TCT-446 Long-Term Clinical Outcomes after Percutaneous Coronary Intervention for Chronic Total Occlusions in Elderly Patients (≥75 years): Five-Year Outcomes from a 1,791 Patient Multi-National Registry

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No evidence for cardiac dysfunction in Kif6 mutant mice.

A KIF6 variant in man has been reported to be associated with adverse cardiovascular outcomes after myocardial infarction. No clear biological or physiological data exist for Kif6. We sought to investigate the impact of a deleterious KIF6 mutation on cardiac function in mice. Kif6 mutant mice were generated and verified. Cardiac function was assessed by serial echocardiography at baseline, after ageing and after exercise. Lipid levels were also measured. No discernable adverse lipid or cardiac phenotype was detected in Kif6 mutant mice. These data suggest that dysfunction of Kif6 is linked to other more complex biological/biochemical parameters or is unlikely to be of material consequence in cardiac function

Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

<p>Abstract</p> <p>Background</p> <p>In the setting of primary percutaneous coronary intervention, patients with a chronic total occlusion in a non-infarct related artery were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction patients with a chronic total occlusion in a non-infarct related artery should undergo additional percutaneous coronary intervention of the chronic total occlusion on top of optimal medical therapy shortly after primary percutaneous coronary intervention. Possible beneficial effects include reduction in adverse left ventricular remodeling and preservation of global left ventricular function and improved clinical outcome during future coronary events.</p> <p>Methods/Design</p> <p>The Evaluating Xience V and left ventricular function in Percutaneous coronary intervention on occLusiOns afteR ST-Elevation myocardial infarction (EXPLORE) trial is a randomized, prospective, multicenter, two-arm trial with blinded evaluation of endpoints. Three hundred patients after primary percutaneous coronary intervention for ST-elevation myocardial infarction with a chronic total occlusion in a non-infarct related artery are randomized to either elective percutaneous coronary intervention of the chronic total occlusion within seven days or standard medical treatment. When assigned to the invasive arm, an everolimus-eluting coronary stent is used. Primary endpoints are left ventricular ejection fraction and left ventricular end-diastolic volume assessed by cardiac Magnetic Resonance Imaging at four months. Clinical follow-up will continue until five years.</p> <p>Discussion</p> <p>The ongoing EXPLORE trial is the first randomized clinical trial powered to investigate whether recanalization of a chronic total occlusion in a non-infarct related artery after primary percutaneous coronary intervention for ST-elevation myocardial infarction results in a better preserved residual left ventricular ejection fraction, reduced end-diastolic volume and enhanced clinical outcome.</p> <p>Trial registration</p> <p>trialregister.nl NTR1108.</p

Alles dotteren bij het hartinfarct? Voorlopig niet

Treatment for acute myocardial infarction currently entails immediate percutaneous revascularization of the culprit artery. Around 50% of the patients with an acute myocardial infarction have additional multivessel coronary artery disease. Patients with multivessel disease are known to have a worse prognosis compared to patients with single vessel disease. Also, immediate additional revascularization in the acute phase has not been associated with improved outcome but with more complications. In the current practice guidelines, additional revascularization is contra-indicated in the acute phase and only warranted in case of persistent symptoms or ischaemia after the acute event. Elective PCI resolves symptoms but its impact on prognosis is less evident. The outcome of the PRAMI trial claims that percutaneous coronary intervention (PCI) of all > 50% lesions improves prognosis. This seems unrealistic. We believe that the study design with a composite endpoint that incorporates the normal treatment strategy ensures a positive outcome but without clinical significanc

Contemporary overview and clinical perspectives of chronic total occlusions

Chronic total occlusions (CTOs) are often detected on diagnostic coronary angiograms, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to high technical difficulty, perceived risk of complications, and a lack of randomized data. However, successful CTO-PCI can significantly increase a patient's quality of life, improve left ventricular function, reduce the need for subsequent CABG surgery, and possibly improve long-term survival. A number of factors must be taken into account for the selection of patients for CTO-PCI, including the extent of ischaemia surrounding the occlusion, the level of myocardial viability, coronary location of the CTO, and probability of procedural success. Moreover, in patients with ST-segment elevation myocardial infarction, a CTO in a noninfarct-related artery might lead to an increase in infarct area, increased end-diastolic left ventricular pressure, and decreased left ventricular function, which are all associated with poor clinical outcomes. In this Review, we provide an overview of the anatomy and histopathology of CTOs, perceived benefits of CTO-PCI, considerations for patient selection for this procedure, and a summary of emerging techniques for CTO-PC

Meta-analysis on the impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcome

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) may have a beneficial effect on survival through a better-preserved or improved LVEF. Current literature consists of small observational studies therefore we performed a weighted meta-analysis on the impact of revascularization of CTOs on left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and long-term mortality. We conducted a meta-analysis evaluating LVEF before and after CTO PCI and long-term mortality. No language or time restrictions were applied. References from the identified articles and reviews were examined to find additional relevant manuscripts. Of the 812 citations, 34 studies performed between 1987-2014 in 2243 patients were eligible for LVEF and 27 studies performed between 1990-2013 in 11,085 patients with success and 4347 patients that failed CTO PCI were eligible for long-term mortality. After successful CTO PCI, LVEF increased with 4.44% (95% CI: 3.52-5.35, p <0.01) compared to baseline. In a small cohort of ~70 patients, no significant difference in LVEF was observed after non-successful CTO PCI or reocclusion. Additionally, 8 studies reported the change in left ventricular end-diastolic volume (LVEDV) in a total of 412 patients. LVEDV decreased with 6.14 ml/m(2) (95% CI: -9.31 to -2.97, p <0.01). Successful CTO PCI was also associated with reduced mortality in comparison with failed CTO PCI (OR: 0.52, 95% CI: 0.43-0.62, p-value <0.01). The current meta-analysis revealed that successful recanalization of a CTO resulted in an overall improvement of 4.44% absolute LVEF points, reduced adverse remodeling and an improvement of survival (OR: 0.52