Abstract
OBJECTIVE:
Successful revascularization of chronic total occlusions has been associated with improved left ventricular systolic function, reduced anginal symptoms, increased exercise capacity, and increased survival. This study was conducted to determine the impact of revascularization in chronic total occlusion on left ventricular function using novel echocardiographic techniques.
METHODS:
A total of 129 patients with chronic total occlusion who underwent revascularization between April 2011 and November 2012 were included in this study. Echocardiographic assessments with two-dimensional speckle tracking echocardiography and real-time three-dimensional echocardiography were performed before the procedure and one month after the procedure. The left ventricular ejection fraction, left ventricular volumes, and three-dimensional systolic dyssynchrony index were quantified.
RESULTS:
An immediate procedural success was obtained in 118 patients (91.5%). There were no acute or subacute stent thromboses during follow-up. The mean left ventricular ejection fraction significantly increased (p<0.001), while the left ventricular end-diastolic and end-systolic volumes significantly decreased (p = 0.001 and p<0.001, respectively). The three-dimensional systolic dyssynchrony index also decreased significantly (p<0.001). The global longitudinal strain showed a significant increase after successful revascularization (p<0.001). An increase in the global longitudinal strain was correlated with an increase in the left ventricular ejection fraction (r = 0.27, p = 0.02). The patients with a left ventricular ejection fraction ≥50% displayed a greater improvement in the global longitudinal strain, and the patients with diabetes showed less improvement.
CONCLUSIONS:
Using novel echocardiographic techniques, our results showed that restoring the coronary blood flow in chronic total occlusion patients reduces the left ventricular volumes and improves the left ventricular ejection fraction and the global longitudinal strain of hibernating myocardium.
Chronic Total Occlusions; Left Ventricular Function; Percutaneous Coronary Intervention
INTRODUCTION
Coronary artery chronic total occlusion (CTO) is one of the most challenging obstacles faced by
interventional cardiologists. Approximately one-third to one-half of the patients with significant
coronary artery disease (CAD) on angiography have at least one CTO (11. Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR.
Effect of chronic total occlusion on treatment strategy. Am J Cardiol. 2005;95(9):1088-91,
http://dx.doi.org/10.1016/j.amjcard.2004.12.065.
http://dx.doi.org/10.1016/j.amjcard.2004...
,22. Srinivas VS, Brooks MM, Detre KM, King SB, Jacobs AK, Johnston J, et al.
Contemporary percutaneous coronary intervention versus balloon angioplasty for multivessel coronary
artery disease: a comparison of the National Heart, Lung and Blood Institute Dynamic Registry and
the Bypass Angioplasty Revascularisation Investigation (BARI) study. Circulation.
2002;106(13):1627-33, http://dx.doi.org/10.1161/01.CIR.0000031570.27023.79.
http://dx.doi.org/10.1161/01.CIR.0000031...
). Although collaterals are capable of maintaining
myocardial viability at rest, they may fail to provide adequate blood flow during exercise, which
can result in angina. Successful percutaneous coronary interventions (PCIs) of CTOs have been shown
to improve the left ventricular (LV) systolic function, reduce angina, increase exercise capacity,
and reduce the need for late bypass surgery (33. Melchior JP, Doriot PA, Chatelain P, Meier B, Urban P, Finci L, et al.
Improvement of left ventricular contraction and relaxation synchronism after recanalization of
chronic total coronary occlusion by angioplasty. J Am Coll Cardiol. 1987;9(4):763-8,
http://dx.doi.org/10.1016/S0735-1097(87)80230-9.
http://dx.doi.org/10.1016/S0735-1097(87)...
4. Suero J, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, et al. 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. J Am Coll Cardiol.
2001;38(2):409-14, http://dx.doi.org/10.1016/S0735-1097(01)01349-3.
http://dx.doi.org/10.1016/S0735-1097(01)...
-55. Olivari Z, Rubartelli P, Pisicone F, Ettori F, Fontanelli A, Salemme L, et al. On
behalf of TOAST-GISE Investigators. Immediate results and one-year clinical outcome after
percutaneous coronary interventions in chronic total occlusions, (TOAST-GISSE). J Am Coll
Cardiol. 2003;41(10):1672-8, http://dx.doi.org/10.1016/S0735-1097(03)00312-7.
http://dx.doi.org/10.1016/S0735-1097(03)...
).
An accurate assessment of LV function by determining the LV volumes and the ejection fraction
(EF) is important in evaluating the prognoses of patients with CAD. Two-dimensional speckle tracking
echocardiography (2D-STE) can assess the global LV function, and it is superior for EF measurements
because it is angle-independent, less subject to artifacts, and easier to conduct than
Doppler-derived tissue velocity imaging (66. Marwick TH. Should we be evaluating the ventricle or the myocardium? Advances in
tissue characterization. J Am Soc Echocardiogr. 2004;17(2):168-72,
http://dx.doi.org/10.1016/j.echo.2003.10.021
http://dx.doi.org/10.1016/j.echo.2003.10...
,77. Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, et al.
Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of
myocardial function. J Am Soc Echocardiogr. 2004;17(10):1021-9,
http://dx.doi.org/10.1016/j.echo.2004.06.019
http://dx.doi.org/10.1016/j.echo.2004.06...
). Based on 2D-STE, automated function imaging is used to reflect
the systolic LV function by assessment of the LV global longitudinal strain (GLS). Longitudinal
tissue deformation is evaluated by frame-by-frame tracking of the individual speckles throughout the
cardiac cycle. This imaging technique discriminates between active and passive myocardial motion and
enables angle-independent quantification of myocardial deformation in two dimensions (88. Reisner SA, Lysyansky P, Agmon Y, Mutlak D, Lessick J, Friedman Z. Global
longitudinal strain: a novel index of left ventricular systolic function. J Am Soc
Echocardiogr. 2004;17(6):630-3, http://dx.doi.org/10.1016/j.echo.2004.02.011.
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,99. Delgado V, Mollema SA, Ypenburg C, Tops LF, van der Wall EE, Schalij MJ, et al.
Relation between global left ventricular longitudinal strain assessed with novel automated function
imaging and biplane left ventricular ejection fraction in patients with coronary artery disease.
J Am Soc Echocardiogr. 2008;21(11):1244-50,
http://dx.doi.org/10.1016/j.echo.2008.08.010.
http://dx.doi.org/10.1016/j.echo.2008.08...
). 2D-STE is based on
tracking the characteristic speckle patterns created by interference of ultrasound beams in the
myocardium, and its accuracy has been confirmed using sonomicrometry and magnetic resonance imaging
(MRI) as reference methods (1010. Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E, et al.
Noninvasive myocardial strain measurement by speckle tracking echocardiography: Validation against
sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol. 2006;47(4):789-93,
http://dx.doi.org/10.1016/j.jacc.2005.10.040.
http://dx.doi.org/10.1016/j.jacc.2005.10...
).
The aim of this study was to investigate the changes in the LV volumes, LVEF, and GLS of patients with CTO, before and one month after PCI, using novel echocardiographic methods.
MATERIALS AND METHODS
Patient selection
A total of 129 patients with CTO who had attempted PCI at Bezmialem Foundation University
Hospital between April 2011 and November 2012 were screened for inclusion in this study. Eleven
patients who had failed PCI were excluded, and 118 patients who had been successfully revascularized
were included in the study. All of the patients underwent physical examination, chest X-ray, 12-lead
electrocardiography (ECG), and transthoracic echocardiographic (2DE) evaluations. Echocardiography
was also repeated one month after the revascularization procedure. CTO was defined as lumen
compromise resulting in either Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1, with
a likely duration of >3 months (1111. Stone GW, Kandzari DE, Mehran R, Colombo A, Schwartz RS, Bailey S, et al.
Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I.
Circulation. 2005;112(15):2364-72,
http://dx.doi.org/10.1161/CIRCULATIONAHA.104.481283.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
). All of the patients
included had a native vessel occlusion estimated to be of at least three months in duration based on
a history of sudden chest pain, a previous myocardial infarction (MI) in the same target vessel
territory, or the time between diagnosis made on coronary angiography and PCI. All of the patients
had symptomatic angina and/or a positive functional ischemia study. PCI and stent implantation were
performed in a standard manner. Drug-eluting stents (DESs) were used in all of the angioplasty
procedures. Heparin was administered to maintain an activated clotting time >250 seconds. A PCI
of the CTO was performed with modern techniques such as bilateral injections; specialized
hydrophilic, tapered tip, and stiff wires; parallel wires; microcatheters; and a retrograde approach
when possible. After the PCI, all of the patients were prescribed lifelong aspirin. Clopidogrel was
prescribed for at least 12 months in all of the patients. The patients were followed prospectively
by a telephone interview or an outpatient visit after 30 days. Procedural success was defined as the
successful recanalization and dilation of at least one CTO per patient with or without stent
implantation, a residual stenosis of <50%, and a TIMI flow >2. The procedure time was defined
as the time difference between the patient's entry and exit from the catheterization room.
The study protocol was approved by the institutional clinical research and ethics committee of Bezmialem Foundation University Hospital, and all of the patients provided written informed consent.
2DE and 2D-STE were performed on the subjects at rest in the left lateral decubitus position with synchronized electrocardiography by two professional cardiologists, who were blinded to the clinical data, with a commercially available system (Philips iE33, Bothell, WA, USA) equipped with a broadband S5-1 transducer (frequency transmitted: 1.7 MHz; received: 3.4 MHz). The parasternal long-axis views were used to derive the M-Mode measurements of the left atrial (LA) size and the LV end-diastolic (LVEDD) and end-systolic (LVESD) dimensions. The endocardial borders were traced in the end-systolic frame of the 2D images from the three apical views. Four consecutive end-expiratory cardiac cycles using high-frame-rate (50 Hz or more) harmonic imaging in each echocardiographic view were acquired. The speckles were tracked frame by-frame throughout the LV wall during the cardiac cycle, and basal, mid, and apical regions of interest were created. The operator manually adjusted the segments that failed to be tracked. All of the measurements were made blinded to the other results and the clinical details.
Real-time three-dimensional echocardiography (RT3DE) images were obtained from an apical window with the patient in the same position as for 2D-STE. Full-volume images were gathered over four cardiac cycles using a matrix array transducer (×4 transducer; Philips iE33, Andover, MA). Measurements of the 3D-LV volumes and the 3D-EF were performed off-line (QLAB workstation using 3D-Advanced Quantification, Philips). The systolic dyssynchrony index (SDI) was defined as the standard deviation of the time to minimum systolic volume of the 16 LV segments, expressed as a percent of the RR duration. A higher SDI indicated greater LV dyssynchrony.
Intra-observer variability was determined by the observer repeating the measurement of the GLS in 20 randomly selected patients ten days after the first measurement. Inter-observer variability was determined by another observer measuring these variables in the same database. The intra- and inter- observer reproducibility of GLS parameter was shown acceptable. The intra- and inter- observer variations were 5.4% and 6.7% for GLS, respectively.
Statistical analysis
The continuous variables are reported as the mean ± standard deviations (SD), and the categorical variables are expressed as percentages. Comparisons of the categorical and continuous variables between the two groups were performed using the χ2 test and an unpaired t-test, respectively. The GLS and velocities were compared using an independent two sample t-test. The correlation between the GLS and LVEF variables was tested using a correlation analysis. The delta values are defined as the difference between the first month and the preprocedure value. A value of p<0.05 was considered statistically significant. The SPSS 15.0 for Windows statistical software package program (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis.
RESULTS
Table 1 shows the baseline demographic, angiographic, and procedural characteristics of the study patients. The mean age of the patients was 58±9 years. There were no acute or subacute stent thrombosis. There was no death, acute MI, coronary perforation, emergency re-PCI, emergency coronary artery bypass graft surgery (CABG), or acute stroke during the periprocedural period. Pericardiocentesis was required for only one patient because of tamponade. The mean procedure time was 79±39 min, the fluoroscopy time was 34±19 min, and the amount of contrast was 492±174 ml. Contrast-induced nephropathy was developed in 14 (11%) patients, and one patient underwent hemodialysis.
Half of the patients (63 patients, 48.8%) suffered from angina pectoris (≥2 CCS) before the procedure, and the occurrence of angina pectoris decreased significantly after PCI. Compared with the measurements before the procedure, the LVEDV and LVESV decreased significantly (p = 0.001 and p<0.001, respectively) and the mean LVEF increased significantly (p<0.001) after the procedure. The SDI derived from RT3DE decreased significantly after successful revascularization (p<0.001). The GLS increased significantly one month after PCI (p<0.001) (Table 2). We found that the increase in the GLS was correlated with an improvement in the LVEF (r = 0.27, p = 0.02; Figure 1). The patients with an LVEF ≥50% displayed greater improvement in the GLS compared with the patients with an LVEF <50% (1.1±0.9 vs. 0.12±0.3, p<0.001). The patients with diabetes mellitus (DM) showed a lower degree of GLS improvement compared with the patients without DM (1.1±1.0 vs. 0.62±0.6, p = 0.07).
Relationship between recovery of the global longitudinal strain (ΔGLS) and improvement of the left ventricular ejection fraction (ΔLVEF) during follow-up.
DISCUSSION
In this study, we used 2DSTE and RT3DE to determine that successful revascularization of CTO of the coronary arteries may improve the LV contractile function. We found that the improvement in the myocardial contractile function based on strain analysis seems to be more significant in the patients with a LVEF ≥50% and less significant in the patients with DM. To the best of our knowledge, this is the first study showing the benefit of revascularization of CTOs on LV function using 2DSTE and RT3DE.
LV systolic function is most commonly assessed by the LVEF using 2DE. The assessment of patients
with CTO may be challenging with 2DE because many of these patients suffer from long-term myocardial
ischemia or MI and develop aneurysmal formation or advanced ventricular remodeling. Strain and
strain rate imaging using the 2D-STE method is a novel echocardiographic technique for the
evaluation of regional and global myocardial function, is relatively free from angle dependency and
the frame-rate limitations of tissue Doppler imaging, and enables calculations to be made more
easily. The global LV contractile function, as assessed by 2D-STE, was shown to be superior to EF
measurements by 2DE (66. Marwick TH. Should we be evaluating the ventricle or the myocardium? Advances in
tissue characterization. J Am Soc Echocardiogr. 2004;17(2):168-72,
http://dx.doi.org/10.1016/j.echo.2003.10.021
http://dx.doi.org/10.1016/j.echo.2003.10...
,77. Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, et al.
Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of
myocardial function. J Am Soc Echocardiogr. 2004;17(10):1021-9,
http://dx.doi.org/10.1016/j.echo.2004.06.019
http://dx.doi.org/10.1016/j.echo.2004.06...
). RT3DE is the other new echocardiographic technique for calculating the actual LV volume
based on the actual LV shape, rather than on geometrical assumptions. It has good reproducibility
even in cases of heart cavity deformation or segmental wall motion abnormalities. It is more
accurate than 2DE, and its accuracy approaches that of the gold standard, namely MRI (1212. Bauer F, Shiota T, Qin JX, White RD, Thomas JD. Measurement of left atrial and
ventricular volume in real-time 3D echocardiography: Validation by nuclear magnetic resonance. Arch
Mal Coeur Vaiss. 2001;94(1):31-8.,1313. Jenkins C, Bricknell K, Hanekom L, Marwick TH. Reproducibilityand accuracy of
echocardiographic measurements of left ventricular parameters using real-time three-dimensional
echocardiography. J Am Coll Cardiol. 2004;44(4):878-86,
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).
Despite the presence of coronary collaterals, the majority of patients with a CTO show various
degrees of LV dysfunction. The possibility of a functional recovery and its beneficial effect on
survival are the rationale for the often technically demanding attempt to recanalize a CTO (33. Melchior JP, Doriot PA, Chatelain P, Meier B, Urban P, Finci L, et al.
Improvement of left ventricular contraction and relaxation synchronism after recanalization of
chronic total coronary occlusion by angioplasty. J Am Coll Cardiol. 1987;9(4):763-8,
http://dx.doi.org/10.1016/S0735-1097(87)80230-9.
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4. Suero J, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, et al. 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. J Am Coll Cardiol.
2001;38(2):409-14, http://dx.doi.org/10.1016/S0735-1097(01)01349-3.
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chronically ischemic myocardium depends on the presence of hibernating or stunned but viable
myocardium (1919. Wijns W, Vatner SF, Camici PG. Hibernating myocardium.
N Engl J Med. 1998;339(3):173-81.). When reperfusion is acquired, the
hibernating myocardium at least partially restores the contractile function, resulting in regional
and global LV function recovery (2020. Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E, et al.
Relationship between preoperative viability and postoperative improvement in LVEF and heart failure
symptoms. J Nucl Med. 2001;42(1):79-86.). Baks et al. showed the
beneficial effect of successful CTO revascularization on the end-systolic and end-diastolic volumes.
They showed that the extent of dysfunctional but viable myocardium before revascularization was
related to an improvement in the end-systolic volume and LVEF (2121. Baks T, van Geuns RJ, Duncker DJ, Cademartiri F, Mollet NR, Krestin GP, et al.
Prediction of left ventricular function after drug-eluting stent implantation for chronic total
coronary occlusions. J Am Coll Cardiol. 2006;47(4):721-5,
http://dx.doi.org/10.1016/j.jacc.2005.10.042.
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). In the present study, we found a reduction in LV volumes; however, we used RT3DE, which
is more robust than 2DE. Cheng et al. used contrast-enhanced MRI to demonstrate that successful
CTO-PCI results in improved LV function and attenuated LV remodeling if the vessel patency is
maintained (2222. Cheng ASH, Selvanayagam JB, Jerosch-Herold M, van Gaal WJ, Karamitsos TD,
Neubauer S, et al. Percutaneous treatment of chronic total coronary occlusions improves regional
hyperemic myocardial blood flow and contractility: insights from quantitative cardiovascular
magnetic resonance imaging. JACC Cardiovasc Interv. 2008;1(1):44-53,
http://dx.doi.org/10.1016/j.jcin.2007.11.003.
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). The improvements in LVEF and myocardial
function in our study, based on 2DSTE and RT3DE, are consistent with the results of Cheng et al. The
improvements in the LVEF and GLS observed in the current study may be a result of the recovered
hibernating myocardium.
Multiple retrospective studies have shown the potential benefit of PCI in patients with CTO.
Successful treatment improves anginal symptoms, exercise tolerance, and LV function. The prospective
Total Occlusion Angioplasty Study (TOAST-GISE) showed that revascularization of a CTO is associated
with relieved angina and reduces the 12-month incidence of cardiac death or MI and the need for CABG
(55. Olivari Z, Rubartelli P, Pisicone F, Ettori F, Fontanelli A, Salemme L, et al. On
behalf of TOAST-GISE Investigators. Immediate results and one-year clinical outcome after
percutaneous coronary interventions in chronic total occlusions, (TOAST-GISSE). J Am Coll
Cardiol. 2003;41(10):1672-8, http://dx.doi.org/10.1016/S0735-1097(03)00312-7.
http://dx.doi.org/10.1016/S0735-1097(03)...
). Joyal et al. recently identified 13 observational
studies comparing the outcomes after successful versus failed CTO recanalizations, showing that
successful CTO recanalization was associated with a 44% reduction in mortality, a 78% reduction in
the subsequent need for CABG, and a 55% reduction in residual or recurrent angina (2323. Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total
occlusions: a systematic review and meta-analysis. Am Heart J. 2010;160(1):179-87,
http://dx.doi.org/10.1016/j.ahj.2010.04.015.
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). In accordance with the above mentioned studies, successful
revascularization of CTOs in our study resulted in a significant improvement in anginal symptoms.
Approximately half of the patients did suffer from angina CCS 2 or greater before the procedure, and
none of them had CCS 2 or greater after the procedure.
Numerous experimental studies have demonstrated that ischemia depresses the regional systolic
function, resulting in severe systolic dyssynchrony, prolonged tension development in the ischemic
regions, and impaired global relaxation (2424. Kumada T, Karliner JS, Pouleur H, Gallagher KP, Shirato K, Ross J Jr. Effects of
coronary occlusion on early ventricular diastolic events in conscious dogs. Am J Physiol.
1979;237(5):H542-9.,2525. Green MV, Jones-Collins BA, Bacharach SL, Findley SL, Patterson RE, Larson SM.
Scintigraphic quantitation of asynchronous myocardial motion during the left ventricular isovolumic
relaxation period: a study in the dog during acute ischemia. J Am Coll Cardiol. 1984;4(1):72-9,
http://dx.doi.org/10.1016/S0735-1097(84)80321-6.
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). Bonow et al. reported that CAD was associated with
dyssynchrony, which improved after mechanical revascularization (2626. Bonow RO, Vitale DF, Bacharach SL, Frederick TM, Kent KM, Green MV. Asynchronous
left ventricular regional function and impaired global diastolic filling in patients with coronary
artery disease: reversal after coronary angioplasty. Circulation. 1985;71(2):297-307,
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). In the present study, the SDI derived by RT3DE, which is a marker of dyssynchrony, was
improved one month after CTO revascularization. The improvement in dyssynchrony may be related to an
improvement in the hibernating myocardium and in decreased LV volumes.
Endothelial dysfunction, structural changes of the microcirculation, and a negative influence on
the development and prognosis of CAD are well-established features of patients with DM (2727. Schofield I, Mlik R, Izzard A, Austin C, Heagerty A. Vascular structural and
functional changes in type 2 diabetes mellitus: evidence for the roles of abnormal myogenic
responsiveness and dyslipidemia. Circulation. 2002;106(24):3037-43,
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28. Watts GF, O'Brien SF, Silvester W, Millar JA. Impaired
endothelium-dependent and independent dilatation of forearm resistance arteries in men with
diettreated non-insulin-dependent diabetes: role of dyslipidaemia. Clin Sci (Lond).
1996;91(5):567-73.-2929. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M.
Mortality from coronary heart disease in subjects with type 2 diabetes and in non-diabetic subjects
with and without prior myocardial infarction. N Engl J Med.
1998;339(4):229-34.). Patients with DM
have a greater extent of CAD and are prone to impaired clinical outcomes compared with nondiabetic
patients (3030. Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, et al. Impact of
diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial
infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes)
Registry. Circulation. 2000;102(9):1014-9,
http://dx.doi.org/10.1161/01.CIR.102.9.1014.
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31. Comparison of coronary bypass surgery with angioplasty in patients with
multivessel disease. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators.
N Engl J Med. 1996;335(4):217-25.-3232. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US
adults. The Journal of the American Medical Association: JAMA. 1999;281(14):1291-7,
http://dx.doi.org/10.1001/jama.281.14.1291.
http://dx.doi.org/10.1001/jama.281.14.12...
). A
previous observational study about CTO PCI in diabetics was performed by Safley et al. They reported
that DM patients do not seem to have the same survival benefits from successful PCI of a CTO as
patients without DM (3333. Safley DM, House JA, Rutherford BD, Marso SP. Success rates of percutaneous
coronary intervention of chronic total occlusions and long-term survival in patients with diabetes
mellitus. Diab Vasc Dis Res. 2006;3(1):45-51,
http://dx.doi.org/10.3132/dvdr.2006.006.
http://dx.doi.org/10.3132/dvdr.2006.006...
). In our study, we found relatively
less improvement in the GLS in diabetic patients. It is still not clear why diabetics benefit less
from PCI of a CTO, but we speculate that the extensive atherosclerosis and impaired microvascular
circulation may explain the worse outcomes in this population.
Limitations
There are several limitations to this study. The main limitation is its observational nature and the fact that it was nonrandomized. Additionally, the duration of occlusion was not known with certainty in some of the cases. A lack of follow-up data beyond the hospital stay is another limitation.
Our results showed that restoring the blood flow to dysfunctional but viable myocardium led to a moderate improvement in LV function and a reduction in the adverse remodeling in the majority of patients with a CTO. Angiographical success was accompanied by anginal relief.
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No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Oct 2013
History
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Received
14 June 2013 -
Reviewed
22 July 2013 -
Accepted
27 July 2013