Impact of Coronary Chronic Total Occlusion on Long-term Clinical Outcome in Patients with Unprotected Left Main Disease Undergoing Percutaneous Coronary Intervention

Objectives:Reported data regarding the prevalence,prognostic impact,and safety and efficacy of revascularization of coronary chronic total occlusion(CTO)in patients with left main coronary artery(LMCA)disease who undergo percutaneous coronary intervention(PCI)are scarce.The aim of the present study was to compare clinical outcomes among patients with LMCA disease undergoing PCI.Outcomes were compared between those with and without coronary CTO and between those with CTO who had successful and unsuccessful CTO recanalization procedures.Methods:All consecutive patients with significant LMCA disease(>50%stenosis at coronary angiography)who underwent PCI between July 2014 and December 2018 were retrospectively included in our study.The primary endpoint of the study was long-term mortality.Secondary endpoints included the incidence of myocardial infarction,repeat percutaneous or surgical revascularization,stroke,and stent thrombosis.Results:Between July 2014 and December 2018,578 patients underwent PCI for LMCA disease at Pederzoli Hospital and University of Turin were enrolled.They were divided into 3 groups:group A:374(65%)patients without CTO,group B:108(19%)patients with untreated or unsuccessfully treated CTO,and group C:96(17%)patients with successfully treated CTO.At a median follow-up of(1090±279)days,there were no statistically significant differences between the groups in terms of the primary and secondary endpoints.However,there was a trend towards higher mortality in patients with untreated or unsuccessfully treated CTO(13%vs.19%vs.14%in groups A,B,and C,respectively;P=0.12).The primary and secondary endpoints were further analyzed based on the presence or absence of myocardial viability:subgroup C1:54(56%)patients with successful percutaneous transluminal coronary angioplasty(PTCA)having viability,and subgroup C2:42(44%)patients with successful PTCA not having viability.There was a trend toward a statistically significant higher rate of death among patients in group B,who underwent unsuccessful recanalization with viable myocardium(19%vs.9%vs.19%in groups B,C1,and C2,respectively,P=0.05).On multivariable analysis,the propensity for successful revascularization of CTO was associated with a reduced risk of death(P=0.01;odds ratio,0.75;95%confidence interval:0.62-0.87).Conclusions:Among patients with LMCA disease undergoing PCI,CTO represents a common finding associated with worse prognosis.Successful revascularization of CTO in patients with viable myocardium appears to significantly improve prognosis.

Effects of Tirofiban and Nicorandil on Effective Reperfusion and the Levels of IL-4 and sICAM-1 After PCI for Chronic Coronary Total Occlusion

Aim:The effects of tirofiban combined with nicorandil on effective reperfusion,and the levels of interleukin-4(IL-4)and soluble intercellular adhesion molecule-1(sICAM-1)after percutaneous coronary intervention(PCI)for chronic coronary total occlusion(CTO)were investigated.Method:From January 1,2017,to June 31,2019,a total of 40 patients with CTO receiving PCI in Shandong Qian-foshan Hospital were randomly divided into a control group(treated with single tirofiban)and a cocktail group(treated with nicorandil combined with tirofiban).Effective reperfusion was compared between groups.In addition,differences in coronary serum IL-4 and sICAM-1 levels before and 10 min after the operation were compared between groups,and the incidence rates of adverse reactions were observed.Finally,patient follow-up occurred at 1 month and 6 months,and the total incidence rates of adverse cardiac events in both groups were assessed.Results:The levels of IL-4 and sICAM-1 in the cocktail group significantly decreased after the operation(P<0.05).In addition,after the operation,significantly greater decreases in the IL-4 and sICAM-1 levels were observed in the cocktail group than the control group(P<0.05).The Seattle Angina Scale(SAQ)score of the cocktail group,compared with the control group,showed a significant improvement after vessel opening in the patients with CTO.At the 1-month follow-up,the SAQ score of the cocktail group,compared with the control group,indicated further improvements in terms of angina attack frequency.No significant differences were observed in the incidence rates of adverse reactions between groups(P>0.05).Conclusion:The treatment of patients with CTO undergoing PCI with nicorandil and tirofiban alleviated the inflam-matory response,improved the SAQ scores,and decreased the occurrence of angina pectoris in patients.Moreover,this treatment is safe and reliable,and has important clinical significance.

Comparison of long-term clinical outcomes after percutaneous coronary intervention between in-stent restenosis and de novo chronic total occlusion

Background The occurrence of in-stent restenosis(ISR)coronary chronic total occlusion(CTO)is presently increasing. However,there were few data related to the long-term clinical outcomes after percutaneous coronary intervention(PCI)between ISR CTO and de novo CTO. Methods A total of 435 CTO patients who had attempted PCI between Jan 2013 and November 2017 were screened for inclusion in this study. The Kaplan-Meier method was applied to estimate event-free survival and the log-rank test to compare long-term outcome. Cox regression analysis was used to identify associations between adverse events and risk factors. Results There were84 ISR CTO cases and 351 de novo CTO cases in this study. Successful revascularization was achieved similar between ISR CTO group and de novo CTO group(84.5% vs. 87.2%,P=0.592). The prevalence of MACE[17.9% vs. 9.1%;hazard ratio(HR):2.323;95% confidence interval(CI)1.233-4.37;P=0.004]and TLR(8.3% vs. 3.4%;HR:2.627;95% CI 1.05-6.53;P<0.016)were higher in the ISR CTO group,during the 2-year follow-up. Conclusions The procedural success rate of ISR CTO achieved was comparable to that of de novo CTO in the contemporary practice. But the long-term clinical outcome was significantly worse in term of major adverse cardiac events and target lesion revascularization.

Clinical and angiographic features associated with coronary collateralization in stable angina patients with chronic total occlusion

Objective： Coronary collateral circulation is an alternative source of blood supply to myocardium in the presence of advanced coronary artery disease. We sought to determine which clinical and angiographic variables are associated with collateral development in patients with stable angina and chronic total coronary occlusion. Methods： Demographic variables, biochemical measurements, and angiographic findings were collected from 478 patients with stable angina and chronic total coronary occlusion. The presence and extent of collaterals supplying the distal aspect of a total coronary occlusion from the contra-lateral vessel were graded from 0 to 3 according to the Rentrop scoring system. Results： Low （Rentrop score of 0 or 1） and high （Rentrop score of 2 or 3） coronary collateralizations were detected in 186 and 292 patients, respectively. Despite similar age, cigarette smoking, and medical treatment, patients with low collateralization were female in a higher proportion and less hypertensive, and had higher rates of type 2 diabetes and dyslipidemia than those with high coUateralization （for all comparisons, P〈0.05）. In addition, patients with low collateralization exhibited more single-vessel disease, less right coronary artery occlusion, more impaired renal function, and higher serum levels of high-sensitivity C-reactive protein （hsCRP） compared with those with high col- lateralization. Multivariate analysis revealed that age of 〉65 years, female gender, diabetes, no history of hypertension dyslipidemia, moderate to severe renal dysfunction, single-vessel disease, and elevated hsCRP levels were inde- pendently associated with low coronary collateralization. Conclusions： Coronary collateralization was reduced in almost 40% of stable angina patients with chronic total occlusion, which was related to clinical and angiographic factors. The impact of coronary collateralization on outcomes after revascularization needs further investigation.