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      CTO (Chronic Total Occlusion)

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      , MD 1 , , , MD 1
      Cardiovascular Innovations and Applications
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            Main article text

            Introduction

            Chronic total occlusion (CTO), is a common abnormality in patients with known coronary artery disease. Many of these patients have been undertreated because of the poor prognosis associated with other known coronary artery disease; e.g., multivessel CAD (MVCAD).

            CTO definition

            CTO is defined as an occlusion or very low grade TIMI flow of at least 3 months duration [1]. This suggests that dead muscle may be present. If this is the case, as suggested by the work of Khoeif et al. [1], a simple way to evaluate this question is to obtain some indication of LV dysfunction (regional wall motion, RWM) prior to recanalization of a CTO and perform another LV function test after recanalization for comparison - perhaps an echo or another form of imaging to assess RWM such as a cardiac MRI. Collaterals may be present suggesting viability, and these patients are most likely to improve regional wall motion with CTO recanalization.

            Early success of CTO/PCI

            Early success of CTO PCI is defined as the recanalization of the occluded artery. This occurs in about 80% of the time when done by experienced CTO operators and the success rate increases over time.

            Early successful opening of an occluded artery does not correlate with prognosis when the perfused myocardium shows no viability.

            Lack of literature on the subject of CTO

            I could not find any reports in the English literature in which there was normalization of affected regional LV wall motion (not EF) after successful early recanalization of a typical total occlusion in the absence of viable myocardium. Discussions with interventional cardiologists have failed to reveal whether there are any data on improved regional wall motion after CTO revascularization in non-viable myocardium in the area supplied by the totally occluded epicardial coronary artery.

            What must be done

            It seems to me that patients who had a successful early opening of a CTO should have an improved prognosis but only if there is viable muscle.

            Unfortunately, patients with non-viable myocardium did not show any improvement in regional wall motion after recanalization of CTO. Only if there is viability of the ventricular myocardium supplied by the now opened CTO, can there be a correlation with long term prognosis (see Table 1).

            Table 1

            Expected Objective Findings Early and Three Months After the Early Opening of a CTO.

            ViabilityTIMI FlowRWMPrognosis
            NonviableNo changeNo changeNo change
            ViableImprovementImprovementImprovement

            Kawashima et al. [2] used the SYNTAX scoring system to evaluate the efficacy of CTO on RWM and prognosis and found that, expected objective findings early and 3 months after the early opening of the CTO, a SYNTAX score greater than 8 implied a poor prognosis and a score less than 8 implied a better prognosis. At 10 years follow up, revascularization of CTO did not affect mortality unless it was offered to patients with refractory angina in the setting of myocardial viability.

            Summary and conclusions

            1. There are no studies in patients with non-viable myocardium subtending a CTO to show improvement of RWM after opening of the CTO.

            2. Patients without symptomatic multivessel CAD or no symptoms of angina have not been evaluated since there was no indication for study in the catheterization laboratory.

            3. CTO of collateral vessels that feed viable myocardium may lead to improvement in regional myocardial wall motion and thus potentially a decrease in mortality.

            4. CTO recanalization in patients with active angina improve symptoms despite limited ability to demonstrate an improvement in wall motion.

            References

            1. , , , . Evaluation of the impact of percutaneous coronary interventions of CTO on regional myocardial function using strain echo. Egypt Heart J 2019;71:8.

            2. , , , , , , et al. Mortality 10 years after percutaneous or surgical revascularization in patients with total coronary artery occlusions. J Am Coll Cardiol 2021;77:529–40.

            Author and article information

            Journal
            CVIA
            Cardiovascular Innovations and Applications
            CVIA
            Compuscript (Ireland )
            2009-8782
            2009-8618
            September 2021
            September 2021
            : 6
            : 1
            : 67-68
            Affiliations
            [1] 1University of Florida Medical School, Gainesville, FL 32610, USA
            Author notes
            Correspondence: C.R. Conti, University of Florida Medical School, 1600 SW Archer Rd, Gainesville, FL 32610 USA, E-mail: conticr@ 123456medicine.ufl.edu
            Article
            cvia.2021.0015
            10.15212/CVIA.2021.0015
            7aa5f6df-f0ee-4429-81e7-aa0957dd9697
            Copyright © 2021 Cardiovascular Innovations and Applications

            This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

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            General medicine,Medicine,Geriatric medicine,Transplantation,Cardiovascular Medicine,Anesthesiology & Pain management

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