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Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Chronic total coronary occlusion treated by percutaneous coronary intervention: long-term outcome in patients with
Francesca Sanguineti1, Philippe Garot, Stephen O'Connor
1Hôpital Privé Jacques Cartier, Hôpital Privé Claude Galien, Institut Cardiovasculaire Paris Sud (ICPS), Ramsay Générale de Santé, Massy, Quincy, France.
Insights
Successful chronic total occlusion (CTO) recanalisation improves long-term survival and reduces major adverse cardiac events (MACE). This benefit appears even greater for diabetic patients undergoing CTO percutaneous coronary intervention (PCI).
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Long-term outcomes after chronic total occlusion (CTO) recanalisation are debated, particularly in diabetic patients.
- Percutaneous coronary intervention (PCI) for CTO aims to improve patient prognosis but requires careful evaluation of long-term results.
- Diabetic patients often present with complex coronary artery disease, posing unique challenges for CTO PCI.
Purpose of the Study:
- To evaluate the very long-term clinical outcomes of diabetic versus non-diabetic patients after successful or failed CTO recanalisation.
- To compare cardiac death, target lesion revascularisation (TLR), myocardial infarction (MI), and major adverse cardiac events (MACE) between groups.
- To identify predictors of cardiac death in a large cohort undergoing CTO PCI.
Main Methods:
- A retrospective analysis of 1,320 consecutive patients undergoing PCI for CTO between 2004 and 2012.
- Comparison of outcomes in patients with successful versus failed CTO recanalisation, with a median follow-up of 4.2 years.
- Multivariate analysis to identify predictors of cardiac death, including diabetes, left ventricular ejection fraction, and age.
Main Results:
- The overall CTO PCI success rate was 75%, with no significant difference between diabetic (69.8%) and non-diabetic patients (75%).
- Successful recanalisation was associated with significantly lower rates of cardiac death (13.2% vs. 17.2%) and MACE (27.5% vs. 33.7%).
- Diabetes was a significant predictor of cardiac death (HR 2.44), alongside reduced LVEF and increasing age. Failed PCI showed markedly higher cardiac mortality in diabetic patients (24.7% vs. 9.3%).
Conclusions:
- CTO recanalisation is associated with improved long-term survival and reduced MACE up to nine years.
- The benefits of successful CTO recanalisation, particularly in reducing cardiac death, may be more pronounced in diabetic patients.
- Procedural success in CTO PCI is a crucial determinant of long-term survival, with diabetes being a significant risk factor for adverse outcomes.
Aims:
Despite technical advancements, long-term outcomes after chronic total occlusion (CTO) recanalisation remain a subject of debate, especially in diabetic patients. The aim of this study, therefore, was to assess the very long-term clinical outcome of diabetic vs. non-diabetic patients in a large cohort from a high-volume CTO PCI centre according to whether or not CTO recanalisation had been successfully achieved.
Methods And Results:
Between 2004 and 2012, 1,320 consecutive patients underwent PCI for CTO, 27.4% (362/1320) of whom were diabetics. We compared cardiac death, target lesion revascularisation (TLR), myocardial infarction (MI) and combined major adverse cardiac events (MACE) in patients with successful versus failed PCI (median follow-up 4.2 years). The PCI success rate was 75% (990/1,320 patients), with no significant differences between diabetics and non-diabetics (69.8% vs. 75%, respectively, p=0.07). Successful recanalisation was associated with lower cardiac death rates (13.2% vs. 17.2%, respectively, p<0.001) and lower MACE (27.5% vs. 33.7%, respectively, p=0.02). There were no significant differences in TLR (8.9% vs. 14.2% for failed recanalisation, p=0.29) and MI (4.7% vs. 10% for failed recanalisation). Successful recanalisation was a predictor of survival (HR 0.5, 95% CI: 0.32-0.81, p=0.005), whereas diabetes (HR 2.44, 95% CI: 1.52-3.83, p<0,001), left ventricular ejection fraction (HR 0.96, 95% CI: 0.94-0.99, p=0.004) and age (HR 1.06, 95% CI: 1.03-1.08, per year increment, p<0.0001) were predictors of cardiac death at follow-up. Cardiac mortality rates varied markedly after failed PCI between diabetic (20/103, 24.7%) and non-diabetic patients (15/227, 9.3%, p<0.0001 for comparison between groups), suggesting an interaction between the presence of diabetes and procedural outcome.
Conclusions:
CTO recanalisation was associated with improved long-term survival, a reduced rate of MACE for up to nine years, and suggests a greater reduction in cardiac death among diabetic patients.
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