The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction

Werner, Gerald S.; Surber, Ralf; Ferrari, Markus; Fritzenwanger, Michael; Figulla, Hans R.

doi:10.1093/eurheartj/ehl270

Cited by 172 publications

(111 citation statements)

References 32 publications

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“…Patients with well‐developed collaterals showed an improved restoration of dysfunctional segments in the CTO territory, compared with patients with poorly developed collaterals 22. In addition, Werner et al showed that few patients with well‐developed collaterals show a normal coronary flow reserve, which suggests that even in these patients episodes of ischemia can occur, which would be a trigger for VA 9, 23…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long‐Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter‐Defibrillator (the eCTOpy‐in‐ICD Study)

Dongen

Yılmaz

Elias

et al. 2018

JAHA

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BackgroundPrevious studies report conflicting results about a higher incidence of ventricular arrhythmias in patients with a chronic total coronary occlusion (CTO). We aimed to investigate this association in a large cohort of implantable cardioverter defibrillator patients with long‐term follow‐up.Methods and ResultsAll consecutive patients from 1992 onwards who underwent implantable cardioverter defibrillator implantation for ischemic cardiomyopathy at the Leiden University Medical Center were evaluated. Coronary angiograms were reviewed for the presence of a CTO. The occurrence of ventricular arrhythmias and survival status at follow‐up were compared between patients with and patients without a CTO. A total of 722 patients constitute the study cohort (age 66±11 years; 84% males; 74% primary prevention, median left ventricular ejection fraction 30% [first–third quartile: 25–37], 44% received a cardiac resynchronization therapy defibrillator). At baseline, 240 patients (33%) had a CTO, and the CTOs were present for at least 44 (2–127) months. The median follow‐up duration was 4 (2–6) years. On long‐term follow‐up, CTO patients had a higher crude appropriate device therapy rate (37% versus 27%, P=0.010) and a lower crude survival rate (51% versus 67%, P<0.001) compared with patients without a CTO. Corrected for baseline characteristics including left ventricular ejection fraction, the presence of a CTO was an independent predictor for appropriate device therapy.ConclusionsThe presence of a CTO in implantable cardioverter defibrillator patients was associated with more appropriate device therapy and worse prognosis at long‐term follow‐up. Further investigation is warranted regarding a potential beneficial effect of CTO revascularization on the incidence of ventricular arrhythmias.

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Section: Discussionmentioning

confidence: 99%

Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long‐Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter‐Defibrillator (the eCTOpy‐in‐ICD Study)

Dongen

Yılmaz

Elias

et al. 2018

JAHA

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“…However, Werner et al18 reported that physiological function of CTO collaterals in patients without Q‐wave MI was limited to only less than 10% of collaterals having a normal functional reserve during adenosine infusion. Furthermore, even with a well‐developed collateral flow, at least one third of CTO patients had coronary steal, which is the phenomenon that decreases perfusion flow at the collateral vessel during pharmacological stress 18. Thus, the myocardium‐protecting function of well‐developed collateral circulation would be incomplete at rest and during exercise, and therefore it could not protect the myocardium damage thoroughly.…”

Section: Discussionmentioning

confidence: 99%

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Chronic Total Coronary Occlusion With Well‐Developed Collaterals

Choi

Rha

et al. 2017

JAHA

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BackgroundThe impact of percutaneous coronary intervention (PCI) on chronic total occlusion in patients with well‐developed collaterals is not clear.Methods and ResultsA total of 640 chronic total occlusion patients with collateral flow grade ≥2 were divided into 2 groups; chronic total occlusion patients either treated with PCI (the PCI group; n=305) or optimal medical therapy (the optimal medical therapy group; n=335). To adjust for potential confounders, a propensity score matching analysis was performed. Major clinical outcomes were compared between the 2 groups up to 5 years. In the entire population, the PCI group had a lower hazard of myocardial infarction (hazard ratio [HR], 0.177; P=0.039; 95% confidence interval [CI], 0.03–0.91) and the composite of total death or myocardial infarction (HR, 0.298; P=0.017; 95% CI, 0.11–0.80); however, it showed higher hazard of target lesion revascularization (HR, 3.942; P=0.003; 95% CI, 1.58–9.81) and target vessel revascularization (HR, 4.218; P=0.001; 95% CI, 1.85–9.60). After propensity score matching, a total of 158 matched pairs were generated. Although the PCI group showed a higher hazard of target lesion revascularization (HR, 2.868; P=0.027; 95% CI, 1.13–7.31) and target vessel revascularization (HR=2.62; P=0.022; 95% CI, 1.15–5.97), it still exhibited a lower incidence of the composite of total death or myocardial infarction (HR, 0.263; P=0.017; 95% CI, 0.087–0.790). The mean ejection fraction was improved from 47.8% to 51.6% (P<0.001) after PCI.ConclusionsIn our study, successful revascularization by PCI for chronic total occlusion lesions with well‐developed collaterals was associated with lower incidence of death and myocardial infarction, improved left ventricular function, but increased repeat revascularization rate.

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“…There is no doubt that treatment of CTO affecting an ischemic myocardial area that causes symptoms, such as angina, should improve patient symptoms by providing a greater perfusion flow than that provided by collateral circulation, as a consequence of opening the occluded artery (Werner et al, 2006). In the FACTOR Trial (Flow Cardia Approach to CTO Recanalization), 125 patients completed the Seattle Angina Questionnaire at baseline and one month after percutaneous coronary intervention (Grantham et al, 2010).…”

Section: Discussionmentioning

confidence: 99%

Chronic Total Coronary Artery Occlusion Recanalisation with Percutaneous Coronary Intervention — Single Centre 10-Year Experience

Kalniņš

Strēle

Kurcalte

et al. 2018

Proceedings of the Latvian Academy of Sciences. Section B. Natural, Exact, and Applied Sciences.

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The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction

Abstract: A limited increase in collateral flow and the high prevalence of coronary steal during stress underscore the functional limitation of collaterals in CTOs without prior Q-wave MI. Even presumably 'well-collateralized' CTOs may benefit from a revascularization.

Cited by 172 publications

References 32 publications

Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long‐Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter‐Defibrillator (the eCTOpy‐in‐ICD Study)

Evaluation of the Impact of a Chronic Total Coronary Occlusion on Ventricular Arrhythmias and Long‐Term Mortality in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter‐Defibrillator (the eCTOpy‐in‐ICD Study)

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Chronic Total Coronary Occlusion With Well‐Developed Collaterals

Chronic Total Coronary Artery Occlusion Recanalisation with Percutaneous Coronary Intervention — Single Centre 10-Year Experience

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