Impact of Chronic Total Occlusion Revascularization in Patients With Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention Renato Valenti, MD, Marco Marrani, MD, Giulia Cantini, MD, Angela Migliorini, MD, Nazario Carrabba, MD, Ruben Vergara, MD, Giampaolo Cerisano, MD, Guido Parodi, MD, PhD, and David Antoniucci, MD* Coronary chronic total occlusion (CTO) carries a poor outcome in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI). We sought to investigate the prognostic impact of a staged successful CTO-PCI in patients with AMI treated with primary PCI. Outcome analysis included consecutive patients treated by successful primary PCI with coexisting noneinfarct-related artery CTO who survived after 1 week from AMI. A comparison between patients with successful CTO-PCI and patients with failed or nonattempted CTO-PCI was performed. The primary end points of the study were 1year and 3-year cardiac survival. Of 1,911 patients who underwent successful primary PCI for AMI from 2003 to 2012, 169 (10%) had noneinfarct-related artery CTO of a major branch. A staged CTO-PCI attempt was performed in 74 patients (44%) and was successful in 58 (success rate 78%). All patients with successful CTO-PCI received drug-eluting stents. In the successful CTO-PCI group, a complete coronary revascularization was achieved in 88% of the patients. The 1-year cardiac mortality rate was 1.7% in the successful CTO-PCI group and 12% in nonattempted or failed CTO-PCI group (p [ 0.025). Successful CTO-PCI was an independent predictor of 3-year cardiac survival (hazard ratio 0.20, 95% confidence interval 0.05 to 0.92, p [ 0.038). In conclusion, successful CTO-PCI in survivors after primary PCI is associated with improved long-term cardiac survival. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;114:1794e1800)
Chronic total occlusion (CTO) in the setting of acute myocardial infarction (AMI) carries a poor early and late outcome despite successful primary percutaneous coronary intervention (PCI).1e8 No data exist regarding the impact on long-term survival of CTO-PCI in patients with AMI after successful primary PCI. We sought to investigate the prognostic impact of a staged successful CTO-PCI in patients with AMI treated with successful primary PCI. Methods From the Florence PCI registy, we identified consecutive patients treated by successful primary PCI (Thrombolysis In Myocardial Infarction [TIMI] grade 3 flow and residual infarct artery stenosis 30 minutes and 1 mm in at least 2 contiguous electrocardiographic leads or presumably new left bundle branch block. Patients received 325 mg of aspirin orally and a loading dose of 600 mg of clopidogrel (or 60 mg of prasugrel since 2010) before or immediately after the procedure. Abciximab was used routinely. Heparin was given to achieve an activated clotting time of 200 to 250 seconds. Since 2010 the use of bivalirudin was allowed. Rheolytic thrombectomy or manual aspiration thrombectomy was performed routinely if there was angiographic evidence of TIMI thrombus grade 3 to 5. IRA stenting was performed using bare-metal stents or drug-eluting stents according to the expected adherence to dual long-term antiplatelet treatment. Successful primary PCI was defined as a residual stenosis of the culprit lesion 3 months. Details of the Florence CTOPCI registry have been previously published.9e11 Briefly, the indication for the percutaneous treatment of CTO was the demonstration of viable myocardium in the territory of the occluded vessel by echographic or scintigraphic provocative tests, whereas no CTO angiographic characteristic was considered as an absolute contraindication to PCI attempt. Patients underwent PCI instead of coronary www.ajconline.org
Coronary Artery Disease/CTO in AMI Table 1 Baseline characteristic
From 2003 to 2012, 1911 pts underwent successful primary PCI (TIMI grade 3 flow)
Variable CTO 217 pts (11%) Side-branch CTO 34 pts Main-branch CTO 183 pts (10%) 14 pts died within 7 days after PCI One week survivors 169 pts (92%)
CTO-PCI attempted in 74/169 pts (44%)
CTO-PCI successful in 58/74 pts (78%)
Successful CTO-PCI 58 pts
1795
CTO-PCI not attempted in 95/169 pts (56%)
CTO-PCI failure in 16/74 pts (22%)
Persistently occluded CTO 111 pts
Figure 1. Patient flow diagram.
surgery because of high-surgical risk or patients’ willingness. CTO-PCI and PCI of non-IRA vessels with a stenosis >75% on visual assessment were scheduled up to 30 days after successful primary PCI. PCI was performed using standard techniques. Most CTO were attempted using the anterograde approach and dedicated coronary wires and devices. All successful recanalized CTO vessels were treated with drug-eluting stents. Procedural success was defined as a final diameter of stenosis 20 mm RVD (mm), mean SD Diameter 2.5 mm Heavy calcification Rotational atherectomy Stent implanted, n Stents / Patient Total stent length (mm), mean SD Post-PCI MLD (mm), mean SD Fluoroscopic time (min), median (IQR) Contrast (ml), median (IQR) Other vessel PCI
Three-vessel coronary disease Non-IRA, non-CTO PCI Left main PCI Complete revascularization*
All patients (n¼169)
Successful CTO-PCI (n ¼ 58)
Failed/Non-attempted CTO-PCI (n ¼ 111)
151 (89%) 63 (37%) 19 (12%) 5 (3.0%) 116 (69%) 16 3 232 1.37 58 (36%) 27 17 12.0 (8.0-20.0) 182 (84-350) 33 (19%)
51 (88%) 25 (43%) 6 (10.3%) 3 (5.2%) 38 (65%) 16 3 81 1.40 23 (40%) 25 15 10.5 (6.0-17.2) 236 (80-437) 17 (29%)
100 (90%) 38 (34%) 13 (12%) 2 (1.8%) 78 (72%) 16 2 151 1.36 35 (33%) 27 16 13.0 (8.0-20.0) 170 (84-290) 16 (14%)
All patients (n¼74)
Successful (n¼58)
Failed (n¼16)
23 (31%) 22 (30%) 29 (39%) 37 22 54/74 (73%) 2.77 0.33 3/74 (4.0%) 28/74 (39%) 2/74 (2.8%) 24 (16-33) 300 (200-435)
19 (33%) 19 (33%) 20 (34%) 37 22 44/58 (77%) 2.78 0.32 2/58 (3.4%) 22/58 (39%) 2/58 (3.6%) 75 1.29 50 29 2.71 0.30 24 (14-32) 300 (200-420)
4 (25%) 3 (19%) 9 (56%) 35 23 10/16 (62%) 2.77 0.35 1/16 (6.2%) 6/16 (40%) 0 28 (20-39) 300 (250-500)
All patients (n¼169)
Successful CTO-PCI (n ¼ 58)
Failed/Non-attempted CTO-PCI (n ¼ 111)
87 72/87 9 54
(51%) (83%) (5.3%) (32%)
34 27/34 5 51
(59%) (79%) (8.6%) (88%)
53 45/53 4 3
(48%) (85%) (3.6%) (2.7%)
p value
0.666 0.258 0.789 0.220 0.420 0.677 0.775 0.374 0.371 0.107 0.342 0.020
0.762 0.364 0.151 0.891 0.344 0.914 0.524 0.921 0.458 0.096 0.551
0.198 0.508 0.168
Chronic total occlusion (CTO) in the setting of acute myocardial infarction (AMI) carries a poor early and late outcome despite successful primary percutaneous coronary intervention (PCI).1e8 No data exist regarding the impact on long-term survival of CTO-PCI in patients with AMI after successful primary PCI. We sought to investigate the prognostic impact of a staged successful CTO-PCI in patients with AMI treated with successful primary PCI. Methods From the Florence PCI registy, we identified consecutive patients treated by successful primary PCI (Thrombolysis In Myocardial Infarction [TIMI] grade 3 flow and residual infarct artery stenosis 30 minutes and 1 mm in at least 2 contiguous electrocardiographic leads or presumably new left bundle branch block. Patients received 325 mg of aspirin orally and a loading dose of 600 mg of clopidogrel (or 60 mg of prasugrel since 2010) before or immediately after the procedure. Abciximab was used routinely. Heparin was given to achieve an activated clotting time of 200 to 250 seconds. Since 2010 the use of bivalirudin was allowed. Rheolytic thrombectomy or manual aspiration thrombectomy was performed routinely if there was angiographic evidence of TIMI thrombus grade 3 to 5. IRA stenting was performed using bare-metal stents or drug-eluting stents according to the expected adherence to dual long-term antiplatelet treatment. Successful primary PCI was defined as a residual stenosis of the culprit lesion 3 months. Details of the Florence CTOPCI registry have been previously published.9e11 Briefly, the indication for the percutaneous treatment of CTO was the demonstration of viable myocardium in the territory of the occluded vessel by echographic or scintigraphic provocative tests, whereas no CTO angiographic characteristic was considered as an absolute contraindication to PCI attempt. Patients underwent PCI instead of coronary www.ajconline.org
Coronary Artery Disease/CTO in AMI Table 1 Baseline characteristic
From 2003 to 2012, 1911 pts underwent successful primary PCI (TIMI grade 3 flow)
Variable CTO 217 pts (11%) Side-branch CTO 34 pts Main-branch CTO 183 pts (10%) 14 pts died within 7 days after PCI One week survivors 169 pts (92%)
CTO-PCI attempted in 74/169 pts (44%)
CTO-PCI successful in 58/74 pts (78%)
Successful CTO-PCI 58 pts
1795
CTO-PCI not attempted in 95/169 pts (56%)
CTO-PCI failure in 16/74 pts (22%)
Persistently occluded CTO 111 pts
Figure 1. Patient flow diagram.
surgery because of high-surgical risk or patients’ willingness. CTO-PCI and PCI of non-IRA vessels with a stenosis >75% on visual assessment were scheduled up to 30 days after successful primary PCI. PCI was performed using standard techniques. Most CTO were attempted using the anterograde approach and dedicated coronary wires and devices. All successful recanalized CTO vessels were treated with drug-eluting stents. Procedural success was defined as a final diameter of stenosis 20 mm RVD (mm), mean SD Diameter 2.5 mm Heavy calcification Rotational atherectomy Stent implanted, n Stents / Patient Total stent length (mm), mean SD Post-PCI MLD (mm), mean SD Fluoroscopic time (min), median (IQR) Contrast (ml), median (IQR) Other vessel PCI
Three-vessel coronary disease Non-IRA, non-CTO PCI Left main PCI Complete revascularization*
All patients (n¼169)
Successful CTO-PCI (n ¼ 58)
Failed/Non-attempted CTO-PCI (n ¼ 111)
151 (89%) 63 (37%) 19 (12%) 5 (3.0%) 116 (69%) 16 3 232 1.37 58 (36%) 27 17 12.0 (8.0-20.0) 182 (84-350) 33 (19%)
51 (88%) 25 (43%) 6 (10.3%) 3 (5.2%) 38 (65%) 16 3 81 1.40 23 (40%) 25 15 10.5 (6.0-17.2) 236 (80-437) 17 (29%)
100 (90%) 38 (34%) 13 (12%) 2 (1.8%) 78 (72%) 16 2 151 1.36 35 (33%) 27 16 13.0 (8.0-20.0) 170 (84-290) 16 (14%)
All patients (n¼74)
Successful (n¼58)
Failed (n¼16)
23 (31%) 22 (30%) 29 (39%) 37 22 54/74 (73%) 2.77 0.33 3/74 (4.0%) 28/74 (39%) 2/74 (2.8%) 24 (16-33) 300 (200-435)
19 (33%) 19 (33%) 20 (34%) 37 22 44/58 (77%) 2.78 0.32 2/58 (3.4%) 22/58 (39%) 2/58 (3.6%) 75 1.29 50 29 2.71 0.30 24 (14-32) 300 (200-420)
4 (25%) 3 (19%) 9 (56%) 35 23 10/16 (62%) 2.77 0.35 1/16 (6.2%) 6/16 (40%) 0 28 (20-39) 300 (250-500)
All patients (n¼169)
Successful CTO-PCI (n ¼ 58)
Failed/Non-attempted CTO-PCI (n ¼ 111)
87 72/87 9 54
(51%) (83%) (5.3%) (32%)
34 27/34 5 51
(59%) (79%) (8.6%) (88%)
53 45/53 4 3
(48%) (85%) (3.6%) (2.7%)
p value
0.666 0.258 0.789 0.220 0.420 0.677 0.775 0.374 0.371 0.107 0.342 0.020
0.762 0.364 0.151 0.891 0.344 0.914 0.524 0.921 0.458 0.096 0.551
0.198 0.508 0.168
