Author + information
- Luca Baldetti1,
- Cosmo Godino2,
- Alessia Giannattasio3,
- Andrea Munafò3,
- Carlo Andrea Pivato2,
- Andrea Scotti4,
- Alessandro Beneduce3,
- Giulia Perfetti2,
- Alberto Cappelletti5,
- Valeria Magni2,
- Mauro Carlino2,
- Alberto Margonato2 and
- Antonio Colombo6
- 1IRCCS San Raffaele Hospital, Milan, Milan, Italy
- 2San Raffaele Scientific Institute, 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 left ventricular systolic dysfunction due to ischemia, myocardial hibernation and scar. Aim of this study was to assess whether CTO recanalization could reduce cardiac and arrhythmic mortality outcomes at a very long term follow-up at varying degrees of systolic dysfunction.
Between 1998-2008 we collected data of 912 patients undergoing coronary angiography (CA) due to angina/proof of ischemia. Those showing at least one CTO and in whom an attempt of recanalization was pursued at the index CA were included in this study. They were divided in “revascularized” or “not revascularized” according to successful CTO recanalization and in “mid range-normal EF” (n=802) or “low EF” (n=110) whether EF was higher/equal to or lower than 40%. Follow-up was censored at last visit or at 10 years (minimum 5 years). Endpoints were cardiac mortality (due to heart failure, ACS, arrhythmia) and sudden/aborted death.
Patients in the non revascularized arm (n=271) of the “mid range-normal EF” were older (64.0±10.1 vs 61.0±10.1 years; p<0.01), more frequently showed complex CAD with more than one CTO (12.9 vs 7.7%; p=0.02), three-vessel CAD (44.7 vs 36.4%; p=0.02) and blunt stump CTO (48.7 vs 27.3%; p<0.01) vs those revascularized (n=531). Revascularized patients more frequently presented with single vessel disease (24.8 vs 18.0%; p=0.03). “Low EF” non revascularized patients (n=56) had more blunt stump CTO (48.2 vs 29.6%; p=0.04) vs those revascularized (n=54) that often had a single vessel disease (15.1 vs 3.6%; p=0.04) mostly involving LAD artery (48.1 vs 16.1%; p<0.01). Median follow-up was 9.8 years (IQR 5.9-12.1). In the “mid range-normal EF”, a total of 37 and 34 (7.0 vs 12.5%; p=0.005; RR 0.50; 95%CI 0.32-0.80) cardiac deaths and 10 and 11 (2.1 vs 5.5%; p=0.04; RR 0.41; 95%CI 0.17-0.96) sudden/aborted deaths occurred in the revascularized vs the non revascularized arm. In the “low EF”, a total of 8 and 24 (14.8 vs 42.8%; p<0.001; RR 0.26; 95%CI 0.12-0.59) cardiac deaths and a total of 4 and 10 (7.4% vs 17.9%; p=0.02; RR 0.28; 95%CI 0.09-0.90) sudden or aborted deaths occurred in the revascularized vs the non revascularized arm. Thus, cardiac and arrhythmic mortality were lower in the revascularized arm in both EF groups, but more markedly in the low EF group.
At a follow-up of 10 years, CTO recanalization was associated with lower rates of cardiac and arrhythmic mortality. This was particularly evident with severely reduced LVEF, where a non-revascularized CTO conferred a significant risk of subsequent cardiac (and especially arrhythmic) death.
CORONARY: PCI Outcomes