Long-Term Follow-Up of Elective Chronic Total Coronary Occlusion Angioplasty

Analysis From the U.K. Central Cardiac Audit Database

In a recent issue of the Journal, George et al. (1) conducted a multicenter registry study on 13,443 patients and found that, during a mean follow-up of 2.6 years, percutaneous revascularization of chronic total occlusions (CTO) was associated with improved long-term survival.

As correctly highlighted in the study limitation section and in the accompanying editorial by Mahmud (2), there were numerous potential biases with this retrospective observational analysis. For example, patients with “unsuccessful” CTO were older and had higher prevalence of other clinical risk factors, already known to adversely affect prognosis.

Notwithstanding, the authors performed additional secondary analysis and found that complete revascularization (defined as post-procedural obstruction of <50% in all major epicardial coronary arteries) conferred the best mortality outcome.

Given that we believe the labels in the central illustration graph have been erroneously inverted (patients undergoing successful CTO with/without complete revascularization have higher cumulative mortality?), in any case, these results deserve further attention.

Indeed, despite statistical issues and the controversial definition of complete revascularization, mortality data of the complete revascularization group (CTO and other major vessels) were quite similar to those of patients undergoing partial revascularization (only CTO), and completely overlapped at 2.5 years. In fact, these results are in line with previous large randomized trials, showing no clear death or myocardial infarction benefit from an initial strategy of revascularization (3). In conclusion, in our opinion, it appears premature to conclude that “the improvement was greatest in patients when complete revascularization was achieved.”

• 2014 American College of Cardiology Foundation