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1. EuroIntervention. 2016 Jul 20;12(4):423-30. doi: 10.4244/EIJV12I4A75.

The impact of the location of a chronic total

occlusion in a non-infarct-related artery on longterm mortality in ST-elevation myocardial
infarction patients.
Hoebers LP1, Elias J, van Dongen IM, Ouweneel DM, Claessen BE, Piek JJ, Henriques JP.
Author information: 1AMC Heart Center, Academic Medical Center, University of Amsterdam,
Amsterdam, The Netherlands.

Abstract
AIMS:
Several studies have evaluated the impact of a CTO on short- and long-term mortality in STEMI patients.
It has been speculated that the adverse effect on prognosis could differ per coronary location. The purpose
of this study was to evaluate whether the long-term prognosis of STEMI patients differs according to the
coronary location of the CTO.
METHODS AND RESULTS:
Between 2000 and 2012, a total of 480 STEMI patients with a CTO in a non-infarct-related artery were
included. The primary outcome for the present analysis was three-year all-cause mortality, evaluating the
impact of the coronary CTO and infarct location. Four hundred and thirteen patients had a single CTO in a
non-infarct-related artery, whereas 67 patients had more than one CTO and in this group mortality was
higher. In patients with a single CTO, the highest risk of mortality was observed when the culprit lesion
was located in the LAD or proximal LCX or when the CTO lesion was located in the proximal LAD.
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CONCLUSIONS:
We previously reported that STEMI patients with a CTO have a worse prognosis than STEMI patients
without a CTO. We now show that, in these patients, LAD or proximal LCX location for the culprit lesion,
or proximal LAD location for the CTO lesion, is associated with the highest risk. As a result, almost all
CTO patients are at increased risk for mortality due to the combination of the culprit and CTO artery
location.
Free Article
PMID: 27436598 [PubMed - in process]
Similar articles

2. Int J Cardiol. 2015;187:90-6. doi: 10.1016/j.ijcard.2015.03.164. Epub 2015 Mar 17.

Meta-analysis on the impact of percutaneous

coronary intervention of chronic total occlusions
on left ventricular function and clinical outcome.
Hoebers LP1, Claessen BE1, Elias J1, Dangas GD2, Mehran R2, Henriques JP3.
Author information: 1Academic Medical Center, University of Amsterdam, The Netherlands.2Mount Sinai
Medical Center, New York, NY, United States.3Academic Medical Center, University of Amsterdam, The
Netherlands. Electronic address: j.p.henriques@amc.uva.nl.

Abstract
BACKGROUND:
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) may have a benecial effect
on survival through a better-preserved or improved LVEF. Current literature consists of small
observational studies therefore we performed a weighted meta-analysis on the impact of revascularization
of CTOs on left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and
long-term mortality.
METHODS:
We conducted a meta-analysis evaluating LVEF before and after CTO PCI and long-term mortality. No
language or time restrictions were applied. References from the identied articles and reviews were
examined to nd additional relevant manuscripts.
RESULTS:
Of the 812 citations, 34 studies performed between 1987-2014 in 2243 patients were eligible for LVEF
and 27 studies performed between 1990-2013 in 11,085 patients with success and 4347 patients that failed
CTO PCI were eligible for long-term mortality. After successful CTO PCI, LVEF increased with 4.44%
(95% CI: 3.52-5.35, p<0.01) compared to baseline. In a small cohort of ~70 patients, no signicant
difference in LVEF was observed after non-successful CTO PCI or reocclusion. Additionally, 8 studies
reported the change in left ventricular end-diastolic volume (LVEDV) in a total of 412 patients. LVEDV
decreased with 6.14 ml/m(2) (95% CI: -9.31 to -2.97, p<0.01). Successful CTO PCI was also associated
with reduced mortality in comparison with failed CTO PCI (OR: 0.52, 95% CI: 0.43-0.62, p-value<0.01).
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CONCLUSIONS:
The current meta-analysis revealed that successful recanalization of a CTO resulted in an overall
improvement of 4.44% absolute LVEF points, reduced adverse remodeling and an improvement of
survival (OR: 0.52).
Copyright 2015 Elsevier Ireland Ltd. All rights reserved.
PMID: 25828320 [PubMed - indexed for MEDLINE]
Similar articles

Publication Types
Meta-Analysis
Review
MeSH Terms
Chronic Disease
Coronary Occlusion/physiopathology
Coronary Occlusion/surgery*
Humans
Percutaneous Coronary Intervention/methods*
Risk Factors
Stroke Volume
Treatment Outcome
Ventricular Function, Left/physiology*
3. Catheter Cardiovasc Interv. 2013 Jul 1;82(1):85-92. doi: 10.1002/ccd.24731. Epub 2013 Mar 2.

Long-term clinical outcomes after percutaneous

coronary intervention for chronic total occlusions
in elderly patients (75 years): ve-year outcomes
from a 1,791 patient multi-national registry.
Hoebers LP1, Claessen BE, Dangas GD, Park SJ, Colombo A, Moses JW, Henriques JP, Stone GW, Leon
MB, Mehran R; Multinational CTO Registry.
Author information: 1Academic Medical Center, University of Amsterdam, The Netherlands.

Comment in
Coronary chronic total occlusion in the elderly: demographic inevitability, treatment uncertainty.
[Catheter Cardiovasc Interv. 2013]

Abstract
OBJECTIVE:

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To investigate procedural success rates and long-term clinical outcome of percutaneous coronary
intervention (PCI) for chronic total occlusions (CTO) in elderly patients.
BACKGROUND:
Little is known about procedural success and long-term clinical outcome of PCI for CTO in the elderly.
METHODS:
A total of 1,791 consecutive patients with 1,852 CTO underwent PCI at three large centers in USA, Italy,
and South Korea. Outcomes included procedural success and major adverse cardiac events (MACE,
composite of mortality, myocardial infarction, or coronary artery bypass graft surgery [CABG]).Time-toevent analyses were performed using Kaplan-Meier statistics, and the log-rank statistic was used to test for
differences between patients aged 75 and patients aged <75 years.
RESULTS:
Two hundred and thirteen patients (12%) were aged 75 years. Procedural success rates were similar in
elderly patients compared with patients <75 years (63.8% vs. 69.1%, P = 0.12). Median follow-up was 890
days (IQR: 380-1,480 days). MACE rates after successful versus failed PCI were 25.8% versus 42.3% in
the elderly (P = 0.02) and 11.2 versus 20.8% in younger patients (P < 0.01). In elderly patients, this
reduction in MACE after successful PCI was mainly driven by a reduction in CABG (0.0% vs. 20.4%, P <
0.01), there were no signicant differences in terms of mortality (19.6% vs. 24.6%, P = 0.13) or MI
(11.5% vs. 8.0%, P = 0.87).
CONCLUSION:
CTO PCI in patients 75 years has similar success as in patients <75 years. In elderly patients undergoing
CTO PCI, MACE rates were relatively high but successful revascularization is associated with a reduction
in MACE at 5-year follow-up in both elderly and younger patients.
Copyright 2013 Wiley Periodicals, Inc.
PMID: 23436690 [PubMed - indexed for MEDLINE]
Similar articles

Publication Types
Multicenter Study
MeSH Terms
Age Factors
Aged
Aged, 80 and over
Chronic Disease
Coronary Occlusion/diagnosis
Coronary Occlusion/mortality
Coronary Occlusion/therapy*
Female
Humans
Italy
Kaplan-Meier Estimate
Male
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Middle Aged
Multivariate Analysis
Percutaneous Coronary Intervention/adverse effects
Percutaneous Coronary Intervention/mortality
Proportional Hazards Models
Registries
Republic of Korea
Risk Factors
Time Factors
Treatment Outcome
United States
4. Catheter Cardiovasc Interv. 2013 Jul 1;82(1):76-82. doi: 10.1002/ccd.24579. Epub 2013 Feb 26.

Impact of target vessel on long-term survival

after percutaneous coronary intervention for
chronic total occlusions.
Claessen BE1, Dangas GD, Godino C, Henriques JP, Leon MB, Park SJ, Stone GW, Moses JW, Colombo
A, Mehran R; Multinational CTO Registry.
Author information: 1Cardiovascular Research Foundation, New York, New York 10029, USA.

Comment in
The clinical impact of CTO recanalization: left much more than right. [Catheter Cardiovasc Interv.
2013]

Abstract
BACKGROUND:
This study sought to investigate whether there is a differential prognostic effect of successful percutaneous
coronary intervention (PCI) of chronic total occlusions (CTO) according to the target vessel the CTO is
located in.
METHODS:
Between 1998 and 2007, a total of 1,791 patients underwent PCI of a CTO at three tertiary care centers in
the US, Italy, and South Korea. Patients with CTOs in multiple target vessels or the left main stem were
excluded (n = 57). Of the remaining 1,734 patients, 609 had a CTO in the left anterior descending (LAD,
35.1%), 391 in the left circumex (LCX, 22.5%), and 734 in the right coronary artery (RCA, 42.3%).
Five-year mortality and the need for coronary artery bypass grafting (CABG) were compared between
patients with successful vs. unsuccessful PCI stratied by target vessel.
RESULTS:
Procedural success was obtained in 71.1% of LAD patients, 69.1% of LCX patients, and 65.1% of RCA
patients (P = 0.06). The mean follow-up duration was 1,178 days. Kaplan-Meier estimates of long-term
mortality were 6.7% vs. 11.0% (P = 0.03), 5.5% vs. 13.9% (P < 0.01), and 6.6% vs. 4.1% (P = 0.80) in
successful vs. unsuccessful LAD, LCX, and RCA patients, respectively. After multivariate analysis,
successful CTO PCI remained associated with lower mortality in the LAD (HR 0.41, P = 0.02) and LCX
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groups (HR 0.32, P < 0.01). The need for CABG was lower after successful CTO PCI in all three groups
(LAD 4.6% vs. 16.0%, P < 0.01; LCX 2.9% vs. 18.2%, P < 0.01, RCA 2.3% vs. 8.4%, P < 0.01).
CONCLUSION:
The results from this large contemporary cohort of patients suggest that successful PCI of a CTO in the
LAD and the LCX, but not the RCA, is associated with improved long-term survival.
Copyright 2013 Wiley Periodicals, Inc.
PMID: 22888007 [PubMed - indexed for MEDLINE]
Similar articles

Publication Types
Comparative Study
Multicenter Study
Observational Study
MeSH Terms
Aged
Chronic Disease
Coronary Angiography
Coronary Artery Bypass
Coronary Occlusion/diagnostic imaging
Coronary Occlusion/mortality
Coronary Occlusion/therapy*
Female
Humans
Italy
Kaplan-Meier Estimate
Male
Middle Aged
Multivariate Analysis
Percutaneous Coronary Intervention*/adverse effects
Percutaneous Coronary Intervention*/mortality
Predictive Value of Tests
Proportional Hazards Models
Registries
Republic of Korea
Risk Factors
Time Factors
Treatment Outcome
United States
5. Heart. 2012 Dec;98(23):1732-7. doi: 10.1136/heartjnl-2012-302376. Epub 2012 Sep 26.

Prevalence, predictors and clinical impact of

unique and multiple chronic total occlusion in
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non-infarct-related artery in patients presenting

with ST-elevation myocardial infarction.
Bataille Y1, Dry JP, Larose E, Dry U, Costerousse O, Rods-Cabau J, Rinfret S, De Larochellire R,
Abdelaal E, Machaalany J, Barbeau G, Roy L, Bertrand OF.
Author information: 1Quebec Heart-Lung Institute, Quebec, Canada.

Abstract
OBJECTIVES:
To investigate the predictors and impact on long-term survival of one chronic total occlusion (CTO) or
multiple CTOs in patients presenting with ST-elevation myocardial infarction (STEMI).
DESIGN:
Single-centre retrospective observational study.
SETTING:
University-based tertiary referral centre.
PATIENTS:
Between 2006 and 2011, a total of 2020 consecutive patients referred with STEMI were categorised into
single vessel disease, multivessel disease (MVD) without CTO, with one CTO or with multiple CTOs.
INTERVENTION:
Primary percutaneous coronary intervention.
MAIN OUTCOME MEASURE:
The primary end-point was the 1-year mortality.
RESULTS:
The prevalence of single vessel disease, MVD without CTO, with one CTO or with multiple CTOs was
70%, 22%, 7.2% and 0.8%, respectively. Independent clinical predictors for the presence of CTO were
cardiogenic shock (OR 5.05; 95% CI 3.29 to 7.64), prior myocardial infarction (OR 2.06; 95% CI 1.35 to
3.09), age >65 years (OR 1.94; 95% CI 1.40 to 2.71) and history of angina (OR 1.94; 95% CI 1.29 to
2.87). Mortality was worse in patients with multiple CTOs (76.5%) compared with those with one CTO
(28.1%) or without CTO (7.3%) (p<0.0001). After adjustment for left ventricular ejection fraction and
renal function, MVD was an independent predictor for 1-year mortality (HR: 1.81; 95% CI 1.18 to 2.77,
p=0.007), but CTO was not (HR: 1.07; 95% CI 0.66 to 1.73, p=0.78).
CONCLUSIONS:
Simple clinical factors are associated with the presence of CTO in non-infarct-related artery in patients
presenting with STEMI. In these patients, long-term survival was independently associated with MVD,
left ventricular ejection fraction and renal function, but not with CTO per se.
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PMID: 23014480 [PubMed - indexed for MEDLINE]

Similar articles

Publication Types
Comparative Study
Research Support, Non-U.S. Gov't
MeSH Terms
Aged
Coronary Occlusion/diagnosis
Coronary Occlusion/epidemiology*
Coronary Occlusion/etiology
Electrocardiography*
Female
Follow-Up Studies
Humans
Male
Middle Aged
Myocardial Infarction/complications*
Myocardial Infarction/mortality
Myocardial Infarction/surgery
Percutaneous Coronary Intervention*
Prevalence
Prognosis
Quebec/epidemiology
Retrospective Studies
Risk Factors
Survival Rate/trends
Time Factors
6. Am Heart J. 2012 Oct;164(4):509-15. doi: 10.1016/j.ahj.2012.07.008.

Deadly association of cardiogenic shock and

chronic total occlusion in acute ST-elevation
myocardial infarction.
Bataille Y1, Dry JP, Larose , Dry U, Costerousse O, Rods-Cabau J, Gleeton O, Proulx G, Abdelaal E,
Machaalany J, Nguyen CM, Nol B, Bertrand OF.
Author information: 1Quebec Heart-Lung Institute, Quebec, Canada.

Abstract
BACKGROUND:
The association between cardiogenic shock and 1 or >1 chronic total occlusion (CTO) in unselected
patients presenting with ST-elevation myocardial infarction (MI) (STEMI) has not been characterized.
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METHODS:
Patients with STEMI referred with or without cardiogenic shock were categorized into no CTO, 1 CTO,
and >1 CTO. The primary end point was the 30-day mortality.
RESULTS:
Between 2006 and 2011, 2,020 consecutive patients were included. A total of 141 patients (7%) presented
with cardiogenic shock on admission. The prevalence of 1 CTO and >1 CTO in a non-infarct-related
artery was 23% and 5%, respectively, among patients with shock compared with 6% and 0.5% in patients
without shock (P < .0001). Independent predictors of cardiogenic shock included left main-related MI
(odds ratio [OR] 6.55, 95% CI 1.39-26.82, P = .019), CTO (OR 4.20, 95% CI 2.64-6.57, P < .001),
creatinine clearance <60 mL/min (OR 3.41, 95% CI 2.32-4.99, P < .0001), and left anterior descendingrelated MI (OR 2.20, 95% CI 1.51-3.23, P < .0001). Thirty-day mortality was 100% in shock patients with
>1 CTO, 65.6% with 1 CTO, and 40.2% in patients without CTO (P < .0001). After adjustment for left
ventricular ejection fraction and renal function, CTO remained an independent predictor for 30-day
mortality (hazard ratio [HR] 1.83; 95% CI 1.10-3.01, P = .02).
CONCLUSION:
In patients with STEMI, CTO was strongly associated with cardiogenic shock on admission. In this
setting, mortality was substantially higher in patients with 1 CTO and exceedingly high in those with >1
CTO. The presence of CTO was an independent predictor of early mortality.
Copyright 2012 Mosby, Inc. All rights reserved.
PMID: 23067908 [PubMed - indexed for MEDLINE]
Similar articles

Publication Types
Research Support, Non-U.S. Gov't
MeSH Terms
Aged
Coronary Occlusion/complications
Coronary Occlusion/epidemiology
Coronary Occlusion/mortality*
Coronary Occlusion/therapy
Female
Humans
Male
Middle Aged
Myocardial Infarction/complications*
Myocardial Infarction/mortality
Myocardial Infarction/therapy
Odds Ratio
Percutaneous Coronary Intervention
Prevalence
Shock, Cardiogenic/complications
Shock, Cardiogenic/mortality*
7. Am J Cardiol. 2013 Jul 15;112(2):194-9. doi: 10.1016/j.amjcard.2013.03.010. Epub 2013 Apr 18.
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Interaction of chronic total occlusion and chronic

kidney disease in patients undergoing primary
percutaneous coronary intervention for acute STelevation myocardial infarction.
Bataille Y1, Plourde G, Machaalany J, Abdelaal E, Dry JP, Larose E, Dry U, Nol B, Barbeau G, Roy L,
Costerousse O, Bertrand OF.
Author information: 1Quebec Heart-Lung Institute, Department of Cardiology, Quebec, Quebec, Canada.

Abstract
Chronic total occlusion (CTO) in a non-infarct-related artery and chronic kidney failure (CKD) are
associated with worse outcomes after primary percutaneous coronary intervention (PCI). The aim of this
study was to investigate the interaction of CTO and CKD in patients who underwent primary PCI for acute
ST-segment elevation myocardial infarction (STEMI). Patients with STEMIs with or without CKD,
dened as an estimated glomerular ltration rate <60 ml/min/1.73 m(2), were categorized into those with
single-vessel disease and those with multivessel disease with or without CTO. The primary outcomes were
the incidence of 30-day and 1-year mortality. Among 1,873 consecutive patients with STEMIs included
between 2006 and 2011, 336 (18%) had CKD. The prevalence of CTO in a non-infarct-related artery was
13% in patients with CKD compared with 7% in those without CKD (p= 0.0003). There was a signicant
interaction between CKD and CTO on 30-day mortality (p= 0.018) and 1-year mortality (p= 0.013).
Independent predictors of late mortality in patients with CKD were previous myocardial infarction (hazard
ratio [HR] 1.71, 95% condence interval [CI] 1.01 to 2.79), age >75 years (HR 1.86, 95% CI 1.19 to
2.95), a left ventricular ejection fraction after primary PCI <40% (HR 2.20, 95% CI 1.36 to 3.63), left
main culprit artery (HR 4.46, 95% CI 1.64 to 10.25), and shock (HR 7.44, 95% CI 4.56 to 12.31), but
multivessel disease with CTO was not a predictor. In contrast, multivessel disease with CTO was an
independent predictor of mortality in patients without CKD (HR 3.30, 95% CI 1.70 to 6.17). In
conclusion, in patients with STEMIs who underwent primary PCI, with preexisting CKD, the prevalence
of CTO in a non-infarct-related artery was twice as great. In these patients, the clinical impact of CTO
seems to be overshadowed by the presence of CKD.
Copyright 2013 Elsevier Inc. All rights reserved.
PMID: 23601580 [PubMed - indexed for MEDLINE]
Similar articles

Publication Types
Research Support, Non-U.S. Gov't
MeSH Terms
Aged
Chronic Disease
Coronary Occlusion/complications*
Coronary Occlusion/epidemiology
Female
Follow-Up Studies
Humans
Male
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Middle Aged
Myocardial Infarction/complications*
Myocardial Infarction/mortality
Myocardial Infarction/surgery*
Percutaneous Coronary Intervention*
Prevalence
Renal Insufciency, Chronic/complications*
Renal Insufciency, Chronic/mortality
8. Am J Cardiol. 2010 Apr 1;105(7):955-9. doi: 10.1016/j.amjcard.2009.11.014. Epub 2010 Feb 13.

Effect of multivessel coronary disease with or

without concurrent chronic total occlusion on
one-year mortality in patients treated with
primary percutaneous coronary intervention for
cardiogenic shock.
van der Schaaf RJ1, Claessen BE, Vis MM, Hoebers LP, Koch KT, Baan J Jr, Meuwissen M, Engstrom
AE, Kikkert WJ, Tijssen JG, de Winter RJ, Piek JJ, Henriques JP.
Author information: 1Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.

Abstract
Despite early revascularization, mortality remains high in patients with ST-segment elevation myocardial
infarction (STEMI) complicated by cardiogenic shock. It has been shown that the effect of multivessel
disease (MVD) on mortality in patients with STEMI treated with primary percutaneous coronary
intervention is mainly caused by the presence of chronic total occlusion (CTO) in a noninfarct-related
coronary artery. Whether this association also exists in patients with STEMI with cardiogenic shock is
unknown. In our institution, 292 consecutive patients with STEMI complicated by cardiogenic shock were
admitted from 1997 to 2005 and treated with primary percutaneous coronary intervention. Patients were
classied as having single vessel disease, MVD without CTO, and CTO. Cox regression analysis was used
for multivariate analysis. The 1-year mortality rate of patients with single-vessel disease, MVD, and CTO
was 31%, 47%, and 63%, respectively. After adjustment for possible confounders, MVD alone was not an
independent predictor of 1-year mortality (hazard ratio 1.5, 95% condence interval 0.98 to 2.3, p = 0.07).
In contrast, CTO in a noninfarct-related artery was an independent predictor of 1-year mortality (hazard
ratio 2.1, 95% condence interval 1.5 to 3.1, p <0.01). In conclusion, the presence of CTO in a noninfarct-related artery was an independent predictor of 1-year mortality. In contrast, MVD alone lost its
predictive signicance after multivariate analysis.
Copyright 2010 Elsevier Inc. All rights reserved.
PMID: 20346312 [PubMed - indexed for MEDLINE]
Similar articles

MeSH Terms
Aged
Angioplasty, Balloon, Coronary*
Coronary Disease/complications
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Coronary Disease/mortality
Coronary Disease/pathology
Coronary Vessels/pathology
Female
Humans
Male
Multivariate Analysis
Myocardial Infarction/complications*
Myocardial Infarction/mortality*
Myocardial Infarction/pathology
Shock, Cardiogenic/complications*
Shock, Cardiogenic/therapy*
Treatment Outcome
9. JACC Cardiovasc Interv. 2009 Nov;2(11):1128-34. doi: 10.1016/j.jcin.2009.08.024.

Evaluation of the effect of a concurrent chronic

total occlusion on long-term mortality and left
ventricular function in patients after primary
percutaneous coronary intervention.
Claessen BE1, van der Schaaf RJ, Verouden NJ, Stegenga NK, Engstrom AE, Sjauw KD, Kikkert WJ, Vis
MM, Baan J Jr, Koch KT, de Winter RJ, Tijssen JG, Piek JJ, Henriques JP.
Author information: 1Department of Cardiology, Academic Medical Center-University of Amsterdam,
Amsterdam, the Netherlands.

Abstract
OBJECTIVES:
The aim of this study was to evaluate the effect of a concurrent chronic total occlusion (CTO) in patients
with ST-segment elevation myocardial infarction (STEMI) on long-term mortality and left ventricular
ejection fraction (LVEF).
BACKGROUND:
The impact of a CTO in a non-infarct-related artery (IRA) on prognosis after STEMI is unknown.
METHODS:
Between 1997 and 2005, we admitted 3,277 STEMI patients treated with primary percutaneous coronary
intervention. Patients were categorized as single-vessel disease (SVD), multivessel disease (MVD)
without CTO, and MVD with a CTO in a non-IRA. We performed a "landmark survival analysis" to 5
years follow-up with a landmark set at 30 days. Additionally, we analyzed the evolution of LVEF within 1
year.
RESULTS:
Of the patients, 2,115 (65%) had SVD, 742 patients (23%) had MVD without CTO, and 420 patients
(13%) had a concurrent CTO. Presence of a CTO was a strong and independent predictor for 30-day
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mortality (hazard ratio [HR]: 3.6, 95% condence interval [CI]: 2.6 to 4.7, p < 0.01), whereas MVD
without CTO was a weak predictor (HR: 1.6, 95% CI: 1.2 to 2.2, p = 0.01). In 30-day survivors, CTO
remained a strong predictor (HR: 1.9, 95% CI: 1.4 to 2.8, p < 0.01), and MVD lost its independent
prognostic value (HR: 1.1, 95% CI: 0.8 to 1.5, p = 0.45). Furthermore, CTO was associated with LVEF
</=40% immediately after STEMI (odds ratio: 1.9, 95% CI: 1.3 to 2.8, p < 0.01) and a further decrease in
LVEF within the rst year (odds ratio: 3.5, 95% CI: 1.6 to 7.8, p < 0.01).
CONCLUSIONS:
The presence of a CTO and not MVD alone is associated with long-term mortality even when early deaths
are excluded from analysis. The presence of a CTO is associated with reduced LVEF and further
deterioration of LVEF.
Free Article
PMID: 19926056 [PubMed - indexed for MEDLINE]
Similar articles

MeSH Terms
Angioplasty, Balloon, Coronary/adverse effects
Angioplasty, Balloon, Coronary/mortality*
Chronic Disease
Cohort Studies
Coronary Occlusion/complications
Coronary Occlusion/mortality*
Coronary Occlusion/physiopathology
Coronary Occlusion/therapy*
Coronary Stenosis/complications
Coronary Stenosis/mortality*
Coronary Stenosis/physiopathology
Coronary Stenosis/therapy*
Female
Humans
Kaplan-Meier Estimate
Logistic Models
Male
Middle Aged
Myocardial Infarction/etiology
Myocardial Infarction/mortality*
Myocardial Infarction/physiopathology
Myocardial Infarction/therapy*
Odds Ratio
Proportional Hazards Models
Risk Assessment
Risk Factors
Severity of Illness Index
Stroke Volume*
Time Factors
Treatment Outcome
Ventricular Function, Left*
10. Medicine (Baltimore). 2016 Jan;95(2):e2441. doi: 10.1097/MD.0000000000002441.

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Impact of Chronic Total Occlusion in a

Noninfarct-related Artery on Clinical Outcomes
in Patients With Acute ST-elevation Myocardial
Infarction Undergoing Primary Percutaneous
Coronary Intervention.
Zhang HP1, Zhao Y, Li H, Tang GD, Ai H, Zheng NX, Liu JH, Sun FC.
Author information: 1From the Department of Cardiology, Beijing Hospital, The Fifth Afliated Hospital
of Peking University (H-PZ, YZ, HL, G-DT, HA, N-XZ, F-CS); and Department of Cardiology, Beijing
Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases,
Beijing, China (J-HL).

Abstract
In the setting of primary percutaneous coronary intervention (PCI), encountering with chronic total
occlusion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. Limited information on the
impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients
undergoing primary PCI has raised more concerns. The aim of the present study was to evaluate the
effect of concurrent CTO in a non-IRA on the clinical outcomes in patients with STEMI undergoing
primary PCI.In the present prospective study, 555 consecutive patients with STEMI who underwent early
primary PCI from January 2010 to December 2013 were included. The patients were divided into 2
groups: no CTO and CTO. Data on 12 months follow-up was obtained from 449 patients. The primary
endpoint was the composite of hospitalization from angina, reinfarction, heart failure, or rerevascularization, and cardiac death at 12 months follow-up.Of the 555 patients, 75 (13.5%) had CTO in
a non-IRA. Compared with patients in no CTO group, more patients in CTO group had hypertension
(62.7% vs 46.5%, P=0.009), diabetes (49.3% vs 35.0%, P=0.024), and 3-vessel disease (52.0% vs
32.3%, P=0.001). Patients with CTO had a lower left ventricular ejection fraction (LVEF) (40.1%
16.8% vs 54.3%12.1%, P=0.038), more presented with cardiogenic shock on admission (13.3% vs
4.8%, P=0.008), compared with patients without CTO. Complete revascularization (CR) was less
achieved in CTO group than in no CTO group (33.3% vs 49.1%, P=0.013). The 12-month cardiac
mortality rate was 14.5% versus 6.2% (P=0.039), the incidence of 12-month primary endpoint was
38.7% versus 21.2% (P=0.003) for CTO and no CTO group, respectively. Multivariate analysis revealed
that after correction for baseline differences, CTO in a non-IRA (hazard ratio 4.183, 95% condence
interval 1.940-6.019, P=0.001), cardiogenic shock on admission (hazard ratio 3.286, 95% condence
interval 1.097-9.845, P=0.034), and 3-vessel disease (hazard ratio 2.678, 95% condence interval 1.2215.874, P=0.014) remained an independent predictor of 1-year cardiac mortality in patients with STEMI
undergoing primary PCI.CTO in a non-IRA in patients with STEMI undergoing primary PCI is
associated with a poor prognosis. The presence of CTO in a non-IRA, cardiogenic shock on admission
and 3-vessel disease might be an independent risk factor for greater 1-year cardiac mortality in patients
with acute STEMI undergoing primary PCI.
PMCID: PMC4718255 Free PMC Article
PMID: 26765429 [PubMed - indexed for MEDLINE]
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Publication Types
Comparative Study
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MeSH Terms
Age Factors
Aged
Angioplasty, Balloon, Coronary/methods*
Angioplasty, Balloon, Coronary/mortality
Chronic Disease
Cohort Studies
Coronary Angiography/methods
Coronary Occlusion/diagnostic imaging*
Coronary Occlusion/mortality
Coronary Occlusion/therapy
Electrocardiography/methods*
Female
Follow-Up Studies
Hospital Mortality/trends*
Humans
Kaplan-Meier Estimate
Length of Stay
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction/diagnosis
Myocardial Infarction/mortality
Myocardial Infarction/therapy*
Predictive Value of Tests
Proportional Hazards Models
Prospective Studies
Risk Assessment
Sex Factors
Survival Rate
Treatment Outcome
11. Eur Heart J. 2012 Mar;33(6):768-75. doi: 10.1093/eurheartj/ehr471. Epub 2012 Jan 12.

Prognostic impact of a chronic total occlusion in

a non-infarct-related artery in patients with STsegment elevation myocardial infarction: 3-year
results from the HORIZONS-AMI trial.
Claessen BE1, Dangas GD, Weisz G, Witzenbichler B, Guagliumi G, Mckel M, Brener SJ, Xu K,
Henriques JP, Mehran R, Stone GW.
Author information: 1Cardiovascular Research Foundation, New York, NY 10022, USA.

Comment in
Chronic total occlusions in non-infarct-related arteries. [Eur Heart J. 2012]

Abstract
AIMS:
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We sought to investigate the impact of multivessel disease (MVD) with and without a chronic total
occlusion (CTO) in a non-infarct-related artery (IRA) on mortality in patients with ST-segment elevation
myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
METHODS AND RESULTS:
In the HORIZONS-AMI trial, of 3283 patients undergoing primary PCI, 1524 patients (46.4%) had
single-vessel disease (SVD), 1477 (45.0%) had MVD without a CTO, and 283 (8.6%) had MVD with a
CTO in a non-IRA. Compared with SVD patients and MVD patients without a CTO, patients with a nonIRA CTO were signicantly less likely to achieve post-procedural TIMI 3 ow (P = 0.0003), more often
had absent myocardial blush (P = 0.0002), and less frequently achieved complete ST-segment resolution
(P = 0.0001). By multivariable analysis, MVD with CTO in a non-IRA was an independent predictor of
both 0- to 30-day mortality [hazard ratio (HR) 2.88, 95% condence interval (CI) 1.41-5.88, P = 0.004]
and 30-day to 3-year mortality (HR 1.98, 95% CI 1.19-3.29, P= 0.009), while MVD without a CTO was
a signicant predictor for 0- to 30-day mortality (HR 2.20, 95% CI 1.00-3.06, P = 0.049) but not late
mortality.
CONCLUSION:
In patients with STEMI undergoing primary PCI in the HORIZONS-AMI trial, MVD with or without a
CTO in a non-IRA was an independent predictor of early mortality. The presence of a CTO in a non-IRA
was also an independent predictor of increased late mortality to 3 years.
Free Article
PMID: 22240495 [PubMed - indexed for MEDLINE]
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Publication Types
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
MeSH Terms
Aged
Angioplasty, Balloon, Coronary/mortality
Chronic Disease
Coronary Artery Disease/mortality*
Coronary Artery Disease/therapy
Coronary Occlusion/mortality*
Coronary Occlusion/therapy
Female
Follow-Up Studies
Humans
Male
Middle Aged
Myocardial Infarction/mortality*
Myocardial Infarction/therapy
Prognosis
12. ScienticWorldJournal. 2014 Feb 10;2014:756080. doi: 10.1155/2014/756080. eCollection 2014.

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Evaluation of the effect of concurrent chronic

total occlusion and successful staged
revascularization on long-term mortality in
patients with ST-elevation myocardial infarction.
Shi G1, He P1, Liu Y1, Lin Y1, Yang X1, Chen J1, Zhou Y1, Tan N1.
Author information: 1Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong
General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou 510080, China.

Abstract
AIMS:
To investigate the impact of chronic total occlusion (CTO) in non-infarct-related artery (IRA) on the
long-term prognosis and evaluate the clinical signicance of staged revascularization in patients with STsegment elevation myocardial infarction (STEMI).
METHODS:
1266 STEMI patients with primary percutaneous coronary intervention (PCI) were categorized as singlevessel disease (SVD), multivessel disease (MVD) without and with CTO. We study the clinical outcomes
of patients after primary PCI in the following 3 years. Additionally, patients with CTO received staged
revascularization, and major adverse cardiac events (MACE) during 3-year follow-up were recorded.
RESULTS:
Presence of CTO was a predictor of both early mortality [hazard ratio (HR) 3.4, 95% condence interval
(CI) 2.4-4.5, P < 0.01] and late mortality (HR 1.9, 95% CI 1.4-3.6, P < 0.01), whereas MVD without
CTO was only a predictor of early mortality (HR 1.7, 95% CI 1.3-2.3, P < 0.05). In CTO group, 100
patients had successful CTO recanalization, and 48 patients failed. During 3-year follow-up, patients with
failed procedure had higher cardiac mortality (22.9% versus 9.0%, P = 0.020) and lower MACE-free
survival (50.0% versus 72.0%, P = 0.009) compared to patients with successful procedure.
CONCLUSION:
The presence of CTO and not MVD alone is associated with long-term mortality. Successful
revascularization of CTO in the non-IRA is associated with improved clinical outcomes in patients with
STEMI undergoing primary PCI.
PMCID: PMC3934529 Free PMC Article
PMID: 24790581 [PubMed - indexed for MEDLINE]
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Publication Types
Research Support, Non-U.S. Gov't
MeSH Terms
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Aged
Chronic Disease
Coronary Occlusion/complications
Coronary Occlusion/surgery*
Female
Follow-Up Studies
Humans
Kaplan-Meier Estimate
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction/complications*
Myocardial Infarction/mortality
Outcome Assessment (Health Care)/methods
Outcome Assessment (Health Care)/statistics & numerical data
Percutaneous Coronary Intervention/methods*
Prognosis
Proportional Hazards Models
Survival Rate
Time Factors
Vascular Diseases/complications
13. J Invasive Cardiol. 2012 Sep;24(9):428-32.

Impact of chronic total coronary occlusion on

microvascular reperfusion in patients with a rst
anterior ST-segment elevation myocardial
infarction.
Suzuki M1, Enomoto D, Mizobuchi T, Kazatani Y, Honda K.
Author information: 1Section of Cardiology, Department of Community Emergency Medicine, Ehime
University Graduate School of Medicine, Toon, Ehime 791-0295, Japan. suzuki-m@m.ehime-u.ac.jp

Abstract
BACKGROUND:
We investigated an impact of the presence of chronic total coronary occlusion (CTO) in a non-infarct
related coronary artery on microvascular reperfusion in patients with a rst anterior ST-segment elevation
myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI).
METHODS:
In accordance with the presence or absence of CTO in a non-infarct related coronary artery, we analyzed
Thrombolysis in Myocardial Infarction myocardial perfusion (TMP) grade on a scale of 0 to 3, with
higher scores indicating better perfusion, and ST-segment resolution in sum of lead I, aVL, and V1
through V6 to evaluate microvascular reperfusion in a total of 140 consecutive patients with a rst
anterior STEMI.
RESULTS:
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We identied CTO in 15 patients (11% of total). The incidence of impaired microvascular reperfusion
was greater in patients with CTO vs without CTO, dened as TMP grades 0 or 1 together with <30% STsegment resolution (33% vs 6%, respectively; P=.0006) and the enzymatic infarct was larger (10304
8060 IU/L vs 6804 4959 IU/L; P=.009). Logistic regression analysis revealed that CTO is closely
associated with incidental impaired microvascular reperfusion (odds ratio, 6.801; 95% condence
interval, 1.284-36.209; P=.024).
CONCLUSION:
The presence of CTO in a non-infarct related coronary artery might confer a considerable disadvantage
upon microvascular reperfusion and result in adverse clinical outcomes of PCI for a rst anterior STEMI.
Free Article
PMID: 22954561 [PubMed - indexed for MEDLINE]
Similar articles

MeSH Terms
Aged
Coronary Artery Disease/complications*
Coronary Occlusion/surgery*
Female
Humans
Male
Middle Aged
Myocardial Infarction/surgery*
Myocardial Reperfusion*
Percutaneous Coronary Intervention/methods*
Treatment Outcome
14. Catheter Cardiovasc Interv. 2011 Mar 1;77(4):484-91. doi: 10.1002/ccd.22664.

Impact of chronic total occlusions on markers of

reperfusion, infarct size, and long-term
mortality: a substudy from the TAPAS-trial.
Lexis CP1, van der Horst IC, Rahel BM, Lexis MA, Kampinga MA, Gu YL, de Smet BJ, Zijlstra F.
Author information: 1Department of Cardiology, Thorax Center, University Medical Center Groningen,
Groningen, The Netherlands. c.p.h.lexis@thorax.umcg.nl

Comment in
1 is manageable but 2 may be 2 much: shall we open CTOs? [Catheter Cardiovasc Interv. 2011]

Abstract
OBJECTIVES:

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This study evaluated the impact of a chronic total occlusion (CTO) in a non-infarct related coronary
artery (IRA) on markers of reperfusion, infarct size, and long-term cardiac mortality in patients with STelevation myocardial infarction (STEMI).
BACKGROUND:
A concurrent CTO in STEMI patients has been associated with impaired left ventricular function and
outcome. However, the impact on markers of reperfusion is unknown.
METHODS:
All 1,071 STEMI patients included in the TAPAS-trial between January 2005 and December 2006 were
used for this substudy. Endpoints were the association between a CTO in a non-IRA and myocardial
blush grade (MBG) of the IRA, ST-segment elevation resolution (STR), enzymatic infarct size, and
clinical outcome.
RESULTS:
A total of 90 patients (8.4%) had a CTO. MBG 0 or 1 occurred more often in the CTO group (34.2%
versus 20.6% (Odds Ratio [OR] 2.00, 95% condence interval [CI]: 1.22-3.23, P = 0.006)). Incomplete
STR occurred more often in the CTO group, (63.6% versus 48.2% [OR 1.96, 95% CI: 1.22-3.13, P =
0.005]). Median level of maximal myocardial-band of creatinin kinase (CK-MB) in the CTO group was
75 g/l (IQR 28-136) and 51 g/l (IQR 18-97) in the no-CTO group (P = 0.021). The presence of a CTO
in a non-IRA in STEMI patients was an independent risk factor for cardiac mortality (HR 2.41, 95% CI:
1.26-4.61, P = 0.008) at 25 months follow-up.
CONCLUSION:
A CTO in a non-IRA is associated with impaired reperfusion markers and impaired long-term outcome in
STEMI patients.
Copyright 2010 Wiley-Liss, Inc.
PMID: 20518009 [PubMed - indexed for MEDLINE]
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Publication Types
Randomized Controlled Trial
MeSH Terms
Aged
Angioplasty, Balloon, Coronary*/adverse effects
Angioplasty, Balloon, Coronary*/mortality
Biomarkers/blood
Chi-Square Distribution
Chronic Disease
Collateral Circulation
Coronary Angiography
Coronary Circulation*
Coronary Occlusion/complications
Coronary Occlusion/diagnostic imaging
Coronary Occlusion/mortality
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Coronary Occlusion/physiopathology
Coronary Occlusion/therapy*
Creatine Kinase, MB Form/blood
Electrocardiography
Female
Humans
Logistic Models
Male
Middle Aged
Myocardial Infarction/complications
Myocardial Infarction/diagnostic imaging
Myocardial Infarction/mortality
Myocardial Infarction/physiopathology
Myocardial Infarction/therapy*
Myocardial Perfusion Imaging
Myocardium/enzymology
Myocardium/pathology*
Netherlands
Odds Ratio
Proportional Hazards Models
Risk Assessment
Risk Factors
Suction
Thrombectomy*/adverse effects
Thrombectomy*/methods
Thrombectomy*/mortality
Treatment Outcome
Substances
Biomarkers
Creatine Kinase, MB Form
15. J Magn Reson Imaging. 2016 Oct;44(4):972-82. doi: 10.1002/jmri.25235. Epub 2016 Mar 23.

Myocardial extracellular volume fraction

measurement in chronic total coronary occlusion:
Association with myocardial injury, angiographic
collateral ow, and functional recovery.
Chen YY1, Ren DY2, Zeng MS1, Yang S1, Yun H1, Fu CX3, Ge JB2, Jin H4, Qian JY2, Zhang WG5.
Author information: 1Department of Radiology, Zhongshan Hospital, Fudan University, Department of
Medical Imaging, Shanghai Medical school, Fudan University and Shanghai Institute of Medical
Imaging, Shanghai, China.2Department of Cardiology, Zhongshan Hospital, Fudan University and
Shanghai Institute of Cardiovascular Diseases, Shanghai, China.3Siemens Shenzhen Magnetic
Resonance, Shenzhen, China.4Department of Radiology, Zhongshan Hospital, Fudan University,
Department of Medical Imaging, Shanghai Medical school, Fudan University and Shanghai Institute of
Medical Imaging, Shanghai, China. jin.hang@outlook.com.5Department of Radiology, The First
Afliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Abstract
PURPOSE:
To investigate whether myocardial extracellular volume fraction (ECV) measurement by cardiac MR is
indicative of myocardial injury, angiographic collateral ow, and functional recovery in patients with
chronic total coronary occlusion (CTO).
MATERIALS AND METHODS:
A total of 50 CTO patients undergoing 1.5 Tesla MR were prospectively enrolled, and 28 underwent a
second MR 6 months after revascularization. T1-mapping based indices, including pre- and postcontrast
T1 values and ECV, were obtained from infarcted and non-infarcted myocardium, myocardial segments,
and coronary territory. The severity of myocardial injury was rated by transmurality extent of infarction
(TEI) and regional wall motion abnormalities (RWMA) score. Angiographic collateral ow was
evaluated using Rentrop classication. Improvement in segmental wall motion at 6 months was also
assessed.
RESULTS:
ECV and postcontrast T1 value signicantly outperformed precontrast T1 value for identifying
myocardial infarction (area under the receiver operating characteristic curve [AUC]: 0.998 and 0.953
versus 0.824, all P < 0.02). Myocardial ECV was strongly correlated with TEI (P = 0.000), RWMA score
(P = 0.000), and collateral classication (P = 0.007 for left anterior descending artery [LAD] territory, P
= 0.001 for non-LAD territory). Furthermore, the likelihood of functional recovery was better predicted
by ECV than by late gadolinium enhancement (LGE) (AUC: 0.76 versus 0.68, P < 0.02).
CONCLUSION:
Myocardial ECV may be a useful surrogate to assess myocardial injury and angiographic collateral ow
in CTO, and ECV provides incremental value to LGE in assessing functional recovery after
revascularization. J. MAGN. RESON. IMAGING 2016;44:972-982.
2016 International Society for Magnetic Resonance in Medicine.
PMID: 27008315 [PubMed - in process]
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16. Circulation. 1998 Apr 28;97(16):1557-62.

Noninvasive assessment of signicant left

anterior descending coronary artery stenosis by
coronary ow velocity reserve with transthoracic
color Doppler echocardiography.
Hozumi T1, Yoshida K, Ogata Y, Akasaka T, Asami Y, Takagi T, Morioka S.
Author information: 1Division of Cardiology, Kobe General Hospital, Japan. jse@warp.or.jp

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Abstract
BACKGROUND:
Coronary ow reserve has been considered an important diagnostic index of the functional signicance
of coronary artery stenosis. With Doppler technique, it has been assessed as the ratio of hyperemic to
basal coronary ow velocity (coronary ow velocity reserve [CFVR]) by invasive or semiinvasive
methods with a Doppler catheter, a Doppler guide wire, and a transesophageal Doppler
echocardiographic probe. Recent technological advancement in transthoracic Doppler echocardiography
(TTDE) provides measurement of coronary ow velocity in the distal portion of the left anterior
descending coronary artery (LAD) and may be useful in the noninvasive CFVR measurement. The
purpose of this study was to evaluate the value of CFVR determined by TTDE for the assessment of
signicant LAD stenosis.
METHODS AND RESULTS:
We studied 36 patients who underwent coronary angiography for the assessment of coronary artery
disease. The study population consisted of 12 patients with signicant LAD stenosis (group A) and 24
patients without signicant LAD stenosis (group B). With TTDE, coronary ow velocities in the distal
LAD were recorded at rest and during hyperemia induced by intravenous infusion of adenosine (0.14 mg
x kg(-1) x min(-1)) under the guidance of color Doppler ow mapping. Adequate spectral Doppler
recordings of coronary ow in the distal LAD for the assessment of CFVR were obtained in 34 of 36
study patients (94%). The peak and mean diastolic coronary ow velocities at baseline did not differ
between groups A and B (23.6+/-10.3 versus 22.9+/-6.6 cm/s and 16.4+/-8.6 versus 14.5+/-4.0 cm/s,
respectively). However, the peak and mean coronary ow velocities during hyperemia in group A were
signicantly smaller than those in group B (35.6+/-16.3 versus 54.2+/-16.3 cm/s and 24.7+/-13.1 versus
37.9+/-13.0 cm/s, respectively; P<.01). There were signicant differences in CFVR obtained from peak
and mean diastolic velocity between groups A and B (1.5+/-0.2 versus 2.4+/-0.4 and 1.5+/-0.2 versus
2.6+/-0.4, respectively; P<.001). A CFVR from peak diastolic velocity <2.0 had a sensitivity of 92% and
a specicity of 82% for the presence of signicant LAD stenosis. A CFVR from mean diastolic velocity
<2.0 had a sensitivity of 92% and a specicity of 86% for the presence of signicant LAD stenosis.
CONCLUSIONS:
CFVR determined by TTDE is useful in the noninvasive assessment of signicant stenotic lesion in the
LAD.
Free Article
PMID: 9593560 [PubMed - indexed for MEDLINE]
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MeSH Terms
Adult
Aged
Blood Flow Velocity
Coronary Circulation*
Coronary Disease/diagnostic imaging*
Coronary Disease/physiopathology*
Echocardiography, Doppler, Color
Female
Humans
Male
Middle Aged
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Predictive Value of Tests

Prospective Studies
17. Curr Cardiol Rev. 2014 May;10(2):88-98.

The evidence base for revascularisation of

chronic total occlusions.
Bagnall A, Spyridopoulos I1.
Author information: 1Department of Cardiology, The Freeman Hospital, Freeman Road, Newcastle upon
Tyne, NE7 7DN. UK. Alan.Bagnall@nuth.nhs.uk.

Abstract
When patients with ischaemic heart disease are considered for revascularisation the Heart Team's aim is
to choose a therapy that will provide complete relief of angina for an acceptable procedural risk.
Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the
presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to
revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery.
From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when
faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high
risk, there remains a reluctance to undertake CTO PCI, despite signicant recent advances in procedural
success and safety and a considerable body of evidence supporting a survival benet following
successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia
and left ventricular dysfunction and further explores the evidence relating their treatment to improved
quality of life and prognosis in patients with these features.

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