Impact of Chronic Total Coronary Occlusion on Recurrence of Ventricular Arrhythmias in Ischemic Secondary Prevention Implantable Cardioverter-Defibrillator Recipients (VACTO Secondary Study): Insights From Coronary Angiogram and Electrogram Analysis

JACC Cardiovasc Interv. 2017 May 8;10(9):879-888. doi: 10.1016/j.jcin.2017.02.008.

Abstract

Objectives: This study sought to evaluate the incidence and clinical effect of coronary chronic total occlusions (CTOs) in patients with ischemic cardiomyopathy receiving an implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac death (SCD).

Background: CTOs are common in patients with ischemic cardiomyopathy, which is the major cause of SCD. However, the impact of CTO in SCD survivors receiving an ICD is unknown.

Methods: A total of 425 patients who had survived an episode of ventricular arrhythmias and underwent ICD implantation for secondary prevention in 8 centers were included. Coronary angiogram, CTO angiographic characteristics, and ventricular arrhythmia pattern were centrally analyzed. Primary and secondary endpoints were appropriate ICD therapies and mortality during a median follow-up of 4.1 years, according to the presence of CTO in the baseline angiogram.

Results: Appropriate ICD therapies were higher in patients with CTO (51.7% vs. 36.3%; p = 0.001 at 4 years). Left ventricular ejection fraction (LVEF) (p = 0.015) and CTO (p = 0.001) were independent predictors of appropriate ICD therapy. Ventricular arrhythmia onset was associated to a shorter coupling interval and lower prematurity index in CTO patients. Defibrillator therapies were independently associated with worse LVEF (p = 0.046) and renal dysfunction (p = 0.023) among patients with CTO, and a tendency was observed in patients with better collateral flow (p = 0.093). Patients with poorer renal function (p = 0.029), LVEF (p = 0.041), and CTO (p = 0.033) experienced higher mortality rate.

Conclusions: Among ICD recipients for secondary prevention of SCD, coronary CTO conferred a higher risk of VA recurrence and mortality in long-term follow-up. Angiographic and VA patterns could provide insights into the mechanisms of SCD and may have implications for the use of interventions designed to limit ICD shocks in this high-risk population.

Keywords: chronic total occlusion; coronary artery disease; implantable cardioverter-defibrillator; ventricular arrhythmias.

Publication types

  • Multicenter Study
  • Observational Study

MeSH terms

  • Aged
  • Arrhythmias, Cardiac / diagnosis
  • Arrhythmias, Cardiac / mortality
  • Arrhythmias, Cardiac / therapy*
  • Chronic Disease
  • Coronary Angiography*
  • Coronary Occlusion / diagnostic imaging*
  • Coronary Occlusion / mortality
  • Death, Sudden, Cardiac / etiology
  • Death, Sudden, Cardiac / prevention & control*
  • Defibrillators, Implantable*
  • Electric Countershock / adverse effects
  • Electric Countershock / instrumentation*
  • Electric Countershock / mortality
  • Electrophysiologic Techniques, Cardiac*
  • Europe / epidemiology
  • Female
  • Humans
  • Incidence
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Proportional Hazards Models
  • Risk Factors
  • Secondary Prevention / instrumentation*
  • Time Factors
  • Treatment Outcome