Health Status Benefits of Successful Chronic Total Occlusion Revascularization Across the Spectrum of Left Ventricular Function: Insights From the OPEN-CTO Registry

Temporal trends of case-fatality in patients undergoing dual-injection coronary chronic total occlusion recanalization

AIMS

Recently, interventional techniques and material to treat chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) have evolved significantly. Nevertheless, it is still unknown whether this progress improved treatment success and patients' outcome. In a nationwide sample, we sought to analyze trends of patients' characteristics, complications and in-hospital case-fatality of patients undergoing CTO revascularization in Germany.

METHODS AND RESULTS

We analyzed data on characteristics, treatments, and in-hospital outcomes for all coronary artery disease (CAD) patients (ICD-code I25) undergoing dual-injection CTO recanalization (OPS procedural code: 8-839.9) in Germany from 2009 to 2020. Overall, 4,998,457 inpatients aged ≥ 18 years with diagnosis of CAD were treated in German hospitals in this period. Among these, 52,879 patients (1.1%) underwent CTO recanalization. Annual number of CTO PCIs increased from 1263 in 2009 to 6435 in 2020 (β 3.48 [95% CI 3.44-3.52]; p < 0.001) in parallel with a significant decrease of case-fatality (2.2% in 2009 to 1.4% in 2020; β  - 0.60 [95% CI  - 0.82 to  - 0.39]; p < 0.001). Overall, 754 (1.4%) patients with CTO recanalization died during the in-hospital stay and in-hospital case-fatality grew exponentially with age (β 0.82 [95% CI 0.73-0.90]; p < 0.001). Significant predictors of in-hospital case fatality with an OR > 3 were cancer, stroke, hemopericardium, acute renal failure, pulmonary embolism and shock.

CONCLUSION

Annual number of CTO procedures performed in Germany increased from 2009 to 2020 with a concomitant anti-proportional decrease in the case-fatality. Our findings may help to draw more attention to predictors of in-hospital case fatality in patients hospitalized for CTO recanalization.

Complete Revascularization and Angina-Related Health Status in the ISCHEMIA Trial

BACKGROUND

The impact of complete revascularization (CR) on angina-related health status (symptoms, function, quality of life) in chronic coronary disease (CCD) has not been well studied.

OBJECTIVES

Among patients with CCD randomized to invasive (INV) vs conservative (CON) management in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), we compared the following: 1) the impact of anatomic and functional CR on health status compared with incomplete revascularization (ICR); and 2) the predicted impact of achieving CR in all INV patients compared with CON.

METHODS

Multivariable regression adjusting for patient characteristics was used to compare 12-month health status after independent core laboratory-defined CR vs ICR in INV patients who underwent revascularization. Propensity-weighted modeling was then performed to estimate the treatment effect had CR or ICR been achieved in all INV patients, compared with CON.

RESULTS

Anatomic and functional CR were achieved in 43.3% and 57.8% of 1,641 INV patients, respectively. Among revascularized patients, CR was associated with improved Seattle Angina Questionnaire Angina Frequency compared with ICR after adjustment for baseline differences. After modeling CR and ICR in all INV patients, patients with CR and ICR each had greater improvements in health status than CON, with better health status with CR than ICR. The projected benefits of CR were most pronounced in patients with baseline daily/weekly angina and not seen in those with no angina.

CONCLUSIONS

Among patients with CCD in ISCHEMIA, health status improved more with CR compared with ICR or CON, particularly in those with frequent angina. Anatomic and functional CR provided comparable improvements in quality of life. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Quantitative coronary computed tomography angiography assessment of chronic total occlusion percutaneous coronary intervention

BACKGROUND

Morphological and clinical characteristics are widely used to predict the success of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO). However, the impact of quantitative characteristics derived from coronary computed tomography angiography (CCTA) on guidewire crossing and PCI success is still unclear. This study aimed to explore the association between these quantitative characteristics and the difficulty of PCI for CTO.

METHODS

A total of 207 CTO lesions from 201 patients (84.6% male; mean age 58.9 years) with pre-procedural CCTA scans who had undergone PCI for CTO were retrospectively enrolled in this case-control study. A semi-automated CCTA plaque-analysis software was adopted to obtain the total plaque volume and volume of each component according to the Hounsfield Unit (HU) value, including dense calcium (>351 HU), fibrous (131-350 HU), fibrofatty (76-130 HU), and necrotic core (-30-75 HU) tissue. Differences in the quantitative characteristics of the CTO lesions were compared between: (I) the group of lesions with successful guidewire crossing (≤30 min) and the group with failed guidewire crossing (≤30 min); (II) the group of lesions with procedural success [defined as achieving residual stenosis of <30% and a grade 3 thrombolysis in myocardial infarction (TIMI) flow] and the group with procedural failure. Logistic regression was used to explore the association of quantitative characteristics with successful guidewire crossing in ≤30 min and procedural success.

RESULTS

A total of 131 (63.3%) lesions of 126 patients achieved successful guidewire crossing in ≤30 min and 157 (75.8%) lesions of 152 (75.6%) patients achieved procedural success. Quantitative characteristics such as occlusion length, plaque volume, volume of dense calcium, and fibrous and fibrofatty tissue showed significant differences between the groups of lesions with successful guidewire crossing in ≤30 min and with failed guidewire crossing in ≤30 min, as well as the groups of lesions with procedural success and with procedural failure. According to the results of logistic regression analysis, lower percentages of dense calcium [odds ratio (OR) =0.970, 95% confidence interval (CI): 0.950 to 0.991; P=0.004] and fibrous (OR =0.970, 95% CI: 0.949 to 0.992; P=0.007) tissue and higher percentage of necrotic core tissue (OR =1.018, 95% CI: 1.005 to 1.030; P=0.005) were significantly associated with successful guidewire crossing in ≤30 min. Decreased percentages of dense calcium (OR =0.969; 95% CI: 0.949 to 0.989; P=0.002) and fibrous tissue (OR =0.966, 95% CI: 0.944 to 0.990; P=0.005) and higher percentage of necrotic core tissue (OR =1.022, 95% CI: 1.008 to 1.036; P=0.002) were associated with procedural success. After adjusting for cardiovascular risk factors, the percentages of dense calcium, fibrous, and necrotic core tissue were still associated with successful guidewire crossing in ≤30 min, and the quantitative parameters showed consistent association with procedural success.

CONCLUSIONS

Quantitative characteristics derived from CCTA for CTO are associated with successful guidewire crossing and procedural success of PCI.

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

Background

Heart 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).

Methods

Patients 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 &gt;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.

Results

A 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 &lt; 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.

Conclusions

We 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.

The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention

Selected patients with coronary chronic total occlusion (CTO) benefit with respect to symptoms, quality of life, ischemia reduction, and potentially longevity among other benefits. CTO lesions tend to be the most technically challenging for practicing interventional cardiologists to deliver a successful and safe result and clinical experience for a given patient. The Hybrid algorithm for CTO percutaneous coronary intervention and the subsequent subalgorithms for focused technical challenges have a standardized process and provide a consistent platform for optimized patient care, medical education, and clinical investigation in patients challenged with total occlusion and complex coronary disease.

Percutaneous Coronary Intervention for Chronic Total Occlusion

Treatment of coronary chronic total occlusions represents one of the major challenges in the field of interventional cardiology. This is due to the complexity of these procedures and to the relatively higher risk of complications. In recent years, the development of innovative techniques and the evolution of materials have produced significant progress in this field. Better procedural outcomes have been achieved, with fewer complications. This article highlights the most recent scientific evidence and techniques, with the intention to guide interventional cardiologists in optimal patient selection and procedure choice.

A Contemporary Definition of Periprocedural Myocardial Injury After Percutaneous Coronary Intervention of Chronic Total Occlusions

OBJECTIVES

The aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality.

BACKGROUND

Coronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes.

METHODS

A total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint.

RESULTS

Using spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment.

CONCLUSIONS

This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Percutaneous coronary intervention outcomes in patients with stable coronary disease and left ventricular systolic dysfunction

AIMS

We sought to better understand the role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) and moderate or severe left ventricular systolic dysfunction.

METHODS AND RESULTS

Using data from the Duke Databank for Cardiovascular Disease, we analysed patients who underwent coronary angiography at Duke University Medical Center (1995-2012) that had stable CAD amenable to PCI and left ventricular ejection fraction ≤35%. Patients with acute coronary syndrome or Canadian Cardiovascular Society class III or IV angina were excluded. We used propensity-matched Cox proportional hazards to evaluate the association of PCI with mortality and hospitalizations. Of 901 patients, 259 were treated with PCI and 642 with medical therapy. PCI propensity scores created from 24 variables were used to assemble a matched cohort of 444 patients (222 pairs) receiving PCI or medical therapy alone. Over a median follow-up of 7 years, 128 (58%) PCI and 125 (56%) medical therapy alone patients died [hazard ratio 0.87 (95% confidence interval 0.68, 1.10)]; there was also no difference in the rate of a composite endpoint of all-cause mortality or cardiovascular hospitalization [hazard ratio 1.18 (95% confidence interval 0.96, 1.44)] between the two groups.

CONCLUSIONS

In this well-profiled, propensity-matched cohort of patients with stable CAD amenable to PCI and moderate or severe left ventricular systolic dysfunction, the addition of PCI to medical therapy did not improve long-term mortality, or the composite of mortality or cardiovascular hospitalization. The impact of PCI on other outcomes in these high-risk patients requires further study.