Letter to Editor:
With great interest, I read the manuscript entitled: “The Retrograde
Approach to Chronic Total Occlusion (CTO) Percutaneous Coronary
Interventions: Technical Analysis and Procedural Outcomes.” (1) that
was published in JACC Cardiovascular Intervention. The authors
unfortunately underreported true major adverse cardiac events (MACE).
They describe an MACE of 3.5% even though coronary perforation alone
occurred in 5.8% of their cases. It is not clear why such an important
adverse event is not included in the MACE. Due to the enormous negative
impact of coronary perforations occurring during percutaneous coronary
interventions (PCI), in every institution, it will trigger immediate
peer review from the hospital peer review committee like death.
Furthermore, any single perforation will raise troponin so their
procedural myocardial infarction rate should be at least 5.8% which
should raise the MACE rate much higher than the reported MACE rate of
3.5%. There are now plenty of studies showing no improvement in
mortality in patients undergoing CTO never improves with CTO
intervention and other soft points are also in question (2-4). We have
published the largest CTO outcome data involving 259,574 CTO
interventions showing higher all-cause inpatient mortality and
complications in patients undergoing CTO PCI compared to other PCIs. (5)
The CTO cohort had a 3.17% mortality rate in comparison to a mortality
rate of 2.57% of other PCIs. (OR:1.24; CI]: 1.18-1.31; P <
.001). Compared to other PCIs, all postprocedural complications were
more than 3 times higher in CTO PCI patients. Therefore, there should be
a word of caution and CTO PCI should only be performed in a patient with
resistant limiting angina despite maximal medical therapy and is aware
that CTO PCI does not improve long-term mortality and that PCI CTO is a
high-risk procedure. We recently alerted physicians about this problem.
(6) Being inertia is not an option and we need Journals like JACC
intervention to be more active in this regard. We need accountability
for too many unnecessary CTO PCIs that are being performed leading to
great harm. (7)