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Impact of successful and failed revascularization of chronic total occlusion on left ventricular function and infarct size

Introduction

Non-randomised studies have reported a prognostic advantage with percutaneous coronary intervention (PCI) in the treatment of chronic total occlusions (CTO). Failure to cross and successfully open a CTO confers a worse clinical outcome, however most trials have included occlusions of short duration (7-30 days). PCI success rates are inversely related to the age of vessel occlusion reflecting temporal, cellular changes within a CTO, namely progressive collagen deposition.

Purpose

To assess the medium-term cardiac outcomes of PCI in the treatment of true CTO (endorsed by an expert consensus panel, requiring Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 on angiography and ≥12 weeks duration) using quantitative cardiac magnetic resonance (CMR) imaging.

Methods

23 patents (mean age 60 ± 11, 82% male) referred for PCI to a single vessel de novo CTO underwent CMR examination within one week prior to and 6 months after their procedure. PCI success was defined as recanalisation of the occluded vessel and stent implantation with a final residual diameter stenosis <30%. Left ventricular (LV) function and transmural extent of infarction (TEI) were assessed using standard SSFP and T1-weighted imaging on a 1.5 T MRI system. LV volumes and mass were quantified using a dedicated software package (QMass). Segmental wall thickening (SWT) was calculated by (end systolic - end-diastolic wall thickness)/end-diastolic wall thickness × 100%. Myocardial segments were considered dysfunctional if SWT was ≤45%. Viable segments included dysfunctional myocardium with TEI <25%.

Results

TIMI 3 flow was successfully achieved in 13 of the 23 patients (59%), all treated with drug eluting stents. Baseline demographics were well matched in each group (Table 1). Opening a CTO did not result in improvement in either regional or global systolic function however it was associated with a significant increase in SWT in dysfunctional but viable segments (Table 2). Failed PCI was not associated with a worse cardiac outcome in terms of LV remodelling and infarct size as compared to patients with an open artery however one patient experienced a peri-procedural myocardial infarct (MI).

Table 1 Baseline demographics
Table 2 Results

Conclusion

In this single-centre pilot study failed revascularisation of true CTOs was not associated with worse cardiac outcomes compared to successful PCI. Despite a lack of improvement in global systolic function opening a CTO improved SWT within dysfunctional but viable segments. Larger, randomised studies are required to assess the long-term benefits and morbidity of PCI in the treatment of CTOs.

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Correspondence to Gideon A Paul.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Paul, G.A., Zia, M., Connelly, K.A. et al. Impact of successful and failed revascularization of chronic total occlusion on left ventricular function and infarct size. J Cardiovasc Magn Reson 12, P210 (2010). https://doi.org/10.1186/1532-429X-12-S1-P210

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Keywords

  • Percutaneous Coronary Intervention
  • Cardiac Magnetic Resonance
  • Drug Elute Stents
  • Chronic Total Occlusion
  • Transmural Extent