European Heart Journal Advance Access originally published online on January 23, 2009
European Heart Journal 2009 30(4):506; doi:10.1093/eurheartj/ehn606
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Survival benefit after percutaneous treatment of chronic total coronary occlusions
Department of Cardiology
Instituto Clinico Humanitas – IRCCS
Via Manzoni 56
Rozzano – Milano 20089
Italy
Tel: +39 02 4851 9479
Fax: +39 02 4851 9479
E-mail: guido.belli{at}humanitas.it
In their recently published paper, Valenti et al.1 report how successful percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs) was associated with a significant 2-year survival benefit in a large series of 486 patients. Improved outcome was driven by achievement of complete revascularization of patients with multivessel disease. The paper is most interesting for the selection of a very high-risk cohort: mortality at 2 years was reported at 6% vs. a staggering 16.2% (P < 0.001) after complete or incomplete revascularization, respectively. In fact, analysis of the Kaplan–Meier survival curves shown in Figure 2 reveals how most of the deaths in the group with ‘incomplete revascularization’ occurred relatively soon, during the first year of observation. Completeness of revascularization, indirectly reflecting successful CTO reopening, was found as an independent predictor of survival by multivariate analysis, together with age, history of myocardial infarction, CTO vessel, and low ejection fraction. The CTO failure cohort of 142 patients had a mean age of 69.8 years and a moderate left ventricular systolic dysfunction with a mean ejection fraction of 41% (with an EF lower than 40% in 38% of patients). All patients had evidence of viable myocardium subtended by the CTO; one-third of patients had a CTO of the left anterior descending coronary artery and 68% had either left main or two-three vessel disease. However, and rather surprisingly, they were referred for surgical revascularization in only 9.1% of cases. A question arises on the possibility that ‘unmeasured’ clinical and functional variables (or should we call it ‘clinical judgement’?) may have determined such ‘conservative’ strategy, but no further insight can be gleaned from the data presented, and no description of the 17 reported deaths is given. Could the avoidance of surgery indeed be because patients were considered at excessive risk? If so, the stated conclusion that ‘PCI success for CTO confers a 2-year survival benefit’ appears to be rather optimistic, since the retrospective nature of the analysis cannot rule out an alternative explanation, that is CTO-failure representing more of a ‘marker’ of sicker patients than a direct cause of poor prognosis,2 especially within the first year of observation.
References
- Valenti R, Migliorini A, Signorini U, Vergara R, Parodi G, Carrabba N, Cerisano G, Antoniucci D. Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. Eur Heart J (2008) doi: 10.1093/eurheartj/ehn357.
- Prasad A, Rihal CS, Lennon RJ, Wiste HJ, Singh M, Holmes DR. Trends in outcome after percutaneous coronary intervention for chronic total occlusions. A 25-year experience from the Mayo Clinic. J Am Coll Cardiol (2007) 49:1611–1618.
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