Short Communication - Interventional Cardiology (2022) Volume 14, Issue 5

Clinical effects of percutaneous coronary intervention of chronic total occlusion in noninfarct-related artery after acute myocardial infarction

Corresponding Author:
Junbo Ge
Department of Cardiology,
Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases,
Fudan University,
Shanghai,
China,
E-mail: [email protected]

Received date: 29-Aug-2022, Manuscript No. FMIC-22-68208; Editor assigned: 31-Aug-2022, PreQC No. FMIC-22-68208 (PQ); Reviewed date: 14-Sep-2022, QC No. FMIC-22-68208;Revised date: 21-Sep-2022, Manuscript No. FMIC-22-68208 (R);Published date: 28-Sep-2022, DOI: 10.37532/1755-5310.2022.14(5).552

Abstract

The success rate of Percutaneous Coronary Intervention (PCI) in coronary Chronic Total Occlusion (CTO) has improved with technical and technological progress, however, the clinical benefit of CTO PCI is still controversial. In this article, we summarize the clinical studies with long term follow up data investigating the effect of CTO PCI in noninfarct-related artery after acute myocardial infarction.

Keywords

Percutaneous coronary intervention • Chronic total occlusion • Acute myocardial infarction

Description

In the current era, the technical success rate of Percutaneous Coronary Intervention (PCI) of coronary Chronic Total Occlusions (CTOs) has achieved nearly 90%, along with the improvements in techniques, devices and operator’s experiences, as well as the standardization of the procedure [1,2]. However, CTO PCI remains a controversial procedure as its clinical benefit remains to be determined. The Randomized Clinical Trials (RCTs) demonstrated improvement in Quality Of Life (QOL) [3,4] and relieved myocardial ischemic burden [5] in patients underwent CTO PCI compared with Optimal Medical Therapy (OMT), but failed to show recovery of regional wall motion or benefit on Major Adverse Cardiovascular Events (MACEs) in these patients [3-6]. Consequently, the recommendation level of CTO PCI in 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization is IIB [7]. The results of the ongoing ISCHEMIA-CTO (Revascularization or Optimal Medical Therapy of CTO; NCT03563417) may add evidence to the benefit of CTO-PCI in patients with myocardial ischemia.

Recently, clinical studies focused on the effect of CTO PCI in non-culprit arteries of patients with Acute Myocardial Infarction (AMI), as patients with AMI and concurrent CTO had worse clinical outcomes compared with patients with AMI but without CTO [8]. Moreover, Fujimoto Y, et al. demonstrated patients with AMI with CTO in non-culprit arteries had worse clinical outcomes than those with 90% to 99% stenosis in non-culprit arteries during a median follow-up duration of 1.2 years [9], suggesting patients with CTO had more myocardial damage and early revascularization may be considered. However, the long term follow up results of EXPLORE trial failed to confirm the beneficial effect of early CTO PCI on MACE after ST-Segment Elevation Myocardial Infarction (STEMI) [10]. Instead, a significantly higher rate of cardiac death was demonstrated in patients randomized to CTO PCI [10]. The long term follow up data from the randomized EXPLORE trial seems to be contrary to the data from retrospective studies, which demonstrated lower rate of cardiac death in patients in CTO PCI group after AMI (Table 1) [11-14].

Authors Year published Study design Area Sites Target Number of patients Group Time interval after IRA PCI MACE/MACCE definition J-CTO score Procedural success Follow-up duration Cardiac death MACE/MACCE
Elias, et al. [10] 2018 Randomized clinical trial Europe and Canada 14 centers STEMI and concurrent CTO 302 CTO PCI vs. MT (n=148) (n=154) 5.0 ± 1.9 days cardiac death, MI, and CABG 2 ± 1 vs. 2 ± 1 73% Median 3.9 years 6% vs. 1% p=0.02 13.5% vs. 12.3% p=0.93
Valenti, et al. [11] 2014 Retrospective Italy Single center STEMI and concurrent CTO 169 s-CTO vs. o-CTO (n=58)  (n=111) within 1 month - - 78.40% Median 3.9 years 3.7% vs. 14.9% p=0.03 -
Choi, et al [12] 2016 Retrospective Korea 9 centers AMI and concurrent CTO 324 s-CTO vs. o-CTO (n=170) (n=154) - all‐cause death, stroke, nonfatal MI, and any revascularization - - Median 3.5 years 7.6% vs. 20.1% p=0.001 15.9% vs. 37.7% p<0.001
Yoshida, et al. [13] 2020 Retrospective Japan Single center AMI and concurrent CTO 172 s-CTO vs. o-CTO (n=65) (n=107) within 3 months cardiac death, MI, and CABG 1(1-2) vs. 1(1-2) 73.90% Median 4.1 years 19.0% vs. 51.9% p=0.004 22.7% vs. 57.1% p=0.0002
Cui, et al. [14] 2020 Retrospective China Single center STEMI and concurrent CTO 287 CTO PCI vs. MT (n=91) (n=196) 8 (5-40) days all‐cause death, stroke, nonfatal MI, and unplanned revascularization - 80.20% Mean 6.1 years 4.4% vs. 16.8% - 22% vs. 46.9% p=0.002
Qin, et al. [15] 2022 Retrospective China Single center AMI and concurrent CTO 330 CTO PCI vs. MT (n=198) (n=132) within 1 year all‐cause death, stroke, nonfatal MI, and any revascularization - 83.80% Median 2.6 years 3.0% vs. 12.1% p=0.004 22.2% vs. 37.1% p=0.055

Table 1: Clinical studies with long term follow up data investigating the effect of percutaneous coronary intervention of chronic total occlusion in noninfarct-related artery after acute myocardial infarction.

It should be noted that the procedural success (73%) in EXPLORE trial was relatively lower than that in retrospective studies published recently (>80%), which may cause underestimation of the value of CTO recanalization [14,15]. Furthermore, the early CTO-PCI (5.0 ± 1.9 days) after primary PCI in EXPLORE may aggravate inflammation and cause adverse left ventricular remodeling.

Conclusion

Therefore, a well-designed randomized clinical trial with reasonable time interval after Infarct Related Artery (IRA) PCI is required to show whether patients may benefit from CTO-PCI after AMI under contemporary techniques and experiences. As patients with AMI and concurrent CTO have high risk of clinical events, the sample size to demonstrate the effect of CTO PCI on hard end points will not be too big.

Nowadays, the technical issue in CTO recanalization is no longer a challenge. We need to identify the group of high-risk patients who will benefit from CTO-PCI in terms of hard cardiovascular outcomes.

References

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