Left Ventricular Mechanics in Multivessel Coronary Artery Disease with Versus Without Chronic Total Occlusion

Chronic total coronary occlusion (CTO) occurs within advanced coronary artery disease (CAD), but its association with left ventricular (LV) deformation and pressure-strain-loop-derived myocardial work beyond global LV ejection fraction (LVEF) is uncertain. We performed a retrospective cross-sectional analysis of 148 unique patients with multivessel or left-main CAD, including 70 with and 78 without CTO. Absolute global longitudinal strain (GLS) was the principal endpoint; global work index (GWI), constructive work (GCW), wasted work (GWW), and work efficiency (GWE) were secondary endpoints. Sequential CTO coefficients were estimated using HC3 heteroscedasticity-consistent linear models in a pool of patients with complete global mechanics and LVEF data. A history of myocardial infarction was more frequent with CTO (42.9% vs. 23.1%), with lower LVEF and larger LV volumes. In crude distributional comparisons among 136 patients with global mechanics data, median GLS was 14.0% versus 15.5% (p = 0.021), while median GCW was 1723 versus 1997 mmHg% (p = 0.026). In the multivariable regression analysis, the CTO-minus-non-CTO GLS coefficient was -1.40 percentage points (95% CI, -2.80 to 0.00) unadjusted, -1.10 (95% CI, -2.58 to 0.38) after clinical adjustment, and -0.16 (95% CI, -1.24 to 0.92) after adding LVEF. CTO status marked a modest adverse global LV mechanical phenotype, but clinically adjusted estimates were imprecise and markedly attenuated after accounting for LVEF. Prospective studies integrating ischemia, scar, viability, and longitudinal follow-up are needed.