Long-Term Survival Benefit of Revascularization Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion and Well-Developed Collateral Circulation

Jang, Woo Jin; Yang, Jeong Hoon; Choi, Seung‐Hyuk; Song, Young Bin; Hahn, Joo‐Yong; Choi, Jin‐Ho; Kim, Wook Sung; Lee, Young Tak; Gwon, Hyeon‐Cheol

doi:10.1016/j.jcin.2014.10.010

Cited by 156 publications

(100 citation statements)

References 29 publications

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“…31) Furthermore, Jang and colleagues reported the long-term survival benefit of CTO revascularization as compared to medical therapy using a propensity score-matched population. 32) However, the association between improvement of LV systolic function and revascularization of coronary CTO has not been investigated in patients with heart failure. Our study focused on a systolic heart failure population, and showed the possible benefit of CTO revascularization for LV systolic function improvement.…”

Section: Discussionmentioning

confidence: 99%

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

et al. 2016

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SummaryRevascularization therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be considered for heart failure with reduced ejection fraction (HFrEF). However, revascularization therapy does not always improve left ventricular ejection fraction (LVEF). The purpose of this study was to investigate the determinants of LVEF improvement following revascularization in HFrEF patients. From 2,229 consecutive decompensated heart failure patients, a total of 47 HFrEF patients who underwent revascularization were included in the analysis. Improvement of LVEF was defined as [(LVEF during chronic phase) -(LVEF during acute phase)] ≥ 10%. Univariate and multivariate logistic regression analyses were applied to investigate the determinants of LVEF improvement. The prevalence of revascularization by PCIs including chronic total occlusion (CTO) was significantly greater in the improved EF group (45.0%) as compared to the non-improved EF group (11.1%) (P = 0.02). Multivariate logistic regression analysis revealed that revascularization by PCIs including CTO was the significant determinant of the LVEF improvement after adjusting for confounding factors (OR 5.43, 95% CI 1.06-27.74, P = 0.04). Optimal medical therapy (angiotensin-converting enzyme (ACE) inhibitor and/or angiotensin II receptor blocker (ARB) and beta-blockers) was less frequently prescribed in patients with CABG (50.0% for ACE inhibitor and/or ARB and 41.7% for beta-blocker) than in patients without CABG (94.3% for both) (P < 0.01 and P < 0.001, respectively). In conclusion, revascularization by PCIs including CTO was the significant determinant of LVEF improvement in HFrEF patients. Our results underscore the importance of optimal medical therapy even if patients receive complete revascularization such as CABG. (Int Heart J 2016; 57: 565-572) Key words: Percutaneous coronary intervention, Coronary artery bypass grafting, Chronic total occlusion H eart failure is a common disease with a prevalence of 1-2% in the adult population, 1) and still has high mortality in developed countries. One-year mortality rates in population-based studies have been reported to be 25% to 45%.2-5) The mortality rate was higher in heart failure with reduced ejection fraction (HFrEF) than heart failure with preserved ejection fraction (HFpEF). 6) Mortality rates of HFrEF (ejection fraction < 50%) patients were reported to be 32% at one year and 68% at 5 years.6) The most common cause of HFrEF is coronary artery disease, which accounts for approximately two-thirds of HFrEF. 7)Revascularization therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be considered in heart failure with coronary artery disease, and sometimes improves clinical outcomes including left ventricular function. [8][9][10][11][12] However, revascularization therapy is not always effective in heart failure with coronary artery disease.13) It is unknown which types of patients receive the benefits such as improvement o...

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Section: Discussionmentioning

confidence: 99%

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

et al. 2016

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“…Jang et al10 examined the long‐term outcomes of different treatment strategies among 738 patients with at least one CTO lesion and well‐developed collateral channels. During a median follow‐up of 42 months, patients who underwent coronary revascularization (with PCI or CABG; n=502) had a lower incidence of cardiac death (hazard ratio [HR], 0.29; 95% confidence interval [CI], 0.15–0.58; P <0.01) and MACE (HR, 0.32; 95% CI, 0.21–0.49; P <0.01), even after propensity matching (cardiac death: HR, 0.27; 95% CI, 0.09–0.80; P =0.02; and MACE: HR, 0.44; 95% CI, 0.23–0.82; P =0.01) 10…”

Section: Clinical Benefitsmentioning

confidence: 99%

Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies

Tajti

Brilakis

2018

JAHA

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“…A surgical approach by CABG might be preferred in patients with high Syntax scores [20]. Also, CTO is often associated with multivessel coronary artery disease [3,21]. CABG might be necessary during progression of coronary disease later on and a DCB-only approach can facilitate subsequent bypass surgery.…”

Section: Commentarymentioning

confidence: 99%

Why Treat Chronic Total Occlusion without Stents? - A Short Comment

Köln¹,

Kleber²

2017

J Clin Exp Cardiolog

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The treatment of chronic total occlusions is complex and associated with several risks and problems. Among therapeutic options including bypass surgery and medical therapy PCI represents an important strategy. PCI with stents, however, has limitations in such lesions due to characteristics like lesion length, unknown reference diameter and delayed stent coverage. Drug coated balloons have shown promising properties to overcome some of those limitations: They promote positive vessel remodeling and have a minimal thrombosis rate. In a first multicenter study it has been shown that drug coated balloons in proper indications and applied with appropriate technique might become a new treatment option for patients with chronic total occlusions. CommentaryChronic total occlusions (CTO) of coronary arteries have been a focus point of research in interventional cardiology for several years. Recanalization, balloon dilatation and implantation of drug eluting stents (DES) are recognized treatment options for patients with symptomatic CTO. Recanalization of CTO ranks among the most complicated percutaneous coronary interventions (PCI) and the procedures are to be performed by well-equipped and experienced centers. During the last decades the procedural success rates increased due to improved technical equipment and increasing operator experience [1,2].It is still uncertain whether PCI is the optimal treatment method for CTO and it competes with coronary artery bypass grafts (CABG) and medical treatment. Large retrospective registries have shown a reduction of adverse events and a clinical improvement after successful CTO PCI [3,4]. The only recently conducted DECISION-CTO trial [5] was the first large randomized controlled trial (RCT) to compare different treatment modalities for CTO. It failed to show a significant difference between PCI and optimal medical therapy. In general CTO PCI should only be considered for symptomatic patients with viable myocardium and no contraindications for PCI.Further research and new strategies might improve CTO PCI in the future, amongst them bioresorbable vascular scaffolds and drug coated balloons (DCB). CTO vessels usually have long lesions to be treated [6], have often an unknown vascular diameter and might have a number of side branches, often not readily recognizable beforehand.Thus, there are several characteristics of CTO that call for a stent free PCI approach. In the attempt of covering the lesion completely frequently more than 5 cm of the affected vessel have to be stented during CTO PCI. DES of such lengths has shown an increased risk of diffuse restenosis and other stent-linked complications [7]. The selection of a proper stent size can be difficult due to the lack of a reference diameter. An inappropriate stent size however can lead to either extensive vessel damage or to secondary malapposition. Also side branches might be occluded.In addition, even in comparison with similar long non-CTO lesions a delayed coverage of stent struts has been observed in CTO after DES imp...

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Long-Term Survival Benefit of Revascularization Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion and Well-Developed Collateral Circulation

Abstract: In patients with coronary CTO and well-developed collateral circulation, aggressive revascularization may reduce the risk of cardiac mortality and MACE.

Cited by 156 publications

References 29 publications

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

Determinants of Left Ventricular Systolic Function Improvement Following Coronary Artery Revascularization in Heart Failure Patients With Reduced Ejection Fraction (HFrEF)

Chronic Total Occlusion Percutaneous Coronary Intervention: Evidence and Controversies

Why Treat Chronic Total Occlusion without Stents? - A Short Comment

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