FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W4387597750> ?p ?o ?g. }

• W4387597750 abstract "HomeJournal of the American Heart AssociationAhead of PrintSurvival Following Recanalization of Chronic Total Occlusion: The Devil Is in the Details Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBSurvival Following Recanalization of Chronic Total Occlusion: The Devil Is in the Details Reza Masoomi and Lorenzo Azzalini Reza MasoomiReza Masoomi https://orcid.org/0000-0003-3478-0968 , Division of Cardiology, Department of Medicine, , University of Washington, , Seattle, , WA, Search for more papers by this author and Lorenzo AzzaliniLorenzo Azzalini * Correspondence to: Lorenzo Azzalini, MD, PhD, MSc, Division of Cardiology, Department of Medicine, University of Washington Medical Center, 1959 NE Pacific St, Box 356422, Seattle, WA 98195. Email: E-mail Address: [email protected] https://orcid.org/0000-0001-9758-0360 , Division of Cardiology, Department of Medicine, , University of Washington, , Seattle, , WA, Search for more papers by this author Originally published13 Oct 2023https://doi.org/10.1161/JAHA.123.032178Journal of the American Heart Association. 2023;0:e032178Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has traditionally received intense scrutiny because of higher procedural complexity, lower success, and higher complication rates compared with non‐CTO PCI.1 Over the past decade, the field has witnessed notable enhancements in success rates and safety margins. Appropriately selected patients undergoing CTO PCI have demonstrated significant improvements across various parameters, including angina status, quality of life, depression, ischemic burden, and physical performance.1, 2 Several observational studies have previously reported that unsuccessful CTO PCI is associated with worse long‐term clinical outcomes (including mortality) compared with successful CTO PCI, but these observations are plagued by the intrinsic limitations of their nonrandomized design, which are centered on their inability to appropriately identify and control for clinical confounders.3, 4, 5 In fact, randomized clinical trials have failed to demonstrate a difference in hard clinical end points between CTO PCI and optimal medical therapy,6 highlighting the challenges in designing and conducting randomized studies in this area of research.Against such background, a new perspective on this topic is provided in this issue of the Journal of the American Heart Association (JAHA) by Holck et al,7 who analyzed the outcomes of 19 033 patients undergoing non‐CTO PCI and 2108 patients undergoing CTO PCI between 2009 and 2019 within the Central Region of Denmark. Their study was based on 2 main hypotheses: compared with patients undergoing PCI for non‐CTO indications, (1) patients who underwent successful CTO revascularization have similar all‐cause mortality; and (2) patients with residual CTOs after failed CTO PCI have worse all‐cause mortality. In the entire population, mean age was 66.7±11.8 years. The prevalence of prior PCI was 19.0%, prior coronary artery bypass grafting, 4.1%; and diabetes, 18.3%. Mean left ventricular ejection fraction was 51.7±11.9%. The success rate of all CTO lesions at the patient level was 74% in the CTO group. A total of 5496 patients (26.0%) died within 9 years of follow‐up, and the median follow‐up was 5.7 years. All‐cause mortality was higher in patients with CTO versus non‐CTO patients (29.7% versus 25.6%; P<0.001), but this difference lost statistical significance on multivariable analysis (adjusted hazard ratio [HR], 1.08 [95% CI, 0.97–1.20]; P=0.165). Intriguingly, although successful CTO PCI had a similar risk of all‐cause death compared with non‐CTO PCI (adjusted HR, 0.99 [95% CI, 0.87–1.12]; P=0.873), unsuccessful CTO PCI was independently associated with worse survival compared with non‐CTO PCI (adjusted HR, 1.35 [95% CI, 1.13–1.63]; P=0.001). Notably, compared with non‐CTO PCI patients, patients who underwent unsuccessful CTO PCI had worse prognosis in both the early post‐PCI period and the long‐term, with an HR of 2.23 (95% CI, 1.65–3.01) between 0 and 30 days, and an HR of 1.74 (95% CI, 1.50–2.02) between 30 days and 9 years.These observations bring us to the core of the debate elicited by the study by Holck et al7: what is the underlying cause for the increased all‐cause mortality observed in cases of unsuccessful CTO PCI? In our view, 3 possible explanations can be entertained. First, the completeness of revascularization: patients with unsuccessful CTO PCI receive, by definition, incomplete revascularization, which has been associated with worse outcomes (including survival) by several studies.8, 9 However, it seems unlikely that the effects of incomplete revascularization become manifest in the early (0–30 days) postinterventional period. The second explanation pertains to the potential detrimental effects of an unsuccessful procedure. Interestingly, Guan et al reported that suboptimal CTO PCI (defined as persistence of significant side branch occlusion, final thrombolysis in myocardial infarction flow grade 1 or 2, or residual percentage diameter stenosis >30%) was associated with higher incidence of 5‐year cardiac death or myocardial infarction compared with both successful and failed CTO PCI.10 Unfortunately, the study by Holck et al7 does not distinguish between suboptimal and failed CTO PCI, which hampers further speculations. The third explanation is that an unknown, residual confounder is still present despite multivariable adjustment, which is surely a possibility, as it has previously been identified as a strong limitation of observational studies in this particular area of research.Holck and colleagues are to be congratulated for their efforts in addressing this relevant clinical question. The strengths of their study include their large cohort, representative of a moderate‐sized geographic region of their country, the long follow‐up, and the systematic tracking of the outcome of interest (all‐cause mortality) via a national administrative repository. Nevertheless, the study also presents certain limitations that merit discussion. Foremost, the choice of all‐cause mortality as the primary end point of this study is particularly controversial, as all‐cause death is confounded by a variety of nonischemic (and non–CTO‐related) conditions that can lead to death (eg, cancer and infections). In fact, it has been reported that the excess noncardiac mortality seen in PCI‐treated patients (compared with coronary artery bypass grafting) is most likely attributable to coding errors (cardiac deaths being coded as noncardiac).11 Moreover, the choice of mortality as the primary end point is controversial. Randomized data have consistently shown that, with the exception of primary PCI for ST‐segment–elevation myocardial infarction,12 PCI in all comers does not improve survival,13, 14 which has been proven also for CTO PCI.6 Yet, paradoxically, the study by Holck et al7 suggests that failing to recanalize a CTO is associated with a higher risk of death. Again, this may be attributable to 1 of the mechanisms previously described, but we can only speculate because the present study does not elucidate on the pathophysiological mechanisms linking a failed CTO PCI with higher mortality.10 Furthermore, additional limitations of the present study include lack of granularity with regard to coronary anatomy and procedural variables, as well as data on complications. Finally, the lack of quantification of incomplete revascularization (reasonably incomplete versus truly incomplete) and how repeated CTO PCI attempts were handled in the analyses does not allow parsing out the true impact of CTO PCI on clinical outcomes and leads to further speculation on the mechanisms underlying the study findings.CTO PCI remains a persistent clinical and research challenge, stemming from the complex patient population and procedural techniques it encompasses. As stated by Holck et al,7 the determination of whether CTO PCI should be undertaken on the basis of prognostic indications necessitates forthcoming CTO trials, given the inherent bias associated with observational studies. Further light on this topic will be shed by the ISCHEMIA‐CTO trial (NCT03563417), which is randomizing >1500 patients to CTO PCI versus optimal medical therapy, with the goal to test 2 hypotheses: (1) in asymptomatic patients with ≥10% of myocardial ischemia, PCI is superior to optimal medical therapy in terms of relative reduction in major adverse cardiovascular and cerebrovascular events; and (2) in symptomatic patients with ≥5% of myocardial ischemia, PCI is superior to optimal medical therapy in terms of improved quality of life. Although this trial holds the potential to provide more definitive answers on the clinical impact of CTO recanalization, its results are expected no earlier than 2029. In the meantime, the jury is still out, and this topic will likely continue to fuel heated debates across peer‐reviewed publications, conferences, and social media.DisclosuresDr Azzalini received honoraria from Teleflex, Abiomed, GE Healthcare, Asahi Intecc, Philips, Abbott Vascular, Reflow Medical, and Cardiovascular System, Inc; serves on the advisory board of GE Healthcare; and owns equity in Reflow Medical. Dr Masoomi has no disclosures to report.Footnotes* Correspondence to: Lorenzo Azzalini, MD, PhD, MSc, Division of Cardiology, Department of Medicine, University of Washington Medical Center, 1959 NE Pacific St, Box 356422, Seattle, WA 98195. Email: azzalini@uw.eduThis article was sent to Jennifer Tremmel, MD, Associate Editor, for editorial decision and final disposition.See Article by Holck et al.For Disclosures, see page 2.REFERENCES1 Azzalini L, Karmpaliotis D, Santiago R, Mashayekhi K, Di Mario C, Rinfret S, Nicholson WJ, Carlino M, Yamane M, Tsuchikane E, et al. Contemporary issues in chronic total occlusion percutaneous coronary intervention. JACC Cardiovasc Interv. 2022; 15:1–21. doi: 10.1016/j.jcin.2021.09.027CrossrefMedlineGoogle Scholar2 Sapontis J, Salisbury AC, Yeh RW, Cohen DJ, Hirai T, Lombardi W, McCabe JM, Karmpaliotis D, Moses J, Nicholson WJ, et al. Early procedural and health status outcomes after chronic total occlusion angioplasty: a report from the OPEN‐CTO registry (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures). JACC Cardiovasc Interv. 2017; 10:1523–1534. doi: 10.1016/j.jcin.2017.05.065CrossrefMedlineGoogle Scholar3 Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta‐analysis. Am Heart J. 2010; 160:179–187. doi: 10.1016/j.ahj.2010.04.015CrossrefMedlineGoogle Scholar4 Khan MF, Wendel CS, Thai HM, Movahed MR. Effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta‐analysis comparing successful versus failed percutaneous intervention for chronic total occlusion. Catheter Cardiovasc Interv. 2013; 82:95–107. doi: 10.1002/ccd.24863CrossrefMedlineGoogle Scholar5 Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, Abdullah S, Grodin J, Kumbhani DJ, Vo M, et al. Meta‐analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol. 2015; 115:1367–1375. doi: 10.1016/j.amjcard.2015.02.038CrossrefMedlineGoogle Scholar6 Lee SW, Lee PH, Ahn JM, Park DW, Yun SC, Han S, Kang H, Kang SJ, Kim YH, Whan Lee C, et al. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion. Circulation. 2019; 139:1674–1683. doi: 10.1161/CIRCULATIONAHA.118.031313LinkGoogle Scholar7 Holck EN, Winther NS, Mogensen LJH, Christiansen EH. Chronic total occlusion is not a risk factor for mortality in patients with successful percutaneous coronary intervention–a cohort study. J Am Heart Assoc. 2023; 12:e030989. doi: 10.1161/JAHA.123.030989LinkGoogle Scholar8 Genereux P, Palmerini T, Caixeta A, Rosner G, Green P, Dressler O, Xu K, Parise H, Mehran R, Serruys PW, et al. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) score. J Am Coll Cardiol. 2012; 59:2165–2174. doi: 10.1016/j.jacc.2012.03.010CrossrefMedlineGoogle Scholar9 Farooq V, Serruys PW, Bourantas CV, Zhang Y, Muramatsu T, Feldman T, Holmes DR, Mack M, Morice MC, Ståhle E, et al. Quantification of incomplete revascularization and its association with five‐year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation. 2013; 128:141–151. doi: 10.1161/CIRCULATIONAHA.113.001803LinkGoogle Scholar10 Guan C, Yang W, Song L, Chen J, Qian J, Wu F, Zou T, Shi Y, Sun Z, Xie L, et al. Association of acute procedural results with long‐term outcomes after CTO PCI. JACC Cardiovasc Interv. 2021; 14:278–288. doi: 10.1016/j.jcin.2020.10.003CrossrefMedlineGoogle Scholar11 Gaudino M, Hameed I, Farkouh ME, Rahouma M, Naik A, Robinson NB, Ruan Y, Demetres M, Biondi‐Zoccai G, Angiolillo DJ, et al. Overall and cause‐specific mortality in randomized clinical trials comparing percutaneous interventions with coronary bypass surgery: a meta‐analysis. JAMA Intern Med. 2020; 180:1638–1646. doi: 10.1001/jamainternmed.2020.4748CrossrefMedlineGoogle Scholar12 Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361:13–20. doi: 10.1016/S0140-6736(03)12113-7CrossrefMedlineGoogle Scholar13 De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PAL, Piroth Z, Jagic N, Möbius‐Winkler S, Rioufol G, Witt N, et al. Fractional flow reserve‐guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012; 367:991–1001. doi: 10.1056/NEJMoa1205361CrossrefMedlineGoogle Scholar14 Mehta SR, Wood DA, Storey RF, Mehran R, Bainey KR, Nguyen H, Meeks B, Di Pasquale G, López‐Sendón J, Faxon DP, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2019; 381:1411–1421. doi: 10.1056/NEJMoa1907775CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics Copyright © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.123.032178PMID: 37830351 Originally publishedOctober 13, 2023 KeywordsmortalityEditorialsvascular diseaseschronic total occlusionpercutaneous coronary interventionsurvivalPDF download SubjectsPercutaneous Coronary Intervention" @default.
• W4387597750 created "2023-10-14" @default.
• W4387597750 creator A5054403069 @default.
• W4387597750 creator A5076556116 @default.
• W4387597750 date "2023-10-13" @default.
• W4387597750 modified "2023-10-18" @default.
• W4387597750 title "Survival Following Recanalization of Chronic Total Occlusion: The Devil Is in the Details" @default.
• W4387597750 cites W1596886107 @default.
• W4387597750 cites W2052944838 @default.
• W4387597750 cites W2059289792 @default.
• W4387597750 cites W2080418381 @default.
• W4387597750 cites W2082947112 @default.
• W4387597750 cites W2133924558 @default.
• W4387597750 cites W2153129343 @default.
• W4387597750 cites W2743515617 @default.
• W4387597750 cites W2916496138 @default.
• W4387597750 cites W2970909790 @default.
• W4387597750 cites W3092193456 @default.
• W4387597750 cites W3100252009 @default.
• W4387597750 cites W4206982991 @default.
• W4387597750 cites W4387600081 @default.
• W4387597750 doi "https://doi.org/10.1161/jaha.123.032178" @default.
• W4387597750 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/37830351" @default.
• W4387597750 hasPublicationYear "2023" @default.
• W4387597750 type Work @default.
• W4387597750 citedByCount "0" @default.
• W4387597750 crossrefType "journal-article" @default.
• W4387597750 hasAuthorship W4387597750A5054403069 @default.
• W4387597750 hasAuthorship W4387597750A5076556116 @default.
• W4387597750 hasBestOaLocation W43875977501 @default.
• W4387597750 hasConcept C126322002 @default.
• W4387597750 hasConcept C164705383 @default.
• W4387597750 hasConcept C71924100 @default.
• W4387597750 hasConceptScore W4387597750C126322002 @default.
• W4387597750 hasConceptScore W4387597750C164705383 @default.
• W4387597750 hasConceptScore W4387597750C71924100 @default.
• W4387597750 hasLocation W43875977501 @default.
• W4387597750 hasLocation W43875977502 @default.
• W4387597750 hasOpenAccess W4387597750 @default.
• W4387597750 hasPrimaryLocation W43875977501 @default.
• W4387597750 hasRelatedWork W1531601525 @default.
• W4387597750 hasRelatedWork W2758277628 @default.
• W4387597750 hasRelatedWork W2899084033 @default.
• W4387597750 hasRelatedWork W2935909890 @default.
• W4387597750 hasRelatedWork W2948807893 @default.
• W4387597750 hasRelatedWork W3173606202 @default.
• W4387597750 hasRelatedWork W3183948672 @default.
• W4387597750 hasRelatedWork W4387497383 @default.
• W4387597750 hasRelatedWork W2778153218 @default.
• W4387597750 hasRelatedWork W3110381201 @default.
• W4387597750 isParatext "false" @default.
• W4387597750 isRetracted "false" @default.
• W4387597750 workType "article" @default.