Benefits of chronic total coronary occlusion percutaneous intervention in patients with heart failure and reduced ejection fraction: insights from a cardiovascular magnetic resonance study

Montserrat Cardona, Victoria Martín, Susanna Prat-Gonzalez, José Tomás Ortiz, Rosario Jesús Perea, Teresa Maria de Caralt, Mónica Masotti, Félix Pérez-Villa, Manel Sabaté, Montserrat Cardona, Victoria Martín, Susanna Prat-Gonzalez, José Tomás Ortiz, Rosario Jesús Perea, Teresa Maria de Caralt, Mónica Masotti, Félix Pérez-Villa, Manel Sabaté

Abstract

Background: Chronic total occlusion percutaneous coronary intervention (CTO-PCI) can improve angina and left ventricular ejection fraction (LVEF). These benefits were not assessed in populations with heart failure with reduced ejection fraction (HFrEF). We studied the effect of CTO-PCI on left ventricular function and clinical parameters in patients with HFrEF.

Methods: Using cardiovascular magnetic resonance (CMR), we studied 29 patients with HFrEF and evidence of viability and/or ischemia in the territory supplied by a CTO who were successfully treated with CTO-PCI. In patients with multi-vessel disease, non-CTO PCI was also performed. Imaging parameters, clinical status, and brain natriuretic peptide (BNP) levels were evaluated before and 6 months after CTO-PCI.

Results: A decrease in left ventricular end-systolic volume (160 ± 54 ml vs. 143 ± 58 ml; p = 0.029) and an increase in LVEF (31.3 ± 7.4 % vs. 37.7 ± 8 %; p < 0.001) were observed. There were no differences in LVEF improvement between patients who underwent non-CTO PCI (n = 11) and those without this intervention (n = 18); (p = 0.73). The number of segments showing perfusion defects was significantly reduced (0.5 ± 1 vs. 0.2 ± 0.5; p = 0.043). Angina (p = 0.002) and NYHA functional class (p = 0.004) improved, and BNP levels decreased (p = 0.004) after CTO-PCI.

Conclusions: In this group of patients with HFrEF showing CMR evidence of viability and/or ischemia within the territory supplied by the CTO, an improvement in ejection fraction, left ventricular end-systolic volume and ischemia burden was observed after CTO-PCI. Clinical and laboratory parameters also improved.

Trial registration: ClinicalTrials.gov NCT02570087 . Registered 6 October 2015.

Keywords: Angioplasty; Cardiovascular magnetic resonance; Chronic total coronary occlusion; Heart failure with reduced ejection fraction; Myocardial viability.

Figures

Fig. 1
Fig. 1
Flow chart of patient inclusion. Abbreviations: CABG, coronary artery bypass graft; CMR, cardiovascular magnetic resonance; CTO, chronic total occlusion; ICD, implantable cardioverter defibrillator; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention
Fig. 2
Fig. 2
CMR study before PCI in a patient with a CTO in the mid-LAD coronary artery and no other significant coronary stenosis, but a history of previous inferior ST-elevation myocardial infarction with mid RCA stent implantation. a Stress perfusion images showing an inducible defect in mid-apical anterior and anteroseptal segments (white arrow). b Resting perfusion images showing no perfusion defects. c LGE study showing transmural enhancement in mid-inferior segment (>75 % transmural extension) (white arrow). Absence of enhancement in basal, mid, and apical antero-septal segments
Fig. 3
Fig. 3
Graph showing a significant reduction in brain natriuretic peptide (BNP) levels after successful CTO-PCI (n = 31)
Fig. 4
Fig. 4
Graph showing changes in New York Heart Association (NYHA) functional class for dyspnea after successful CTO-PCI (n = 32)

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