PCI of Concurrent Coronary Chronic Total Occlusion After STEMI

After ST-segment elevation myocardial infarction (STEMI), early percutaneous coronary intervention (PCI) of concurrent coronary chronic total occlusion (CTO) in a non-infarct-related artery was safe and feasible, according to a study published in the Journal of the American College of Cardiology.

About 50% of patients who undergo PCI for STEMI have multivessel disease, or significant stenoses or CTO of arteries not related to the infarct. “In patients with STEMI, concomitant CTO drives LV function and mortality in patients with multivessel disease and may be an important modifiable risk factor,” José P.S. Henriques, MD, PhD, of the University of Amsterdam in the Netherlands, told Cardiology Advisor.

The rates of morbidity and mortality among STEMI patients with concurrent CTO are twice as high as those among patients with single-vessel disease. Observational data suggest that PCI of CTO may improve left ventricular ejection fraction (LVEF) and survival.

In the EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Segment Elevation Myocardial Infarction) trial, Dr Henriques and colleagues investigated whether PCI of concurrent CTO within 1 week after treatment for STEMI improved LVEF and LV end-diastolic volume (LVEDV) on cardiac magnetic resonance (CMR) at 4 months.

A total of 304 patients with STEMI treated with primary PCI were randomly assigned in a 1:1 ratio to early PCI of concurrent CTO vs conservative treatment without PCI of CTO. The CTO recanalization success rate was 73%.

No difference was found in LVEF or LVEDV between the treatment groups at 4 months (P =.60 and P =.70, respectively).

In a subgroup analysis, PCI in patients with CTO of the left anterior descending (LAD) coronary artery had significantly improved LVEF compared with control patients (47.2% vs 40.4%; P =.02). Although LVEDV was similar between CTO PCI patients with LAD and those with non-LAD occlusions, a significant interaction between location of CTO (LAD vs non-LAD) and treatment assignment was found (P =.039).

Rates of major adverse coronary events at 4 months were similar between the groups (5.4% of CTO PCI vs 2.6% of control; P =.25).

“Additional CTO PCI within 1 week after primary PCI for STEMI was feasible and safe,” the authors wrote. In addition, early CTO PCI appeared to be beneficial in patients with CTO in the LAD.

But in order to make any definite conclusions about early CTO PCI, more data and research are needed. “Longer-term follow-up data and additional CMR data from EXPLORE will be presented at the Transcatheter Cardiovascular Therapeutics 2016 meeting,” Dr Henriques said. “Additional subanalyses are also pending to prepare for investigating CTO PCI further in EXPLORE-2.”

Disclosures: This study was funded by research grants from the Academic Medical Center, University of Amsterdam and Abbott Vascular. Drs Henriques and van der Schaaf reported financial relationships with Abbott Vascular and Biotronik. Dr Henriques has also received grants from BBraun and Abiomed. Dr van der Schaaf has also received grants and fees from Biosensors and Boston Scientific, as well as speakers’ fees from OrbusNeich and Asahi Intecc. Dr Råmunddal has been a proctor for Boston Scientific.  

Reference

Henriques JPS, Hoebers LP, Råmunddal T, et al; for the EXPLORE Trial Investigators. Percutaneous intervention for concurrent chronic total occlusions in patients with STEMI: the EXPLORE trial. J Am Coll Cardiol. 2016 Oct 3;68(15):1622-1632. doi: 10.1016/j.jacc.2016.07.744 [Epub ahead of print].