The myocardium supplied by a chronic total occlusion is a persistently ischemic zone

Authors

  • Rajesh Sachdeva MD,

    Corresponding author
    1. WellStar Cardiology, North Fulton Hospital, Roswell, Georgia
    2. Department of Internal Medicine, Division of Cardiology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
    • Correspondence to: Rajesh Sachdeva, North Fulton Hospital, Roswell, GA 30076. E-mail: rrsachdeva@gmail.com

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  • Mayank Agrawal MD,

    1. Department of Internal Medicine, Division of Cardiology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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  • Shawn E. Flynn MD,

    1. Department of Internal Medicine, Division of Cardiology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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  • Gerald S. Werner MD,

    1. Medizinische Klinik I (Cardiology & Intensive Care), Klinikum Darmstadt GmbH, Darmstadt, Germany
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  • Barry F. Uretsky MD

    1. Department of Internal Medicine, Division of Cardiology, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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  • Conflict of interest: Dr. Sachdeva serves on speaker bureau for Volcano Corporation and St. Jude Medical; other co-authors have no conflict of interest to disclose.

Abstract

Well-developed collaterals to a myocardial segment supplied by a chronic total occlusion (CTO) and/or left ventricular dysfunction in the CTO regions in patients with chronic stable angina suggest that severe ischemia is unlikely to be present. We evaluated the presence and severity of ischemia using fractional flow reserve (FFR) of the myocardium supplied by a CTO in patients and compared the results with a non-CTO control group.

Methods

Patients undergoing FFR and successful percutaneous coronary intervention (PCI) of a CTO were evaluated and compared to a matched non-CTO control group.

Results

One hundred patients were included (50 CTO/50 controls). CTO lesions were longer (31.6 ± 18.9 vs 20.2 ± 14.9 mm, P = 0.004) and required more stents (2.2 ± 0.8 vs 1.2 ± 0.5, P = 0.001). FFR was lower (P = 0.0003) with CTO (0.45 ± 0.15) than controls (0.58 ± 0.17) prior to intervention but similar after PCI (CTO 0.91 ± 0.05 vs non-CTO 0.90 ± 0.08). All CTO patients demonstrated an ischemic FFR, even with severe regional dysfunction or well-developed collaterals. Resting ischemia was present in 78% (39/50) of CTO patients as evidenced by a resting Pd/Pa of <0.80.

Conclusion

In symptomatic patients, a CTO, even with regional left ventricular impairment and/or excellent collateral development, reveals an ischemic zone. This ischemic zone can be normalized by PCI with outcomes appearing to be comparable to non-CTO patients. © 2013 Wiley Periodicals, Inc.

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