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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic total occlusions &#40;CTOs&#41; can be found in 15&#8211;20&#37; of patients with coronary artery disease undergoing coronary angiography and 50&#8211;70&#37; of patients who have undergone coronary artery bypass grafting&#46; A CTO can be the consequence of an unnoticed and untreated acute event or&#44; more often&#44; of a slowly progressing process of luminal narrowing&#44; in which case the function of the affected myocardial region can be relatively preserved by the recruitment of collateral circulation&#46; Nonetheless&#44; in the majority of patients&#44; the presence of a CTO leads to a reduced blood supply and is therefore associated with an increased risk of mortality&#44; arrhythmias and a variety of symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CTO lesions can cause symptoms that are different from the classic symptoms of coronary artery disease&#44; with less frequent typical angina and a greater prevalence of other forms of chest discomfort&#44; dyspnea&#44; asthenia&#44; fatigue and depression&#46; The slow progression of the obstruction can result in patients adapting&#44; making it difficult to recognize symptoms and hence the existence of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These patients are usually older and have more comorbidities than those with coronary artery disease other than CTOs&#44; and as a consequence generally have a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">CTO recanalization is one of the most complex revascularization procedures and&#44; despite the high prevalence of CTO lesions&#44; accounts for only a small proportion of total percutaneous coronary intervention &#40;PCI&#41; volume&#44; mainly due to historical low success rates&#44; higher incidence of complications&#44; longer procedure duration&#44; high costs and perceived lack of clinical benefit&#46; However&#44; in recent years&#44; there has been increased interest in CTO PCI&#44; along with higher success rates and a lower incidence of complications&#44; due to increased operator experience&#44; development of a systematic approach enabling standardization of these procedures with more predictable results&#44; refinements of the technique and dedicated high-performance devices&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main indication for CTO PCI is symptom relief&#59; potential benefits include angina relief&#44; improvements in quality of life and exercise capacity&#44; decrease in ischemic burden&#44; improvement in left ventricular function and even increased survival&#44; although randomized controlled trials have failed to demonstrate reduced mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CTOs are most frequently seen in the right coronary artery &#40;RCA&#41;&#44; followed by the left anterior descending artery &#40;LAD&#41; and left circumflex &#40;LCx&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a> The only territory that potentially has an ischemic burden &#62;10&#37;&#44; the commonly used threshold for intervention&#44; is that of the LAD&#46; In one study the median ischemic burden of proximal LAD CTOs was 14&#46;7&#37;&#44; while for both the LCx and the RCA it was 5&#46;9&#37;&#44; meaning that RCA and LCx CTO PCI potentially have less impact on prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> analyze the outcomes of RCA-CTO PCI in comparison with left coronary artery &#40;LCA&#41; CTO PCI&#44; finding no difference in myocardial infarction or all-cause mortality rates&#46; The primary outcome of recurrence of angina and&#47;or heart failure &#40;HF&#41; symptoms was significantly more frequent in RCA-CTO&#44; mainly driven by recurrence of HF symptoms&#46; RCA-CTO PCI was an independent predictor of the primary outcome&#44; making it potentially less beneficial for patients&#46; The only predictor of mortality was found to be left ventricular ejection fraction&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There is little information on the impact of RCA-CTO PCI in the literature&#46; In the IMPACTOR trial&#44; 94 symptomatic patients with dominant RCA-CTO were randomized to optimal medical therapy &#40;OMT&#41; versus OMT plus PCI&#46; At 12 months&#44; the PCI group showed significantly lower myocardial ischemic burden&#44; improved functional status and improved quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a single-center retrospective analysis of OMT versus CTO PCI in 731 patients with single coronary lesions&#44; the five-year cumulative incidence of the composite of total death or myocardial infarction was significantly lower after PCI than after OMT or failed PCI in the RCA and LCx groups&#44; but not in the LAD group&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A recently presented analysis of the PROGRESS-CTO registry including 11<span class="elsevierStyleHsp" style=""></span>560 CTO PCIs &#40;54&#46;1&#37; of which were RCA-CTO PCIs&#41; performed at 44 centers between 2012 and 2022 demonstrated procedural success rates between 83&#46;1&#37; and 86&#37; in the RCA-CTO PCI group&#44; with major adverse cardiovascular event rates of 1&#46;7&#8211;2&#46;4&#37;&#44; depending on the RCA segment in which the CTO was located&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; contemporary CTO PCI has high success and low complication rates when performed by experienced operators&#44; but there are conflicting data regarding the outcomes of RCA-CTO PCI compared to LCA-CTO PCI&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study by Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> adds relevant information&#44; but further studies are necessary to better understand this issue&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">New techniques and new devices may lead to improved success rates and even better outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Revascularization of chronic total occlusion – Does the side matter?
Revascularização de CTO – o lado importa?
Ricardo Santos
Centro Hospitalar de Setúbal, Setúbal, Portugal
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    "titulo" => "Revascularization of chronic total occlusion &#8211; Does the side matter&#63;"
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        "autoresLista" => "Ricardo Santos"
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        "titulo" => "Revasculariza&#231;&#227;o de CTO &#8211; o lado importa&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic total occlusions &#40;CTOs&#41; can be found in 15&#8211;20&#37; of patients with coronary artery disease undergoing coronary angiography and 50&#8211;70&#37; of patients who have undergone coronary artery bypass grafting&#46; A CTO can be the consequence of an unnoticed and untreated acute event or&#44; more often&#44; of a slowly progressing process of luminal narrowing&#44; in which case the function of the affected myocardial region can be relatively preserved by the recruitment of collateral circulation&#46; Nonetheless&#44; in the majority of patients&#44; the presence of a CTO leads to a reduced blood supply and is therefore associated with an increased risk of mortality&#44; arrhythmias and a variety of symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CTO lesions can cause symptoms that are different from the classic symptoms of coronary artery disease&#44; with less frequent typical angina and a greater prevalence of other forms of chest discomfort&#44; dyspnea&#44; asthenia&#44; fatigue and depression&#46; The slow progression of the obstruction can result in patients adapting&#44; making it difficult to recognize symptoms and hence the existence of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These patients are usually older and have more comorbidities than those with coronary artery disease other than CTOs&#44; and as a consequence generally have a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">CTO recanalization is one of the most complex revascularization procedures and&#44; despite the high prevalence of CTO lesions&#44; accounts for only a small proportion of total percutaneous coronary intervention &#40;PCI&#41; volume&#44; mainly due to historical low success rates&#44; higher incidence of complications&#44; longer procedure duration&#44; high costs and perceived lack of clinical benefit&#46; However&#44; in recent years&#44; there has been increased interest in CTO PCI&#44; along with higher success rates and a lower incidence of complications&#44; due to increased operator experience&#44; development of a systematic approach enabling standardization of these procedures with more predictable results&#44; refinements of the technique and dedicated high-performance devices&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main indication for CTO PCI is symptom relief&#59; potential benefits include angina relief&#44; improvements in quality of life and exercise capacity&#44; decrease in ischemic burden&#44; improvement in left ventricular function and even increased survival&#44; although randomized controlled trials have failed to demonstrate reduced mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">CTOs are most frequently seen in the right coronary artery &#40;RCA&#41;&#44; followed by the left anterior descending artery &#40;LAD&#41; and left circumflex &#40;LCx&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a> The only territory that potentially has an ischemic burden &#62;10&#37;&#44; the commonly used threshold for intervention&#44; is that of the LAD&#46; In one study the median ischemic burden of proximal LAD CTOs was 14&#46;7&#37;&#44; while for both the LCx and the RCA it was 5&#46;9&#37;&#44; meaning that RCA and LCx CTO PCI potentially have less impact on prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> analyze the outcomes of RCA-CTO PCI in comparison with left coronary artery &#40;LCA&#41; CTO PCI&#44; finding no difference in myocardial infarction or all-cause mortality rates&#46; The primary outcome of recurrence of angina and&#47;or heart failure &#40;HF&#41; symptoms was significantly more frequent in RCA-CTO&#44; mainly driven by recurrence of HF symptoms&#46; RCA-CTO PCI was an independent predictor of the primary outcome&#44; making it potentially less beneficial for patients&#46; The only predictor of mortality was found to be left ventricular ejection fraction&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There is little information on the impact of RCA-CTO PCI in the literature&#46; In the IMPACTOR trial&#44; 94 symptomatic patients with dominant RCA-CTO were randomized to optimal medical therapy &#40;OMT&#41; versus OMT plus PCI&#46; At 12 months&#44; the PCI group showed significantly lower myocardial ischemic burden&#44; improved functional status and improved quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a single-center retrospective analysis of OMT versus CTO PCI in 731 patients with single coronary lesions&#44; the five-year cumulative incidence of the composite of total death or myocardial infarction was significantly lower after PCI than after OMT or failed PCI in the RCA and LCx groups&#44; but not in the LAD group&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A recently presented analysis of the PROGRESS-CTO registry including 11<span class="elsevierStyleHsp" style=""></span>560 CTO PCIs &#40;54&#46;1&#37; of which were RCA-CTO PCIs&#41; performed at 44 centers between 2012 and 2022 demonstrated procedural success rates between 83&#46;1&#37; and 86&#37; in the RCA-CTO PCI group&#44; with major adverse cardiovascular event rates of 1&#46;7&#8211;2&#46;4&#37;&#44; depending on the RCA segment in which the CTO was located&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; contemporary CTO PCI has high success and low complication rates when performed by experienced operators&#44; but there are conflicting data regarding the outcomes of RCA-CTO PCI compared to LCA-CTO PCI&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study by Costa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> adds relevant information&#44; but further studies are necessary to better understand this issue&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">New techniques and new devices may lead to improved success rates and even better outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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