A Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion - REVASC

Contribution To Literature:

The REVASC trial failed to show that CTO-PCI was superior to medical therapy at improving regional left ventricular (LV) function.

Description:

The goal of the trial was to evaluate chronic total occlusion percutaneous coronary intervention (CTO-PCI) compared with medical therapy among patients with CTO.


Study Design

  • Randomized
  • Parallel

Patients with CTO were randomized to CTO-PCI (n = 101) versus medical therapy (n = 104).

  • Total number of enrollees: 205
  • Duration of follow-up: 12 months
  • Mean patient age: 65 years
  • Percentage female: 10%
  • Percentage with diabetes: 32%

Inclusion criteria:

  • Patients with angina or abnormal functional study with at least one CTO

Exclusion criteria:

  • LV ejection fraction (LVEF) <25%
  • Acute coronary syndrome within 72 hours
  • Contraindication to cardiac magnetic resonance

Other salient features/characteristics:

  • CTO territory: right coronary artery in 63%
  • Technical success of the first CTO attempt: 86%
  • Technical success including second attempts: 99%

Principal Findings:

The primary outcome, change in segmental wall thickening from baseline to 6 months, was 4.1 in the CTO-PCI group compared with 6.0 in the medical therapy group (p = 0.57). Findings were the same among those with dysfunctional segmental wall motion at baseline. Patients with less extensive coronary disease (SYNTAX score ≤13) appeared to benefit from CTO-PCI vs. medical therapy (p for interaction = 0.002).

Secondary outcomes:

  • Change in LVEF: 0.9% in the CTO-PCI group vs. 0.7% in the medical therapy group (p = 0.79)
  • Major adverse cardiac events at 6 months: 4.0% in the CTO-PCI group vs. 5.8% in the medical therapy group (p = not significant).
  • Clinically driven revascularization at 12 months: 5.0% in the CTO-PCI group vs. 15.4% in the medical therapy group (p = 0.02)

Interpretation:

Among patients with angina or abnormal stress test and presence of CTO, CTO-PCI was not beneficial. CTO-PCI was not associated with an improvement in segmental wall thickening or improvement in LV systolic function, except perhaps in the group with less extensive coronary disease. Major adverse events were similar between treatment groups except for fewer revascularization procedures at 12 months in the CTO-PCI group. Recent randomized trials (DECISION-CTO) have failed to find demonstrable benefit in clinically relevant outcomes from CTO-PCI. 

References:

Mashayekhi K, Nührenberg TG, Toma A, et al. A Randomized Trial to Assess Regional Left Ventricular Function After Stent Implantation in Chronic Total Occlusion: The REVASC Trial. JACC Cardiovasc Interv 2018;Sep 12:[Epub ahead of print].

Editorial Comment: Jaber WA. Chronic Total Occlusion Intervention: The Case for More Evidence. JACC Cardiovasc Interv 2018;Sep 12:[Epub ahead of print].

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Magnetic Resonance Imaging

Keywords: Acute Coronary Syndrome, Angina Pectoris, Coronary Artery Disease, Coronary Occlusion, Exercise Test, Magnetic Resonance Imaging, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Stroke Volume, Ventricular Function, Left


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