Heartbeat: The ongoing controversy of intervention for chronic total coronary occlusions

In patients undergoing primary percutaneous intervention (PCI) for ST-elevation myocardial infarction (STEMI), about 10% also have a chronic total occlusion (CTO) of a non-culprit coronary artery. It remains controversial whether PCI of the CTO vessel, in addition to the culprit vessel, improves clinical outcome. The results of the randomised Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) study of 302 STEMI patients with successful PCI of the culprit vessel are reported in this issue of Heart. 1 Overall, there was no difference in major adverse cardiac events (MACE) at a median follow-up of 3.9 years in those with or without PCI of the CTO vessel (13.5% vs 12.3%, HR 1.03, 95% CI 0.54 to 1.98; p=0.93, figure 1). Although all-cause mortality did not differ between groups, cardiac mortality was higher with CTO-PCI (6.0% vs 1.0%, p=0.02). More patients with CTO-PCI were free of angina at 1 year (6.0% vs 1.0%, p=0.02) but his difference was not sustained on longer term follow-up. Overall, CTO-PCI in the setting of STEMI was not associated with a reduction in MACE, improvement in ventricular function or sustained reduction in symptoms. Figure 1 Clinical effect of early CTO-PCI vs CTO-no PCI on MACE in patients with ST-elevation myocardial infarction with a concurrent CTO: long-term follow-up. Kaplan-Meier estimates of the cumulative event rate of the composite end point of MACE: cardiac death, CABG and MI. Analyses were performed on a intention-to-treat basis. CTO, chronic total …