Skip to main content


Log in

Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion

  • Original Article
  • Published:
Cardiovascular Intervention and Therapeutics Aims and scope Submit manuscript


Periprocedural myocardial injury (PMI) has been generally associated with major adverse cardiac events (MACE), however, limited studies addressed its clinical implications following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). To evaluate the determinants and prognostic implication of PMI following CTO-PCI. Retrospective single-centre study of 125 consecutive patients undergoing CTO-PCI was attempted between December 2013 and December 2017. Angiographic success was achieved in 115 patients (92.0%) and cTn-I values were obtained 12–24 h following PCI. PMI was defined as an elevation of cTn-I above 5 times the 99th-percentile upper reference limit. Baseline demographic, clinical, angiographic and procedural characteristics were compared. Multivariate analysis was performed to determine the predictors of PMI and the correlates of PMI and 1-year MACE, a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. Overall, mean age was 67 ± 17 years; 25 patients (21.7%) were female; and PMI occurred in 41 patients (35.7%). Multivessel coronary artery disease (MVD) (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.09–10.67; p = 0.04) and procedural complications (a composite of iatrogenic coronary artery dissection/haematoma or perforation) (OR, 19.08; 95% CI, 3.77–96.65; p < 0.01) predicted PMI. Significant collateralization (Rentrop 3) (hazard ratio, [HR], 0.19; 95% CI, 0.06–0.64; p < 0.01) and procedural complications (HR, 8.86; 95% CI, 2.66–29.46; p < 0.01) were independently associated with 1-year MACE, while PMI was not (p = 0.26). In this contemporary cohort, PMI following successful CTO-PCI was a common finding and was predicted by MVD and procedural complications. PMI was not independently associated with 1-year MACE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Tomasello SD, Boukhris M, Giubilato S, Marza F, Garbo R, Contegiacomo G, et al. Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions. Eur Heart J. 2015;36:3189–98.

    Article  Google Scholar 

  2. Azzalini L, Jolicoeur EM, Pighi M, Millán X, Picard F, Tadros V-X, et al. Epidemiology, management strategies, and outcomes of patients with chronic total coronary occlusion. Am J Cardiol. 2016;118:1128–35.

    Article  Google Scholar 

  3. Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, et al. A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions. Eur Heart J. 2018;39:2484–93.

    Article  CAS  Google Scholar 

  4. Obedinskiy AA, Kretov EI, Boukhris M, Kurbatov VP, Osiev AG, Ibn EZ, et al. The impactor-CTO trial JACC. Cardiovasc interv. 2018;11:1309–11.

    Google Scholar 

  5. Megaly M, Saad M, Tajti P, Burke MN, Chavez I, Gössl M, et al. Meta-analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling. J Interv Cardiol. 2018;31:562–71.

    Article  Google Scholar 

  6. Christakopoulos GE, Christopoulos G, Carlino M, Jeroudi OM, Roesle M, Rangan BV, et al. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol. 2015;115:1367–75.

    Article  Google Scholar 

  7. Lee S-W, Lee PH, Kang SH, Choi H, Chang M, Roh J-H, et al. Determinants and prognostic significance of periprocedural myocardial injury in patients with successful percutaneous chronic total occlusion interventions. JACC Cardiovasc Interv. 2016;9:2220–8.

    Article  Google Scholar 

  8. Jaguszewski M, Gilis-Malinowska N, Gutierrez-Chico JL, Chmielecki M, Skarzynski P, Burakowski S, et al. Periprocedural myocardial injury after recanalization of single chronic coronary occlusion—a propensity score analysis comparing long-term clinical outcomes. J Invasive Cardiol. 2017;29:63–7.

    PubMed  Google Scholar 

  9. Toma A, Stähli BE, Gebhard C, Gick M, Minners J, Mashayekhi K, et al. Clinical implications of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention for chronic total occlusion: role of antegrade and retrograde crossing techniques. EuroIntervention. 2018;13:2051–9.

    Article  Google Scholar 

  10. Brilakis ES, Mashayekhi K, Tsuchikane E, Rafeh NA, Alaswad K, Araya M, et al. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation. 2019;140:420–33.

    Article  Google Scholar 

  11. Ganesha Babu G, Malcolm Walker J, Yellon DM, Hausenloy DJ. Peri-procedural myocardial injury during percutaneous coronary intervention: an important target for cardioprotection. Eur Heart J. 2010;32:23–31.

    Article  Google Scholar 

  12. Di Serafino L, Borgia F, Maeremans J, Pyraxas SA, De Bruyne B, Wijns W, et al. Periprocedural myocardial injury and long-term clinical outcome in patients undergoing percutaneous coronary interventions of coronary chronic total occlusion. J Invasive Cardiol. 2016;28:410–4.

    PubMed  Google Scholar 

  13. Feldman DN, Kim L, Rene AG, Minutello RM, Bergman G, Wong SC. Prognostic value of cardiac troponin-I or troponin-T elevation following nonemergent percutaneous coronary intervention: a meta-analysis. Catheter Cardiovasc Interv. 2011;77:1020–30.

    Article  Google Scholar 

  14. Nienhuis MB, Ottervanger JP, Bilo HJ, Dikkeschei BD, Zijlstra F. Prognostic value of troponin after elective percutaneous coronary intervention: a meta-analysis. Catheter Cardiovasc Interv. 2008;71:318–24.

    Article  Google Scholar 

  15. Lo N, Michael TT, Moin D, Patel VG, Alomar M, Papayannis A, et al. Periprocedural myocardial injury in chronic total occlusion percutaneous interventions: a systematic cardiac biomarker evaluation study. JACC Cardiovasc Interv. 2014;7:47–54.

    Article  Google Scholar 

  16. Zhang Q, Hu J, Yang ZK, Ding FH, Zhang JS, Du R, et al. Correlates and outcomes related to periprocedural myocardial injury during percutaneous coronary intervention for chronic total occlusion: results from a prospective, single center PCI registry. Catheter Cardiovasc Interv. 2016;87:616–23.

    Article  Google Scholar 

  17. Dautov R, Ybarra LF, Nguyen CM, Gibrat C, Joyal D, Rinfret S. Incidence, predictors and longer-term impact of troponin elevation following hybrid chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv. 2018;92:E308–16.

    Article  Google Scholar 

  18. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012;33:2551–67.

    Article  Google Scholar 

  19. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40:237–69.

    Article  Google Scholar 

  20. Galassi AR, Werner GS, Boukhris M, Azzalini L, Mashayekhi K, Carlino M, et al. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention. 2019;15:198–208.

    Article  Google Scholar 

  21. Lee S-W, Lee PH, Ahn J-M, Park D-W, Yun S-C, Han S, et al. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total occlusion: the Decision-CTO Trial. Circulation. 2019;139:1674–83.

    Article  Google Scholar 

  22. Cottens D, Maeremans J, McCutcheon K, Lamers S, Roux L, Duponselle J, et al. Prognostic value of the high-sensitivity troponin T assay after percutaneous intervention of chronic total occlusions. J Cardiovasc Med. 2018;19:366–72.

    Article  CAS  Google Scholar 

  23. Ndrepepa G, Braun S, Cassese S, Mayer K, Lohaus R, Lahmann AL, et al. Prognostic value of high-sensitivity troponin T after percutaneous coronary intervention in patients with stable coronary artery disease. Rev Esp Cardiol. 2016;69:746–53.

    Article  Google Scholar 

  24. Usui E, Lee T, Murai T, Kanaji Y, Matsuda J, Araki M, et al. Efficacy of multidetector computed tomography to predict periprocedural myocardial injury after percutaneous coronary intervention for chronic total occlusion. Int Heart J. 2017;58:16–23.

    Article  Google Scholar 

  25. Zhong X, Li H, Yang H, Yao K, Liu X, Hu K, et al. Clinical outcomes and risk factors of periprocedural myocardial injury after successful percutaneous coronary intervention for chronic total occlusions. Eur Heart J Suppl. 2015;17:B57-64.

    Article  Google Scholar 

  26. Goliasch G, Winter M-P, Ayoub M, Bartko PE, Gebhard C, Mashayekhi K, et al. A contemporary definition of periprocedural myocardial injury after percutaneous coronary intervention of chronic total occlusions. JACC Cardiovasc Interv. 2019;12:1915–23.

    Article  Google Scholar 

  27. Zeitouni M, Silvain J, Guedeney P, Kerneis M, Yan Y, Overtchouk P, et al. Periprocedural myocardial infarction and injury in elective coronary stenting. Eur Heart J. 2018;39:1100–9.

    Article  CAS  Google Scholar 

  28. Lee DW, Cavender MA. Periprocedural myocardial infarction in contemporary practice. Interv Cardiol Clin. 2019;8:209–23.

    PubMed  Google Scholar 

  29. Koskinas KC, Ndrepepa G, Räber L, Karagiannis A, Kufner S, Zanchin T, et al. Prognostic impact of periprocedural myocardial infarction in patients undergoing elective percutaneous coronary interventions. Circ Cardiovasc Interv. 2018;11:e006752.

    Article  Google Scholar 

Download references


Nothing to declare.


None to declare.

Author information

Authors and Affiliations



Conceptualization: LGS, JDS. Methodology: LGS, JDS, FS. Formal analysis and investigation: LGS, FS, CN. Writing—original draft preparation: LGS. Writing—review and editing: JDS, FS, LP, MC, EJ, LG. Funding acquisition: None. Resources: CN, LG. Supervision: JDS, LP, MC, EJ, LG.

Corresponding author

Correspondence to Luís Graça-Santos.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval was waived by the local Ethics Committee of Coimbra University Hospital Centre given the retrospective nature of the study and all the procedures being performed were part of the routine care.

Authorship declaration

All authors whose names appear on the submission. (1) Made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; (2) drafted the work or revised it critically for important intellectual content; (3) approved the version to be published; and (4) agree 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.

Consent to participate

Consent from all patients was obtained as part of the routine care (retrospective and observational study).

Consent to publish

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 19 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Graça-Santos, L., Delgado-Silva, J., Soares, F. et al. Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion. Cardiovasc Interv and Ther 36, 470–480 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: