Author + information
- Cosmo Godino1,
- Luca Baldetti2,
- Alessia Giannattasio3,
- Andrea Munafò3,
- Carlo Andrea Pivato1,
- Andrea Scotti4,
- Alessandro Beneduce3,
- Giulia Perfetti1,
- Alberto Cappelletti5,
- Valeria Magni1,
- Mauro Carlino1,
- Alberto Margonato1 and
- Antonio Colombo6
- 1San Raffaele Scientific Institute, Milan, Milan, Italy
- 2IRCCS San Raffaele Hospital, Milan, Milan, Italy
- 3Cardiothoracic Vascular Department, San Raffaele Scientific Institute, Milan, Milan, Italy
- 4Cardiothoracic Vascular Department, San Raffaele Scientific Institute, Milano, Milan, Italy
- 5IRCCS San Raffaele Institute, Milan, Milan, Italy
- 6Interventional Cardiology Institute San Raffaele Hospital - Stamford Hospital - Columbia University - Centro Cuore Columbus, Milan, Milan, Italy
Chronic total occlusions (CTOs) are associated with angina, ischemia, myocardial dysfunction, arrhythmias and poor outcomes. Whether CTO revascularization could effectively translate in lower mortality is still matter of debate. Aim of this study was to assess whether CTO recanalization could improve mortality outcomes at a very long term follow-up of 10 years.
Between 1998-2008 we collected data of 912 patients undergoing coronary angiography (CA) due to angina/proof of ischemia. Patients showing at least one CTO and in whom an attempt of recanalization was pursued at the index CA were included in this study. The cohort was divided in “revascularized” (n=585) or “not revascularized” (n=327) according to successful CTO recanalization. Moreover, patients were included only if a 5-year follow-up was available. Follow-up was censored at last visit or at 10 years. Endpoints were overall mortality, cardiac mortality (due to heart failure, ACS, arrhythmia), sudden/aborted death (appropriate shock in those bearing an ICD).
Baseline clinical characteristics were similar. However, “non revascularized” tended to be older (64.8±10.2 vs 61.5±10.1 years; p<0.01), had a lower ejection fraction (LVEF) (50.4±11.4 vs 53.4±10.0%; p<0.01) and more frequently presented with unstable angina (20.7 vs 14.7%; p=0.02). At CA, “non revascularized” often had complex CAD with more than one CTO (12.8 vs 7.4%; p=0.01), blunt stump CTO (48.6 vs 27.5%; p <0.01) and less bridging collaterals (34.2 vs 47.4%; p<0.01). Righ coronary artery was more involved (43.4 vs 36.6%; p=0.04). “Revascularized” patients more frequently presented with single vessel CAD (23.9 vs 15.9%; p=0.03), often involving LAD artery (32.0 vs 22.3%; p=0.02). Median follow-up was 9.8 years (IQR 5.9-12.1). A total of 113 and 116 deaths occurred in the “revascularized” and in the “non revascularized” groups, respectively: overall mortality was significantly lower in the “revascularized” group (19.3 vs 35.5%; p<0.001; RR 0.46; 95%CI 0.36-0.56). A total of 45 and 58 cardiac and of 14 and 21 sudden deaths occurred in the “revascularized” and in the “non revascularized” groups, respectively. Cardiac mortality (7.7 vs 17.7%; p<0.001; RR 0.38; 95%CI: 0.26-0.56) and arrhythmic mortality (2.4 vs 6.4%; p=0.001; RR 0.31; 95%CI 0.16-0.62) were significantly lower in the “revascularized” group. At Cox regression, age (HR 1.08; 95%CI 1.06-1.09; p<0.001), LVEF (HR 0.97; 95%CI 0.96-0.98; p<0.001) and CTO non-recanalization (RR 1.72; 95%CI 1.32-2.24; p<0.001) were found powerful predictors of all cause death. The same variables predicted cardiac mortality with similar relative risks: age (HR 1.08; 95%CI 1.06-1.10; p <0.001), LVEF (HR 0.96; 95%CI 0.95-0.98; p<0.001) and CTO non-recanalization (RR 2.02; 95%CI 1.36-3.00; p<0.001). Age (HR 1.08; 95%CI 1.04-1.12; p<0.001), LVEF (HR 0.95; 95%CI 0.92-0.97; p<0.001) and CTO non-recanalization (RR 2.43; 95% CI 1.22-4.83; p=0.01) also predicted sudden/aborted death.
This study demonstrates how, at a very long-term follow-up of 10 years, CTO recanalization improved outcomes, reducing overall, cardiac and arrhythmic mortality. A non-revascularized CTO confers a 2-fold increase risk of subsequent cardiovascular mortality and 3-fold risk of sudden death.
CORONARY: PCI Outcomes