Risk of cardiac and sudden death with and without revascularisation of a coronary chronic total occlusion

Abstract

ObjectiveThe aim of this study is to evaluate the long-term risk of cardiac death and sudden cardiac death (SCD) and/or sustained ventricular arrhythmias (SVAs) in patients with coronary chronic total occlusions (CTO) revascularised versus those with CTO not revascularised by percutaneous coronary intervention (PCI).MethodsFrom a cohort of 1357 CTO-PCI patients, 1162 patients who underwent CTO PCI attempt were included in this long-term analysis: 837 patients were revascularised by PCI (CTO-R group) and 325 were not revascularised (CTO-NR group). Primary adverse endpoint was the incidence of cardiac death; secondary endpoint was the cumulative incidence of SCD/SVAs.ResultsUp to 12-year follow-up (median 6 year), compared with CTO-R patients, those with CTO-NR had significantly higher rate of cardiac death (13%[43/325]vs6%[48/837]; p<0.001) and SCD/SVAs (7.5%[24/325]vs2.5%[20/837]; p<0.001). The risk of cardiac death and SCD/SVAs was mainly driven by the subgroup of infarct-related artery (IRA) CTO patients and was significantly higher only in IRA CTO-NR patients (18%vs7%, p<0.001, 14%vs5%, p=0.001; IRA CTO-NR vs IRA CTO-R, respectively). At multivariable Cox hazards regression analysis, CTO-NR remains one of the strongest independent predictors of higher risk of cardiac death and of SCD/SVAs in the overall population and in IRA CTO patients.ConclusionsAt long-term follow-up, patients with CTO not revascularised by PCI had worse outcomes compared with those with CTO revascularised, with >2-fold risk of cardiac death and threefold risk of SCD/SVAs. The presence of an infarct-related artery (IRA CTO) not revascularised identified the category of patients with the highest rate of adverse events .

Long‐term clinical effects of recanalization of chronic coronary total occlusions in patients with left ventricular systolic dysfunction

“…Godino et al found that a large amount of sudden cardiac death occurred in patients with LVEF >40% suggesting that such events are probably caused by ventricular arrhythmias triggered by residual myocardial ischemia rather than by LV dysfunction itself. 21 Our study confirms and extends the results of previous studies, with the additive value of a much longer follow-up and the inclusion of a specific study population characterized by LV systolic dysfunction. In fact, this is the first study comparing the results of CTO recanalization focused in patients with post-ischemic LV systolic dysfunction.…”

Revascularization of coronary chronic total occlusions in an infarct‐related artery and recurrence of ventricular arrhythmias among patients with secondary prevention implantable cardioverter defibrillator

“…This generalized opinion is challenged by several reports demonstrating that the scar is a dynamic tissue, metabolically active, which undergoes a constant process of structural and electrical remodeling 6,14,15 . The results presented here are coherent with data from other reports showing a significant association between IRACTO and ventricular arrhythmias 1,3,4 and indicating a potential effect of IRACTO revascularization on the electrical remodeling of the scar 17,18 and the occurrence of VA or sudden death 2 . Altogether, this increasing evidence might imply a paradigmatic shift in the management of patients with VA and prior MI.…”

“…The little attention paid to viability and ischemia in patients admitted due to VA reflects the current paradigm that chronic ischemia does not play a significant role in the genesis of VA in patients with post‐MI scar and stable coronary artery disease. The present work and other recent evidence 1‐4 challenge this paradigm.…”

“…On the contrary, our work has included a population with very high risk of VA. Thus, the two studies provide complementary information: the report by Godino et al suggests that preventive IRACTO revascularization may be helpful to reduce long‐term occurrence of arrhythmic events among low‐risk patients without a history of ventricular arrhythmias 2 . Our report suggests a strong association between IRACTO revascularization and lower recurrence of ventricular arrhythmias in a very high‐risk population with secondary prevention ICDs.…”

“…IRACTO revascularization was successful at controlling VA in a patient with VT storm 21 . In another study among patients undergoing percutaneous CTO revascularization, successful revascularization of an IRACTO was an independent predictor of freedom from ventricular arrhythmias or sudden death during follow‐up 2 ; this report included patients at low risk for VA, only 0.08% of patients had had ventricular arrhythmias before the inclusion and only 4% of patients had ventricular arrhythmias or sudden death during follow‐up 2 . On the contrary, our work has included a population with very high risk of VA.…”