| Background:The clinical presentation of the coronary chronic total occlusion (CTO) varies from asymptomatic to occult heart failure and cardiacgenenic shock. The treatments include medical therapy, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). However, the selection of the treatment is often difficult because of insufficient randomized clinical trials comparing the 3 treatment strategies. PCI is the most selected treatment for CTO. However, the recanalization rate varies from center to center. The success rate depends on the complexity of the CTO. Also the recanalization is also not equal to the improved left ventricular function. The present study will analyze what factors are contributing to successful recanalization, the long term clinical outcomes and the effects on myocardial salvage.Methods:The patients who underwent coronary angiography (CAG) from 2008 to 2013 were consecutively enrolled. The patients were divided into 3 groups, the total occlusion and stenosis groups (group 1); total occlusion myocardial perfusion group (group 2); CTO PCI group (group 3). In the group 1 comparison was made between total occlusion and high grade stenosis and the patients were followed for the major adverse cardiovascular events. In the group 2 patients were divided into total occlusion and stenosis. The SPECT summed rest score, CAG indices (Syntax score, total MPG and MPG×Area), echocardiography indices (LVED and EF) were calculated. In the group 3,559 CTO patients were divided into successful and unsuccessful recanalization. The MPG, Rentrop score, Retrograde MPG, LVED and EF were calculated.Results:In the group 1,253 total occlusion and 629 stenosis were included. After PSmatch 253 total occlusion and 253 stenosis left. No difference in clinical characters was found between total occlusion and stenosis except Syntax score. No difference was found among the medical treatment, PCI and CABG. After PSmatch the MACE was significantly higher in total occlusion than in stenosis (P<0.05). No difference in MACE among the 3 treatments. In the group 2 there were 111 patients who underwent SPECT and CAG, of them 41 had total occlusion and 70 had stenosis. The total occlusion had significantly larger SRS, higher SYNTAX score, reduced total MPG and MPG×Area, enlarged LVED and reduced EF (P<0.05). The correlation coefficients between the SRS and other indices were:MPG×area=-0.20, total MPG=-0.32, LVED=0.35, EF=-0.53. Stepwise multivariate analysis showed that the SRS were independently correlated with EF, total occlusion and sex. In the group 3,559 CTO attempted PCI. The success rate was 67%. After PSmatch, the patients with success showed fewer prio myocardial infarction, fewer smoker, younger and higher LDL (P<0.05). After PSmatch there were significantly more complex CTO, higher J-score and higher SYNTAX score in the unsuccessful patients. Stepwise multivariate analysis showed age, unfavorite CTO and higher J-score predicted unsuccessful recanalization. After successful PCI there were 175 MPG2-3 and 99 MPG0-1. Low MPG accounted for 36%. After PSmatch low MPG had low Rentrop score, low Retrograde MPG and increased LVED (P<0.05). There were 190 Rentrop score 0-1 and 369 Rentrop score 2-3. Low Rentrop score accounted for 34%. After PSmatch we found that low Rentrop score were correlated with complex CTO, high J-score, Retrograde MPG, low EF and enlarged LVED (P<0.05)Conclusion:Medication and CABG have similar clinical outcome irrespective of CTO or stensis. But CTO PCI may have poor clinical outcome in comparison with stenosis. In CTO PCI the artery integrity damage is more than stenosis. The myocardial perfusion and left ventricular function are poor in the CTO patients. MPG, total MPG, Rentrop score, EF and LVED are useful predictors of myocardial recovery after successful recanalization. Age, complex CTO and J-Score are 3 main anatomic factors affecting recanalization. MPG and Rentrop score help predict viability after recanalization. |
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