Korean Circ J.  2022 Feb;52(2):150-161. 10.4070/kcj.2021.0240.

Ischemic Burden Assessment Using Single Photon Emission Computed Tomography in Single Vessel Chronic Total Occlusion of Coronary Artery

• Yoon YH
• Han S
• Kwon O
• Lee K
• Kim JH
• Lee J
• Kim To
• Roh JH
• Lee PH
• Kang SJ
• Lee JH
• Kim YH
• Lee CW
• Moon DH
• Lee SW

• KMID: 2525455
• DOI: http://doi.org/10.4070/kcj.2021.0240

Abstract

Background and Objectives
Studies evaluating the nature of ischemic burden of chronic total occlusion (CTO) vessels are still lacking.
Methods
A total of 165 patients with single vessel CTO >2.5 mm in an epicardial coronary artery who underwent single photon emission computed tomography (SPECT) were enrolled in the study. Ischemic burden was calculated with the use of semi-quantitative SPECT analysis, and was defined as the summed difference score (SDS) divided by the maximal limit of the score (=SDS/68).
Results
The mean age of the participants was 59.5 years and the CTO of the left anterior descending coronary artery (LAD), left circumplex coronary artery (LCX), and right coronary artery (RCA) accounted for 93 (56.4%), 18 (10.9%), and 54 (32.7%) patients, respectively. The median ischemic burden of the total population was 8.8%, and it was highest in the LAD CTO (10.3%) compared with the LCX (5.9%) and RCA CTO (5.9%, p<0.001). High-ischemic burden (ischemic burden >10%) was observed in 66 patients (40.0%), and in 47 patients (50.5%) of the LAD CTO. Ischemic burden was different according to the CTO location only in LAD CTO. The statistically significant predictors for high-ischemic burden were hypertension, baseline ejection fraction >45%, LAD CTO, proximal CTO location, and de novo CTO. Japanese-CTO score and Rentrop scale collateral grade were not associated with high-ischemic burden.
Conclusions
Only 40% of patients with single vessel CTO had ischemic burden >10%. For CTO vessels, measurement of ischemic burden using SPECT prior to revascularization may be helpful in identifying beneficial subjects.

Keyword

Chronic total occlusion; Ischemic burden; Single photon emission computed tomography

Figure

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  Figure 1 Box-Whisker plot of ischemic burden in each coronary vessel CTO.CTO = chronic total occlusion; LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; RCA = right coronary artery

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  Figure 2 Box-Whisker plot of ischemic burden in each coronary vessel CTO according to CTO location or collateral grade. (A) Ischemic burden based on the location of CTO in each coronary vessel. (B) Ischemic burden based on Rentrop collateral grade in each coronary vessel.CTO = chronic total occlusion; LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; RCA = right coronary artery.

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  Figure 3 Angiography and SPECT images of representative 2 cases. (A) The 65-year-old man presenting with stable chest pain started 4 months ago. An echocardiogram showed EF of 63%, and there was no regional wall motion abnormality. Angiography showed mid LAD CTO with collateral grade 3 via diagonal branch and septal-septal channels. The SPECT showed a low ischemic burden (SRS = 3, SSS = 4, SDS = 1, ischemic burden = 1.5%). (B) The 72-year-old man presenting with stable chest pain started 8 months ago. An echocardiogram showed EF of 47%, and there was regional wall motion abnormality in LAD territory. Angiography showed mid LAD CTO with collateral grade 2 via diagonal branch and septal-septal channels. The SPECT showed a high ischemic burden (SRS = 6, SSS = 20, SDS = 14, ischemic burden = 20.1%).CTO = coronary total occlusion; EF = ejection fraction LAD = left anterior descending coronary artery; SDS = summed difference score; SPECT = single photon emission computed tomography; SRS = summed rest score; SSS = summed stress score.

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  Figure 4 Kaplan-Meier curves for long-term clinical outcomes according to high or low ischemic burden at baseline SPECT results.HR = hazard ratio; MI = myocardial infarction.

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