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Original research article
Risk of cardiac and sudden death with and without revascularisation of a coronary chronic total occlusion
  1. Cosmo Godino1,
  2. Alessia Giannattasio2,
  3. Andrea Scotti2,
  4. Luca Baldetti1,
  5. Carlo Andrea Pivato3,
  6. Andrea Munafò1,
  7. Alberto Cappelletti1,
  8. Alessandro Beneduce1,
  9. Francesco Melillo1,
  10. Mauro Chiarito3,
  11. Giuseppe Biondi Zoccai4,5,
  12. Giacomo Frati4,5,
  13. Gabriele Fragasso1,
  14. Lorenzo Azzalini1,
  15. Mauro Carlino1,
  16. Matteo Montorfano1,
  17. Alberto Margonato1,
  18. Antonio Colombo1
  1. 1 Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
  2. 2 Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
  3. 3 Interventional Cardiology Unit, Istituto Clinico Humanitas, Milan, Italy
  4. 4 Division of Cardiology, IRCCS Neuromed, Pozzilli, Italy
  5. 5 Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
  1. Correspondence to Dr Cosmo Godino, Cardio-Thoracic-Vascular, San Raffaele Hospital, Milan, Italy; godino.cosmo{at}


Objective The aim of this study is to evaluate the long-term risk of cardiac death and sudden cardiac death (SCD) and/or sustained ventricular arrhythmias (SVAs) in patients with coronary chronic total occlusions (CTO) revascularised versus those with CTO not revascularised by percutaneous coronary intervention (PCI).

Methods From a cohort of 1357 CTO-PCI patients, 1162 patients who underwent CTO PCI attempt were included in this long-term analysis: 837 patients were revascularised by PCI (CTO-R group) and 325 were not revascularised (CTO-NR group). Primary adverse endpoint was the incidence of cardiac death; secondary endpoint was the cumulative incidence of SCD/SVAs.

Results Up to 12-year follow-up (median 6 year), compared with CTO-R patients, those with CTO-NR had significantly higher rate of cardiac death (13%[43/325]vs6%[48/837]; p<0.001) and SCD/SVAs (7.5%[24/325]vs2.5%[20/837]; p<0.001). The risk of cardiac death and SCD/SVAs was mainly driven by the subgroup of infarct-related artery (IRA) CTO patients and was significantly higher only in IRA CTO-NR patients (18%vs7%, p<0.001, 14%vs5%, p=0.001; IRA CTO-NR vs IRA CTO-R, respectively). At multivariable Cox hazards regression analysis, CTO-NR remains one of the strongest independent predictors of higher risk of cardiac death and of SCD/SVAs in the overall population and in IRA CTO patients.

Conclusions At long-term follow-up, patients with CTO not revascularised by PCI had worse outcomes compared with those with CTO revascularised, with >2-fold risk of cardiac death and threefold risk of SCD/SVAs. The presence of an infarct-related artery (IRA CTO) not revascularised identified the category of patients with the highest rate of adverse events .

  • coronary occlusion
  • sudden cardiac death
  • percutaneous coronary intervention
  • coronary artery disease

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  • Contributors All authors have read and approved the manuscript. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Each author has contributed significantly to the submitted work and namely: CG, AG, AS and FM started the study and did the final validation of the results; LB, CAP, AM and AB were responsible for the collection analysis and interpretation of the data. AC, MC, GFrag and LA revised the manuscript for intellectual content. GBZ and GFrat revised the manuscript for the statistical methods; the paper received an important input from MC, MM, AM and AC. CG is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The study protocol was performed in accordance with the protocol of the institutional ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.