A novel method for the percutaneous induction of myocardial infarction by occlusion of small coronary arteries in the rabbit.

Arrhythmic sudden cardiac death (SCD) is an important cause of mortality following myocardial infarction (MI). The rabbit has similar cardiac electrophysiology to humans and is therefore an important small animal model to study post-MI arrhythmias. The established approach of surgical coronary ligation results in thoracic adhesions that impede epicardial electrophysiological studies. Adhesions are absent following a percutaneously induced MI, which is also associated with reduced surgical morbidity and so represents a clear refinement of the approach. Percutaneous procedures have previously been described in large rabbits (3.5-5.5 kg). Here, we describe a novel method of percutaneous MI induction in smaller rabbits (2.5-3.5 kg) that are readily available commercially. New Zealand White rabbits (n = 51 males, 3.1 ± 0.3 kg) were anesthetized using isoflurane (1.5-3%) and underwent either a percutaneous MI procedure involving microcatheter tip deployment (≤1.5 Fr, 5 mm), coronary ligation surgery, or a sham procedure. Electrocardiography (ECG) recordings were used to confirm ST-segment elevation indicating coronary occlusion. Blood samples (1 and 24 h) were taken for cardiac troponin I (cTnI) levels. Ejection fraction (EF) was measured at 6-8 wk. Rabbits were then euthanized (Euthatal) and hearts were processed for magnetic resonance imaging and histology. Mortality rates were similar in both groups. Scar volume, cTnI, and EF were similar between both MI groups and significantly different from their respective sham controls. Thus, percutaneous coronary occlusion by microcatheter tip deployment is feasible in rabbits (2.5-3.5 kg) and produces an MI with similar characteristics to surgical ligation with lower procedural trauma and without epicardial adhesions.NEW & NOTEWORTHY Surgical coronary ligation is the standard technique to induce myocardial infarction (MI) in rabbits but is associated with procedural trauma and the generation of thoracic adhesions. Percutaneous coronary occlusion avoids these shortcomings and is established in pigs but has only been applicable to large rabbits because of a mismatch between the equipment used and target vessel size. Here, we describe a new scalable approach to percutaneous MI induction that is safe and effective in 2.5-3.5-kg rabbits.

Correlation between triglyceride glucose index and collateral circulation formation in patients with chronic total occlusion of coronary arteries in different glucose metabolic states.

BACKGROUND: To investigate the correlation between triglyceride glucose index (TyG) and collateral circulation in patients with chronic total occlusion (CTO) of coronary arteries in different glucose metabolic states. METHODS: A total of 681 patients who underwent coronary angiography between January 2020 and December 2021 to determine the presence of CTO lesions in at least one major coronary artery were retrospectively included in this study. Patients were categorized into a group with poor collateral circulation formation (Rentrop grade 0-1, n = 205) and a group with good collateral circulation formation (Rentrop grade 2-3, n = 476) according to the Rentrop scale. They were also categorized according to their glucose metabolism status: normal glucose regulation (NGR) (n = 139), prediabetes mellitus (Pre-DM) (n = 218), and diabetes mellitus (DM) (n = 324). Correlation between TyG index and collateral circulation formation was analyzed by logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS: Among patients with CTO, TyG index was significantly higher in the group with poor collateral circulation formation than in the group with good collateral circulation formation. Logistic regression analysis showed that TyG index was an independent risk factor for poor collateral circulation formation (OR 5.104, 95% CI 3.323-7.839, P < 0.001). The accuracy of TyG index in predicting collateral circulation formation was evaluated by the ROC curve, which had an area under the curve of 0.779 (95% CI 0.738-0.820, P < 0.001). The restrictive cubic spline curves showed that the risk of poor collateral circulation formation in the Pre-DM and DM groups was initially flat and finally increased rapidly, except for the NGR group. TyG index was significantly associated with an increased risk of poor collateral circulation formation in the Pre-DM and DM groups. CONCLUSIONS: TyG index was significantly associated with the risk of poor collateral circulation formation in patients with CTO, especially those with Pre-DM and DM.

Assessment of Myocardial Viability and Risk Stratification in Coronary Chronic Total Occlusion: A Qualitative and Quantitative Stress Cardiac MRI Study.

BACKGROUND: Indicators for assessing myocardial viability and risk stratification in patients with coronary chronic total occlusion (CTO) are still in the research stage. PURPOSE: To use stress-MRI to assess myocardial function, blood perfusion, and viability and to explore their relationship with collateral circulation. STUDY TYPE: Prospective. SUBJECTS: Fifty-one patients with CTO in at least one major artery confirmed by X-ray coronary angiography (male: 46; age 55.2 ± 10.8 years). FIELD STRENGTH/SEQUENCE: 3.0T; TurboFlash, balanced steady-state free precession cine, and phase-sensitive inversion recovery sequences. ASSESSMENT: Stress-MRI was used to obtain qualitative and quantitative parameters of segmental myocardium. Myocardial segments supplied by CTO target vessels were grouped according to the degree of collateral circulation assessed by radiographic coronary angiography (no/mild, moderate, or good). Depending on qualitative stress perfusion assessment and late gadolinium enhancement (LGE) extent, segments were also categorized as negative, viable, or trans-infarcted. STATISTICAL TESTS: Independent sample Student's t-test, one-way analysis of variance (ANOVA) test, Mann-Whitney U test, Kruskal-Wallis test, Spearman correlation coefficient (r). P < 0.05 was considered statistically significant. RESULTS: A total of 334 segments were supplied by CTO target vessels. The radial strain (RS), circumferential strain (CS), longitudinal strain (LS) of the negative, viable, and trans-infarcted regions showed a significant and stepwise impairment. Myocardial blood flow at rest was positively correlated with RS, CS, and LS (r = 0.42, 0.43, 0.38, respectively). Among the different collateral circulation, there were no significant differences in RS, CS, LS, and LGE volume (P = 0.788, 0.562, 0.122, 0.170, respectively), and there were also no statistically significant differences in the proportions of negative, viable, and trans-infarcted regions (P = 0.372). DATA CONCLUSION: Myocardial perfusion obtained by stress-MRI combined with strain and LGE may comprehensively evaluate myocardial function and viability, and has potential to facilitate risk stratification of CTO. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 1.

Guide catheter extension use are associated with higher procedural success in chronic total occlusion percutaneous coronary interventions.

BACKGROUND: Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications. AIM: Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use. RESULTS: From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J-CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78-2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41-2.41, p = 0.986), in-hospital death (OR: 1.39, 95% CI: 0.54-3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52-2.19, p = 0.850) were similar in both groups. CONCLUSION: In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes.

Successful treatment by recross IVUS-guided reentry in coronary total occlusion: STRIVE-CTO.

Complex coronary total occlusion (CTO) lesions percutaneous treatment, especially in contexts where traditional antegrade strategies have failed and retrograde approaches are unsuitable, due to lack of interventional collaterals or high risk of complications, presents a considerable challenge for interventional cardiologists. Antegrade dissection reentry has historically offered a bailout strategy in cases with unsuccessful antegrade wire escalation. Nevertheless, the technique-whether employing dual-lumen microcatheters or dedicated reentry devices, such as Stingray-encounters several limitations, particularly when the delivery of the system is not possible, or extraplaque large hematomas, which complicates reentry. This paper introduces an innovative technique combining the use of the Recross MC Dual Microcatheter with real-time intravascular ultrasound guidance for refined re-wiring in CTO interventions. This approach facilitates accurate reentry zone selection and ensures precise, controlled puncturing into the true lumen, thereby enabling safe and predictable CTO recanalization.

Intracoronary snaring of the retrograde guidewire: A novel method to solve compartment mismatch in complex retrograde CTO PCI.

The retrograde approach has allowed a remarkable improvement in the success rate of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). After collateral channel crossing, the most crucial aspect of retrograde CTO PCI is creating the connection between the antegrade and retrograde system. Currently, the most common technique to achieve this is reverse controlled antegrade and retrograde subintimal tracking. However, this maneuver sometimes fails due to compartment mismatch (intraplaque situation of one wire and extraplaque situation of the other). New approaches are therefore needed to overcome challenges in this important step of the procedure. Here we present an innovative solution to this problem, which involved capturing the retrograde guidewire (advanced into a side branch at the distal cap) with a microsnare that had been advanced antegradely: this severed the dissection flap separating the antegrade and retrograde system, thus allowing us to successfully recanalize the CTO.

Intravascular ultrasound-guided STAR 2.0: A new technique for chronic total occlusion recanalization.

The use of the subintimal space has allowed a massive advancement in the field of chronic total occlusion percutaneous coronary intervention (PCI). The STAR technique is the first of subintimal techniques. Despite a high acute success rate, follow-up results showed unfavorable outcomes with half of the treated patients showing restenosis/reocclusion at 6 months. We present three cases in which a modification of the STAR technique guided by intravascular ultrasound (IVUS), namely the STAR 2.0, was used as a bailout for successful PCI of chronic total occlusions.

Applicability of J-CTO channel score to predict microcatheter tracking during retrograde percutaneous coronary intervention of chronic total occlusions: Insights from the SURFING MICRO registry.

BACKGROUND: The J-chronic total occlusion (CTO) channel score can predict guidewire tracking of the collateral channels (CCs), but its efficacy in predicting microcatheter tracking has never been tested in the setting of retrograde CTO-percutaneous coronary intervention (PCI). AIMS: Predicting microcatheter collateral tracking during retrograde CTO-PCIs. METHODS: A total of 189 patients undergoing retrograde CTO-PCI from April 2017 to August 2021 were screened. The primary outcome of interest was a correlation between J-CTO channel score and microcatheter tracking failure (MTF) after successful CC tracking by the guidewire. The independent association between anatomical features of the J-CTO channel score and the primary outcome of interest was explored. RESULTS: After adjustment, only small size (adjusted OR: 12.70, 95% confidence interval [CI]: 1.79-89.82; p = 0.01) and continuous bends (adjusted OR: 14.15, 95% CI: 2.77-72.34; p < 0.001) remained significantly associated with an increased risk of MTF for septal collaterals. The small size was the only predictor of the MTF for epicardial collaterals (OR: 6.39, 95% CI: 1.13-35.96; p = 0.020) at univariate analysis. Patients in the MTF group had a lower incidence of procedural success compared with patients in the microcatheter tracking success (MTS) group (40.0% vs. 93.9%, p < 0.001) and had a higher incidence of collateral perforations (20.0% vs. 3.0%, p < 0.001). CONCLUSION: Small and tortuous septal collaterals, identified by a score ≥3, are associated with an increased risk of MTF, lower incidence of procedural success, and higher risk of procedural complications driven by collateral perforations.

Retrograde chronic total occlusion percutaneous coronary intervention via ipsilateral collaterals.

BACKGROUND: There is limited data on retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) via ipsilateral epicardial collaterals (IEC). AIMS: To compare the clinical and angiographic characteristics, and outcomes of retrograde CTO PCI via IEC versus other collaterals in a large multicenter registry. METHODS: Observational cohort study from the Prospective Global registry for the study of Chronic Total Occlusion Intervention (PROGRESS-CTO). RESULTS: Of 4466 retrograde cases performed between 2012 and 2023, crossing through IEC was attempted in 191 (4.3%) cases with 50% wiring success. The most common target vessel in the IEC group was the left circumflex (50%), in comparison to other retrograde cases, where the right coronary artery was most common (70%). The Japanese CTO score was similar between the two groups (3.13 ± 1.23 vs. 3.06 ± 1.06, p = 0.456); however, the IEC group had a higher Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score (1.95 ± 1.02 vs. 1.27 ± 0.92, p < 0.0001). The most used IEC guidewire was the SUOH 03 (39%), and the most frequently used microcatheter was the Caravel (43%). Dual injection was less common in IEC cases (66% vs. 89%, p < 0.0001). Technical (76% vs. 79%, p = 0.317) and procedural success rates (74% vs. 79%, p = 0.281) were not different between the two groups. However, IEC cases had a higher procedural complications rate (25.8% vs. 16.4%, p = 0.0008), including perforations (17.3% vs. 9.0%, p = 0.0001), pericardiocentesis (3.1% vs. 1.2%, p = 0.018), and dissection/thrombus of the donor vessel (3.7% vs. 1.2%, p = 0.002). CONCLUSION: The use of IEC for retrograde CTO PCI was associated with similar technical and procedural success rates when compared with other retrograde cases, but higher incidence of periprocedural complications.

Performance of the minimalistic hybrid approach algorithm versus other conventional algorithms in the percutaneous treatment of chronic total occlusions.

BACKGROUND: The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). AIMS: This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms. METHODS: We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization. RESULTS: Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195). CONCLUSION: The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.

International survey of chronic total occlusion percutaneous coronary intervention operators.

BACKGROUND: Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) practice has received limited study. AIM: To examine the contemporary CTO PCI practice. METHODS: We performed an online, anonymous, international survey of CTO PCI operators. RESULTS: Five hundred forty-five CTO PCI operators and 190 interventional cardiology fellows with an interest in CTO PCI participated in this survey. Almost half were from the United States (41%), most (93%) were men, and the median h/week spent in the hospital was 58. Median annual case numbers were 205 (150-328) for PCIs and 20 (5-50) for CTO PCIs. Almost one-fifth (17%) entered CTO cases into registries, such as PROGRESS-CTO (55%) and EuroCTO (20%). More than one-third worked at academic institutions (39%), 31% trained dedicated CTO fellows, and 22% proctored CTO PCI. One-third (34%) had dedicated CTO PCI days. Most (51%) never discharged CTO patients the same day, while 17% discharged CTO patients the same day >50% of the time. After successful guidewire crossing, 38% used intravascular imaging >90% of the time. Most used CTO scores including J-CTO (81%), PROGRESS-CTO (35%), and PROGRESS-CTO complications scores (30%). Coronary artery perforation was encountered within the last month by 19%. On a scale of 0-10, the median comfort levels in treating coronary artery perforation were: covered stents 8.8 (7.0-10), coil embolization 5.0 (2.1-8.5), and fat embolization 3.7 (0.6-7.3). Most (51%) participants had a complication cart/kit and 25% conducted regular complication drills with catheterization laboratory staff. CONCLUSION: Contemporary CTO PCI practices vary widely. Further research on barriers to following the guiding principles of CTO PCI may improve patient outcomes.

Technical aspects of entrapped coronary guidewire retrieval using rotational atherectomy device: A case series.

BACKGROUND: This article highlights four unique cases where rotational atherectomy (RA Rotapro, Boston Scientific) was used to cut and retrieve an entrapped coronary guidewire with parts extending into the aorta We discuss the technique and step by step approach to the retrieval procedure. CASE SUMMARY: Three of four cases described a guide wire entrapment in the right coronary artery (RCA), and one in the left anterior descending artery via retrograde route. In all cases the guide wire was intact within the intracoronary segment. In Case 1, the guide wire (Runthrough; Terumo) was entrapped in an acute marginal branch during chronic total occlusion (CTO) percutaneous coronary intervention. In Case 2, a whisper wire (Abbott) was entrapped during re-wiring of the right posterolateral branch through stent struts, the traction on the wire caused severe malformation of distal and proximal stents requiring second staged procedure to complete revascularization of the RCA CTO. In Case 3, a Runthrough wire was entrapped between two layers of stents and fractured at the proximal point with filaments extending into descending aorta. And in Case 4, a Pilot 200 (Abbott) wire was entrapped retrograde in the subintimal space via saphenous vein graft connection by tying a knot at the distal tip of the wire. In all four cases RA was used to successfully cut and remove the entrapped guide wires. DISCUSSION: Rotablation technique appears to be a safe and effective strategy for the management of entrapped coronary guidewire when conventional strategies fail.

Validation of the BCIS CHIP Score in chronic total occlusion percutaneous coronary intervention.

BACKGROUND: The complex high-risk indicated percutaneous coronary intervention (CHIP) score is a tool developed using the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and predict in-hospital major adverse cardiac or cerebrovascular events (MACCE). AIM: To assess the validity of the CHIP score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We evaluated the performance of the CHIP score on 8341 CTO PCIs from the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) performed at 44 centers between 2012 and 2023. RESULTS: In our cohort, 7.8% (n = 647) of patients had a CHIP score of 0, 50.2% (n = 4192) had a CHIP score of 1-2, 26.2% (n = 2187) had a CHIP score of 3-4, 11.7% (n = 972) had a CHIP score of 5-6, 3.3% (n = 276) had a CHIP score of 7-8, and 0.8% (n = 67) had a CHIP score of 9+. The incidence of MACCE for a CHIP score of 0 was 0.6%, reaching as high as 8.7% for a CHIP score of 9+, confirming that a higher CHIP score is associated with a higher risk of MACCE. The estimated increase in the risk of MACCE per one score unit increase was 100% (95% confidence interval [CI]: 65%-141%). The AUC of the CHIP score model for predicting MACCE in our cohort was 0.63 (95% CI: 0.58-0.67). There was a positive correlation between the CHIP score and the PROGRESS-CTO MACE score (Spearman's correlation: 0.37; 95% CI: 0.35-0.39; p < 0.001). CONCLUSIONS: The CHIP score has modest predictive capacity for MACCE in CTO PCI.

Using Ping-pong technique along with rapid inflate-deflate ballooning to solve total left main occlusion during transcatheter aortic valve replacement procedure.

Coronary obstruction during transcatheter aortic valve replacement (TAVR) poses a significant threat, prompting a closer examination of prevention and bailout strategies. Following TAVR deployment with a coronary artery obstruction complication and recognizing the complexities involved in engaging the left main coronary artery through TAVR cells. This case introduces the "Ping-pong" technique using a second guide catheter. When faced with difficulty in engaging the catheter through TAVR cells, an innovative solution is proposed. Inserting a wire into the valsalva and utilizing a rapid inflate-deflate balloon maneuver successfully facilitates catheter access into the left main, offering a promising intervention for challenging scenarios. In conclusion, this study emphasizes the severe implications of coronary obstruction during TAVR. The innovative "Ping-pong" technique and rapid inflate-deflate balloons emerge as valuable interventions, showcasing their potential in challenging catheter engagement scenarios. These insights offer a promising avenue for enhancing patient outcomes in TAVR procedures.

Novel valve-in-surgical bioprosthetic transcatheter aortic valve replacement: Undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN).

An 86-year-old female with history of surgical aortic valve replacement presented with clinical signs of heart failure. Echocardiography revealed a reduction in left ventricular systolic function and severe bioprosthetic aortic valve dysfunction. This is the first reported case of valve-in-valve transcatheter aortic valve replacement with concomitant undermining iatrogenic coronary obstruction with radiofrequency needle procedure in a surgical bioprosthetic valve.

A stepwise approach to coronary artery stenting in acute type A aortic dissection.

We present three cases of acute coronary obstruction postsurgical repair of type A aortic dissection, which were successfully treated with percutaneous coronary intervention. We describe a step-by-step approach to performing percutaneous coronary intervention in selective cases of coronary obstruction related to type A aortic dissection.

Evaluation of 12-lead electrocardiogram at 0.55T for improved cardiac monitoring in magnetic resonance imaging.

BACKGROUND: The 12-lead electrocardiogram (ECG) is a standard diagnostic tool for monitoring cardiac ischemia and heart rhythm during cardiac interventional procedures and stress testing. These procedures can benefit from magnetic resonance imaging (MRI) information; however, the MRI scanner magnetic field leads to ECG distortion that limits ECG interpretation. This study evaluated the potential for improved ECG interpretation in a "low field" 0.55T MRI scanner. METHODS: The 12-lead ECGs were recorded inside 0.55T, 1.5T, and 3T MRI scanners, as well as at scanner table "home" position in the fringe field and outside the scanner room (seven pigs). To assess interpretation of ischemic ECG changes in a 0.55T MRI scanner, ECGs were recorded before and after coronary artery occlusion (seven pigs). ECGs was also recorded for five healthy human volunteers in the 0.55T scanner. ECG error and variation were assessed over 2-minute recordings for ECG features relevant to clinical interpretation: the PR interval, QRS interval, J point, and ST segment. RESULTS: ECG error was lower at 0.55T compared to higher field scanners. Only at 0.55T table home position, did the error approach the guideline recommended 0.025 mV ceiling for ECG distortion (median 0.03 mV). At scanner isocenter, only in the 0.55T scanner did J point error fall within the 0.1 mV threshold for detecting myocardial ischemia (median 0.03 mV in pigs and 0.06 mV in healthy volunteers). Correlation of J point deviation inside versus outside the 0.55T scanner following coronary artery occlusion was excellent at scanner table home position (r2 = 0.97), and strong at scanner isocenter (r2 = 0.92). CONCLUSION: ECG distortion is improved in 0.55T compared to 1.5T and 3T MRI scanners. At scanner home position, ECG distortion at 0.55T is low enough that clinical interpretation appears feasible without need for more cumbersome patient repositioning. At 0.55T scanner isocenter, ST segment changes during coronary artery occlusion appear detectable but distortion is enough to obscure subtle ST segment changes that could be clinically relevant. Reduced ECG distortion in 0.55T scanners may simplify the problem of suppressing residual distortion by ECG cable positioning, averaging, and filtering and could reduce current restrictions on ECG monitoring during interventional MRI procedures.

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion.

AIMS: Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. METHODS AND RESULTS: The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). CONCLUSION: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Safety and feasibility of rotational atherectomy (RA) versus conventional stenting in patients with chronic total occlusion (CTO) lesions: a systematic review and meta-analysis.

BACKGROUND AND AIM: Interventional cardiologists face challenges in managing chronic total occlusion (CTO) lesions, with conflicting results when comparing rotational atherectomy (RA) to conventional PCI. This meta-analysis aims to provide a critical evaluation of the safety and feasibility of RA in CTO lesions. METHODS: PubMed, Scopus, Web of Science, Ovid, and Cochrane central library until April 2023 were searched for relevant studies. MACE was our primary outcomes, other outcomes were all cause of death, cardiac death, MI, and TVR. Also, we reported angiographic outcomes as technical success, procedural success, and procedural complications in a random effect model. The pooled data was analyzed using odds ratio (OR) with its 95% CI using STATA 17 MP. RESULTS: Seven studies comprising 5494 patients with a mean follow-up of 43.1 months were included in this meta-analysis. Our pooled analysis showed that RA was comparable to PCI to decrease the incidence of MACE (OR = 0.98, 95% CI [0.74 to 1.3], p = 0.9). Moreover, there was no significant difference between RA and conventional PCI in terms of other clinical or angiographic outcomes. CONCLUSION: Our study showed that RA had comparable clinical and angiographic outcomes as conventional PCI in CTO lesions, which offer interventional cardiologists an expanded perspective when addressing calcified lesions. PROSPERO REGISTRATION: CRD42023417362.

Elevated neutrophyl-to-lymphocyte ratioand smoking are associated with chronic total occlusion in patients with ST elevation myocardial infarction.

BACKGROUND: Atherosclerosis is a progressive disease characterized by the build-up of lipids and connective tissue in the large arteries. Some patients experience chronic total occlusion (CTO). Inflammation plays a key role in the development and complications of atherosclerosis. Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with the development of acute coronary syndrome (ACS). We aimed to assess the relationship between NLR and CTO in ACS patients with ST elevated myocardial infarction (STEMI) in Indonesia. METHODS: This cross-sectional study was performed with secondary data obtained from patient medical records at Cipto Mangunkusumo National Central Hospital, Jakarta. Inclusion criteria were patients with ACS and STEMI who underwent coronary angiography in 2015-2018. RESULTS: A total of 98 patients were enrolled in the analysis. Most subjects with CTO were male, elderly (> 60), smoking, had no history of diabetes mellitus (DM) or hypertension, no family history of coronary heart disease (CHD), but had a history of ACS and had never consumed statin or antiplatelet medications. Bivariate logistic regression analysis revealed that male gender (PR = 1.820; 95%CI 0.871-3.805; p = 0.025) and smoking (PR = 1.781; 95%CI 1.028-3.086; p = 0.004) were significantly correlated with CTO. Receiver operator characteristic (ROC) curve revealed that higher NLR (≥ 6.42) could predict a CTO diagnosis with positive predictive value (PPV) of 91%. Multivariate analysis revealed that NLR was correlated with an 11.2-fold increase in occurrence of CTO (95%CI 3.250-38.303; p < 0.001). Additionally, smoking was correlated with a 7-fold increase in CTO (95% CI 1.791-30.508; p = 0.006). CONCLUSION: NLR value of ≥ 6.42 is potentially useful as a marker of CTO in STEMI patients. In addition, smoking increases the risk of CTO in ACS/STEMI patients.