Changes in myocardial ischemic burden following percutaneous coronary intervention of chronic total occlusions

Safley, David M.; Koshy, Sindhu; Grantham, J. Aaron; Bybee, Kevin A.; House, John A.; Kennedy, Kevin F.; Rutherford, Barry D.

doi:10.1002/ccd.23002

Cited by 104 publications

(59 citation statements)

References 20 publications

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“…11 In patients without symptoms, the threshold for performing coronary revascularization including CTO-PCI should be considerably higher, yet patients with large areas of ischemia (eg, ischemic burden .12.5%) could also derive benefit from CTO revascularization. 12 Some patients may also be ''asymptomatic'' because they gradually limit their activities to prevent symptoms from appearing.…”

Section: N Benefits Of Cto-pcimentioning

confidence: 99%

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Brilakis¹,

Burke²

2017

Journal of the Minneapolis Heart Institute Foundation

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Outcomes of chronic total occlusion-percutaneous coronary intervention have significantly improved in recent years. Chronic total occlusion-percutaneous coronary intervention can provide significant clinical benefits, such as angina reduction. At experienced centers, high success rates can currently be achieved, with use of all chronic total occlusion crossing techniques (antegrade wire escalation, antegrade dissection/ reentry, and the retrograde approach) orchestrated by use of procedural algorithms, such as the hybrid algorithm. Growth of chronic total occlusion-percutaneous coronary intervention is also fueled by continuous development of novel equipment, such as guidewires, microcatheters, support catheters, and dissection/reentry equipment. Readiness and ability to treat complications, such as perforation and donor vessel closure, is critical for all centers performing the procedure. Chronic total occlusionpercutaneous coronary intervention is a powerful and continuously developing tool for achieving complete coronary revascularization.

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Section: N Benefits Of Cto-pcimentioning

confidence: 99%

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Brilakis¹,

Burke²

2017

Journal of the Minneapolis Heart Institute Foundation

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“…Safley et al [38] identified 301 patients who underwent PCI for chronic total occlusion and in whom MPI was performed within 12 ± 3 mo before PCI and a followup study within 12 ± 3 mo after PCI. The change in % ischemia was +5.39% (P = 0.006), -1.70% (P = 0.008), -6.32% (P < 0.001), and -16.26% (P < 0.001) in patients with no/minimal (< 5% ischemic myocardium), mild (5%-9.9%), moderate (10%-16%), and severe (> 16%) ischemia, respectively.…”

Section: Mortality?mentioning

confidence: 99%

Myocardial ischemia is a key factor in the management of stable coronary artery disease

Iwasaki¹

2014

WJC

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Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decisionmaking for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.© 2014 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Coronary artery bypass surgery; Coronary revascularization; Fractional flow reserve; Myocardial ischemia; Myocardial perfusion imaging; Percutaneous coronary intervention Core tip: Studies of myocardial perfusion imaging demonstrate that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit. For patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality probably because of worsened ischemia. Studies using fractional flow reserve demonstrate that ischemia-guided percutaneous coronary intervention (PCI) is superior to angiography-guided PCI, and the presence of ischemia is the key factor in decision-making for PCI. Thus, myocardial ischemia is a key factor in the management of patients with stable coronary artery disease.Iwasaki K. Myocardial ischemia is a key factor in the management of stable coronary artery disease. World J Cardiol

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“…In a study of 301 patients who underwent myocardial perfusion imaging before and after CTO PCI, a baseline ischaemic burden of >12.5 % was optimal in identifying patients most likely to have a significant decrease in ischaemic burden post-CTO PCI, suggesting that the highest benefit of CTO PCI is more likely to be achieved in patients with significant baseline myocardial ischaemia. 69 …”

Section: Completeness Of Coronary Revascularisation and Outcomesmentioning

confidence: 99%

Percutaneous Treatment of Coronary Chronic Total Occlusions Part 1: Rationale and Outcomes

Galassi

Grantham

Kandzari

et al. 2014

Interventional Cardiology Review

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A chronic total occlusion (CTO) is defined as a completely occluded coronary artery with no antegrade flow (thrombolysis in myocardial infarction [TIMI] 0 flow) for at least three months.1 CTOs are present in 15-30 % of patients undergoing coronary angiography.2-5 In a Canadian prospective registry of 14,439 patients undergoing coronary angiography a CTO was present in 18.4 % of all patients with significant coronary artery disease (CAD).2 Approximately 1/3-1/2 6,7 of patients undergoing CTO percutaneous coronary intervention (PCI) have had a prior acute myocardial infarction (MI). This suggests acute onset of the occlusion, whereas in the remaining patients gradual development of CTO from high-grade lesions likely occurred.The basic histopathologic feature of a CTO is a proximal cap of the occlusion. This is often fibrotic or calcified and may provide considerable resistance to wire advancement during CTO PCI. Distal to the proximal cap and along the occlusion length follows a segment of loose fibrous tissue or organised thrombus, with various extent of calcification. 8,9 In several of these lesions, residual channels may be observed that are not visible under angiography. In addition, microchannels may appear during the CTO's consolidation process, however these are mostly located in the adventitia with extremely tortuous courses and do not generally traverse the entire occluded segment.10 A recent autopsy study of 95 CTO lesions from 82 patients reported frequent negative remodelling of the CTO body (more frequent with longer duration of the occlusion), very rare presence of microchannels and more frequent tapering of the distal cap as compared with the proximal cap (79 % vs. 50 %, P<0.0001). Successful CTO percutaneous coronary intervention (PCI) can significantly improve angina and improve left ventricular function. Although currently unproven, successful CTO PCI might also reduce the risk for arrhythmic events in patients with ischaemic cardiomyopathy, provide better tolerance of future acute coronary syndrome, and possibly improve survival. Evaluation by a heart team comprised of both interventional and non-interventional cardiologists and cardiac surgeons is important for determining the optimal revascularisation strategy in patients with coronary artery disease and CTOs. Ad hoc CTO PCI is generally not recommended, so as to allow sufficient time for (a) discussion with the patient about the indications, goals, risks, and alternatives to PCI; (b) careful procedural planning; and (c) contrast and radiation exposure minimisation. Use of drug-eluting stents is recommended for CTO PCI, given the lower rates of angiographic restenosis compared to bare metal stents.

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Changes in myocardial ischemic burden following percutaneous coronary intervention of chronic total occlusions

Abstract: Ischemic burden is reduced following CTO PCI, and the decrease is greater at high ischemic burden. A threshold of 12.5% ischemic burden is suggested as a criterion for performing PCI in the setting of CTO.

Cited by 104 publications

References 20 publications

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Update in Chronic Total Occlusion Percutaneous Coronary Interventions

Myocardial ischemia is a key factor in the management of stable coronary artery disease

Percutaneous Treatment of Coronary Chronic Total Occlusions Part 1: Rationale and Outcomes

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