Impact of Residual Chronic Total Occlusion of Right Coronary Artery on the Long-term Outcome in Patients Treated for Unprotected Left Main Disease

Abstract

W ith continual improvements in stent technology and adjunctive pharmacotherapy, we have supportive evidence regarding percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation in selected unprotected left main (ULM) lesions involving ostium/body or distal bifurcation with low-to-moderate SYNTAX scores. [1][2][3][4][5][6][7][8] Conversely, in patients with SYNTAX score >32, coronary artery bypass grafting (CABG) is recommended. 9 The presence of chronic total occlusion of the right coronary artery (CTO-RCA) contributes to the generation of a high SYNTAX score in patients with ULM stenosis. There is scarcity of data on the impact of residual CTO-RCA in patients undergoing PCI for ULM, and we aim to study this aspect in our cohort of patients. MethodsBetween P=0.014), resulting in the similar major adverse cardiovascular events rates between the 2 groups. When we analyzed patients with concomitant ULM and CTO-RCA, cardiac-death was significantly higher in patients with residual as compared with treated CTO-RCA (log-rank P=0.01) despite no difference in baseline characteristics. Conclusions-Cardiac-death occurred more frequently in patients with residual CTO-RCA as compared with those without residual CTO-RCA. These findings suggest that recanalization of CTO-RCA has significant impact on the longterm cardiac-mortality in patients undergoing ULM-percutaneous interventions probably by offering reserve coronary circulation, if in-stent restenosis were to occur in the treated left main. (Circ Cardiovasc Interv. 2013;6:154-160.)Key Words: chronic total coronary occlusion ◼ drug-eluting stent ◼ left main coronary artery ◼ right coronary artery

Chronic total occlusions — Current techniques and future directions

“…This review will focus on the development of new techniques for CTO PCI with an emphasis on procedurally relevant histopathology and the differing methodologies that have emerged from sites in Japan and the United States of America. A discussion of the prognostic importance of CTOs and the rationale for revascularisation is beyond the scope of this review and has been published elsewhere [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27].…”

Right coronary artery patency as a modulator for unprotected left main PCI risk: myth or reality?

“…Moreover, RCA CTO was recognized as an independent predictor of 3-year cardiac mortality (HR 2.15 [1.02-4.05]; P = 0.043). In line with these results, Takagi et al [7] concluded that in patients undergoing ULM PCI, cardiac death was higher in patients with residual RCA CTO as compared to those without residual RCA CTO (HR 2.163 [1.018-4.597]; P = 0.045) at 1466 days follow-up. Besides, they showed that recanalization of RCA CTO significantly improves long-term survival (P = 0.010).…”

Five-Year Outcomes of Successful Percutaneous Coronary Intervention with Drug-Eluting Stents versus Medical Therapy for Chronic Total Occlusions

“…Many trials have investigated the relationship between the risk of mortality and CTO in various populations. 1 2 3 4 5 6 The HORIZONS-AMI trial reported that the presence of CTO was an independent predictor of both increased early (within 30 days, HR: 2.88, 95% CI: 1.41–5.88, p =0.004) and late mortality (from 30 days to 3 years, HR: 1.98, 95% CI: 1.19–3.29, p =0.009) in STEMI patient. 2 The PL-ACS study, reported CTO was an independent predictor of 1-year mortality (HR: 1.42, 95% CI: 1.01–2.00, p =0.047) in patients with non-STEMI.…”

“…It has been found that the presence of CTO is associated with a higher mortality rate in patients with acute myocardial infarction, multi-vessel disease (MVD), or left main disease. 1 2 3 4 5 6 The presence of CTO has also been shown to be associated with a reduced left ventricular ejection fraction (LVEF; <40%) and further deterioration of LVEF in ST-segment elevation myocardial infarction (STEMI) patients. 5 In the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 61% of CTO patients were treated with medical therapy (MT), while only one third (39%) were treated with early coronary revascularization by percutaneous coronary intervention (PCI; 24%) or coronary artery bypass graft surgery (CABG; 15%).…”