art-header-clip
ExploreTrial

                                                  btnGotoERCF

EXPLORE COMPLETED!!!!

304 patients enrolled!

High risk subgroups

In addition, we investigated the impact of MVD with and without a CTO in several high risk subgroups. One of them was the diabetic cohort, which showed the same overall result.

Figure 5: Five year mortality after primary PCI in diabetic patients with SVD, MVD without CTO and MVD with a CTO in a non-IRA.

background figure 5

Claessen BE, Hoebers LP, Heart. 2010 Dec;96(24):1968-72.

Another high risk subgroup was the cardiogenic shock (CS) cohort.

In STEMI patients without cardiogenic shock, MVD is only associated with short- and long-term mortality when a coexisting CTO is present. In these non shock patients, only MVD with a coexisting CTO was associated with a reduced LVEF after STEMI in comparison to MVD without a CTO and SVD. In patients with cardiogenic shock, MVD with and without a coexisting CTO were both associated with 30-day mortality. However, both variables lost its predictive value in 30-day survivors up to 5 years of follow-up in comparison to SVD, although for MVD with a CTO, the association was only borderline non significant.

Figure 6: Landmark survival analysis in STEMI patients with cardiogenic shock, stratified for SVD, MVD without a CTO and MVD with a CTO.

kaplan meierpicture111125

van der Schaaf RJ, Am J Cardiol. 2010 Apr 1;105(7):955-9. 

Additionally, we investigated the effect of a CTO on left ventricular ejection fraction (LVEF) in patients who received an echocardiography after PPCI. As you can see in the next figure, patients with a CTO more often had a LVEF of 40% or lower in comparison to the other two groups. There was no significant difference between the groups with SVD and MVD without a CTO.

Figure 7: Proportion of STEMI patients with a LVEF ≤ 40% after PPCI for STEMI. 

background figure 7

                 Claessen BE, JACC Cardiovasc Interv. 2009 Nov;2(11):1128-34.


During the first year follow-up, it seems that patients with a CTO had a stronger reduction in their LVEF in comparison to the other two groups, see next figure.


Figure 8: Proportion of STEMI patients with a further reduction of LVEF during the first follow-up year.

background figure 8

                Claessen BE, JACC Cardiovasc Interv. 2009 Nov;2(11):1128-34.

The proportion of CS patients with a LVEF ≤ 40% was 24% for SVD, 44% for MVD without a CTO and 42% for MVD with a CTO.  In patients without CS, MVD with a coexisting CTO was more often associated with LVEF ≤ 40% in comparison to patients with MVD without a CTO or SVD whereas in patients with CS, MVD with and without a CTO were both more often associated with LVEF ≤ 40% in comparison to patients with SVD.

figure 2 111209
After evaluation of the abovementioned data, we can conclude that the presence of a CTO drives mortality in STEMI patients with MVD and is associated with a reduced LVEF and a further reduction of LVEF. 

This data has lead us to the explore trial, which will investigate the effect of CTO revascularization within the first week, on left ventricular function.