Choice of CTO scores to predict procedural success in clinical practice. A comparison of 4 different CTO PCI scores in a comprehensive national registry including expert and learning CTO operators

Abstract

Background We aimed to compare the performance of the recent CASTLE score to J-CTO, CL and PROGRESS CTO scores in a comprehensive database of percutaneous coronary intervention of chronic total occlusion procedures. Methods Scores were calculated using raw data from 1,342 chronic total occlusion procedures included in REBECO Registry that includes learning and expert operators. Calibration, discrimination and reclassification were evaluated and compared. Results Mean score values were: CASTLE 1.60±1.10, J-CTO 2.15±1.24, PROGRESS 1.68±0.94 and CL 2.52±1.52 points. The overall percutaneous coronary intervention success rate was 77.8%. Calibration was good for CASTLE and CL, but not for J-CTO or PROGRESS scores. Discrimination: the area under the curve (AUC) of CASTLE (0.633) was significantly higher than PROGRESS (0.557) and similar to J-CTO (0.628) and CL (0.652). Reclassification: CASTLE, as assessed by integrated discrimination improvement, was superior to PROGRESS (integrated discrimination improvement +0.036, p<0.001), similar to J-CTO and slightly inferior to CL score (– 0.011, p = 0.004). Regarding net reclassification improvement, CASTLE reclassified better than PROGRESS (overall continuous net reclassification improvement 0.379, p<0.001) in roughly 20% of cases. Conclusion Procedural percutaneous coronary intervention difficulty is not consistently depicted by available chronic total occlusion scores and is influenced by the characteristics of each chronic total occlusion cohort. In our study population, including expert and learning operators, the CASTLE score had slightly better overall performance along with CL score. However, we found only intermediate performance in the c-statistic predicting chronic total occlusion success among all scores.

Procedural Success Prediction Scoring Systems Used in Percutaneous Coronary Interventions for Chronic Total Occlusions: A Systematic Evaluation

“…All included studies had an observational design with the scores being applied retrospectively. The most investigated score in clinical studies was J-CTO [15,17,[20][21][22][23][24][25][26][27][28][29][30]34,37,38,[40][41][42][43][44][45][46] followed by PROGRESS-CTO score [18,22,24,28,37,38,41,44,46]. PCI success rate varied across studies from 48.2% [30] to 94.4% [21].…”

“…PROGRESS-CTO score derivation cohort consisted of 521 patients and was subsequently validated internally in 260 patients with a high PCI success rate (92.9%) [41]. In the derivation cohort, the predictive performance was higher (AUC 0.778) than in other studies that externally validated the score, with AUC ranging from 0.557 [37] to 0.788 [38] in the case of elderly patients.…”

“…Nonetheless, a small cohort of patients was included, and results should be confirmed in more extensive studies. CASTLE (EuroCTO) score was derived and externally validated in large cohorts of patients [22,23,37,39]. Though the CASTLE score had a modest predictive value, with AUC ranging from 0.633-0.68, it was comparable to the J-CTO score.…”

“…The CASTLE score had lower performance in complex lesions, but it was still better than the J-CTO score (AUC 0.588 vs. 0.473). [23] Since its development, the CL score has been extensively validated in different studies [15,22,24,37,38,44]. The predictive value of the CL score varies across studies with AUC ranging from 0.624 [22] to 0.800 [38], which is slightly better than the J-CTO score in some cases [15,24,37].…”

“…[23] Since its development, the CL score has been extensively validated in different studies [15,22,24,37,38,44]. The predictive value of the CL score varies across studies with AUC ranging from 0.624 [22] to 0.800 [38], which is slightly better than the J-CTO score in some cases [15,24,37]. Some studies developed original scores for successful PCI prediction [16,19,25,[31][32][33]35].…”