Ischemic Burden Reduction and Long-Term Clinical Outcomes After Chronic Total Occlusion Percutaneous Coronary
Stefan P Schumacher1, Wijnand J Stuijfzand1, Ruben W de Winter1
1Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
Insights
Reducing ischemic burden after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) significantly improves long-term survival and cardiac symptom relief. Greater reduction in perfusion defects and improved blood flow correlate with better outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Nuclear Cardiology
Background:
- The clinical effectiveness of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains a subject of debate.
- Assessing the impact of CTO PCI on myocardial perfusion and long-term patient outcomes is crucial.
Purpose of the Study:
- To evaluate the impact of reducing ischemic burden after CTO PCI on long-term prognosis.
- To assess the effect of CTO PCI on cardiac symptom relief.
- To determine the relationship between quantitative changes in myocardial perfusion and clinical outcomes.
Main Methods:
- 212 patients undergoing successful CTO PCI prospectively received quantitative [15O]H2O positron emission tomography perfusion imaging before and 3 months after the procedure.
- Perfusion defects (PD) and hyperemic myocardial blood flow (hMBF) were quantified and correlated with prognostic outcomes.
- Statistical analyses included Kaplan-Meier curves, log-rank tests, and multivariable Cox regression for risk-adjusted outcomes.
Main Results:
- Superior event-free survival was observed in patients with greater reduction in PD (≥3 segments) and higher hMBF increase (Δ≥1.11 ml·min-1·g-1) post-CTO PCI.
- Patients with no residual PD or normalized hMBF (>2.3 ml·min-1·g-1) at follow-up PET exhibited significantly better event-free survival.
- Normalization of hMBF levels post-CTO PCI was associated with improved long-term relief from angina and dyspnea.
Conclusions:
- Significant reduction in ischemic burden and absence of residual ischemia after CTO PCI are linked to reduced rates of all-cause death and nonfatal myocardial infarction.
- Normalization of hyperemic myocardial blood flow following CTO PCI is associated with long-term cardiac symptom relief.
Objectives:
The authors sought to evaluate the impact of ischemic burden reduction after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on long-term prognosis and cardiac symptom relief.
Background:
The clinical benefit of CTO PCI is questioned.
Methods:
In a high-volume CTO PCI center, 212 patients prospectively underwent quantitative [15O]H2O positron emission tomography perfusion imaging before and three months after successful CTO PCI between 2013-2019. Perfusion defects (PD) (in segments) and hyperemic myocardial blood flow (hMBF) (in ml · min-1 · g-1) allocated to CTO areas were related to prognostic outcomes using unadjusted (Kaplan-Meier curves, log-rank test) and risk-adjusted (multivariable Cox regression) analyses. The prognostic endpoint was a composite of all-cause death and nonfatal myocardial infarction.
Results:
After a median [interquartile range] of 2.8 years [1.8 to 4.3 years], event-free survival was superior in patients with ≥3 versus <3 segment PD reduction (p < 0.01; risk-adjusted p = 0.04; hazard ratio [HR]: 0.34 [95% confidence interval (CI): 0.13 to 0.93]) and with hMBF increase above (Δ≥1.11 ml · min-1 · g-1) versus below the population median (p < 0.01; risk-adjusted p < 0.01; HR: 0.16 [95% CI: 0.05 to 0.54]) after CTO PCI. Furthermore, event-free survival was superior in patients without versus any residual PD (p < 0.01; risk-adjusted p = 0.02; HR: 0.22 [95% CI: 0.06 to 0.76]) or with a residual hMBF level >2.3 versus ≤2.3 ml · min-1 · g-1 (p < 0.01; risk-adjusted p = 0.03; HR: 0.25 [95% CI: 0.07 to 0.91]) at follow-up positron emission tomography. Patients with residual hMBF >2.3 ml · min-1 · g-1 were more frequently free of angina and dyspnea on exertion at long-term follow-up (p = 0.04).
Conclusions:
Patients with extensive ischemic burden reduction and no residual ischemia after CTO PCI had lower rates of all-cause death and nonfatal myocardial infarction. Long-term cardiac symptom relief was associated with normalization of hMBF levels after CTO PCI.
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