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      Clinical, Electrocardiographic, and Procedural Characteristics of Patients With Coronary Chronic Total Occlusions

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          Abstract

          Background and Objectives

          Percutaneous coronary intervention for chronic total occlusion lesions is technically difficult despite equipment advances. Changes in electrocardiographic patterns, such as Q and T waves, during chronic total occlusion can provide information about procedural success and myocardial viability. In this study, we investigated clinical, electrocardiographic, and procedural characteristics of chronic total occlusions.

          Subjects and Methods

          Patients (2,635) who underwent coronary angiography between January 2006 and July 2007 at six Catholic University Hospitals were identified using a dedicated Internet database.

          Results

          A total of 195 patients had total occlusion lesions (7.4%). Percutaneous coronary interventions were attempted in 136 total occlusion lesions (66.0%) in 134 patients. Successful recanalization with stent implantation was accomplished in 89 lesions, with a procedural success rate of 66.4%. One procedure-related death occurred because of no-reflow phenomenon. After excluding 8 patients with bundle branch block, Q and T wave inversions were observed in 60 (32.1%) and 78 patients (41.7%), respectively. The presence of Q waves was associated with severe angina, decreased left ventricular ejection fraction, regional wall motion abnormality, and T wave inversion, but was not related to procedural success.

          Conclusion

          Percutaneous coronary intervention is a safe and useful procedure for the revascularization of coronary chronic total occlusion lesions. The procedural success rate was not related to the presence of pathologic Q waves, which were associated with severe angina and decreased left ventricular function.

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          Most cited references30

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          Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience.

          The study compared procedural outcomes and long-term survival for patients undergoing percutaneous coronary intervention (PCI) of a chronic total coronary artery occlusion (CTO) with a matched non-CTO cohort to determine whether successful PCI of a CTO is associated with improved survival. Percutaneous coronary intervention of a CTO is a common occurrence, and the long-term survival for patients with successful PCI of a CTO has not been clearly defined. Between June 1980 and December 1999, a total of 2,007 consecutive patients underwent PCI for a CTO. Utilizing propensity scoring methods, a matched non-CTO cohort of 2,007 patients was identified and compared to the CTO group. The cohorts were stratified into successful and failed procedures. The in-hospital major adverse cardiac event (MACE) rate was 3.8% in the CTO cohort. Technical success has improved over the last 10 years (overall 74.4%, slope 1.0%/yr, p = 0.02, R2 = 49.9%) as did procedural success (overall 69.9%, slope 1.2%/yr, p = 0.02, R2 = 51.5%) without a concomitant increase in in-hospital MACE rates (slope 0.1%/yr, p = 0.7). There was a distinct 10-year survival advantage for successful CTO treatment compared with failed CTO treatment (73.5% vs. 65.1%, p = 0.001). The CTO versus non-CTO 10-year survival was the same (71.2% vs. 71.4%, p = 0.9). Diabetics in the CTO cohort had a lower 10-year survival compared with nondiabetics (58.3% vs. 74.3%, p < 0.0001). These data represent follow-up of the largest reported series of patients undergoing PCI for a CTO. The 10-year survival rates for matched non-CTO and the CTO cohorts were similar. Success rates have continued to improve without an accompanying increase in MACE rates. A successfully revascularized CTO confers a significant 10-year survival advantage compared with failed revascularization.
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            Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE).

            We sought to investigate the success rate and the acute and 12-month clinical outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in the contemporary era. The technique of PCI involving CTO has improved over time. However, limited data on acute and follow-up results in patients treated with PCI on CTO in recent years are available. Four hundred nineteen consecutive patients scheduled for PCI of CTO of > or =30 days of duration were enrolled in 29 centers; 390 CTOs were confirmed in 376 patients in an independent core laboratory. The end points were technical and procedural success, in-hospital and 12-month major adverse cardiac events (MACE) occurrence, and 12-month symptomatic status. Technical and procedural success was obtained in 77.2% and 73.3% of lesions, respectively. In-hospital major adverse cardiac events occurred in 5.1% of patients. Multivariate analysis identified CTO length >15 mm or not measurable, moderate to severe calcifications, duration > or =180 days, and multivessel disease as significant predictors of PCI failure. At 12 months, patients with a successful procedure experienced a lower incidence of cardiac deaths or myocardial infarction (1.05% vs. 7.23%, p = 0.005), a reduced need for coronary artery bypass surgery (2.45% vs. 15.7%, p < 0.0001), and were more frequently free of angina (88.7% vs. 75.0%, p = 0.008) compared with patients who had an unsuccessful procedure. Successful PCI was achieved in a high percentage of CTOs with a low incidence of complications. At one-year follow-up, patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessful.
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              Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992-2002.

              Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some evidence from one study that successful percutaneous revascularization leads to an improvement in long-term survival rates. However, this study included patients treated for unstable angina with short-duration occlusion, and stent implantation was utilized in only 7%. We re-evaluated the long-term outcomes of a large consecutive series of patients with a CTO of >1-month duration treated at our centre, with stent implantation utilized in the majority. All patients treated with percutaneous coronary intervention (PCI) between 1992 and 2002 were retrospectively identified from a dedicated database. A total of 874 consecutive patients were treated for 885 CTO lesions. Mean follow-up time was 4.47 +/- 2.69 years (median 4.10 years). Patients were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization with either coronary artery bypass surgery or PCI. Successful revascularization was achieved in 576 lesions (65.1%), in which stent implantation was used in 81.0%. At 30 days, the overall MACE rate was significantly lower in those patients with a successful recanalization (5.5 vs. 14.8%, P < 0.00001). At 5 years, survival was significantly higher in those patients with a successful revascularization (93.5 vs. 88.0%, P = 0.02). In addition, there was a significantly higher survival free of MACE (63.7 vs. 41.7%, P < 0.0001), with the majority of events reflecting the need for repeat intervention. Independent predictors for survival were successful revascularization, lower age, and the absence of diabetes mellitus and multivessel disease. Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years. Most events relate to the need for repeat reintervention, and the introduction of drug-eluting stents, with low-restenosis rates, encourages the development of technologies to improve recanalization success rates. However, failed recanalization may be associated acutely with an adverse event, and new technologies must focus on a safe approach to successful recanalization.
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                Author and article information

                Journal
                Korean Circ J
                KCJ
                Korean Circulation Journal
                The Korean Society of Cardiology
                1738-5520
                1738-5555
                March 2009
                25 March 2009
                : 39
                : 3
                : 111-115
                Affiliations
                Department of Cardiology, College of Medicine, The Catholic University of Korea, Seoul, Korea.
                Author notes
                Correspondence: Hee-Yeol Kim, MD, Department of Cardiology, College of Medicine, The Catholic University of Korea, 2 Sosa-dong, Wonmi-gu, Bucheon 420-717, Korea. Tel: 82-32-340-2018, Fax: 82-32-340-2669, cumckhy@ 123456catholic.ac.kr
                Article
                10.4070/kcj.2009.39.3.111
                2771804
                19949597
                a13fc7e2-9cf1-4d6e-8937-83bdbc56e784
                Copyright © 2009 The Korean Society of Cardiology

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 September 2008
                : 10 December 2008
                : 05 January 2009
                Categories
                Original Article

                Cardiovascular Medicine
                angioplasty,electrocardiogram,coronary occlusion
                Cardiovascular Medicine
                angioplasty, electrocardiogram, coronary occlusion

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