Successful CTO PCI may improve long-term survival

Successful chronic total occlusion PCI was associated with a reduction in mortality of nearly 30% in a large cohort of patients from the United Kingdom, according to results of a retrospective analysis.

Perspective from Emmanouil S. Brilakis, MD, PhD

The researchers suggested that in addition to relief of anginal symptoms, emerging data suggest that PCI for CTOs may be associated with a mortality benefit. The current analysis of UK Central Cardiac Audit Databases included data for patients who underwent CTO PCI in England and Wales between Jan. 1, 2005 and Dec. 31, 2009. The aim was to compare successful vs. unsuccessful CTO PCI in 13,443 patients who underwent 14,439 CTO procedures.

The success rate of CTO PCI in the cohort was 70.6% (10,199 cases).

The median follow-up duration was 2.65 years (interquartile range, 1.59-3.83).

Results indicated improvements in survival associated with successful PCI of at least one CTO (HR=0.72; 95% CI, 0.62-0.83).

Complete revascularization also improved survival when compared with partial revascularization (HR=0.70; 95% CI, 0.56-0.87) or failed revascularization (HR=0.61; 95% CI, 0.50-0.74).

“Although causation cannot be implied, successful intervention on a CTO was associated with improved long-term survival,” the researchers concluded, adding that patients may have much to gain from CTO PCI.

Ehtisham Mahmud, MD, of the division of cardiovascular medicine in the Sulpizio Cardiovascular Center at the University of California, San Diego, wrote in an accompanying editorial that there is a growing body of evidence supporting complete revascularization in multivessel CAD.

“A clinical implication of this study is that in the presence of multivessel CAD and a CTO, recanalization of the CTO should be attempted first,” Mahmud wrote. “If successful, complete percutaneous revascularization should then be performed. However, if CTO PCI is unsuccessful, such patients are likely better suited for complete surgical revascularization in the presence of viable myocardium and appropriate surgical targets. There is also a golden opportunity for the field of interventional cardiology with the improvements in the technique of CTO PCI and proliferation of dedicated CTO devices to treat a larger population percutaneously.”

For more information:

George S. J Am Coll Cardiol. 2014;64:235-243.

Mahmud E. J Am Coll Cardiol. 2014;64:244-246.

Disclosure: The researchers report financial disclosures with Abbott Vascular, Boston Scientific, Eli Lilly/Daiichi Sankyo and Medtronic. Mahmud reports financial disclosures with Abbott Vascular, Boston Scientific, Corindus, Medtronic and The Medicines Company.

Perspective

Emmanouil S. Brilakis, MD, PhD

A common criticism of CTO intervention is that there are no data supporting its value in improving clinical outcomes. Although no prospective, randomized controlled clinical trials have been completed to date, there is an increasing body of evidence suggesting that CTO PCI can provide clinical benefit. In one of the largest studies published to date, George and colleagues add to this body of evidence by demonstrating significantly better survival among patients in whom CTO PCI was successful compared to patients in whom CTO PCI failed, especially when complete revascularization was achieved. These results support the continued growth and development of CTO PCI.

Emmanouil S. Brilakis, MD, PhD

Cardiology Today’s Intervention Editorial Board member

Disclosures: Brilakis reports receiving speaker honoraria/consulting fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen, Sanofi Aventis, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.