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Use of Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention
Judit Karacsonyi1, Karen Deffenbacher2, Keith H Benzuly2
1Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.
Insights
Mechanical circulatory support (MCS) is used in a small percentage of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures. While prophylactic MCS shows similar technical success, urgent use is linked to lower success and higher complication rates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Mechanical Circulatory Support
Background:
- Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a complex procedure.
- The role of mechanical circulatory support (MCS) in CTO PCI remains understudied.
- Understanding outcomes associated with MCS use in CTO PCI is crucial for patient management.
Purpose of the Study:
- To analyze the clinical, angiographic characteristics, and procedural outcomes of CTO PCI with and without MCS.
- To compare outcomes between prophylactic and urgent MCS use in CTO PCI.
- To evaluate the impact of MCS on technical and procedural success rates and major adverse cardiac events.
Main Methods:
- Retrospective analysis of 7,171 CTO PCI cases from 35 international centers (2012-2021).
- Data collection included patient demographics, lesion complexity, MCS type, and procedural outcomes.
- Statistical analysis, including multivariable comparisons, was performed to assess outcomes.
Main Results:
- MCS was utilized in 4.5% of CTO PCIs, predominantly prophylactically (78.7%).
- Prophylactic MCS was associated with similar technical success but lower procedural success and higher periprocedural major adverse cardiac events compared to no MCS.
- Urgent MCS use resulted in significantly lower technical and procedural success rates and higher major adverse cardiac events.
Conclusions:
- Mechanical circulatory support is infrequently used in CTO PCI, with a majority of cases being prophylactic.
- Elective MCS use in CTO PCI does not compromise technical success but increases complication risks.
- Urgent MCS deployment in CTO PCI is associated with poor procedural outcomes and increased adverse events, highlighting the need for careful patient selection and management.
Abstract:
The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p <0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p <0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p <0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p <0.001) and procedural (39% vs 86%, p <0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p <0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates.
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