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ExploreTrial

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MVD with and without a CTO

When STEMI patients with MVD were divided into patients with and without a chronic total occlusion (CTO) in a non infarct related artery (IRA) the following observation was made (see next figure).


Figure 2: one year mortality in STEMI patients with SVD, MVD without a CTO and MVD with a CTO in a non IRA.

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        van der Schaaf RJ, Heart, 2006, (12):1760-3 

In this figure, STEMI patients were divided into three groups according to the extent of coronary artery disease in SVD, MVD without a CTO and MVD patients with a coexisting CTO in a non IRA. The prognostic value of MVD was almost completely driven by the presence of a CTO in a non-IRA.


As the majority of the patients died in the first month, we increased the cohort size, extended the follow-up period to 5 years and performed a landmark survival analysis which allowed us to explore the mortality in two time periods: 0-30 days and 30 days and 5 years, see next figure.

Figure 3: Landmark survival analysis: cumulative risk of death during the first 30 days after primary PCI and thereafter. 

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

The 30-day and 5-years mortality in 30-day survivors was much higher in the CTO group in comparison to the other two groups. Moreover, there was no significant mortality difference between SVD and MVD without a CTO in 30-day survivors.

This novel concept has been confirmed in several other STEMI datasets by Moreno et al. in 2006, Lexis et al in 2011 and recently Claessen et al in the Horizons-AMI data. 


Figure 4: effect of a CTO in a non IRA in other STEMI data sets.

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          Claessen Horizons CTO

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.

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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.

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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. 

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                 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.

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                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.

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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.