal treatment strategy of chronic total occlusion (CTO) is currently debated. This meta-analysis aimed to evaluate the long-term clinical outcomes of successful percutaneous coronary intervention (PCI) of CTO. Electronic databases were searched for studies comparing long-term outcomes between successful PCI in patients with CTO using drug-eluting stents and failed procedures. Meta-analysis was conducted with major adverse cardiac events (MACE) and all-cause mortality during the longest follow-up as endpoints. The combined hazard ratios (HRs) were applied to assess the correlation between successful CTO PCI and MACE/all-cause mortality. Eight studies consisting of 6,211 patients published between 2012 and 2020 met our inclusion criteria, and the CTO PCI success rate was 81.2%. Patients in the failed group were much older, and more likely to have morbidities (hypertension and prior myocardial infarction), reduced left ventricular ejection fraction, and severe lesion characteristics (multivessel disease and moderate/severe calcification). Pooled results indicated that successful CTO PCI was significantly associated with prognosis. Compared to failed recanalization, patients receiving successful procedures had an improved MACE (HR: 0.50, 95% CI: 0.40-0.61, p < 0.001). Subgroup analyses further revealed the prognostic value of successful CTO PCI. However, no difference was observed regarding all-cause mortality (HR: 0.79, 95% CI: 0.61-1.02, p = 0.074). The present study showed that CTO recanalization was associated with improved long-term outcomes. However, randomized trials are needed to confirm the results due to the mismatch of baseline characteristics.

Efficacy of the tip-detection method over the retrograde approach for chronic total occlusion percutaneous coronary intervention

Abstract Background The tip-detection method has been acknowledged as a novel strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) when conventional antegrade wiring strategies are ineffective, but a comparison with the retrograde approach has yet to be carried out. Method We retrospectively enrolled 170 consecutive CTO PCI cases and separated them according to the adopted strategies. The wire-manipulation time for each strategy was compared between the tip-detection method and the retrograde approach. The rate of successful wire crossing was analyzed according to the variables in the complexity scores. Results Fifty-six attempts with the tip-detection method were observed, with 46 (82.1%) successful cases. Sixty-one retrograde approaches were performed, in which 29 (47.5%) cases achieved procedural success. In the successful attempts, the wire-manipulation time was significantly shorter with the tip-detection method (20.0 [12.2-36.7] min) than with the retrograde approach (35.0 [20.7-49.7] min) (p=0.008). Incomplete tip-detection wire crossing (taking &amp;gt;30 min) was seen in severely tortuous lesions (odds ratio: 0.26, 95% confidence interval: 0.06–0.97, p = 0.037). Conclusions The tip-detection method can improve the rate and time required for successful CTO PCI compared with the retrograde approach. However, the success rate of the tip-detection method is hampered by lesion tortuosity.Figure

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

The successful percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) improves the long-term outcome in patients with coronary artery disease (CAD). Heavy calcification remains one of the strongest predictors of an unfavorable outcome of PCI. In this case series study, shockwave intravascular lithotripsy (S-IVL)-a novel balloon-based coronary system facilitating modification of calcified coronary lesions was evaluated. The study population consisted of five heavily calcified, undilatable-CTOs lesions treated with S-IVL selected out of all consecutive CTO-PCI patients performed at two high-volume cardiac centers. The registry included 5 patients successful CTO - S-IVL procedures with an average J-CTO of 2.6 points. In the short-term follow-up period, including the first 30 days, no cases of acute in-stent thrombosis, target lesion failure, or major adverse cardiac and cerebrovascular events were noted. The present data suggest that this approach can be safe and useful in the treatment of complex calcified CTO lesions.

Exploring indicators of success in chronic total occlusion percutaneous coronary intervention with Stingray system-based antegrade dissection re-entry: Insights from retrospective analysis.

The predictors of success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) through antegrade dissection and re-entry (ADR) using the Stingray system (Stingray ADR) remain elusive, mainly owing to the lack of consecutive angiographic and procedural records of patients. This study aimed to identify indicators that can determine the success of CTO PCI performed using the Stingray ADR technique. The clinical data of 115 patients who underwent CTO PCI through Stingray ADR at the same cardiac center were retrospectively and consecutively collected. Multivariate logistic regression analysis was performed to investigate the indicators of the success of ADR attempts. The technical success rate of Stingray ADR in CTO PCI was 72.2%. The overall technical success rate of CTO recanalization was 78.3% in all CTO PCIs having used Stingray Low Profile balloon. Vessel calcification (odds ratio [OR]: 4.03; 95% confidence interval [CI]: 1.49-11.88; p = 0.008), and retrograde puncture indicator (OR: 4.89; 95% CI: 1.51-17.11; p = 0.009) were identified as independent positive predictors. Blunt/no stump proximal to the occlusion segment (OR: 0.22; 95% CI: 0.06-0.64; p = 0.009), decision time before Stingray ADR (per 1 h increase) (OR: 0.54; 95% CI: 0.31-0.92; p = 0.026), operation duration of Stingray ADR (per 10 min increase) (OR: 0.62; 95% CI: 0.40-0.94; p = 0.028), and puncture site at the intraplaque region (OR: 0.24; 95% CI: 0.06-0.84; p = 0.026) were identified as the four negative independent predictors. This study revealed independent predictors of the success of CTO PCI performed using the Stingray ADR technique. As for CTO characteristics, the presence of calcification in the CTO segment and a tapered stump proximal to the lesion site can facilitate successful Stingray ADR. As for the procedures, the success rate of Stingray ADR can be improved by initiating the technique decisively and promptly, operating the system quickly and accurately and creating a puncture in the distal cap region of CTO under retrograde guidance.

Predictors of long-term adverse outcomes after successful chronic total occlusion intervention: physiology or morphology?

Quantitative flow ratio (QFR) and target-vessel SYNTAX score (tvSS) are novel indices used to assess lesion physiology and morphology in percutaneous coronary intervention (PCI). Their prognostic implication after successful recanalization of coronary chronic total occlusion (CTO) is unknown. To investigate the prognostic value of QFR measured immediately after successful CTO-recanalization in predicting vessel-oriented adverse events, and to compare it with the pre-procedural morphological tvSS. QFR was measured offline after successful CTO-PCIs in a single center. We grouped the patients according to a cut-off value of post-PCI QFR (0.91). The primary outcome was target-vessel failure (TVF) at 2years. Among 470 CTO lesions performed during the study period, 324 were eligible for QFR analysis (258 with QFR ≥ 0.91 and 66 with QFR < 0.91). The mean age of the study population was 68.3 ± 10.7years. The low QFR group had a lower left ventricular ejection fraction (45.8 ± 13.9% vs. 49.8 ± 12.4%, p = 0.025) and a higher rate of atrial fibrillation (19.7% vs. 11.2%, p = 0.020). The mean tvSS was 12.8 ± 4.8, and it showed no significant difference in both groups (13.6 ± 5.1 vs. 12.6 ± 4.6, p = 0.122). Patients with low post-CTO QFR had a trend to develop more TVF at 2years (21.2% vs. 12.4%, HR 1.74; 95% CI 0.93-3.25, p = 0.086). Low post-CTO QFR failed to predict 2-year TVF (aHR 1.67; 95% CI 0.85-3.29, p = 0.136), while pre-procedural tvSS was an independent predictor for 2-year TVF (aHR 1.06; 95% CI 1.01-1.13, p = 0.030). We found a limited prognostic value of immediate physiological assessment using QFR after successful CTO intervention. Pre-procedure morphological characteristics of CTO lesions using tvSS can play a role in predicting long-term adverse events.

STAR procedure becomes SAFER: First-in-man case series of a new antegrade dissection re-entry technique.

Antegrade dissection and re-entry (ADR) is an integral part of the hybrid algorithm, which has allowed for improved outcomes in chronic total occlusion (CTO) coronary intervention (PCI). A new ADR method, Subintimal Antegrade FEnestration and Re-entry (SAFER), is described. The results of a first-in-man series are presented. SAFER was performed on seven consecutive patients with angiographic and clinical success in all patients. This first-in-man study has shown that the SAFER technique is feasible and effective with the possibility of improving the antegrade PCI CTO success rate.

Computed tomography perfusion and angiography in patients with chronic total occlusion undergoing percutaneous coronary intervention

Background and aimsMyocardial perfusion imaging (MPI) and anatomical imaging with coronary computed tomography angiography (CCTA) can play an important role in the preprocedural planning of a chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to establish the feasibility of a novel dynamic computed tomography perfusion (CTP) analysis for the assessment of myocardial perfusion before and after a successful recanalization of CTO in patients undergoing CCTA as part of a standard preprocedural workup. MethodsIn a prospective observational study symptomatic patients underwent dynamic CTP on a dual-source CT scanner both before and 3 months after successful CTO PCI. ResultsTwenty-seven patients completed the study (63 ± 8 years old, 78% male). Following successful CTO PCI, there was a significant reduction in the ischemic burden (5 [5–7] versus 1 [0–2] segments, p < 0.001), and improvement in myocardial blood flow (85.3 [71.7–94.1] versus 134.6 [123.8–156.9] mL/min, p < 0.001) resulting in an increase in the relative flow reserve (0.49 [0.41–0.57] versus 0.88 [0.74–0.95], p < 0.001). ConclusionsCTP emerges as a robust and safe method for MPI in CTO patients. The single imaging session assessment of both coronary anatomy and perfusion with CT lends itself to precise disease phenotyping in the challenging population of CTO patients.

Effectiveness, safety, and patient reported outcomes of a planned investment procedure in higher-risk chronic total occlusion percutaneous coronary intervention:Rationale and design of the invest-CTO study.

The anatomical complexity of a chronic total occlusion (CTO) correlates with procedural failure and complication rates. CTO modification after unsuccessful crossing has been associated with subsequent higher technical success rates, but complication rates remain high with this approach. While successful CTO percutaneous coronary intervention (PCI) has been associated with improved angina and quality of life (QOL) this has not been demonstrated in anatomically high-risk CTOs. Whether a planned CTO modification procedure, hereafter named Investment procedure, could improve patient outcomes has never been investigated. Invest-CTO is a prospective, single-arm, international, multicenter study, evaluating the effectiveness and safety of a planned investment procedure, with a subsequent completion CTO PCI (at 8-12 weeks), in anatomically high-risk CTOs. We will enroll 200 patients with CTOs defined as high-risk according to our Invest CTO criteria at centers in Norway and United Kingdom.Patients with aorto-ostial lesions, occlusion within a previous stent, or a prior attempt at target vessel CTO PCI within 6 months will be excluded. The co-primary endpoints are cumulative procedural success (%) after both procedures, and a composite safety endpoint at 30 days after completion CTO PCI. Patient reported outcomes (PROs), treatment satisfaction, and clinical endpoints will be reported. This study will prospectively evaluate the effectiveness and safety of a planned two staged PCI procedure in the treatment of high-risk CTOs and may have the potential to change current clinical practice.

Improvement of Symptoms and Quality of Life After Successful Percutaneous Coronary Intervention for Chronic Total Occlusion in Elderly Patients.

Background Data regarding the impact of successful chronic total occlusion treated with percutaneous coronary intervention (CTO-PCI) on symptoms and quality of life (QOL) in elderly patients (≥75 years) are unknown. This prospective study aimed to assess whether successful CTO-PCI could improve the symptoms and QOL in elderly patients (≥75 years). Methods and Results Consecutive patients who underwent elective CTO-PCI were prospectively enrolled and subdivided into 3 groups based on age: age<65 years, 65 years≤age<75 years, and age≥75 years. The primary outcomes included symptoms, as assessed with the New York Heart Association functional class and Seattle Angina Questionnaire, and QOL, as assessed with the 12-Item Short-Form Health Survey questionnaire, at baseline, 1 month, and 1 year after successful CTO-PCI. Of 1076 patients with CTO, 101 were age≥75 years (9.39%). Hemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction levels all decreased with increasing age, and NT-proBNP (N-terminal pro-B-type natriuretic peptide) increased. The proportion of dyspnea and coronary lesions, including multivessel disease, multi-CTO lesion, and calcification were higher in elderly patients. Procedural success rate, intraprocedural complications, and in-hospital major adverse cardiac events were not statistically different in the 3 groups. Importantly, symptoms, including dyspnea and angina, were markedly improved regardless of age at 1-month and 1-year follow-up (P<0.05). Likewise, successful CTO-PCI significantly improved QOL at 1-month and 1-year follow-up (P<0.01). Additionally, the incidence of major adverse cardiac events and all-cause mortality at 1-month and 1-year follow-up was not statistically different in the 3 groups. Conclusions Successful PCI was beneficial and feasible to improve symptoms and QOL in patients ≥75 years of age with CTO.

Is it Worthy Enough to Revascularize Chronically Occluded Coronaries?

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.

DES Strut Thickness and Clinical Outcomes After CTO Recanalization: Insights From LATAM CTO Registry

BackgroundUltra-thin strut drug-eluting stent (UTS-DES) may improve outcomes after percutaneous coronary intervention (PCI) but have received limited study in chronic total occlusion (CTO) PCI. AimsTo compare of 1-year incidence of major adverse cardiac events (MACE) between patients who underwent CTO PCI with ultrathin (≤ 75 μm) versus thin (>75 μm) strut DES in the LATAM CTO registry. MethodsPatients were considered for inclusion only if successful CTO PCI was performed and when only one type of stent strut thickness (ultrathin or thin) was used. A propensity score matching (PSM) was computed to produce similar groups in relation to clinical and procedural characteristics. ResultsBetween January 2015 and January 2020, 2092 patients underwent CTO PCI, of whom 1466 were included in the present analysis (475 in the ultra-thin and 991 in the thin strut DES). In unadjusted analysis the UTS-DES group had lower rate of MACE (HR: 0.63 95 % CI 0.42 to 0.94, p = 0.04) and repeat revascularizations (HR: 0.50 95 % CI 0.31 to 0.81, p = 0.02) at 1-year follow-up. After adjustment for confounding factors in a Cox regression model there was no difference in 1-year incidence of MACE between groups (HR: 1.15 95 % CI 0.41 to 2.97, p = 0.85). On PSM of 686 patients (343 in each group) the 1-year incidence of MACE (HR 0.68 95 % CI 0.37–1.23; P = 0.22) and individual components of MACE did not differ between groups. ConclusionsOne-year clinical outcomes after CTO PCI were similar with ultrathin and thin strut DES.

J-chronic total occlusion score predictive capacity for percutaneous coronary intervention success of chronic total occlusion: Results from a European single center cohort with progressive experience over time.

Several scoring systems have been described to assess the level of difficulty and to predict the probability of success of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). The J-CTO score was initially developed to correlate CTO complexity with guidewire time crossing through the lesion within 30 min. Moreover, almost all scoring systems represent procedures performed by seasoned operators. Herein, this study sought to evaluate the predictive capacity of J-CTO for PCI success in a European single-center cohort with growing experience in the approach of CTO. Five hundred twenty-six procedures were performed between 2007 and 2020 mainly by a single operator. The predictive power of J-CTO score was assessed by area under the receiver-operator characteristic curve (ROC) in the entire cohort and additionally in two separate periods. The goodnessof- fit of the model was evaluated by the Hosmer and Lemeshow statistic. Successful procedure in first-attempt PCI was 79.5% and the overall success including 47 repeated procedures was achieved in 85.8%. The retrograde approach was attempted in 14.4%. The score was inversely associated with procedural success with lower success rate in more difficult CTOs (p < 0.001). ROC curve for the entire cohort, and first block (case 1-200) and second block (case 201-526) was 0.696, 0.661 and 0.748, respectively. The model showed good calibration for the entire cohort (X2 = 1.7; p = 0.43). J-CTO score showed an acceptable predictive power for procedural success in this cohort although its discriminatory power is better as the level of experience is improved.

Evaluation of right atrial function by two-dimensional echocardiography and strain imaging in patients with RCA CTO recanalization

ObjectivesThe right heart is mainly supplied with blood by the right coronary artery (RCA). The impact of RCA chronic total occlusion (CTO) on the function of the right heart [right atrium (RA) and ventricle (RV)] and whether successful recanalization of a RCA CTO improves the function of the right heart is not clearly understood yet. We aimed to evaluate right atrial function after recanalization of the RCA using transthoracic echocardiography with additional strain imaging.Methods and resultsFifty-five patients undergoing RCA CTO recanalization at the University Medical Center of Mainz were included in the study. Right atrial strain was assessed before and 6 months after successful CTO revascularization. The median age of the total collective was 66 (50–90) years. We did not find difference in our analysis of RA Volume (p 0.086), RA area (p 0.093), RA major dimension (p 0.32) and RA minor dimension (p 0.139) at baseline and follow-up. Mean RA reservoir strain at baseline was 30.9% (21.1–43.0) vs. 33.4% (20.7–47.7) at follow up (p < 0.001). Mean RA conduit strain was − 17.5% (− 10.7–(− 29.7)) at baseline vs. − 18.2% (− 9.6–(− 31.7)) at follow-up (p = 0.346). Mean RA contraction strain was − 12.9% (− 8.0- (− 21.3)) at baseline vs. − 15.5% (− 8.7–(− 26.6)) at follow-up (p < 0.001).ConclusionRight atrial function was altered in patients with RCA CTO. Successful revascularisation of an RCA CTO improved RA function assessed by strain imaging at follow-up.

Changes in coronary collateral function after successful chronic total occlusion percutaneous coronary intervention.

Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) incorporates wire escalation and dissection/re-entry recanalisation strategies. The purpose of the study was to investigate changes in collateral function after CTO PCI and to identify whether the mode of successful recanalisation influences collateral function regression. Patients scheduled for elective CTO PCI with evidence of viability in the CTO territory by noninvasive imaging were included in this study. After successful CTO PCI, the aortic pressure (Pa) and distal coronary artery wedge pressure (Pw) during balloon occlusion were measured, both in a resting state and during infusion of intravenous adenosine, allowing the calculation of the pressure-derived collateral pressure index at rest and hyperaemia (CPIrest and the collateral fractional flow reserve [FFRcoll], respectively). Measurements were repeated 3 months later during angiographic follow-up. Eighty-one patients had physiological measurements at baseline and follow-up. In the final cohort the mean age was 64 years and 82% were male. The mean maximal stent diameter and total stent length were 3.2±0.5 mm and 68±31 mm, respectively. Successful strategies were antegrade wiring (64.2%), antegrade dissection re-entry (8.6%), and retrograde dissection re-entry (27.1%). Between the index procedure and follow-up, wedge pressure decreased from 34±11 mmHg to 21±8.5 mmHg (p<0.01), respectively. FFRcoll changed from 0.34±0.11 to 0.19±0.09 (p<0.01) at follow-up and CPIrest from 0.40±0.14 to 0.17±0.09 (p<0.01). Absolute maximum collateral flow decreased from 55±32 ml/min directly after PCI to 38±24 ml/min (p<0.01). There was no relation between the recanalisation technique and changes in FFRcoll. There was a significant reduction in collateral flow over time, independent of the recanalisation technique.

TCT-129 Symptom and Physiological Changes After Successful Chronic Total Occlusion Percutaneous Coronary Intervention

TCT-129 Symptom and Physiological Changes After Successful Chronic Total Occlusion Percutaneous Coronary Intervention

E-30 | Meta-Analysis of Successful vs. Failed Chronic Total Occlusion Percutaneous Coronary Intervention

E-30 | Meta-Analysis of Successful vs. Failed Chronic Total Occlusion Percutaneous Coronary Intervention

Coronary flow autoregulation during Impella CP support post successful chronic total occlusion percutaneous coronary intervention.

Karamasis, Grigoris V.a,b; Khan, Sarosha,c; Alsanjari, Osamaa,c; Davies, John R.a,c; Keeble, Thomas R.a,c Author Information

Development and Validation of a Novel Nomogram to Predict Improved Left Ventricular Ejection Fraction in Patients With Heart Failure After Successful Percutaneous Coronary Intervention for Chronic Total Occlusion.

BackgroundHeart failure with improved left ventricular ejection fraction (HFiEF) is linked to a good clinical outcome. The purpose of this study was to create an easy-to-use model to predict the occurrence of HFiEF in patients with heart failure (HF), 1 year after successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) (CTO PCI).MethodsPatients diagnosed with HF who successfully underwent CTO PCI between January 2016 and August 2019 were included. To mitigate the effect of residual stenosis on left ventricular (LV) function, we excluded patients with severe residual stenosis, as quantitatively measured by a residual synergy between PCI with Taxus and Cardiac Surgery score (rSS) of >8. We gathered demographic data, medical history, angiographic and procedural characteristics, echocardiographic parameters, laboratory results, and medication information. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression models were used to identify predictors of HFiEF 1 year after CTO revascularization. A nomogram was established and validated according to the area under the receiver operating characteristic curve (AUC) and calibration curves. Internal validation was performed using bootstrap resampling.ResultsA total of 465 patients were finally included in this study, and 165 (35.5%) patients experienced HFiEF 1 year after successful CTO PCI. According to the LASSO regression and multivariate logistic regression analyses, four variables were selected for the final prediction model: age [odds ratio (OR): 0.969; 95% confidence interval (CI): 0.952–0.988; p = 0.001], previous myocardial infarction (OR: 0.533; 95% CI: 0.357–0.796; p = 0.002), left ventricular end-diastolic dimension (OR: 0.940; 95% CI: 0.910–0.972; p < 0.001), and sodium glucose cotransporter two inhibitors (OR: 5.634; 95% CI: 1.756–18.080; p = 0.004). A nomogram was constructed to present the results. The C-index of the model was 0.666 (95% CI, 0.613–0.719) and 0.656 after validation. The calibration curve demonstrated that the nomogram agreed with the actual observations.ConclusionsWe developed an simple and effective nomogram for predicting the occurrence of HFiEF in patients with HF, 1 year after successful CTO PCI without severe residual stenosis.

Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions: Predictors of Procedural Success From the ERCTO Registry.

The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood. A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry. In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. Aprimary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P< 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95%CI: 1.37-2.51; P< 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95%CI: 1.72-3.55; P< 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95%CI: 1.28-2.64; P=0.001), Werner collateral connection CC1 (OR: 4.87; 95%CI: 2.90-8.19; P< 0.0001) or CC2 (OR: 5.33; 95%CI: 3.02-9.42; P< 0.0001), and the top tertile of operator volume (>120 cases over 2 years) (OR: 1.88; 95%CI: 1.26-2.79; P=0.002) were associated with the greatest chance of achieving angiographic success. Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

Cardiogenic Shock Following Successful CTO Revascularization

<h3>Introduction</h3> The role of urgent mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. This case highlights myocardial recovery in a patient with ventricular fibrillation following a CTO PCI supported with MCS. <h3>Case Report</h3> A 45 year-old man with recent non-ST elevation myocardial infarction, found to have triple vessel coronary artery disease treated with drug-eluting stent to LAD and OM1, due to patient preference, presents for an elective revascularization of CTO of RCA. Left ventricular function at time of discharge from his prior hospitalization was preserved. Revascularization of CTO was accomplished with placement of Resolute Onyx 3.5x38 mm stent and Resolute Onyx 3.0x26 mm stent to the mid RCA and a Resolute Onyx 3.0x22 mm stent to the distal RCA. There were no complications, and the patient was transferred to a telemetry floor. Soon after transfer he suffered cardiac arrest with ventricular fibrillation. He was defibrillated with return of spontaneous circulation however remained hemodynamically tenuous. Bedside echocardiogram demonstrated severe biventricular dysfunction. Coronary angiography showed stable anatomy with patent stents. Given declining hemodynamic status an Impella CP was placed emergently via the left femoral artery. He was transferred to the cardiac critical care unit where he subsequently developed monomorphic ventricular tachycardia with further hemodynamic deterioration. He was cannulated for VA ECMO and hemodynamic stability was achieved. Due to ongoing hemolysis, Impella CP was exchanged for an axillary Impella 5.5. As results of medical management and aggressive supportive care, subsequent echocardiograms demonstrated recovery of left and right ventricular function. He was decannulated from VA ECMO and Impella 5.5 after four days. Outpatient transthoracic echocardiogram performed four weeks later demonstrate preserved biventricular function. LV ejection fraction was measured at 55% and global longitudinal strain -16.7%. RV longitudinal strain -21.4%. He is tolerating guideline-directed medical therapy for heart failure. <h3>Summary</h3> This case describes ventricular fibrillation following CTO revascularization and highlights the positive outcomes associated with early recognition of deteriorating cardiogenic shock and rapid escalation of mechanical circulatory support.