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Original article
DOI: 10.1016/j.rec.2020.09.009
Available online 12 November 2020
Impact of adherence to the hybrid algorithm for initial crossing strategy selection in chronic total occlusion percutaneous coronary intervention
Impacto de la adherencia a un algoritmo híbrido para la selección de la estrategia inicial de cruce en la intervención coronaria percutánea de oclusiones crónicas
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Iosif Xenogiannisa, Khaldoon Alaswadb, Oleg Krestyaninovc, Dmitrii Khelimskiic, Jaikirshan J. Khatrid, James W. Choie, Farouc A. Jafferf, Mitul Patelg, Ehtisham Mahmudg, Anthony H. Doingh, Phil Dattiloh, Michalis Koutouzisi, Ioannis Tsiafoutisi, Barry Uretskyj, Brian K. Jeffersonk, Taral Patelk, Wissam Jaberl, Habib Samadyl, Abdul M. Sheikhm, Robert W. Yehn, Hector Tamezn, Basem Elbarunyo, Michael P. Loveo, Nidal Abi Rafehp, Assaad Maaloufp, Abou Jaoudeh Fadip, Catalin Tomaq, Alpesh R. Shahr, Raj H. Chandwaneys, Mohamed Omera, Michael S. Megalya, Evangelia Vemmoua, Ilias Nikolakopoulosa, Bavana V. Rangana, Santiago Garciaa, Shuaib Abdullaht, Subhash Banerjeet, M. Nicholas Burkea, Dimitri Karmpaliotisu, Emmanouil S. Brilakisa,
Corresponding author
esbrilakis@gmail.com

Corresponding author: Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, Minnesota 55407, United States.
a Coronary Artery Disease Science Center, Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, United States
b Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, United States
c Meshalkin Novosibrisk Research Institute, Novosibirsk, Russia
d Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, United States
e Department of Cardiology, Baylor Heart and Vascular Hospital, Dallas, Texas, United States
f Department of Cardiology, Massachusetts General Hospital, Boston, Massachussetts, United States
g VA San Diego Healthcare System, La Jolla, California, United States
h Department of Cardiology, Medical Center of the Rockies, Loveland, Colorado, United States
i Department of Cardiology, Red Cross Hospital of Athens, Athens, Greece
j Department of Cardiology, VA Central Arkansas Healthcare System, Little Rock, Arkansas, United States
k Department of Cardiology, Tristar Centennial Medical Center, Nashville, Tennessee, United States
l Department of Cardiology, Emory University Hospital Midtown, Atlanta, Georgia, United States
m Wellstar Health System, Marietta, Georgia, United States
n Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
o Department of Cardiology, St. Boniface General Hospital, Winnipeg, Manitoba, Canada
p Department of Cardiology, St. George Hospital University Medical Center, Beirut, Lebanon
q University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
r Department of Cardiology, Houston Methodist Hospital, Houston, Texas, United States
s Oklahoma Heart Institute, Tulsa, Oklahoma, United States
t Department of Cardiology, VA North Texas Health Care System, Dallas, Texas, United States
u Columbia University, New York, United States
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Table 1. Clinical characteristics of the study patients, classified according to adherence to the hybrid algorithm for selection of the initial crossing strategy
Table 2. Angiographic characteristics of the study lesions, classified according to adherence to the hybrid algorithm for selection of the initial crossing strategy
Table 3. Technical characteristics of the study procedures, classified according to adherence to the hybrid algorithm for selection of the initial crossing strategy
Table 4. Procedural outcomes of the study procedures, classified according to adherence to the hybrid algorithm for selection of the initial crossing strategy
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Abstract
Introduction and objectives

The hybrid algorithm was designed to assist with initial and subsequent crossing strategy selection in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). However, the success of the initially selected strategy has received limited study.

Methods

We examined the impact of adherence to the hybrid algorithm recommendation for initial CTO crossing technique selection in 4178 CTO PCIs from a large multicenter registry.

Results

The initial crossing strategy was concordant with the hybrid algorithm recommendation in 1833 interventions (44%). Patients in the concordant group had a similar age to those in the discordant group but a lower mean J-CTO score (2.0 ± 1.4 vs 2.8 ± 1.1; P < .01). The concordant group showed higher technical success with the first crossing strategy (68% vs 48%; P < .01) and higher overall technical success (88% vs 83%; P < .01) with no difference in the incidence of in-hospital major adverse events (1.8% vs 2.3%; P = .26). In multivariable analysis, after adjustment for age, prior myocardial infarction, prior PCI, prior coronary artery bypass grafting, J-CTO score, and scheduled CTO PCI, nonadherence to the hybrid algorithm was independently associated with lower technical success of the initial crossing strategy (odds ratio, 0.55; 95% confidence interval, 0.48-0.64; P < .01).

Conclusions

Adherence to the hybrid algorithm for initial crossing strategy selection is associated with higher CTO PCI success but similar in-hospital major adverse cardiac events.

Keywords:
Chronic total occlusion
Percutaneous coronary intervention
Hybrid algorithm
Retrograde approach
Abbreviations:
ADR
AWE
CABG
CTO
PCI
Resumen
Introducción y objetivos

El algoritmo híbrido se diseñó para ayudar en la selección de las estrategias de cruce inicial y siguientes en la intervención coronaria percutánea (ICP) para la oclusión crónica total (OTC); sin embargo, el éxito de la estrategia de inicio seleccionada se ha estudiado poco hasta ahora.

Métodos

Se estudió el impacto de la adherencia a la recomendación del algoritmo híbrido para la selección de la técnica de cruce inicial en 4.178 ICP de OTC en un registro multicéntrico de gran tamaño.

Resultados

La estrategia de cruce inicial coincidió con la recomendación del algoritmo híbrido en 1.833 casos (44%). Los pacientes en el grupo concordante tuvieron una edad similar, pero un índice J-OTC menor (2,0 ± 1,4 frente a 2,8 ± 1,1; p < 0,01). El éxito técnico con la primera estrategia de cruce (el 68 frente al 48%; p < 0,01) y el éxito técnico total (el 88 frente al 83%; p < 0,01) fueron mayores en el grupo concordante, mientras que no hubo diferencia en la incidencia de eventos hospitalarios graves (el 1,8 frente al 2,3%; p = 0,26). En el análisis multivariable, tras el ajuste por edad, infarto de miocardio previo, ICP previa, cirugía de derivación coronaria, índice J-OTC e ICP de OTC programada, la falta de adherencia al algoritmo híbrido se asoció independientemente con un éxito técnico menor de la estrategia de cruce inicial (OR = 0,55; IC95%, 0,48-0,64; p < 0,01).

Conclusiones

La adherencia al algoritmo híbrido para la selección de la estrategia inicial de cruce se asoció con mayor éxito de la ICP para la OTC y similar tasa de eventos cardiovasculares hospitalarios graves.

Palabras clave:
Oclusión total crónica
Intervención coronaria percutánea
Algoritmo híbrido
Abordaje retrógrado

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