Contemporary outcomes of chronic total occlusion percutaneous coronary intervention in Europe: the ERCTO registry.

BACKGROUND: Percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) have reached high procedural success rates thanks to dedicated equipment, evolving techniques, and worldwide adoption of state-of-the-art crossing algorithms. AIMS: We report the contemporary results of CTO PCIs performed by a large European community of experienced interventionalists. Furthermore, we investigated the impact of different risk factors for procedural major adverse cardiac and cerebrovascular events (MACCE) and trends of employment of specific devices like dual lumen microcatheters, guiding catheter extensions, intravascular ultrasound and calcium-modifying tools. METHODS: We evaluated data from 8,673 CTO PCIs included in the European Registry of Chronic Total Occlusion (ERCTO) between January 2021 and October 2022. RESULTS: The overall technical success rate was 89.1% and was higher in antegrade as compared with retrograde cases (92.8% vs 79.3%; p<0.001). Compared with antegrade procedures, retrograde procedures had a higher complexity of attempted lesions (Japanese CTO [J-CTO] score: 3.0±1.0 vs 1.9±1.2; p<0.001), a higher procedural and in-hospital MACCE rate (3.1% vs 1.2%; p<0.018) and a higher perforation rate with and without tamponade (1.5% vs 0.4% and 8.3% vs 2.1%, respectively; p<0.001). As compared with mid-volume operators, high-volume operators had a higher technical success rate in antegrade and retrograde procedures (93.4% vs 91.2% and 81.5% vs 69.0%, respectively; p<0.001), and had a lower MACCE rate (1.47% vs 2.41%; p<0.001) despite a higher mean complexity of the attempted lesions (J-CTO score: 2.42±1.28 vs 2.15±1.27; p<0.001). CONCLUSIONS: The adoption of different recanalisation techniques, operator experience and the use of specific devices have contributed to a high procedural success rate despite the high complexity of the lesions documented in the ERCTO.

Utility of Guiding Catheter Extensions for Recanalization of Chronic Total Occlusions: A EuroCTO Club Expert Panel Report.

Guiding catheter extensions (GCEs) have become indispensable tools in the modern approach to percutaneous coronary intervention (PCI). The support offered during complex PCI of uncrossable, or tortuous lesions is particularly valuable in the setting of chronic total occlusions (CTO), both for conventional anterograde wire escalation and for anterograde or retrograde dissection and re-entry techniques. This EuroCTO consensus document describes the use of GCE during CTO recanalization and provides a practical guide to anatomies and techniques in which these devices are applicable. We describe the peculiar features of the most-used device and the practical technique for GCE delivery in standard PCI; further specific indications for antegrade and retrograde CTO PCI are discussed in a specific section. In the antegrade approach, the GCEs may be useful to increase support or facilitate antegrade dissection and re-entry techniques, while in the retrograde approach for reverse controlled antegrade and retrograde tracking, to increase retrograde support for gear delivery, for treatment of CTO in bifurcation and ipsilateral externalization with a single guide catheter. The last section of the paper describes GCE-related complications, challenges, limitations, and future perspectives.

Three-year outcomes of A Randomized Multicentre Trial Comparing Revascularization and Optimal Medical Therapy for Chronic Total Coronary Occlusions (EuroCTO).

BACKGROUND: Percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTO) improves clinical symptoms and quality of life. The longer-term safety of PCI compared to optimal medical therapy (OMT) remains uncertain. AIMS: We sought to evaluate the long-term safety of PCI for CTO in a randomised trial as compared to OMT. METHODS: A total of 396 patients with a symptomatic CTO were enrolled into a randomised, multicentre clinical trial comparing PCI and OMT. Half of the patients had a single CTO; the others had multivessel disease. Non-CTO lesions were treated prior to randomisation (2:1 ratio). During follow-up, crossover from OMT to PCI occurred in 7.3% (1 year) and 17.5% (3 years) of patients. RESULTS: At 3 years, the incidence of cardiovascular death or nonfatal myocardial infarction was not significantly different between the groups (OMT 3.7% vs PCI 6.2%; p=0.29). By per-protocol analysis, the difference remained non-significant (OMT 5.7% vs PCI 4.7%; p=0.67). Overall, major adverse cardiovascular events (MACE) were more frequent with OMT (OMT 21.2% vs PCI 11.2%), largely because of ischaemia-driven revascularisation. The rates of stroke or hospitalisation for bleeding were not different between the groups. CONCLUSIONS: At 3 years there was no difference in the rate of cardiovascular death or myocardial infarction between PCI or OMT among patients with a remaining single coronary CTO. The MACE rate was higher in the OMT group due largely to ischaemia-driven revascularisation. CTO PCI appears to be a safe option for patients with a single remaining significant coronary CTO. CinicalTrials.gov: NCT01760083.

Gender differences in percutaneous coronary intervention for chronic total occlusions from the ERCTO study.

BACKGROUND: Gender-specific data addressing percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in female patients are scarce and based on small sample size studies. AIMS: We aimed to analyze gender-differences regarding in-hospital clinical outcomes after CTO-PCI. METHODS: Data from 35,449 patients enrolled in the prospective European Registry of CTOs were analyzed. The primary outcome was the comparison of procedural success rate in the two cohorts (women vs. men), defined as a final residual stenosis less than 20%, with Thrombolysis In Myocardial Infarction grade flow = 3. In-hospital major adverse cardiac and cerebrovascular events (MACCEs) and procedural complications were deemed secondary outcomes. RESULTS: Women represented 15.2% of the entire study population. They were older and more likely to have hypertension, diabetes, and renal failure, with an overall lower J-CTO score. Women showed a higher procedural success rate (adjusted OR [aOR] = 1.115, confidence interval [CI]: 1.011-1.230, p = 0.030). Apart from previous myocardial infarction and surgical revascularization, no other significant gender differences were found among predictors of procedural success. Antegrade approach with true-to-true lumen techniques was more commonly used than retrograde approach in females. No gender differences were found regarding in-hospital MACCEs (0.9% vs. 0.9%, p = 0.766), although a higher rate of procedural complications was observed in women, such as coronary perforation (3.7% vs. 2.9%, p < 0.001) and vascular complications (1.0% vs. 0.6%, p < 0.001). CONCLUSIONS: Women are understudied in contemporary CTO-PCI practice. Female sex is associated with higher procedural success after CTO-PCI, yet no sex differences were found in terms of in-hospital MACCEs. Female sex was associated with a higher rate of procedural complications.

Contemporary issues of percutaneous coronary intervention in heavily calcified chronic total occlusions: an expert review from the European CTO Club.

Severe calcification is frequent in coronary chronic total occlusions (CTO), and its presence has been associated with increased procedural complexity and poor long-term outcomes following percutaneous coronary intervention (PCI) in an already challenging anatomical setting. The diagnostic characterisation of heavily calcified CTOs using non-invasive and invasive imaging tools can lead to the application of different therapeutic options during CTO PCI, in order to achieve adequate lesion preparation and optimal stent implantation. In this expert review, the European Chronic Total Occlusion Club provides a contemporary, methodological approach, specifically addressing heavily calcified CTOs, suggesting an integration of evidence-based diagnostic methods to tailored, up-to-date percutaneous therapeutic options.

Intraprocedural Residual Mitral Regurgitation and Survival After Transcatheter Edge-to-Edge Repair: Prospective German Multicenter Registry (MITRA-PRO).

BACKGROUND: Residual mitral regurgitation (MR) is thought to be an important predictor of long-term survival following transcatheter edge-to-edge repair (TEER). Intraprocedural MR assessment using transesophageal echocardiography could be limited by image quality, hemodynamics, and patient sedation. The MitraScore is a validated multimodal approach for intraprocedural MR assessment during TEER. OBJECTIVES: This study aimed to assess the impact of residual MR using the MitraScore on 1-year mortality. METHODS: Patients undergoing mitral TEER were eligible for inclusion in the prospective, multicenter MITRA-PRO registry (A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation). Patients with a MitraScore ≤3 were defined as patients with mild residual MR after mitral TEER, whereas a MitraScore ≥4 was considered as relevant residual MR. Mortality, rehospitalization, and major adverse events were assessed 1 year after TEER. RESULTS: A MitraScore ≤3 was found in 1,059 patients (71.0%), whereas 432 patients revealed a MitraScore ≥4 (29.0%). One-year mortality was significantly lower in patients with nonrelevant residual MR (MitraScore ≤3 14.6% vs MitraScore≥4 22.1%). An almost linear relationship between intraprocedural MitraScore after TEER and mortality was observed. The combined clinical endpoint of mortality and rehospitalization within the 1-year follow-up was also significantly lower in the MitraScore ≤3 group (31.5%) than in the MitraScore ≥4 group (40.8%). A subgroup analysis confirmed the predictive value of the MitraScore in patients with primary, secondary, or mixed MR etiologies. CONCLUSIONS: Residual MR assessed by intraprocedural MitraScore after TEER predicts 1-year mortality and rehospitalization. Therefore, the multimodal MitraScore improves MR assessment during mitral TEER and might improve patient survival.(A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation [MITRA-PRO]; DRKS00012288).

In-hospital outcome of re-attempted percutaneous coronary interventions for chronic total occlusion.

BACKGROUND: With the advent of novel recanalization techniques and emerging devices, percutaneous coronary intervention (PCI) has become a promising leading treatment option for patients with chronic total occlusions (CTO). The present study aims to evaluate the acute outcomes of PCI in previously failed re-attempted vs. first-attempted CTO-lesions. METHODS: Between 2012 and 2019, 619 patients were included and treated with PCI of at least one CTO. 253 patients were re-attempted lesions, while 366 were initially attempted lesions. RESULTS: Re-attempted lesions were more complex, including higher Japanese-CTO (J-CTO) score and the need for a retrograde approach. The procedure time and fluoroscopy time were longer in this group. Nevertheless, overall success rates were comparable between both groups of patients. In-hospital events were rare and without significant differences. CONCLUSIONS: Re-attempted CTO lesions are more complex than first-attempt lesions and are associated with longer procedural times. However, they can be safely intervened by experienced operators with a similar success rate.

Pulsed field ablation for pulmonary vein isolation: real-world experience and characterization of the antral lesion size compared with cryoballoon ablation.

BACKGROUND: Pulsed field ablation (PFA) is a new, non-thermal technology in the treatment of atrial fibrillation (AF). Early investigations have shown a promising safety profile with durable pulmonary vein isolation (PVI) and large antral lesions. However, clinical data remains scarce. METHODS: We investigated a cohort of 43 patients. Twenty-three patients underwent PVI with PFA in our hospital and we analyzed them with regard to procedural characteristics and with regard to the size of acute antral lesion which was estimated by using an electroanatomical map of the left atrium (LA). We compared these data with data of 20 patients who had undergone cryoballon (CB) PVI in our hospital. RESULTS: We could show acute isolation of all veins in all patients (100% PFA, 100% CB). Post-ablation high-density mapping revealed no early reconnection (0%). The acute antral lesion size of PFA was significantly higher compared to the CB (67.03 ± 12.69% vs. 57.39 ± 10.91%, p = 0.01). In the PFA group, we found no acute phrenic nerve injury, no major or minor bleeding, and no tamponade but one (4.34%) patient suffered from a stroke. Transient hypotension was observed frequently as well as transient bradycardia or asystole episodes requiring right ventricular pacing. In the CB group, no complications occurred. Furthermore, we discuss practical issues on PFA procedures. CONCLUSIONS: PFA is a promising technology with high acute PV isolation rate and large antral lesions compared to CB. However, larger trials with more patients and data on long-term freedom of AF but also complications are needed.

Telemonitoring Potential of Wearable Cardioverter-Defibrillators during the Follow-Up of Patients with Heart Failure.

BACKGROUND: Wearable cardioverter-defibrillators (WCDs) are a well-established tool to bridge the recovery time of left ventricular ejection fraction (LVEF) until the implantation of an implantable cardioverter defibrillator (ICD), as recommended by the current guidelines. Besides their function to detect and treat malignant arrhythmias, WCDs may be used as a telemonitoring system. In this study, we sought to illustrate and discuss the telemonitoring potential of WCDs and to analyze physical activity in specific patient cohorts. METHODS AND RESULTS: We retrospectively included 140 patients with reduced LVEF who were prescribed WCDs in our clinic. We analyzed the patients' physical activity (n = 105 with a WCD compliance above 21 h/day), body position and resting position. We found a reduced physical activity in women and in patients over the age of 65 compared to younger patients. Furthermore, the patients who were overweight or obese showed significantly reduced physical activity compared to the patients with a normal weight (6365 ± 3572 vs. 4972 ± 2476 vs. 7045 ± 3521, p = 0.02). CONCLUSION: WCDs may be used as a telemonitoring and intervention tool in patients with reduced LVEF. Specific patient groups may benefit from guidance from their treating physician regarding physical activity.

Retrograde Chronic Total Occlusion Percutaneous Coronary Interventions: Predictors of Procedural Success From the ERCTO Registry.

OBJECTIVES: The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood. METHODS: A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry. RESULTS: In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. A primary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P < 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95% CI: 1.37-2.51; P < 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95% CI: 1.72-3.55; P < 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95% CI: 1.28-2.64; P = 0.001), Werner collateral connection CC1 (OR: 4.87; 95% CI: 2.90-8.19; P < 0.0001) or CC2 (OR: 5.33; 95% CI: 3.02-9.42; P < 0.0001), and the top tertile of operator volume (>120 cases over 2 years) (OR: 1.88; 95% CI: 1.26-2.79; P = 0.002) were associated with the greatest chance of achieving angiographic success. CONCLUSIONS: Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

Transesophageal echocardiography guided transseptal puncture and nadir temperatures in cryoballoon pulmonary vein isolation.

Introduction: Cryoballoon (CB) guided pulmonary vein isolation (PVI) is an established procedure in the treatment of atrial fibrillation (AF). Transseptal access is an indispensable step during PVI and may be associated with severe complications. For specific interventions, specific puncture sites of the fossa ovalis are advantageous. Here, we analyzed the potential impact of a transesophageal echocardiography (TOE) guided transseptal puncture on nadir temperatures in CB PVI. Methods and Results: We retrospectively analyzed 209 patients undergoing CB PVI in our hospital. The use of TOE had been at the operator's discretion. No TOE-related complications such as perforation of the pharynx or esophagus or loss of teeth were noted. Concerning the applied freezes, we found significantly lower nadir temperatures in all PVs in the TOE group than in the non-TOE group. Procedure time and fluoroscopy time and complications were similar in both groups. Conclusion: TOE-guided TSP in CB PVI is safe and feasible. Our study found significantly lower nadir temperatures of CB freezes after TOE-guided TSP which potentially underscores the value of a more infero-anterior puncture site.

Validation of the newly introduced CASTLE Score for predicting successful CTO recanalization.

BACKGROUND: The new EuroCTO CASTLE Score was validated against the widely adopted Japanese Multicenter CTO Registry (J-CTO) score in predicting technical success in percutaneous coronary intervention (PCI) for coronary chronic total occlusions (CTO). METHODS: A total of 463 patients treated by CTO PCI were included in a retrospective analysis. Result: The mean CASTLE score was 2.23 ± 1.1 and J-CTO score was 2.84 ± 1.0. The overall technical success rate was 83.2%. At 30 days follow up, a primary composite safety endpoint showed a low proportion of stent thrombosis (0.2%) and re-hospitalization (0.4%). Moreover, an improvement of clinical symptoms was found in 83% of patients. Receiver operating characteristic analysis (ROC) demonstrated a comparable overall discriminatory performance in predicting technical outcome: CASTLE score, area under the ROC curve (AUC) 0.668, 95% CI: 0.606-0.730; J-CTO score AUC 0.692, 95% CI: 0.631-0.752; Comparison of AUCs: p = 0.324. Those findings were even consistent in more complex procedures CASTLE Score ≥ 4 and J-CTO score ≥ 3: CASTLE Score AUC 0.514, 95% CI: 0.409-0.619; J-CTO score, AUC 0.617, 95% CI: 0.493-0.741; Comparison of AUCs: p = 0.211. Furthermore, increasing score values are accompanied by a longer examination and fluoroscopy time, more contrast medium and a higher dose area product. CONCLUSION: Compared to the widely accepted J-CTO score, the new introduced EuroCTO CASTLE score demonstrated a comparable overall discriminatory performance in predicting technical outcomes in CTO PCI.

Reduction of Radiation Exposure in Atrioventricular Nodal Reentrant Tachycardia Ablations Using an Electroanatomical Mapping System With Fluoroscopy Integration Module.

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia. Current guidelines recommend electrophysiology study (EPS) and ablation, which have been proven to show high success rates with very low complication rates. Usually, ablation of AVNRT is performed conventionally using only fluoroscopy. Electroanatomical mapping systems (EMS) are widely used in complex arrhythmias. One of their advantages is their potential in decreasing the need of fluoroscopy time (FT). In this study we analyzed patients undergoing either conventional AVNRT ablation or by using an EMS with a fluoroscopy integrating system (FIS). Materials and Methods: We included 119 patients who underwent AVNRT ablation in our study. Eighty-nine patients were ablated conventionally using only fluoroscopy, 30 patients were ablated using EMS + FIS. Results: We found that the use of EMS + FIS led to a significant reduction of FT (449.90 ± 217.21 vs. 136.93 ± 109.28 sec., p < 0.001) and dose-area-product (DAP, 268.27 ± 265.20 vs. 41.07 ± 27.89 µGym2, p < 0.001) without affecting the procedure time (PT, 66.55 ± 13.3 vs. 67.33 ± 13.81 min, p = 0.783). Furthermore, we found no significance with regard to complications. Conclusion: The use of EMS+FIS is safe and feasible. It leads to a significant reduction of both FT and DAP without affecting PT and safety. Hence, EMS + FIS is beneficial for both the operator and the patients by reducing the radiation exposure.

Wearable Cardioverter-Defibrillator Used as a Telemonitoring System in a Real-Life Heart Failure Unit Setting.

BACKGROUND: In patients with reduced left ventricular ejection fraction (LVEF) who are at risk of sudden cardiac death, a wearable cardioverter-defibrillator (WCD) is recommended as a bridge to the recovery of LVEF or as a bridge to the implantation of a device. In addition to its function to detect and treat malignant arrhythmia, WCD can be used via an online platform as a telemonitoring system to supervise patients' physical activity, compliance, and heart rate. METHODS: We retrospectively analyzed 173 patients with regard to compliance and heart rate after discharge. RESULTS: Mean WCD wearing time was 59.75 ± 35.6 days; the daily wearing time was 21.19 ± 4.65 h. We found significant differences concerning the patients' compliance. Men showed less compliance than women, and younger patients showed less compliance than patients who were older. Furthermore, we analyzed the heart rate from discharge until the end of WCD prescription and found a significant decrease from discharge to 4, 8, or 12 weeks. CONCLUSION: WCD can be used as a telemonitoring system to help the involved heart failure unit or physicians attend to and adjust the medical therapy. Furthermore, specific patient groups should be educated more intensively with respect to compliance.

Fast anatomical mapping of the carina and its implications for acute pulmonary vein isolation.

BACKGROUND: Fast anatomical mapping (FAM) of the left atrium and pulmonary veins (PV) during PV isolation (PVI) generates anatomical information about the carina region additionally. We aimed to investigate the utility of these data in relation to conduction abilities of the intervenous carina. METHODS: We investigated 71 patients with drug-refractory atrial fibrillation (AF) who underwent first-time circumferential PVI using an electroanatomical mapping system. Carina width between ipsilateral PV was measured using FAM and an integrated distance measurement tool. Encirclings were divided into carina ablation and noncarina ablation groups based on the necessity of carina ablation to achieve PVI. RESULTS: In total, 142 encirclings were analyzed and first-pass isolation was observed in 102 (72%) encirclings. Nonfirst-pass PVI solely due to a gap on the line or persistent carina conduction was observed in 10 (7%) and 30 (21%) encirclings, respectively. Encirclings were classified into a carina ablation group (n = 30, 21%) and noncarina ablation group (n = 112, 79%). Carina width was significantly larger in the carina ablation vs nonarina ablation group (right: 11.9 ± 1.5 mm vs 8 ± 1.4 mm, P < .001/left: 12.1 ± 1.3 mm vs 8.1 ± 1.1 mm, P < .001) requiring additional carina ablation. CONCLUSION: Carina-related PV conduction is a common finding after the first-pass ablation during PVI. Measurement of carina width using FAM is feasible and its value correlates with the necessity of carina ablation to achieve PVI.

Influence of excess weight and obesity on performance and outcome of pulmonary vein isolation with the cryoballoon.

Pulmonary vein isolation (PVI) has become a cornerstone therapy in the treatment of atrial fibrillation (AF). Patients with overweight or obesity suffer more often from AF, and studies investigating the safety and feasibility of PVI in these patients have shown varying results. In this study we analyzed PVI performed with the 2nd generation cryoballoon (CB) with regard to safety, procedure and fluoroscopy time in patients with normal weight, overweight and obesity. We analyzed 228 consecutive patients treated with CB PVI in our hospital in 2018 and 2019. Fifty nine (25.88%) patients presented with normal weight (body mass index (BMI) of <25), 115 (50.44%) patients with overweight (BMI between 25 and 29.9) and 54 (23.68%) were obese patients (BMI >30). All pulmonary veins (PV) were isolated successfully. Concerning procedural parameters, neither complications, procedural time, nor fluoroscopy time differed significantly. There was a significant increase of dose area product (DAP) in obese patients compared to normal weight and overweight patients (2035.5 ± 1930.1 µGym2 vs. 975.3 ± 814.9 vs. 1325.1 ± 2081.3, p = 0.001) but no significant difference between overweight and normal weight patients (p = 0.611). Our follow-up data of 168 patients (73.68%) observed for 12 months showed no differences in the recurrence of AF in the three BMI groups [80.9% vs. 83.3% (p = 0.733) vs. 86.55% (p = 0.460)]. In conclusion, CB PVI in overweight and obese patients is safe with similar levels of complications and recurrence of AF as patients of normal weight. However, obese patients and operators are exposed to higher radiation doses.

Global Chronic Total Occlusion Crossing Algorithm: JACC State-of-the-Art Review.

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Dual lumen microcatheters for recanalisation of chronic total occlusions: a EuroCTO Club expert panel report.

Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO cap. This EuroCTO consensus document describes current DLMC and suggests a practical guide to anatomies and techniques in which these devices are applicable.

Radiation Exposure for Percutaneous Interventions of Chronic Total Coronary Occlusions in a Multicenter Registry: The Influence of Operator Variability and Technical Set-up.

AIMS: Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose. METHODS AND RESULTS: We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 ± 1.44 to 2.46 ± 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy•cm² (IQR, 70-241 Gy•cm²) to 102 Gy•cm² (IQR, 58-184 Gy•cm²). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences. CONCLUSIONS: Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction.

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.