Impact of chronic total occlusion on the early outcome of patients undergoing Impella supported high-risk percutaneous coronary intervention

Felix Woitek (Dresden)1, A. Laupp (Dresden)1, S. Haussig (Dresden)1, A. Conrad (Dresden)1, J. Mierke (Dresden)1, E. B. Winzer (Dresden)1, R. Höllriegel (Dresden)1, S. Jellinghaus (Dresden)1, A. Linke (Dresden)1, N. Mangner (Dresden)1

1Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin, Kardiologie und Intensivmedizin Dresden, Deutschland


Background: Chronic total occlusion (CTO) is frequently found in patients undergoing high-risk percutaneous coronary interventions (HRPCI). Mechanical circulatory support is increasingly used in HRPCI to facilitate a more complete revascularization. We investigated the impact of CTO presence (CTO) versus non-presence (nonCTO) on early and mid-term outcomes in patients undergoing Impella-supported HRPCI.

Methods: We used an ongoing single-center registry to examine 76 CTO and 109 nonCTO patients undergoing Impella-supported HRPCI. The primary outcome was 30-day survival and safety was assessed according to ARC-2 and VARC-III definitions. The 1-year survival was also assessed.

Results: Compared with nonCTO, CTO patients were younger (76 (IQR 67; 81) vs 81 (IQR 77; 85) years of age, p<0.001) and median left ventricular ejection fraction was lower (35% (IQR 25; 45) vs 40% (IQR 30; 55), p=0.008). There were no differences with regard ischemic (CCS 3/4: 28.8% vs 37.1%) and heart failure symptoms (NYHA III/IV: 64.0% vs 56.9%). There was a significantly higher rate of 3-vessel but a numerically lower rate of left main disease in CTO compared with non-CTO leading to a comparable median Syntax score (33 (IQR 28; 37) vs 34 (IQR 26; 44), p=0.328).

In CTO, 21 (27.6%) CTO lesions were successfully treated, 8 (10.5%) were unsuccessfully treated, and 47 (61.8%) were left untreated. Overall, fewer lesions were treated in CTO compared with nonCTO (2 (IQR 1;3) vs 3 (IQR 2; 3), p=0.001). The time of Impella support was not different between groups.

With regard to safety, there was a higher rate of myocardial infarction in CTO vs nonCTO (4.1% vs 0%, p=0.067), whereas BARC-defined bleeding and VARC-defined stroke, acute kidney injury, and access site complications were not different.

The Kaplan-Meier estimated 30-day survival was lower for CTO compared with nonCTO (63.3% (95%-CI 50.5; 79.4) vs. 88.5 (95%-CI 80.8; 96.9), p=0.002). Adjusting for the STS score, 3-vessel and left main disease, CTO remained an independent predictor of 30-day mortality (HR 2.8, 95%-CI 1.2; 6.5, p=0.016). The CTO treatment choice had no impact on 30-day mortality in this small cohort. Survival remained lower in CTO compared with nonCTO at 1 year (43.0% (95%-CI 29.2; 63.4) vs. 69.0 (95%-CI 56.1; 84.9), p=0.005).

Conclusion: In patients undergoing Impella-supported HRPCI, the presence of a CTO identifies a population at high risk for increased early and midterm mortality. Further studies are necessary to elucidate the effect of CTO revascularization on early and late outcomes in those patients.

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