Scoring System for Identification of “Survival Advantage” after Successful Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion

Abstract

Background: Percutaneous coronary intervention (PCI) is widely used in patients with chronic total occlusion (CTO), but its benefit in improving long-term outcomes is controversial. We aimed to develop a prediction score for grading “survival advantage” conferred by successful results of CTO-PCI and a scoring system for prediction of the influence of CTO-PCI results on major adverse cardiac and cerebrovascular events (MACCEs). Methods: Follow-up data of 2625 patients who underwent CTO-PCI at 65 Japanese centers were analyzed. An integer scoring system was developed by including statistical effect modifiers on the association between successful CTO-PCI and one-year mortality. Results: Follow-up at 12 months was completed in 2034 patients. During follow-up, 76 deaths (3.7%) occurred. Patients with successful CTO-PCI had a better one-year survival than patients with failed CTO-PCI (log rank P = 0.016). Effect modifiers for the association between successful procedure and one-year mortality included diabetes (P interaction = 0.043), multivessel disease (P interaction = 0.175), Canadian Cardiovascular Society class ≥2 (P interaction = 0.088), and prior myocardial infarction (MI) (P interaction = 0.117). Each component was assigned a single point and summed to develop the scoring system. The patients were then categorized to specify the prediction of survival advantage by successful PCI: ≤2 (normal) and ≥3 (distinct). The differences in one-year mortality between patients with successful and failed treatment were −0.7% and 11.3% for normal and distinct score categories, respectively. In the scoring system for MACCE, score components were prior MI (P interaction = 0.19), left anterior descending artery (LAD)-CTO (P interaction = 0.079), and reattempt of CTO-PCI (P interaction = 0.18). The differences in one-year MACCEs between successful and failed patients for each score category (0, 1, and ≥2) were −1.7%, 7.5%, and 15.1%, respectively. Conclusions: The novel scoring system assessing the advantage of successful PCI can be easily applied in patients with CTO. It is a valid instrument for clinical decision-making while assessing the survival advantage of CTO-PCI and the influence of procedural results on MACCEs.

Percutaneous coronary intervention versus optimal medical therapy for stable coronary artery disease: An umbrella review

“…However, only a limited number of SRs conducted these types of analyses, and ideally authors should provide explanations regarding the selection of variables for these analyses. Future SRs should consider planning for groups of importance that may modify the association between successful PCI and patient outcomes, such as diabetes, multivessel disease, more severe disease, previous myocardial infarction, among others [ 59 ]. It is also important for SRs to evaluate publication bias through graphical and statistical methods.…”

Long-Term Outcomes after Rotational Atherectomy for Calcified Chronic Total Occlusion versus Nonchronic Total Occlusion Coronary Lesions

“…Furthermore, slow flow at the end of CTO PCI procedure is associated with higher MACE according to the report by Wang et al [ 14 ] and as previously mentioned, we can limit these complications by less aggressive balloon/stent dilation after RA and proper selection of burr size and speed. A multicentre study to identify a survival advantage score to predict the outcome after CTO PCI, reported that the association between three variables (multivessel disease, Canadian cardiovascular society (CCS) score ≥2, and previous MI) in CTO patients predict poor long-term outcome after CTO revascularisation [ 23 ]. In our CTO cohort, multivessel disease was present in 68.8% and about 58.7% had CCS ≥ 2, and 21.3% reported previous MI.…”

Process of Care Assessment in Patients With Chronic Total Occlusion

“…Despite this, we should keep in mind that our goal is not to focus on the 'blocked coronary arteries', but to improve anginal symptoms and clinical outcomes in patients with stable ischemic heart disease. In addition to AUC, scoring tools that predict long-term adverse cardiac events 14 or 'survival advantage' 15 after successful CTO procedures can also be a valid instrument for clinical decisionmaking. Careful patient selection and optimizing medical therapy prior to the procedure remain the key components in managing CTO patients.…”