Outcomes of successful vs. failed contemporary chronic total occlusion percutaneous coronary intervention

BACKGROUND: There are limited contemporary data on the impact of success vs. failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We conducted a systematic review and a meta-analysis of contemporary studies that compared the outcomes in patients who underwent successful vs. failed contemporary (2010 onwards) CTO PCI. We performed a sensitivity analysis limited to studies that started enrollment after the publication of the hybrid algorithm in 2012. RESULTS: We included five studies with a total of 6,084 patients (successful CTO PCI n = 4,861, failed CTO PCI n = 1,223). During a median follow-up time of 12 months (range 6-60 months), successful CTO PCI was associated with a lower risk of major adverse cardiovascular events [OR: 0.61, 95% CI (0.41, 0.92), p = 0.02, I(2) = 63%] and all-cause death [OR: 0.57, 95% CI (0.33, 0.99), p = 0.05, I(2) = 60%]. Both groups had similar risk of myocardial infarction (MI) [OR 0.69, 95% CI (0.43, 1.10), p = 0.38, I(2) = 80%], target vessel revascularization (TVR) [OR: 0.56, 95% CI (0.25, 1.27), p = 0.17, I(2) = 80%], and stroke [OR: 0.52, 95% CI (0.14, 1.91), p = 0.33, I(2) = 0%]. CONCLUSION: In contemporary practice, successful CTO PCI was associated with a lower incidence of MACE driven by lower all-cause mortality compared with failed CTO PCI at a median follow-up of 1 year

One-Year Clinical Outcomes of the Hybrid CTO Revascularization Strategy After Hospital Discharge:A Subanalysis of the Multicenter RECHARGE Registry

OBJECTIVES: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) has historically been associated with higher event rates during follow-up. The hybrid algorithm and contemporary wiring and dissection re-entry (DR) techniques can potentially improve long-term outcomes after CTO-PCI. This study assessed the long-term clinical outcomes of the hybrid CTO practice, when applied by operators with varying experience levels. METHODS: We examined the 1-year clinical events after hospital discharge of the RECHARGE population, according to technical outcome and final technique. The primary endpoint was major adverse cardiac event (MACE) rate. Centers that provided ≥90% complete 12-month follow-up were included. RESULTS: Follow-up data of 1067 out of 1165 patients (92%) were provided by 13 centers. Mean follow-up duration was 362.8 ± 0.9 days. One-year MACE-free survival rate was 91.3% (974/1067). MACE included death (1.9%; n = 20), myocardial infarction (1.4%; n = 15), target-vessel failure (5.9%; n = 63), and target-vessel revascularization (TVR) (5.5%; n = 59). Non-TVR was performed in 6.7% (n = 71). MACE was significantly in favor of successful CTO-PCI (8.0% vs 13%; P=.04), even after adjusting for baseline differences (adjusted hazard ratio, 0.59; 95% confidence interval, 0.36-0.98; P=.04). Other events, including individual MACE components, were comparable with respect to technical outcome and final technique (DR vs non-DR techniques). CONCLUSIONS: The use of the hybrid algorithm with contemporary techniques by moderate to highly experienced operators for CTO-PCI is safe and associated with a low 1-year event rate. Successful procedures are associated with a better MACE rate. DR techniques can be used as first-line strategies alongside intimal wiring techniques without compromising clinical outcomes

Psychological change from the inside looking out: a qualitative investigation

Regardless of the type of psychotherapy considered, change is the predominant goal. Psychotherapies differ in their explanations of how change occurs and what it is that needs to change, but pursuing change of something in some way is common. Psychotherapeutic methods, therefore, should be enhanced as knowledge of the change process improves. Furthermore, improving our knowledge about general principles of change may be of greater benefit to psychotherapy than increased knowledge about any particular change technique. This study addresses the questions 'What is psychological change?' and 'How does it occur?' from patients' viewpoints. Answers to these questions were sought using qualitative methodology. At the end of treatment, 27 people were interviewed about their experience of change. Interviews were taped and transcripts analysed using the Framework approach. Change occurred across three domains: feelings, thoughts and actions. Participants described change as both a gradual process and an identifiable moment. In relation to how change occurred, six themes emerged: motivation and readiness, perceived aspects of self, tools and strategies, learning, interaction with the therapist and the relief of talking. Change was experienced in similar ways irrespective of type of treatment. Current stage models of change may not be suited to the explanations of change provided by the participants of this study; the process of insight through reorganization might be a more accurate explanation. Understanding change as a process involving sudden and gradual elements rather than a process occurring through sequential stages could inform the development of more efficacious psychological treatments

The Hybrid Algorithm for Treating Chronic Total Occlusions in Europe:The RECHARGE Registry

BACKGROUND The hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was developed to improve procedural outcomes. Large, prospective studies validating the algorithm in a broad multicenter setting with operators of different experience levels are lacking. OBJECTIVES The RECHARGE (REgistry of Crossboss and Hybrid procedures in FrAnce, the NetheRlands, BelGium and UnitEd Kingdom) registry aims to report achievable results using the hybrid algorithm. METHODS Between January 2014 and October 2015, consecutive patients undergoing hybrid CTO-PCI were prospectively enrolled in 17 centers. Procedural techniques, outcomes, and in-hospital complications were analyzed. RESULTS A total of 1,253 CTO-PCIs were performed in 1,177 patients, of which 86% were men. Mean age was 66 +/- 11 years. The average Japanese CTO score was 2.0 +/- 1.0, and was higher in the failure group (2.6 +/- 0.6 vs. 1.9 +/- 1.0; p < 0.001). Overall procedure success was 86% and major in-hospital complications occurred in 2.6%. Antegrade wire escalation was the preferred primary strategy in 77%, followed by retrograde (17%) and antegrade dissection re-entry strategies (7%). Primary strategies were successful in 60%. Consecutive strategies were applied in 34% and were successful in 74%. Antegrade dissection re-entry and retrograde strategies were the most common bailout strategies and were successful in 67% and 62%, respectively. Median procedure and fluoroscopy time were 90 (interquartile range [ IQR]: 60 to 120) min and 35 (IQR: 21 to 55) min, contrast volume was 250 (IQR: 180 to 340) ml, and radiation doses (air kerma and dose area product) were 1.6 (IQR: 1.0 to 2.7) Gy and 98 (IQR: 57 to 168) Gy.cm(2), respectively. CONCLUSIONS High procedure and patient success rates, combined with a low event rate and improved procedural characteristics, support further use of the hybrid algorithm for a broad community of appropriately trained CTO operators. (C) 2016 by the American College of Cardiology Foundation

Fully Transradial Versus Transfemoral Approach for Percutaneous Intervention of Coronary Chronic Total Occlusions Applying the Hybrid Algorithm:Insights From RECHARGE Registry

Background: Small observational studies demonstrate the feasibility of transradial approach for chronic total occlusion (CTO) percutaneous coronary intervention. The aim of the current study is to assess technical success, complication rates, and procedural efficiency in fully transradial approach (fTRA) and transfemoral approach (TFA) in a large prospective European registry adopting the hybrid algorithm for CTO percutaneous coronary intervention (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom, RECHARGE registry). Methods and Results: We analyzed 1253 CTO percutaneous coronary intervention procedures performed according to the hybrid protocol in 17 European centers, comparing fTRA (single or biradial access) and TFA (single or bifemoral or combined radial and femoral access). fTRA was applied in 306 (24%) and TFA in 947 (76%) cases. The average Japanese CTO score was 2.1±1.2 in fTRA and 2.3±1.1 in TFA (P=0.06). Technical success was achieved in 85% in fTRA and 86% in TFA (P=0.51). Technical success was comparable for fTRA and TFA in different Japanese CTO score subgroups after multivariable analysis and after propensity adjustment. In-hospital major adverse cardiac and cerebral events occurred in 2.0% in fTRA and 2.9% in TFA (P=0.40). Major access site bleeding occurred in 0.3% in fTRA and 0.5% in TFA (P=0.66). fTRA compared with TFA had similar procedural duration (80 minutes [54-120 minutes] versus 90 minutes [60-121 minutes]; P=0.07), similar radiation dose (dose area product 89 Gray×cm2 [52-163 Gray×cm2] versus 101 Gray×cm2 [59-171 Gray×cm2]; P=0.06), and lower contrast agent use (200 mL [150-310 mL] versus 250 mL [200-350 mL]; P<0.01). Conclusions: fTRA CTO percutaneous coronary intervention is a valid alternative to TFA with a high rate of success, low complication rates, and no decrease in procedural efficiency