Procedural outcomes of chronic total occlusion percutaneous coronary interventions in patients with acute kidney injury.

BACKGROUND: The prognostic impact of contrast-associated acute kidney injury (CA-AKI) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains underestimated. METHODS: We examined 2707 consecutive procedures performed in a referral CTO center between 2015 and 2019. CA-AKI was defined as an increase in serum creatinine ≥ 0.3 mg/dL or ≥ 50% within 48 h post-PCI. Primary endpoints were in-hospital major adverse cardiac and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, target vessel revascularization, stroke) and at one year of follow-up. RESULTS: The overall incidence of CA-AKI was 11.5%. Technical success was comparable (87.2% vs. 90.5%, p = 0.056) whereas procedural success was lower in the CA-AKI group (84.3% vs. 89.7%, p = 0.004). Overall in-hospital MACCE was 1.3%, and it was similar in patients with and without CA-AKI (1.6% vs. 1.3%, p = 0.655); however, the rate of pericardial tamponade requiring pericardiocentesis was significantly higher in patients with CA-AKI (2.2% vs. 0.5%, p = 0.001). In multivariate analysis, CA-AKI was not independently associated with higher risk for in-hospital MACCE (adjusted odds ratio [OR] 1.34, 95% confidence intervals [CI] 0.45-3.19, p = 0.563). At a median follow-up time of 14 months (interquartile range [IQR], 11 to 35 months), one-year MACCE was significantly higher in patients with vs. without CA-AKI (20.8% vs. 12.8%, p < 0.001), and CA-AKI increased the risk for one-year MACCE (adjusted hazard ratio [HR] 1.46, 95% CI 1.07-1.95, p = 0.017) following CTO PCI. CONCLUSIONS: CA-AKI in patients undergoing CTO PCI occurs in approximately one out of 10 patients. Our study highlights that patients developing CA-AKI are at increased risk for long-term MACCE.

Association of Prolonged Fluoroscopy Time with Procedural Success of Percutaneous Coronary Intervention for Stable Coronary Artery Disease with and without Chronic Total Occlusion.

BACKGROUND: In percutaneous coronary interventions (PCI), the impact of prolonged fluoroscopy time (FT) on procedural outcomes is poorly studied. METHODS AND RESULTS: We analyzed the outcomes of 12,538 consecutive elective PCIs. The primary endpoint was procedure failure (PF), the composite of technical failure, and adverse in-hospital events including all-cause death, myocardial infarction, stroke, and target vessel revascularization (MACCE), as well as pericardial tamponade. We stratified the procedures as PCI for chronic total occlusion (CTO, n = 2720) and PCI for non-CTO (n = 9818). Logistic regression demonstrated a significant association between fluoroscopy time and procedural failure with a significant interaction with PCI type (both p < 0.001). The odds ratios (OR) of procedural failure for a 10-min increment in FT were 1.15 (confidence interval (CI) 95% 1.12-1.18, p < 0.001) in non-CTO PCI and 1.05 (CI 95% 1.03-1.06, p < 0.001) in CTO PCI. The optimal cut-point for prediction of PF was 21.1 min in non-CTO PCI (procedural success in 98.4% versus 95.3%, adjusted OR for PF 2.79 (CI 95% 1.93-4.04), p < 0.001) and 41 min in CTO PCI (procedural success in 92.3% versus 83.8%, adjusted OR for PF 2.18 (CI 95% 1.64-2.94), p < 0.001). In CTO PCI, the increase in PF with FT was largely driven by technical failure (adjusted OR 2.25 (CI 95% 1.65-3.10), p < 0.001), whereas in non-CTO PCI, it was driven by major complications (adjusted OR 2.94 (CI 95% 1.93-4.53), p < 0.001). CONCLUSIONS: Prolonged FT is strongly associated with procedural failure in both non-CTO and CTO PCI. In CTO PCI, this relation is shifted towards longer FT. The mechanisms of procedural failure differ between CTO and non-CTO PCI.

A Contemporary Definition of Periprocedural Myocardial Injury After Percutaneous Coronary Intervention of Chronic Total Occlusions.

OBJECTIVES: The aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality. BACKGROUND: Coronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes. METHODS: A total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint. RESULTS: Using spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment. CONCLUSIONS: This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population.

Derivation and Validation of a Chronic Total Coronary Occlusion Intervention Procedural Success Score From the 20,000-Patient EuroCTO Registry: The EuroCTO (CASTLE) Score.

OBJECTIVES: The aim was to establish a contemporary scoring system to predict the outcome of chronic total occlusion coronary angioplasty. BACKGROUND: Interventional treatment of chronic total coronary occlusions (CTOs) is a developing subspecialty. Predictors of technical success or failure have been derived from datasets of modest size. A robust scoring tool could facilitate case selection and inform decision making. METHODS: The study analyzed data from the EuroCTO registry. This prospective database was set up in 2008 and includes >20,000 cases submitted by CTO expert operators (>50 cases/year). Derivation (n = 14,882) and validation (n = 5,745) datasets were created to develop a risk score for predicting technical failure. RESULTS: There were 14,882 patients in the derivation dataset (with 2,356 [15.5%] failures) and 5,745 in the validation dataset (with 703 [12.2%] failures). A total of 20.2% of cases were done retrogradely, and dissection re-entry was performed in 9.3% of cases. We identified 6 predictors of technical failure, collectively forming the CASTLE score (Coronary artery bypass graft history, Age (≥70 years), Stump anatomy [blunt or invisible], Tortuosity degree [severe or unseen], Length of occlusion [≥20 mm], and Extent of calcification [severe]). When each parameter was assigned a value of 1, technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score ≥4. The area under the curve (AUC) was similar in both the derivation (AUC: 0.66) and validation (AUC: 0.68) datasets. CONCLUSIONS: The EuroCTO (CASTLE) score is derived from the largest database of CTO cases to date and offers a useful tool for predicting procedural outcome.

Temporal changes in outcomes of women and men undergoing percutaneous coronary intervention for chronic total occlusion: 2005-2013.

OBJECTIVE: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has undergone impressive progress during the last decade, both in strategies and equipment. It is unknown whether technical refinement has translated into improved outcomes in women undergoing CTO-PCI. METHOD AND RESULTS: A total of 2002 consecutive patients (17% females, mean age 65.2 ± 10.7 years) undergoing PCI of at least one CTO lesion at our center between 01/2005 and 12/2013 were evaluated. The incidence of adverse events was compared between two time series (2005-2009 and 2010-2013). A significant increase in adverse lesion characteristics over time was noted in both, women and men (p < 0.001), while technical success rates significantly increased in men but not in women (ptrend < 0.001 in men and ptrend=0.9 in women). The incidence of procedural complications was significantly higher in women as compared to men and increased over the study period in women (p < 0.05) but not in men. Accordingly, multivariate logistic regression analysis identified female sex as a strong predictor of PCI-related complications in recent years, while this was not the case in earlier years (adjusted HR 2.03, 95% CI 0.62-6.6, p = 0.2 and adjusted HR 4.7, 95% CI 1.8-12.3, p = 0.002, respectively, p < 0.001 for log LH ratio). In addition, major adverse cardiovascular events (MACE) after a 3-year follow-up significantly declined in men (log rank = 0.046), while no changes were observed in women. CONCLUSION: While higher success rates and a reduced rate of MACE have been achieved in men, the incidence of procedural complications in women undergoing CTO-PCI has increased over time.

Clinical implications of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention for chronic total occlusion: role of antegrade and retrograde crossing techniques.

AIMS: Periprocedural myocardial injury (PMI) is frequently observed after percutaneous coronary interventions (PCI) for chronic total occlusion (CTO). We aimed to investigate the prognostic impact of PMI with the antegrade as compared to the retrograde crossing technique. METHODS AND RESULTS: A total of 1,909 patients undergoing CTO PCI were stratified according to the presence/absence of PMI (elevation of cardiac troponin T [cTnT] >5x99th percentile of normal), and divided according to tertiles of the difference between peak and baseline cTnT within 24 hours (∆cTnT). The primary endpoint was all-cause mortality at a median follow-up of 3.1 (interquartile range 3.0-4.4) years. PMI occurred in 19.4% and 25.4% after antegrade (n=1,447) and retrograde (n=462) procedures (p<0.001). PMI was significantly associated with mortality after antegrade (adjusted HR 1.39, 95% CI: 1.02-1.88, p=0.04), but not retrograde CTO PCI (adjusted HR 0.93, 95% CI: 0.53-1.63, p=0.80, pint=0.02). With the antegrade, but not with the retrograde approach, mortality also increased with tertiles of ∆cTnT (T1: 11.0%, T2: 18.6%, T3: 21.6%, log-rank p<0.001). CONCLUSIONS: Periprocedural myocardial injury was significantly associated with all-cause mortality following antegrade, but not retrograde CTO PCI. Hence, the higher risk of PMI following retrograde procedures did not translate into worse survival.

Coronary dominance and prognosis in patients with chronic total occlusion treated with percutaneous coronary intervention.

AIM: The prognostic value of coronary artery dominance pattern in patients with chronic total occlusions (CTO) is unknown. The aim of this study was to assess the influence of coronary vessel dominance on short and long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for CTO. METHODS AND RESULTS: Our study population consisted of 2002 consecutive patients (17% females, mean age 65.2 ± 10.7 years) who underwent PCI of at least one coronary CTO lesion at our center between 01/2005 and 12/2013. Based on the origin of the posterior descending coronary artery, coronary circulation was categorised into left, right, and balanced coronary dominance. Right coronary dominance (RD) was present in 88% (n = 1759), left coronary dominance (LD) in 7% (n = 136), and balanced coronary dominance (BD) in 5% (n = 107) of the study population. After a median follow-up duration of 2.6 years [interquartile range 1.1-3.1 years] all-cause mortality was significantly higher in patients with LD as compared with RD and BD (log rank = 0.001). Accordingly, the presence of a LD system was identified as a significant predictor for all-cause mortality (adjusted HR 1.7, 95% CI: 1.2-2.6, P = .007) and major adverse cardiac events (MACE) (adjusted HR 1.4, 95% CI: 1.1-1.8, P = 0.02). CONCLUSION: Our data suggest that LD is an independent predictor of increased all-cause death and MACE in patients with CTO. Therefore, assessment of coronary vessel dominance by angiography may contribute to risk stratification in these patients.

Impact of anemia on long-term outcomes after percutaneous coronary intervention for chronic total occlusion.

OBJECTIVES: A single-centre, observational study was performed in order to investigate the relationship between anemia and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). BACKGROUND: Anemia has been identified as adverse predictor in patients with coronary artery disease undergoing coronary revascularization. Data on the impact of anemia on outcomes in patients undergoing PCI for CTO lesions are lacking. METHODS: A total of 1,964 patients undergoing CTO PCI were stratified according to the presence/absence of anemia (hemoglobin of <13 g/dl for men and <12 g/dl for women). The primary endpoint was all-cause mortality. Median follow-up was 2.6 (interquartile range 1.1-3.1) years. RESULTS: Of the 1,964 patients, 297 (15.1%) had anemia. Anemic as compared to nonanemic patients had and an increased all-cause mortality (27.9% versus 9.1%, P < 0.001), and associations remained significant after multivariable adjustments (adjusted HR 2.26, 95% CI 1.71-2.98, P < 0.001). All-cause mortality decreased with increasing hemoglobin tertiles (T1: 18.6%, T2: 8.6%, T3: 8.2%, log rank P < 0.001). Procedural success was associated with reduced all-cause mortality both in anemic (21.8% versus 47.2%, adjusted HR 0.59, 95% CI 0.37-0.93, P = 0.02) and nonanemic patients (7.8% versus 16.3%, adjusted HR 0.64, 95% CI 0.42-0.98, P = 0.02, interaction P = 0.69). CONCLUSIONS: Although anemia is associated with an increased all-cause mortality in patients undergoing CTO PCI, the survival benefit associated with successful CTO recanalization is maintained.

Outcomes after percutaneous coronary intervention for chronic total occlusion according to baseline renal function.

BACKGROUND: Chronic kidney disease (CKD) adversely affects outcomes in patients with coronary artery disease. Data on the impact of renal impairment on prognosis of patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) are scarce. METHODS: A total of 2002 patients undergoing CTO PCI were stratified according to baseline renal function (group 1: estimated glomerular filtration rate [eGFR] ≥ 90 ml/min/1.73 m2, group 2: 60 to 89 ml/min/1.73 m2, group 3: 30 to 59 ml/min/1.73 m2, and group 4: <30 ml/min/1.73 m2). The primary outcome measure was all-cause mortality at a median follow-up of 2.6 (interquartile range 1.1-3.1) years. RESULTS: All-cause mortality increased with decreasing renal function (group 1: 5.0%, group 2: 9.5%, group 3: 26.4%, and group 4: 38.7%, log rank p < 0.001). Continuous eGFR values were significantly related with all-cause mortality (adjusted HR 0.98, 95% CI 0.98-0.99, p < 0.001). Procedural failure was associated with all-cause mortality both in patients with an eGFR < 60 ml/min/1.73 m2 (42.6 vs. 23.7%, adjusted HR 1.59, 95% CI 1.08-2.32, p = 0.02) and in those with an eGFR ≥ 60 ml/min/1.73 m2 (14.6 vs. 6.5%, adjusted HR 1.73, 95% CI 1.15-2.60, p = 0.009, interaction p = 0.47). CONCLUSIONS: Although renal impairment is associated with all-cause mortality in patients undergoing CTO PCI, successful CTO recanalization is related to improved survival irrespective of renal function.

Comparison of Benefit of Successful Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients With Versus Without Reduced (≤40%) Left Ventricular Ejection Fraction.

Successful recanalization of chronic total occlusions (CTO) has been associated with improved survival. Data on outcomes in patients with left ventricular (LV) systolic dysfunction undergoing percutaneous coronary intervention for CTO, however, are scarce. Between January 2005 and December 2013, a total of 2,002 consecutive patients undergoing elective CTO percutaneous coronary intervention at a tertiary care center were divided into patients with (LV ejection fraction ≤ 40%) and without (LV ejection fraction > 40%) LV systolic dysfunction as defined by transthoracic echocardiography. The primary end point was all-cause mortality. Median follow-up was 2.6 (1.1 to 3.1) years. A total of 348 (17.4%) patients had LV dysfunction. All-cause mortality was higher in patients with LV dysfunction (30.2%) than in those with normal LV function (8.2%, p <0.001), and associations remained significant after adjustment for baseline differences (adjusted hazard ratio [HR] 3.39, 95% confidence interval [CI] 2.57 to 4.47, p <0.001). Successful CTO recanalization was independently associated with reduced all-cause mortality, with similar relative risk reductions in both the preserved (6.6% vs 16.9%, adjusted HR 0.48, 95% CI 0.34 to 0.70, p <0.001) and the reduced LV function groups (26.2% vs 45.2%, adjusted HR 0.63, 95% CI 0.41 to 0.98, p = 0.04, interaction p = 0.28). In conclusion, irrespective of LV function, successful CTO recanalization is associated with a clear survival benefit.

Outcomes of patients with periprocedural atrial fibrillation undergoing percutaneous coronary intervention for chronic total occlusion.

BACKGROUND: Successful CTO recanalization has been associated with clinical benefit. Outcomes of patients with atrial fibrillation undergoing CTO PCI have not been investigated, yet. AIMS: This study sought to evaluate the association between atrial fibrillation and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). METHODS: Consecutive patients undergoing CTO PCI between January 2005 and December 2013 were divided into patients with and without atrial fibrillation, and propensity-matched models used to adjust for baseline differences between groups. The primary outcome was all-cause mortality at a median follow-up of 3.2 (interquartile range 3.1-4.5) years. RESULTS: Of 2002 patients undergoing CTO PCI, atrial fibrillation was present in 169 (8.4%) patients. Patients with atrial fibrillation were older, and more frequently had hypertension, left ventricular systolic dysfunction, and chronic kidney disease. Before matching, all-cause mortality was 39.6 and 14.5% in the atrial fibrillation and the sinus rhythm groups (HR 2.92, 95% CI 2.23-3.82, p < 0.001). In the propensity-matched model, atrial fibrillation remained associated with an increased risk of mortality (HR 1.62, 95% CI 1.06-2.47, p = 0.03). In the unmatched patient cohort, all-cause mortality was significantly reduced in patients with procedural success, both in the atrial fibrillation (34.9 versus 55.0%, adjusted HR 0.99, 95% CI 0.97-1.00, p = 0.02) and the sinus rhythm groups (12.8 versus 23.0%, adjusted HR 0.70, 95% CI 0.53-0.92, p = 0.01). CONCLUSIONS: Although atrial fibrillation is independently associated with mortality after CTO PCI, substantial survival benefit of successful CTO recanalization is observed in both patients with and without atrial fibrillation.

Comparison of Outcomes in Men Versus Women After Percutaneous Coronary Intervention for Chronic Total Occlusion.

Conflicting evidence exists on gender differences in outcomes after coronary stenting, and gender-based data in patients with chronic total occlusions (CTO) who underwent percutaneous coronary intervention (PCI) are scarce. Consecutive patients who underwent CTO PCI from January 2005 to December 2013 were included in the analysis and stratified according to gender. The primary outcome measure was all-cause mortality. Median follow-up was 2.6 years (interquartile range 1.1 to 3.1). Of 2002 patients, 332 (17%) were women. Procedural success was achieved in 82% and 83% of women and men (p = 0.31). All-cause mortality was 15% and 11% in women and men (log-rank p = 0.17) with an adjusted hazard ratio of 0.85 (95% confidence interval [CI] 0.61 to 1.17, p = 0.31). All-cause mortality was significantly reduced in patients with procedural success, both in women (12% vs 32%, adjusted hazard ratio 0.44, 95% CI 0.24 to 0.79, p = 0.006) and men (9% vs 21%, adjusted hazard ratio 0.64, 95% CI 0.47 to 0.88, p = 0.006), with similar mortality benefits associated with successful revascularization in both groups (interaction p = 0.35). In conclusion, recanalization of coronary arterial CTO is equally successful in both women and men.

Impact of multi-vessel versus single-vessel disease on outcomes after percutaneous coronary interventions for chronic total occlusions.

BACKGROUND: Successful chronic total occlusion (CTO) revascularization has been associated with prognostic benefits. Whether the extent of coronary artery disease interferes with these benefits has not been investigated yet. AIMS: We sought to compare the survival after percutaneous coronary intervention (PCI) for CTO between patients with multi- (MVD) and single-vessel disease (SVD). METHODS: A total of 2002 consecutive patients undergoing CTO PCI between 01/2005 and 12/2013 were identified and stratified according to the presence/absence of MVD. The primary endpoint was all-cause mortality. Median follow-up was 2.6 (interquartile range 1.1-3.1) years. RESULTS: A total of 1634 (81.6%) patients had MVD. Procedural success rates were 81.5 and 89.7% in the MVD and SVD groups (p < 0.001). All-cause mortality during entire follow-up was higher in MVD as compared to SVD patients (13.5 versus 5.7%, p < 0.001), and differences were attenuated after multivariable adjustment for baseline characteristics [adjusted hazard ratio (HR) 1.51, 95% CI 0.98-2.33, p = 0.06]. The effect of successful CTO PCI on all-cause mortality was consistent among patients with MVD [11.0 versus 24.5%; adjusted HR 0.60, 95% CI 0.45-0.80, p < 0.001] and SVD [5.2 versus 10.5%; adjusted HR 0.74, 95% CI 0.24-2.26, p = 0.59, P int = 0.65]. However, due to the greater baseline risk in the former group, the absolute survival benefit after successful CTO PCI was higher. CONCLUSIONS: Successful recanalization of a CTO is a strong independent predictor for reduced long-term mortality. Due a higher baseline risk, the absolute benefit in patients with MVD is substantially larger than in patients with SVD.

Course of early subclinical leaflet thrombosis after transcatheter aortic valve implantation with or without oral anticoagulation.

BACKGROUND: After transcatheter aortic valve implantation, early leaflet thickening, presumably reflecting thrombus, has recently been described on computed tomography angiography (CTA) in ~10% of the patients. We sought to investigate the impact of the antithrombotic regimen on the course of leaflet thickening. METHODS: The study comprised 51 patients with leaflet thickening. Based on the time period, patients without an established indication for anticoagulation were put on phenprocoumon plus clopidogrel for at least 3 months or on dual antiplatelet therapy with aspirin and clopidogrel. Follow-up CTAs were evaluated for leaflet restriction, assessed by four-point-grading score, and maximal thickness. FINDINGS: The anticoagulation and the dual antiplatelet therapy group comprised 29 and 22 patients, respectively. After a median of 86 days, we obtained follow-up CTAs in 22 patients on anticoagulation and in 16 patients on dual antiplatelet therapy. Leaflet thickening progressed in 11 on dual antiplatelet therapy, but always regressed onanticoagulation. The course of leaflet restriction and maximal thickness was significantly different between the two groups (P < 0.001): in the dual antiplatelet therapy group, maximal thickness increased by a mean of 1.37 ± 1.67 mm (P = 0.005) and leaflet restriction score by a median 1[quartiles 0;2] (P = 0.013), whereas in the anticoagulation group, maximal thickness regressed by 2.57 ± 1.52 mm (P < 0.001) and leaflet restriction score decreased by 1[-4;0] (P = 0.001). After a median of 91 days after discontinuation of anticoagulation, CTA performed in ten patients revealed a significant recurrent increase in leaflet restriction score and maximal thickness (P = 0.023, P = 0.007). In the entire cohort, changes in leaflet restriction correlated significantly with changes in transvalvular pressure gradients (r = 0.511, P < 0.001). INTERPRETATION: The course of leaflet restriction was fundamentally different depending on the presence or absence of anticoagulation, with consistent regression under phenprocoumon, but mostly progression under antiplatelet therapy alone. Changes in leaflet restriction were associated with changes in transvalvular pressure gradients.

Survival after percutaneous coronary intervention for chronic total occlusion in elderly patients.

AIMS: Few data are available on outcomes of percutaneous coronary intervention (PCI) for coronary chronic total occlusions (CTO) in very elderly patients in the drug-eluting stent (DES) era. We aimed to investigate long-term survival in a single-centre cohort of elderly patients following CTO PCI using DES. METHODS AND RESULTS: A total of 2,002 consecutive patients who underwent PCI of a CTO at our centre between January 2005 and December 2013 were followed for a median of 2.6 years (interquartile range 1.1-3.1 years). Four hundred and nine (409) patients were older than 75 years. The absolute reduction in all-cause mortality by successful CTO PCI was numerically greater in elderly patients as compared to younger patients (22.1% vs. 7.2% at three years). In multivariate models, successful CTO PCI was significantly associated with improved survival in both elderly (adjusted hazard ratio [HR] 0.58, 95% confidence interval [CI]: 0.39 to 0.87; p=0.009) and younger patients (adjusted HR 0.59, 95% CI: 0.40 to 0.86; p=0.006). CONCLUSIONS: In the DES era, elderly patients (≥75 years) derive a similar survival benefit from successful CTO PCI to younger patients. These findings suggest that CTO PCI, when indicated, should not be withheld from the elderly.

Long-Term Follow-Up of Patients With Previous Coronary Artery Bypass Grafting Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion.

Successful revascularization of chronic total occlusions (CTOs) has been associated with clinical benefit. Data on outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention (PCI) for CTO, however, are scarce. A total of 2,002 consecutive patients undergoing PCI for CTO from January 2005 to December 2013 were divided into patients with and without previous CABG, and outcomes were retrospectively assessed. The primary outcome measure was all-cause mortality. Median follow-up was 2.6 years (interquartile range 1.1 to 3.1). A total of 292 patients (15%) had previous CABG; they were older and had a greater prevalence of comorbidities. Procedural success was achieved in 75% and 84% of patients in the previous CABG and the non-CABG groups (p <0.001), respectively. All-cause mortality was 16% and 11% in the previous CABG and the non-CABG groups (p = 0.002), and differences were mitigated after adjustment for baseline characteristics (adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.86 to 1.74, p = 0.27). All-cause death was significantly reduced in patients with procedural success, both in the previous CABG (11% vs 32%, adjusted HR 0.43, 95% CI 0.24 to 0.77, p = 0.005) and the non-CABG groups (10% vs 20%, adjusted HR 0.63, 95% CI 0.45 to 0.86, p = 0.004), with similar mortality benefits associated with successful revascularization in both groups (interaction p = 0.24). In conclusion, the relative survival benefit of successful recanalization of CTO is independent of previous CABG. However, owing to a greater baseline risk, the absolute survival benefit of successful CTO procedures is more pronounced in patients with previous CABG than in non-CABG patients.

Impact of body mass index on long-term mortality in women and men undergoing percutaneous coronary intervention for chronic total occlusion.

BACKGROUND: The obesity paradox has been described in different patient populations. Data on the relation between obesity and outcomes in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) are lacking. Therefore, long-term mortality in patients undergoing CTO PCI was assessed according to different body mass index (BMI) categories. METHODS: A total of 1993 patients undergoing CTO PCI at a tertiary care center between January 2005 and December 2013 were divided into five different BMI categories: underweight, <18.5kg/m2; normal BMI, 18.5-24.9kg/m2; overweight, 25.0-29.9kg/m2; obese, 30.0-34.9kg/m2; and very obese, ≥35.0kg/m2. The primary endpoint was all-cause mortality. RESULTS: Median follow-up was 2.6 (interquartile range 1.1-3.1) years. Of the 1993 patients, 461 (23.1%) were of normal weight, 985 (49.4%) overweight, 396 (19.9%) obese, and 144 (7.2%) very obese. Compared with normal weight BMI patients (16.3%), overweight patients had a lower all-cause mortality (10.2%, Log Rank p=0.001), while obese (11.1%, Log Rank p=0.08) and severely obese (13.2%, Log Rank p=0.39) patients had similar mortality rates. Being overweight was significantly associated with a lower all-cause mortality (HR 0.69, 95% CI 0.53-0.89, p=0.005), and associations remained significant after multivariable adjustments for confounding factors (HR 0.73, 95% CI 0.56-0.95, p=0.02). While being overweight was linked with a reduced all-cause mortality in men (HR 0.65, 95% CI 0.48-0.88, p=0.005), it was not in women (HR 1.25, 95% CI 0.60-2.52, p=0.58). CONCLUSIONS: Overweight is associated with an improved survival in patients undergoing PCI for CTO, particularly in men.

Survival after percutaneous coronary intervention for chronic total occlusion.

BACKGROUND: There is limited data on prognosis after percutaneous coronary intervention (PCI) for coronary chronic total occlusions (CTO) in the era of drug-eluting stents (DES). AIMS: This study investigates the specific contribution of CTO recanalization to the survival benefit of complete revascularization. METHODS: Consecutive patients who underwent PCI of a CTO at our center between 01/2005 and 12/2013 were followed for a median of 2.6 years (interquartile range 1.1-3.1 years). All-cause mortality was compared between patients with successful and failed PCI of CTO without and with adjustment for pertinent co-variables by the Cox models. RESULTS: The study comprised 2002 patients with attempted PCI of CTO (mean age 65.2 ± 11 years, 17 % female), 82 % had multivessel disease. The CTO PCI was successful in 1662 (83 %) patients with a DES rate of 94 %. All-cause mortality was significantly lower in patients with successful PCI of CTO compared to failed PCI of CTO (15.3 vs. 25.9 % at 4 years; P < 0.001). In the multivariable model, both successful CTO PCI and complete revascularization were strong independent predictors of reduced long-term mortality (adjusted hazard ratio (HR) 0.72; 95 % confidence interval (CI) 0.53-0.97; P = 0.03 and adjusted HR 0.59; 95 % CI 0.42-0.82; P = 0.002). Also within the subset of incomplete revascularization, successful PCI of CTO was associated with reduced mortality (adjusted HR: 0.67; 95 % CI: 0.50-0.92; P = 0.012). CONCLUSION: Successful CTO recanalization is an independent predictor for improved long-term survival. Persistent CTO lesions are associated with significantly worse survival than persistent non-occlusive coronary lesions.

Discordant cardiac biomarker levels independently predict outcome in ST-segment elevation myocardial infarction.

AIMS: To investigate the prognostic relevance of elevated Troponin T (cTnT) levels in patients with ST-segment elevation myocardial infarction (STEMI) without significant creatine kinase (CK) elevation on admission. METHODS AND RESULTS: From January 1, 2002 to December 31, 2006 patients with STEMI without significant CK elevation (<2-fold) on admission treated with percutaneous coronary intervention (PCI) were included and stratified according to cTnT plasma levels. Univariate and multivariate regression analyses were used to find independent predictors for mortality. During the 5-year period 514 patients with STEMI and normal CK plasma levels were included. 308 (59.9 %) patients had cTnT levels <0.1 µg/l and 206 (40.1 %) patients had cTnT levels ≥0.1 µg/l. Multivariate logistic regression analysis identified cTnT levels ≥0.1 µg/l and 3-vessel disease as positive, and hemoglobin levels as negative independent predictors for long-term mortality. Discordantly elevated cTnT plasma levels independently predicted higher mortality rates in the first year (HR 3.9, 95 % CI 1.7-9.1, p = 0.002) and during 5 years (HR 2.3, 95 % CI 1.4-3.9, p = 0.002) after PCI for STEMI. CONCLUSIONS: Discordant elevation of cTnT in the presence of normal CK plasma levels on admission is associated with increased mortality in STEMI patients undergoing primary PCI. This may be due to preceding microembolization.