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Randomized Controlled Trial
. 2018 Sep;104(17):1432-1438.
doi: 10.1136/heartjnl-2017-312698. Epub 2018 Feb 20.

Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction

Joëlle Elias  1 , Ivo M van Dongen  1 , Truls Råmunddal  2 , Peep Laanmets  3 , Erlend Eriksen  4 , Martijn Meuwissen  5 , H Rolf Michels  6 , Matthijs Bax  7 , Dan Ioanes  2 , Maarten Jan Suttorp  8 , Bradley H Strauss  9 , Emanuele Barbato  10 , Koen M Marques  11 , Bimmer E P M Claessen  1 , Alexander Hirsch  12 , René J van der Schaaf  13 , Jan G P Tijssen  1 , José P S Henriques  1 , Loes P Hoebers  1 ; EXPLORE investigators
Collaborators, Affiliations
Randomized Controlled Trial

Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction

Joëlle Elias et al. Heart. 2018 Sep.

Abstract

Background: During primary percutaneous coronary intervention (PCI), a concurrent chronic total occlusion (CTO) is found in 10% of patients with ST-elevation myocardial infarction (STEMI). Long-term benefits of CTO-PCI have been suggested; however, randomised data are lacking. Our aim was to determine mid-term and long-term clinical outcome of CTO-PCI versus CTO-No PCI in patients with STEMI with a concurrent CTO.

Methods: The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) was a multicentre randomised trial that included 302 patients with STEMI after successful primary PCI with a concurrent CTO. Patients were randomised to either CTO-PCI or CTO-No PCI. The primary end point of the current study was occurrence of major adverse cardiac events (MACE): cardiac death, coronary artery bypass grafting and MI. Other end points were 1-year left ventricular function (LVF); LV-ejection fraction and LV end-diastolic volume and angina status.

Results: The median long-term follow-up was 3.9 (2.1-5.0) years. MACE was not significantly different between both arms (13.5% vs 12.3%, HR 1.03, 95% CI 0.54 to 1.98; P=0.93). Cardiac death was more frequent in the CTO-PCI arm (6.0% vs 1.0%, P=0.02) with no difference in all-cause mortality (12.9% vs 6.2%, HR 2.07, 95% CI 0.84 to 5.14; P=0.11). One-year LVF did not differ between both arms. However, there were more patients with freedom of angina in the CTO-PCI arm at 1 year (94% vs 87%, P=0.03).

Conclusions: In this randomised trial involving patients with STEMI with a concurrent CTO, CTO-PCI was not associated with a reduction in long-term MACE compared to CTO-No PCI. One-year LVF was comparable between both treatment arms. The finding that there were more patients with freedom of angina after CTO-PCI at 1-year follow-up needs further investigation.

Clinical trial registration: EXPLORE trial number NTR1108 www.trialregister.nl.

Keywords: acute coronary syndromes; chronic coronary disease; percutaneous coronary intervention.

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Conflict of interest statement

Competing interests: JPSH has received grants from Abbott Vascular during the conduct of the study; and has received grants from B. Braun, Abiomed and Biotronik outside the submitted work. RJvdS has received grants from Abbott Vascular, Biotronik and Biosensors; has received personal fees from Biotronik and Boston Scientific; has been a consultant for Biotronik and has received speakers fees from OrbusNeich, Boston Scientific and Asahi Intecc outside the submitted work. TR has been a proctor for Boston Scientific.

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