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CMR useful in patient selection for CTO recanalization
In patients who demonstrate significant myocardial inducible perfusion defect and viability on cardiac magnetic resonance, chronic total occlusion recanalization decreases ischemic burden, promotes reverse remodeling and improves quality of life, researchers reported in JACC: Cardiovascular Imaging.
Chiara Bucciarelli-Ducci, MD, PhD, of the cardiovascular magnetic resonance unit at Royal Brompton Hospital in London, and researchers evaluated 50 consecutive patients with CTO deemed suitable candidates for recanalization after coronary angiography. The researchers defined CTO as the presence of TIMI flow grade 0 within the blocked artery with an estimated duration of occlusion of at least 3 months, as elucidated in the EuroCTO Club consensus document. One month before recanalization and 3 months after the procedure, cardiac magnetic resonance (CMR) imaging was performed. In patients who were identified as suitable candidates for revascularization, the following criteria were met: most segments in the CTO territory had less than 75% transmural extent of infarction by late gadolinium enhancement, and existence of an inducible perfusion defect in the CTO territory.
At baseline and follow-up, coinciding with the time of CMR scans, patients also completed the U.K. version of the Seattle Angina Questionnaire, a 14-item questionnaire that assesses the following three components of quality of life: physical limitations (seven items), angina frequency and perception scale (frequency of symptoms and medication use, and the impact of angina on quality of life; four items) and a treatment satisfaction scale (three items).
At baseline, myocardial perfusion reserve (MPR) was decreased in the CTO territory compared with the remote territory (1.8 ± 0.7 vs. 2.2 ± 0.7; P = .01) and showed significant improvements after recanalization (to 2.3 ± 0.9; P = .02) vs. baseline, and was comparable to the remote region (2.5 ± 1.2; P = .21). No differences in MPR were seen in the remote territory before and after PCI (2.5 ± 1.2) vs. baseline. At 3 months after PCI, left ventricular ejection fraction increased from 63 ± 13% to 67 ± 12% (P < .0001). Also at 3 months after PCI, a decrease was observed in end-systolic volume, from 65 ± 38 mL to 56 ± 38 mL (P < .001). Although there was minimal postprocedural infarction due to distal embolization and side branch occlusion in eight patients (25%), there was an overall improvement in Seattle Angina Questionnaire scores from a median of 54 (range, 45-74) at baseline to 89 (range, 77-98) after CTO canalization (P < .0001), according to the findings.
“There are many economic disincentives to CTO recanalization,” Bucciarelli-Ducci and colleagues wrote. “These procedures are technically challenging and require a long learning curve, longer procedural times and greater contrast volume use and radiation exposure, as well as more use of materials than conventional PCI. Our study suggests that improved patient selection for revascularization can be achieved by CMR.” – by Jennifer Byrne
Disclosure: Bucciarelli-Ducci reports consulting for Circle CVI. Please see the full study for a list of all other researchers’ relevant financial disclosures.