Imaging in CTO: Should you look before you open?
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University of Ottawa Heart Institute, Ottawa, ON, Canada Universidade Federal Fluminense, Rio de Janeiro, Brazil
Received Oct 21, 2020; accepted Oct 22, 2020 doi:10.1007/s12350-020-02433-5
See related article, https://doi.org/10.10 07/s12350-020-02381-0.
It has been almost a decade since the American College of Cardiology recommended percutaneous coronary intervention (PCI) for the treatment of patients with chronic total occlusion (CTO) with appropriate clinical indications and anatomy. Defined as 100% occlusion with TIMI (Thrombolysis in Myocardial Infarction) 0 flow for at least 3 months, CTO is not a rare finding with a prevalence of 16 to 20% in recent registries.1,2 However, the decision to revascularize is not trivial and many factors need to be taken into account for the patient’s benefit. The use of cardiac imaging plays an important role for both appropriate indication of PCI and procedural planning. In this section of the journal, Allahwalla et al. have provided a review of the indications and utility of adjunctive non-invasive imaging modalities for CTO, focusing on appropriate patient selection and periprocedural planning. An overview of each modality was given, providing their specific role in the assessment of patients with CTO. Given the scarcity of randomized trials on the subject, most of the studies cited were on viability and ischemic cardiomyopathy. Although they share similar characteristics, patients with CTO present a different pathophysiology with the involvement of, usually, a single-vessel territory with collateral blood supply, making its evaluation even more challenging. Reprint requests: C. Wiefels, MD, MSc, and A. Y. Chong, MBBS, MRCP(UK), MD, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada; [email protected]; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
One strength of the review performed is that each modality is considered from the fundamentals of the technique, that enable a clear understanding on how the imaging can assess patients with a CTO of a coronary artery. However, it remains unclear how one imaging modality can relate to another in decision-making and planning. Often, a patient may undergo different imaging modalities, incorporating physiological and anatomical evaluation with an absence of clear recommendations provided in the literature. This may be due in part to the controversial data derived from previous randomized trials that have assessed both symptoms and outcome. For patients with a CTO, treatment options include standard approaches for stable CAD including lifestyle and risk factor modifications, and medical therapy.3 The primary indication for CTO-PCI is symptom improvement. Both angina and/or heart failure symptoms in a patient with CTO may improve after revascularization. The EUROCTO multicenter trial (A Randomized Multicentre Trial to Evaluate the Utilization of Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Corona
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