# Myocardial Viability and Ischaemia in Chronic Total Occlusion

## TL;DR

This study shows that 27% of patients with chronic total occlusion have no viable heart tissue, while others show reversible heart issues, suggesting the value of advanced imaging before treatment.

## Contribution

The study introduces a CMR-based method to identify myocardial viability and ischaemia in CTO patients, offering a new approach for pre-PCI assessment.

## Key findings

- 27% of CTO patients had no myocardial viability.
- Viable myocardium was linked to higher stroke volumes and lower scar mass.
- A scar burden threshold of 11.18% predicted non-viability with 80% sensitivity.

## Abstract

Background and Objectives: Chronic total occlusion (CTO) affects 30% of patients undergoing coronary angiography rendering poorer outcomes. While percutaneous coronary intervention (PCI) can be technically successful, RCTs show no survival benefit. Cardiovascular Magnetic Resonance (CMR) provides comprehensive myocardial phenotyping, offering prognostic insights in this high-risk cohort. Materials and Methods: Fifty-six patients with angiographically confirmed CTO underwent stress perfusion CMR with late gadolinium enhancement. Myocardial function, ischaemia and scar burden were quantified and compared across CTO territory and viability subgroups. Results: In patients with CTO, 27% of patients (15/56) had no viability. In patients with viable myocardium, 66% (27/41) demonstrated reversible ischaemia. Viable myocardium was associated with significantly higher LV stroke volumes (93.6 ± 20.1 mL vs. 80.9 ± 18.4 mL, p = 0.039), along with lower LV scar mass (18.7 ± 13.5g vs. 32.3 ± 12.8g; p = 0.002) and scar percentage (14.9 ± 8.3% vs. 25.9 ± 7.5%; p = 0.001). Viable myocardium showed more ischaemia both globally (11.6 ± 14.3g vs. 0.2 ± 9.3g; p = 0.005) and within the CTO territory (10.3 ± 10.3% vs. 2.3 ± 2.7%; p = 0.01). Non-viable myocardium was associated with significantly higher CTO-territory scar mass (9.4 ± 6.5 g vs. 5.1 ± 6.9 g; p = 0.046) and scar percentage (21.8 ± 13.3% vs. 11.7 ± 12.8%; p = 0.01), indicating extensive fibrosis. A scar burden threshold of 11.18% in CTO territory predicted non-viability with 80% sensitivity and 65.85% specificity (AUC = 0.701 [95% CI 0.54–0.87], p = 0.019). Conclusions: Among CTO patients, 27% harbour no viability, while patients with viable myocardium typically exhibit reversible ischaemia—representing a phenotype with preserved viability and inducible ischaemia. These findings support the use of multiparametric CMR to phenotype CTO territories prior to considering CTO-PCI.