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JACC Cardiovasc Interv. 2009 Nov;2(11):1128-34. doi: 10.1016/j.jcin.2009.08.024.

Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention.

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Department of Cardiology, Academic Medical Center-University of Amsterdam, Amsterdam, the Netherlands.



The aim of this study was to evaluate the effect of a concurrent chronic total occlusion (CTO) in patients with ST-segment elevation myocardial infarction (STEMI) on long-term mortality and left ventricular ejection fraction (LVEF).


The impact of a CTO in a non-infarct-related artery (IRA) on prognosis after STEMI is unknown.


Between 1997 and 2005, we admitted 3,277 STEMI patients treated with primary percutaneous coronary intervention. Patients were categorized as single-vessel disease (SVD), multivessel disease (MVD) without CTO, and MVD with a CTO in a non-IRA. We performed a "landmark survival analysis" to 5 years follow-up with a landmark set at 30 days. Additionally, we analyzed the evolution of LVEF within 1 year.


Of the patients, 2,115 (65%) had SVD, 742 patients (23%) had MVD without CTO, and 420 patients (13%) had a concurrent CTO. Presence of a CTO was a strong and independent predictor for 30-day mortality (hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 2.6 to 4.7, p < 0.01), whereas MVD without CTO was a weak predictor (HR: 1.6, 95% CI: 1.2 to 2.2, p = 0.01). In 30-day survivors, CTO remained a strong predictor (HR: 1.9, 95% CI: 1.4 to 2.8, p < 0.01), and MVD lost its independent prognostic value (HR: 1.1, 95% CI: 0.8 to 1.5, p = 0.45). Furthermore, CTO was associated with LVEF </=40% immediately after STEMI (odds ratio: 1.9, 95% CI: 1.3 to 2.8, p < 0.01) and a further decrease in LVEF within the first year (odds ratio: 3.5, 95% CI: 1.6 to 7.8, p < 0.01).


The presence of a CTO and not MVD alone is associated with long-term mortality even when early deaths are excluded from analysis. The presence of a CTO is associated with reduced LVEF and further deterioration of LVEF.

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