National prevalence and outcomes of coronary chronic total occlusion revascularization in patients with congestive heart failure
Authors: Aldrugh S , Kakouros N , Kundu A , Qureshi W 
Published: October 2021

Abstract

Background
There is limited data on the prevalence and outcomes of coronary artery chronic total occlusion (CTO) revascularization in patients with congestive heart failure.

Purpose
Our goal is to study the prevalence and outcomes of CTO revascularization in terms of in-hospital mortality, re-admission rate, and complications in patients stratified by their heart failure status.

Methods
Patients with CTO who underwent percutaneous coronary intervention (PCI) were included for the years 2010 - 2018 from the national readmission database. We compared the national trends, prevalence and outcomes of CTO revascularization in patients with no heart failure, heart failure with preserved ejection fraction (HFpEF), and heart failure with reduced ejection fraction (HFrEF) using one-way ANOVA and logistic regression.

Results
A total of 166,244 (69±11 years, 26% women) patients with coronary CTO who underwent PCI were identified. Of these, 131,664 (79%) patients had no clinical diagnosis of HF, while 26,612 (16%) patients had HFpEF, and 7,968 (5%) patients had HFrEF. Majority of patients with HFpEF and HFrEF had a moderate to high Elixhauser comorbidity score, while those with no HF had mostly low to moderate score (p&lt;0.001). We observed a steady decrease in annual CTO revascularization from a total of 24,708 in 2010 to 13,505 in 2018. However, the percentage of CTO revascularization in patients with HFrEF has increased during this period from 2% in 2010 to 8% in 2018. Interestingly, patients with HFpEF had higher rates of cardiac arrest (Odds Ratio (OR) 2.2; 95% Confidence Interval (CI) 1.8–2.7, p&lt;0.001), ventricular tachycardia/fibrillation (OR 3.7; 95% CI 3.4–4.0, p&lt;0.001), use of mechanical support (OR 5.5; 95% CI 4.9–6.2, p&lt;0.001), and death during admission (OR 2.2; 95% CI 1.8–2.7, p&lt;0.001) than those with no HF and with HFrEF. Similarly, patients with HFpEF had higher rates of intensive care unit admission (9%), than those with HFrEF (5%), and no HF (2%) (p&lt;0.001). Readmission rates were similar across all three groups (0.5–0.7%, p=0.06). The median cost of hospitalization was significantly higher in the HFpEF group compared to the other groups ($98,366, p&lt;0.001).

Conclusion
In this cohort of patients, we observed an overall annual decline in CTO revascularization over the 8-year study period. Despite this decline, we observed an increase in CTO revascularization in patient with HFrEF. Interestingly, patients with HFpEF had elevated in hospital mortality and higher rates of cardiac arrest, ventricular arrhythmias, mechanical circulatory support, and admission to the cardiac care unit than those with no HF, or those with HFrEF. Despite their persevered ejection fraction, our findings suggest that CTO revascularization in with patients with HFpEF carry a significant risk, thus risks versus benefits in this group of patients should be weighed considerably before attempting revascularization.

Funding Acknowledgement
Type of funding sources: None.