Outcomes of chronic total occlusion percutaneous coronary intervention in patients with reduced left ventricular ejection fraction

The Presence of Chronic Total Occlusion in Noninfarct-Related Arteries Is Associated With Higher Mortality and Worse Patient Outcomes Following Percutaneous Coronary Intervention for STEMI: A Systematic Review, Meta-Analysis and Meta-Regression

Reperfusion therapy with percutaneous coronary intervention improves outcomes in patients with ST-elevation myocardial infarction. We conducted a meta-analysis to assess the impact of chronic total occlusion (CTO) in noninfarct-related artery on the outcomes of these patients. Comprehensive searches were performed using PubMed, Google Scholar, and EMBASE. The primary endpoint was the 30-day mortality rate, with secondary endpoints including all-cause mortality, repeat myocardial infarction, and stroke. Forest plots were created for the pooled analysis of the results, with statistical significance set at P < 0.05. A total of 19 studies were included in this meta-analysis, with 23,989 patients (3589 in CTO group and 20,400 in no-CTO group). The presence of CTO was associated with significantly higher odds of 30-day mortality [18.38% vs 5.74%; relative risk (RR), 3.69; 95% confidence intervals (CI), 2.68-5.07; P < 0.00001], all-cause mortality (31.00% vs 13.40%; RR, 2.79; 95% CI, 2.31-3.37; P < 0.00001), cardiovascular-related deaths (12.61% vs 4.1%; RR, 2.61; 95% CI, 1.99-3.44; P < 0.00001), and major adverse cardiovascular events (13.64% vs 9.88%; RR, 2.08; 95% CI, 1.52-2.86; P < 0.00001) than the non-CTO group. No significant differences in repeated myocardial infarction or stroke were observed between the CTO and non-CTO groups. Our findings underscore the need for further research on the benefits and risks of performing staged or simultaneous percutaneous coronary intervention for CTO in the noninfarct-related artery in patients with ST-elevation myocardial infarction.

Impact of lesion length on the outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND

The impact of occlusion length on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

METHODS

We examined the clinical and angiographic characteristics and procedural outcomes of 10,335 CTO PCIs at 42 US and non-US centers between 2012 and 2022. The cohort was divided into two groups based on lesion length (≥20 mm vs. <20 mm).

RESULTS

Long lesions were present in 7208 (70%) patients. Comorbidities were more common in patients with long CTOs. Compared with short lesions, long lesions had higher J-CTO score (2.8 ± 1.1 vs. 1.3 ± 1; p < 0.001) and retrograde wiring was more often the initial (15.5% vs. 4.0%; p < 0.001) and successful (22.8% vs. 8.2%; p < 0.001) crossing strategy. Long lesions were more likely to require longer procedure (123 vs. 91 min; p < 0.001) and fluoroscopy (47.1 vs. 32.2 min; p < 0.001) time, larger contrast volume (218 vs. 200 mL; p < 0.001) and higher air kerma radiation dose (2.4 vs. 1.7 Gy; p < 0.001). After adjusting for potential confounders, long lesions were associated with lower technical success (odds ratio [OR]: 0.91 per 10 mm increase; 95% confidence interval [CI]: 0.88, 0.94) and higher major adverse cardiovascular events (MACE) (OR: 1.08 per 10 mm increase; 95% CI: 1.02, 1.15).

CONCLUSIONS

CTO PCI of long occlusions is independently associated with lower rates of technical success and higher rates of in-hospital MACE.

Impact of proximal cap ambiguity on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO Registry

BACKGROUND

Proximal cap ambiguity is a key parameter in the global chronic total occlusion (CTO) percutaneous coronary intervention (PCI) crossing algorithm.

METHODS

We examined the baseline characteristics and procedural outcomes of 9718 CTO PCIs performed in 9498 patients at 41 US and non-US centers between 2012 and 2022.

RESULTS

Proximal cap ambiguity was present in 35% of CTO lesions. Patients whose lesions had proximal cap ambiguity were more likely to have had prior coronary artery bypass graft surgery (37% vs. 24%; p < 0.001). Lesions with proximal cap ambiguity were more complex with higher J-CTO score (3.1 ± 1.0 vs. 2.0 ± 1.2; p < 0.001) and lower technical (79% vs. 90%; p < 0.001) and procedural (77% vs. 89%; p < 0.001) success rates compared with nonambiguous CTO lesions. The incidence of major adverse cardiovascular events (MACE) was higher in cases with proximal cap ambiguity (2.5% vs. 1.7%; p < 0.001). The retrograde approach was more commonly used among cases with ambiguous proximal cap (50% vs. 21%; p < 0.001) and was more likely to be the final successful crossing strategy (29% vs. 13%; p < 0.001). The antegrade dissection and re-entry (ADR) "move-the-cap" techniques were also more common among cases with proximal cap ambiguity.

CONCLUSIONS

Proximal cap ambiguity in CTO lesions is associated with higher utilization of the retrograde approach and ADR, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

Chronic Total Occlusion Interventions in Patients with Reduced Ejection Fraction

PURPOSE OF THE REVIEW

The goal of this paper is to review the current evidence surrounding CTO PCI in patients with low EF, the most high-risk population to treat. We also present pertinent case examples and offer practical tips to increase success and lower complications when performing CTO PCI in patients with low EF.

RECENT FINDINGS

In a prospective randomized control study, greater improvement in angina frequency and quality of life, assessed by the Seattle Angina Questionnaire, was achieved by CTO PCI compared to optimal medical therapy. Furthermore, after successful CTO PCI, improvements in health status were similar in patients with both low and normal EF. CTO PCI can not only ameliorate symptoms of angina in patients with low EF but may also potentially improve EF in carefully selected populations. However, information regarding treatment of this high-risk population is lacking and large-scale studies targeting patients with severely reduced EF remain necessary.

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

OBJECTIVES

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).

BACKGROUND

While the technical success of general CTO-PCI has improved, CTO-PCI patients with reduced LVEF remain at high-risk for adverse events.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.