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,
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
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.
Percutaneous coronary intervention • Chronic total occlusion • Acute myocardial infarction
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  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 . 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 . 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 , 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) . Instead, a significantly higher rate of cardiac death was demonstrated in patients randomized to CTO PCI . 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. ||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. ||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 ||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. ||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. ||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. ||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|
Abbreviations: IRA: Infarct Related Artery; PCI: Percutaneous Coronary Intervention; MACE: Major Adverse Cardiacvascular Event; MACCE: Major Adverse Cardiovascular and Cerebrovascular Event; STEMI: ST-Segment Elevation Myocardial Infarction; CTO: Chronic Total Occlusion; MT: Medical Therapy; MI: Myocardial Infarction; CABG: Coronary Artery Bypass Grafting; s-CTO: successful CTO; o-CTO: occluded CTO( MT and failed CTO PCI); AMI: Acute Myocardial Infarction
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.
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.
- Tajti P, Xenogiannis I, Gargoulas F, et al. Technical and procedural outcomes of the retrograde approach to chronic total occlusion interventions. EuroIntervention. 16(11): e891-e9 (2020).
- Harding SA, Wu EB, Lo S, et al. A New algorithm for crossing chronic total occlusions from the Asia pacific chronic total occlusion club. JACC Cardiovasc Interv. 10(21): 2135-43 (2017).
- Werner GS, Martin-Yuste V, Hildick-Smith D, et al. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J. 39(26): 2484-93 (2018).
- Obedinskiy AA, Kretov EI, Boukhris M, et al. The IMPACTOR-CTO trial. JACC Cardiovasc Interv. 11(13): 1309-11 (2018).
- Mashayekhi K, Nuhrenberg TG, Toma A, et al. A randomized trial to assess regional left ventricular function after stent implantation in chronic total occlusion: The REVASC trial. JACC Cardiovasc Interv. 11(19): 1982-91 (2018).
- Lee SW, Lee PH, Ahn JM, et al. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion. Circulation. 139(14): 1674-83 (2019).
- Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. J Am Coll Cardiol. 79(2): e21-e129 (2022).
- An X, Yang J, Dou K, et al. The 11-year prognostic impact of chronic total occlusion in the noninfarct-related coronary artery on patients with acute myocardial infarction. J Interv Cardiol. 2021: 6646804 (2021).
- Fujimoto Y, Sakakura K, Jinnouchi H, et al. Comparison of outcomes of patients with acute myocardial infarction between chronic total occlusion vs. 90%-99% stenosis in non-culprit arteries. Am J Cardiol. 170: 17-24 (2022).
- Elias J, van Dongen IM, Ramunddal T, et al. Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction. Heart. 104(17): 1432-8 (2018).
- Valenti R, Marrani M, Cantini G, et al. Impact of chronic total occlusion revascularization in patients with acute myocardial infarction treated by primary percutaneous coronary intervention. Am J Cardiol. 114(12): 1794-800 (2014).
- Choi IJ, Koh YS, Lim S, et al. Impact of percutaneous coronary intervention for chronic total occlusion in non-infarct-related arteries in patients with acute myocardial infarction (from the COREA-AMI Registry). Am J Cardiol. 117(7): 1039-46 (2016).
- Yoshida R, Ishii H, Morishima I, et al. Prognostic impact of recanalizing chronic total occlusion in non-infarct related arteries on long-term clinical outcomes in acute myocardial infarction patients undergoing primary percutaneous coronary intervention. Cardiovasc Interv Ther. 35(3): 259-68 (2020).
- Qin Q, Chen L, Ge L, et al. A comparison of long-term clinical outcomes between Percutaneous Coronary Intervention (PCI) and medical therapy in patients with chronic total occlusion in noninfarct-related artery after PCI of acute myocardial infarction. Clin Cardiol. 45(1): 136-44 (2022).
- Cui KY, Yuan F, Liu H, et al. Long-term outcomes of staged recanalization for concurrent chronic total occlusion in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention. J Geriatr Cardiol. 17(1): 16-25 (2020).