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Ischemia Reduction and Clinical Outcomes After Chronic Total Occlusion PCI
Quick Takes
- Patients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal MI in this small observational study.
- Furthermore, cardiac symptom relief was related to the quantitative hyperemic myocardial blood flow level after CTO PCI.
- Additional prospective studies are indicated to validate the study findings and assess whether identification of potential predictors for effective ischemia reduction instead of baseline ischemia may help better identify patients likely to benefit from CTO PCI.
Study Questions:
What is the impact of ischemic burden reduction after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on long-term prognosis and cardiac symptom relief?
Methods:
The investigators prospectively enrolled 212 patients in a high-volume CTO PCI center, to undergo quantitative [15O]H2O positron emission tomography perfusion imaging before and 3 months after successful CTO PCI between 2013-2019. Perfusion defects (PD) (in segments) and hyperemic myocardial blood flow (hMBF) (in ml · min−1 · g−1) allocated to CTO areas were related to prognostic outcomes using unadjusted (Kaplan-Meier curves, log-rank test) and risk-adjusted (multivariable Cox regression) analyses. The prognostic endpoint was a composite of all-cause death and nonfatal myocardial infarction (MI).
Results:
After a median [interquartile range] of 2.8 years [1.8-4.3 years], event-free survival was superior in patients with ≥3 versus <3 segment PD reduction (p < 0.01; risk-adjusted p = 0.04; hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.13-0.93) and with hMBF increase above (Δ≥1.11 ml · min−1 · g−1) versus below the population median (p < 0.01; risk-adjusted p < 0.01; HR, 0.16; 95% CI, 0.05-0.54) after CTO PCI. Furthermore, event-free survival was superior in patients without versus any residual PD (p < 0.01; risk-adjusted p = 0.02; HR, 0.22; 95% CI, 0.06-0.76) or with a residual hMBF level >2.3 versus ≤2.3 ml · min−1 · g−1 (p < 0.01; risk-adjusted p = 0.03; HR, 0.25; 95% CI, 0.07-0.91) at follow-up positron emission tomography. Patients with residual hMBF >2.3 ml · min−1 · g−1 were more frequently free of angina and dyspnea on exertion at long-term follow-up (p = 0.04).
Conclusions:
The authors concluded that patients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal MI.
Perspective:
This small observational study reports that patients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal MI. Furthermore, cardiac symptom relief was related to the quantitative hMBF level after CTO PCI. Of note, no separate control group treated with optimal medical therapy was included in this study. Additional prospective studies are indicated to validate these findings and assess whether identification of potential predictors for effective ischemia reduction instead of baseline moderate-to-severe ischemia may help better identify patients likely to benefit from CTO PCI.
Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and Imaging, Computed Tomography, Nuclear Imaging
Keywords: Angina Pectoris, Coronary Occlusion, Diagnostic Imaging, Dyspnea, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Perfusion Imaging, Physical Exertion, Positron-Emission Tomography, Secondary Prevention, Tomography, X-Ray Computed
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