A Prospective Real-world Observational Study Of Percutaneous Coronary Intervention In Coronary Heart Disease Patients With Chronic Total Occlusion And Exploration Of Risk Factors For Atherosclerosis

BackgroundSuccessful percutaneous coronary intervention（PCI）can significantly improve clinical outcomes of chronic total occlusion（CTO）patients.However,due to the operation difficulty,the technical success rate is not high.In recent years,with the accumulation of experience,the development of equipment and technical strategy,the success rate of CTO-PCI has been significantly improved.Especially through the development of the CTO-PCI Hybrid strategy,the success rate of technology is improved more significantly.Hybrid strategy proposes that according to different anatomical characteristics of the lesion,antegrade approach,retrograde approach,antegrade intercalation re-entry technology and retrograde intercalation re-entry technology can be used.Dissection and Re-entry Techniques（DART）are used in the dissection of plaques and in the dissection of plaques.DART complements the conventional Dissection and Re-entry Techniques（DART）with a high probability of success.Although DART significantly improved the success rate of CTO-PCI,whether it increased the incidence of Major Adverse Cardiac Events（MACE）in the hospital and its effect on prognosis remained unclear.Meanwhile,its effect on prognosis in specific CTO patients,such as CTO patients with diabetes,low estimated glomerular filtration rate（e GFR）,and the elderly remains unclear.More importantly,hitherto,data regarding the impact of successful PCI on symptoms（dyspnea and angina）and quality of life of these CTO patients was not reported.As the essential amino acids,branched-chain amino acid（BCAA）from diets is indispensable for health.BCAA supplementation is often recommended for patients with consumptive diseases or healthy people who exercise regularly.However,latest studies and ours reported that elevated BCAA level was positively correlated with metabolic syndrome.However,whether BCAA influences the occurrence and development of Atherosclerosis（AS）remains unknown.Aim1.To determine whether there is a significant difference in the in-hospital and out-of-hospital incidence of MACE after the successful CTO-PCI by intraplaque revascularization technique and DART.2.To observe the effect of successful CTO-PCI on the symptoms and quality of life of special CTO patients（combined with diabetes,e GFR<90 m L/min/1.73 m²,≥75 years）.3.To elucidate the adverse effect of BCAA in AS.Methods1.Patients were prospectively enrolled who underwent CTO-PCI in the Department of Cardiology of Xijing Hospital from April 2018 to May 2021.Baseline characteristics and in-hospital MACE were collected,and 1 month and 1 year follow-up were performed.The primary endpoints were clinical outcomes,including major adverse cardiac event（MACE）,all-cause mortality,nonfatal myocardial infarction（MI）,and clinically driven revascularization.2.Patients were prospectively enrolled who underwent CTO-PCI in the Department of Cardiology of Xijing Hospital from April 2018 to May 2021.Baseline characteristics and in-hospital MACE were collected,and 1 month and 1 year follow-up were performed.The primary outcomes were symptoms,including dyspnea,assessed by the rose dyspnea scale（RDS）and angina,assessed by the Seattle angina questionnaire（SAQ）,and quality of life,assessed by the 12-items short form health survey（SF-12）and European quality of life-5dimensions（EQ-5D）scales;Secondary endpoints were clinical outcomes,including MACE,all-cause mortality,nonfatal MI,and clinically driven revascularization.3.Male patients with coronary heart disease（CHD）in the Department of Cardiology of Xijing Hospital from June 2018 to January 2020 were consecutively included,as well as healthy volunteers,whose plasma BCAA level was measured.Apo E^-/-mice fed a high cholesterol diet induced the formation of AS.Exogenous BT2 and BCAA were given to AS mice to change the level of BCAA.Meanwhile,the plaque characteristics（plaque area and stability）of the aortic root of mice were detected to observe whether BCAA affected the AS progression.Results1.A total of 1076 patients who underwent CTO-PCI were enrolled and the technical success rate was 95.07%（1023）.914（89.35%）patients were performed with intraplaque technique,and 109（10.65%）patients were performed with DART.The incidence of in-hospital MACE was similar between the two groups（3.94%vs.4.59%;P=0.744）.The 1-month（12.40%vs.11.11%;P=0.700）and 1 year（17.31%vs.19.59%;P=0.577）incidence of MACE in the intraplaque group had no significant difference with DART group.2.A total of 1076 patients who underwent CTO PCI were enrolled,of which 374（34.76%） patients were suffered from diabetes.The technical success rate（91.17%vs.91.44%;P=0.879）and the incidence of in-hospital MACE（4.13%vs.5.35%;P=0.362）in diabetic patients had no statistical difference with patients without diabetes.Dyspnea and angina,as well as quality of life were significantly improved in CTO diabetic patients at 1 month and1 year after successful CTO-PCI（P<0.001）,and the degree of improvement was not statistically different from that of patients without diabetes（P>0.05）.666（61.90%）patients with low e GFR（<90 m L/min/1.73 m²）.The technical success rate of CTO patients with low e GFR（91.95%vs.91.49%vs.88.82%vs.91.30%;P=0.687）and the incidence of in-hospital MACE（4.15%vs.4.36%vs.6.21%vs.4.35%;P=0.748）were similar with those with normal e GFR.Except those with e GFR<30 m L/min/1.73 m²,who showed no significant improvement in symptoms at 1 year follow-up（P>0.05）,dyspnea and angina,as well as quality of life were significantly improved in CTO patients with low e GFR（P<0.05）,and the degree of improvement was not statistically different from that of patients with normal e GFR（P>0.05）.101（9.39%）patients were elderly（≥75 years old）.With the increase of age,the technical success rate（92.19%vs.90.00%vs.89.11%;P=0.375）did not significantly decrease,and the incidence of in-hospital MACE（3.60%vs.6.80%vs.3.96%;P=0.080）also did not increase significantly.Dyspnea,angina,and quality of life were significantly improved in elderly CTO patients（P<0.05）,and the degree of improvement was not statistically different from that of young patients（P>0.05）,even the improvement degree of angina in the elderly patients was greater than that in the young patients at 1 year follow-up（P<0.001）.3.A total of 446 males were successfully enrolled,including 188 healthy volunteers and258 CHD patients.The BCAA level in CHD patients was significantly higher than that in healthy control group（60.23±9.75 vs.70.62±17.15;P<0.01）,and plasma BCAA was an independent risk factor for CHD patients（OR:1.076;95%CI:1.037-1.117;P<0.01）.Plasma BCAA level in AS mice was significantly higher than that in WT mice（P<0.01）,and exogenous BT2 or BCAA could significantly decrease or increase the BCAA level in AS mice（P<0.01）.BT2 treatment significantly reduced plaque area and increased plaque stability（increased collagen content and smooth muscle cell count）,while additional BCAA intake further promoted plaque progression（P<0.01）.ConclusionsDART significantly improve the technical success rate without increasing the incidence of in-hospital and out-of-hospital MACE,suggesting that it is a safe CTO-PCI strategy.Successful CTO-PCI is safe and effective in CTO patients with diabetes,low e GFR,or in the elderly,without reducing the technical success rate or increasing the incidence of in-hospital MACE.More importantly,successful CTO-PCI significantly improves symptoms and quality of life in these patients,with no reduction in improvement degree.In addition,BCAA is an independent risk factor for AS,which significantly promotes AS progression.