The indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention
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Department of Cardiology, Royal North Shore Hospital, Sydney, Australia Faculty of Health & Medicine, The University of Sydney, Sydney, Australia Minneapolis Heart Institute Foundation, Minneapolis, Minnesota Faculty of Medicine and Health Sciences, Macquarie University, Marsfield, Australia Faculty of Medicine, University of New South Wales, Kensington, Australia Department of Nuclear Medicine, Prince of Wales Hospital, Sydney, Australia Department of Cardiology, Liverpool Hospital, Sydney, Australia Cardiology Department, Royal Prince Alfred Hospital, Sydney, Australia
Received Jun 18, 2020; Revised Jul 24, 2020; accepted Aug 12, 2020 doi:10.1007/s12350-020-02381-0
Coronary chronic total occlusions (CTO) are common in patients undergoing coronary angiography, yet the optimal management strategy remains uncertain, with conflicting results from randomized trials. Appropriate patient selection and careful periprocedural planning are imperative for successful patient management. We review the role of adjunctive imaging modalities including myocardial perfusion imaging (MPI), cardiac magnetic resonance imaging (CMR), echocardiography and computed tomography coronary angiography (CTCA) in myocardial ischemic quantification, myocardial viability assessment, as well as procedural planning for CTO revascularization. An appreciation of the value, indications and limitations of these modalities prior to planned intervention are essential for optimal management. Key Words: Chronic total occlusion Æ CTO Æ imaging Æ CMR Æ myocardial perfusion imaging Æ echocardiography Æ computed tomography
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12350-020-02381-0) contains supplementary material, which is available to authorized users. The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com. The authors have also provided an audio summary of the article, which is available to download as ESM, or to listen to via the JNC/ASNC Podcast. Reprint requests: Usaid K. Allahwala, MBBS, FRACP, Department of Cardiology, Royal North Shore Hospital, Reserve Rd, St. Leonards, Sydney 2065, Australia; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
INTRODUCTION Management of chronic total occlusions (CTO) remains an area of controversy, with conflicting data from recent randomized clinical trials.1–4 The incidence of CTOs ranges between 18-52% depending on the cohort presenting for coronary angiography,5–8 with 6.6% of patients with an ST elevation myocardial infarction (STEMI) having a concurrent CTO.9 Whilst data from registries suggest that alleviation of myocardial ischemia through CTO percutaneous coronary intervention (PCI) or surgical revascularization is associated with improved survival, this has not been borne out in randomized trials. One
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