Coronary chronic total occlusions and mortality in patients with ventricular tachyarrhythmias

Abstract

Aims: This study sought to assess the prognostic impact of coronary chronic total occlusions (CTO) in patients presenting with ventricular tachyarrhythmias on admission.Methods and results: A large retrospective registry was used, including all consecutive patients presenting with ventricular tachyarrhythmias on admission and undergoing coronary angiography from 2002 to 2016. Patients with a CTO were compared with all other patients (non-CTO) for prognostic outcomes. Statistics comprised Kaplan-Meier and Cox regression analyses. Within a total of 1,461 consecutive patients included with ventricular tachyarrhythmias on admission, a CTO was present in 20%. At midterm follow-up of 18 months, the primary endpoint all-cause mortality had occurred in 40% of CTO patients compared to 27% of non-CTO patients (HR 1.563, 95% CI: 1.263-1.934; p=0.001). The rates of secondary endpoints were higher for in-hospital all-cause mortality at index (29% versus 20%, log-rank p=0.027) and the composite endpoint of cardiac death at 24 hours, recurrent ventricular tachyarrhythmias and appropriate ICD therapies at midterm follow-up (28% versus 20%, log-rank p=0.005). Mortality rates were highest in CTO patients with stable coronary artery disease (CAD), acute myocardial infarction and in patients surviving index hospitalisation. Conclusions:In patients presenting with ventricular tachyarrhythmias on admission, the presence of a coronary CTO is independently associated with an increase of midterm all-cause mortality, in-hospital allcause mortality and the composite endpoint of early cardiac death, recurrent ventricular tachyarrhythmias and appropriate ICD therapies.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

“…Firstly, CTO was found in 20% of patients with ventricular tachyarrhythmias, while multiple CTO were found in 22% of these patients. The presence of a native non-revascularized CTO was significantly associated with all-cause mortality at three years, notably with increased rates of the composite endpoint of early cardiac death at 24 h, recurrent ventricular tachyarrhythmias and appropriate implantable cardioverter defibrillator (ICD) therapies [ 47 , 48 ]. A meta-analysis by Chi et al demonstrated that patients with an infarct-related CTO have a significantly higher risk of ventricular tachyarrhythmias, appropriate ICD therapy and increased all-cause mortality compared to those with a non-IRA CTO [ 49 ].…”

‘Off‐pump’ left ventricular reconstruction – A causal and less invasive surgical option for patients with advanced systolic heart failure?

“…From the point of view of an interventional cardiologist, less invasive SVR may be in line with another still underestimated type of PCI, the successful PCI of coronary chronic total occlusions (CTO). CTO are present in more than 20% of patients undergoing coronary angiography . Comparable to SVR, CTO‐PCI is recommended to be performed by highly skilled CTO operators in specialized centres only, where success rates of more than 90% have constantly been demonstrated.…”

“…In contrast to SVR, CTO‐PCI is indicated for patients with relevant myocardial ischaemia in the CTO territory, which is detected in more than 95% of patients even in the presence of preserved ejection fraction and angiographically sufficient coronary collateralization. Predictors of successful CTO‐PCI are well‐described, but the potential prognostic benefit in terms of mortality reduction may even be found in patients with systolic HF and viable myocardium, without transmural scarring and severe akinesia …”

“…CTO are present in more than 20% of patients undergoing coronary angiography. 16,17 Comparable to SVR, CTO-PCI is recommended to be performed by highly skilled CTO operators in specialized centres only, where success rates of more than 90% have constantly been demonstrated. In contrast to SVR, CTO-PCI is indicated for patients with relevant myocardial ischaemia in the CTO territory, which is detected in more than 95% of patients even in the presence of preserved ejection fraction and angiographically sufficient coronary collateralization.…”

“…Predictors of successful CTO-PCI are well-described, but the potential prognostic benefit in terms of mortality reduction may even be found in patients with systolic HF and viable myocardium, without transmural scarring and severe akinesia. 16,18,19 Further prospective randomized controlled trials investigating the prognostic benefit of less invasive SVR and CTO-PCI in patients with advanced systolic HF may bear the potential of a direct and causal treatment option for the extensively treated HF patient.…”