Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization-A Workflow Focusing on Non-Invasive Cardiac Imaging

Kevin Hamzaraj, Andreas Kammerlander, Mariann Gyöngyösi, Bernhard Frey, Klaus Distelmaier, Senta Graf, Kevin Hamzaraj, Andreas Kammerlander, Mariann Gyöngyösi, Bernhard Frey, Klaus Distelmaier, Senta Graf

Abstract

Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician's discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions.

Keywords: cardiac magnetic resonance; chronic total occlusion; coronary artery disease; echocardiography; positron emission tomography; single photon emission computer tomography.

Conflict of interest statement

The authors declare no conflict of interest. Non-invasive myocardial PET and CMR images are presented with permission on behalf of the University Clinic of Radiology and Nuclear Medicine, Medical University of Vienna. Myocardial SPECT images are presented with permission on behalf of the University Clinic of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria.

Figures

Figure 5
Figure 5
Limitations: Non-invasive cardiac imaging modalities for CTO evaluation: CTO–chronic total occlusion, TTE–transthoracic echocardiography, SPECT–single positron emission computer tomography, CMR–cardiac magnetic resonance, PET–positron emission tomography.
Figure 1
Figure 1
Non-invasive cardiac imaging modalities for CTO evaluation CTO–chronic total occlusion, TTE–transthoracic echocardiography, SPECT–single positron emission computer tomography, CMR–cardiac magnetic resonance, PET–positron emission tomography, LV–left ventricle, Tc–technetium, Tl–thallium.
Figure 2
Figure 2
Thallium 201-SPECT study in a patient with a CTO CX as described in the coronary angiography. Short axis views are displayed in row 1–4 and vertical and horizontal long axis views in row 5–8. No significant tracer uptake in stress (row 1,3,5,7) and rest (row 2,4,6,8) acquisitions can be interpreted as lack of viability in the lateral and basal part of inferior myocardial segments (a). On the right, a semi-quantification of tracer uptake from the stress (top) and rest (bottom) acquisitions in a polar map (b).
Figure 3
Figure 3
Combined perfusion (performed with N-13 ammonia) and metabolism (performed with F-18 FDG) PET study allows a differentiation between viable and non-viable myocardium. On the left side (a) is shown a perfusion/metabolism match in the posterior-lateral segments with equally reduced NH3 (top) and FDG (bottom) uptake reflecting scar in this myocardial region. On the right side (b) a perfusion/metabolism mismatch: perfusion (short axis views at the top) and metabolism (short axis views on the bottom) with reduced NH3 uptake and enhanced FDG uptake in the lateral wall. This reflects preserved viability in the hypo-perfused lateral myocardial segments.
Figure 4
Figure 4
Cardiac magnetic resonance stress acquisition on a short axis view (a) with a reduced contrast uptake in posterior-septal segments. (a) On the right side (b) a late gadolinium enhancement in subendocardial posterior-lateral myocardial segments shows significant preserved viability (<50% trans-murality).
Figure 6
Figure 6
Workflow for clinical indication of CTO PCI, TTE—trans-thoracic echocardiography; LM—left main coronary artery; LAD—left anterior descending coronary artery; LVEF—left ventricular ejection fraction; SPECT—single photon emission computer tomography; CMR—cardiac magnetic resonance; PET—positron emission tomography; OMT—optimal medical therapy; PCI—percutaneous coronary intervention.

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