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Coronary Chronic Total Occlusions Affect Long-Term Prognosis in Heart Failure With Mildly Reduced Ejection Fraction
Michael Behnes1, Moritz Schmidberger1, Kambis Mashayekhi2
1Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University Mannheim Germany.
Insights
Coronary chronic total occlusions (CTO) are prevalent in heart failure with mildly reduced ejection fraction (HFmrEF) and significantly increase mortality risk. Successful CTO percutaneous coronary intervention (PCI) improves long-term survival in these patients.
Area of Science:
- Cardiology
- Heart Failure Research
- Interventional Cardiology
Background:
- Coronary artery disease (CAD) is a primary cause of heart failure with mildly reduced ejection fraction (HFmrEF).
- Data on coronary chronic total occlusions (CTO) in HFmrEF patients are limited.
- CTO prevalence and its prognostic impact in HFmrEF require further investigation.
Purpose of the Study:
- To determine the prevalence of CTO in patients with HFmrEF.
- To assess the prognostic significance of CTO in HFmrEF regarding long-term mortality and adverse events.
- To evaluate the impact of percutaneous coronary intervention (PCI) for CTO on outcomes in HFmrEF.
Main Methods:
- Retrospective analysis of consecutive HFmrEF patients (LVEF 41%-49%) undergoing coronary angiography (2016-2022).
- Comparison of outcomes between patients with and without CTO.
- Risk stratification based on CAD extent and assessment of PCI outcomes.
Main Results:
- Coronary CTO was identified in 17% of HFmrEF patients undergoing angiography.
- CTO was associated with significantly higher rates of all-cause mortality (33% vs. 19%) and major adverse cardiac and cerebrovascular events (MACCE) (60% vs. 32%) at 30 months.
- Successful CTO-PCI correlated with improved long-term survival (21% vs. 38%).
Conclusions:
- Coronary CTO is a common finding in HFmrEF patients.
- CTO presence significantly worsens long-term prognosis in HFmrEF.
- PCI for CTO may offer survival benefits in this patient population.
Background:
This study investigates the prevalence and prognostic impact of coronary chronic total occlusions (CTO) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). Although coronary artery disease (CAD) represents the leading HF etiology in HFmrEF, data about CTO in this population are rare.
Methods:
All consecutive patients with HFmrEF (ie, left ventricular ejection fraction 41%-49% with signs and/or symptoms of heart failure) undergoing invasive coronary angiography from 2016 to 2022 were included retrospectively. Patients with at least one CTO were compared to patients without CTO, further risk stratification was performed according to the extend of CAD. The primary end point was long-term all-cause mortality at 30 months (ie, median follow-up). Secondary end points comprised of major adverse cardiac and cerebrovascular events (MACCE), HF-related and cardiac rehospitalization at 30 months. Furthermore, the association of percutaneous coronary intervention (PCI) with long-term outcomes was investigated.
Results:
71% of patients with HFmrEF (1545/2184, primary cohort) underwent invasive coronary angiography. In patients undergoing invasive coronary angiography related to the index hospitalization, CAD was present in 81% (836/1037, final cohort), with a corresponding rate of CTO at 17% (n=141). Coronary CTO was associated with the highest rate of the primary end point (33%) compared with non-CTO (19%), single-vessel (12%) and multivessel CAD (21%) in HFmrEF (P=0.001). Accordingly, HFmrEF patients with CTO had the highest rates of various secondary endpoints, including long-term MACCE compared to non-CTO patients (60% versus 32%, P=0.001). Successful CTO-PCI was associated with improved long-term survival (21% versus 38%; hazard ratio, 0.49 [95% CI, 0.24-0.99]; P=0.046).
Conclusions:
Coronary CTO are common in HFmrEF with a significant impact on long-term prognosis.
Registration:
URL: https://www.clinicaltrials.gov; unique identifier: NCT0560339.
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