Review ArticleThe indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention
Introduction
Management of chronic total occlusions (CTO) remains an area of controversy, with conflicting data from recent randomized clinical trials.1, 2, 3, 4 The incidence of CTOs ranges between 18-52% depending on the cohort presenting for coronary angiography,5, 6, 7, 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 of the explanations for the conflicting data between registries and randomized trials may be due to issues with patient selection, particularly with respect to lack of ischemia quantification and myocardial viability. As such, a detailed understanding of the roles and applicability of various imaging modalities is essential. In this article, we will review and appraise the roles of non-invasive imaging modalities, namely myocardial perfusion imaging (MPI), cardiac magnetic resonance (CMR), echocardiography and computed tomography coronary angiography (CTCA) in ischemia quantification, viability assessment and procedural planning in patients with coronary CTOs (Figure 1).
Section snippets
Myocardial perfusion imaging
Myocardial perfusion imaging (MPI) incorporates various modalities, whereby infusion of a radiolabelled tracer provides information on quantification of regional myocardial blood flow, ischemic extent, and myocardial viability. The commonest MPI modalities are single-photon emission computed tomography (SPECT) and positron emission tomography (PET). PET is a radionuclide imaging technique that allows for non-invasive quantification of myocardial blood flow (MBF) in vivo, relying on the
Conclusion
The optimal treatment of patients with coronary CTOs remains controversial. Identification of myocardial viability and ischemic quantification, either through MPI, dobutamine stress echocardiography or CMR may help identify patients who will benefit from revascularization. Distinguishing hibernating myocardium from non-viable myocardium is particularly important, although not the only factor, to reduce the risk of inappropriate treatment, particularly omission of potentially therapeutic
Disclosures
Dr Allahwala has received an unconditional research grant from Heart Research Australia. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures. Prof Bhindi has received an unconditional
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