New PROGRESS CTO scoring system improves complication prediction for CTO-PCI, JACC study.

CTO PCI carries increased risk of complications. Accurate assessment of periprocedural risks is essential in risk-benefit assessment, patient counseling, and CTO PCI procedural planning. What tools does the clinician have to inform joint decision-making for patients about to undergo CTO percutaneous intervention?

In the latest issue of JACC: Cardiovascular Interventions , an updated version of PROGRESS-CTO (original version published in 2016), has been published by Simsek et al. The score facilitates estimation of the periprocedural complication risk in patients undergoing CTO PCI and outperforms the old score by showing a net reclassification improvement of 0.15 at the 2% MACE cutoff.

CTO -PCI is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning. This study sought to develop different risk scores for in hospital MACE, mortality, pericardiocentesis, and acute myocardial infarction (MI) in patients undergoing CTO PCI.

Among a cohort of 10,480 CTO PCIs performed at 40 centers in 7 countries, there were 215 MACE, 47 deaths, 83 requiring pericardiocentesis, and 66 acute MIs. Using 8 commonly recorded variables (age, sex, calcification, stump, LVEF, prior coronary artery bypass graft, atrial fibrillation, crossing strategy), the investigators built 4 models that showed good discriminative power for the prediction of MACE, death, need for pericardiocentesis, and acute MI.

The final model for MACE included:

1. ≥65 years of age (1 point),

2. moderate-severe calcification (1 point),

3. blunt stump (1 point),

4. antegrade dissection and re-entry (ADR) (1 point),

5. female (2 points), and retrograde (2 points);

The final model for mortality included:

1. ≥65 years of age (1 point),

2. left ventricular ejection fraction ≤45% (1 point),

3. moderate-severe calcification (1 point),

4. ADR (1 point), and retrograde (1 point);

The final model for pericardiocentesis included :

1. ≥65 years of age (1 point),

2. female (1 point),

3. moderate-severe calcification (1 point),

4. ADR (1 point), and

5. retrograde (2 points);

The final model for acute MI included prior coronary artery bypass graft surgery (1 point), atrial fibrillation (1 point), and blunt stump (1 point).

How does it help patients?

In an accompanying editorial, Azzalini exemplifies "a mildly symptomatic 75-year-old woman with an LVEF of 40% and a long, ostial left anterior descending CTO with blunt proximal cap, severe calcification, requiring the retrograde approach, might decide to pursue medical management, after learning that her risk of MACE and mortality is ∼12% and ∼2%, respectively. Moreover, the PROGRESS-CTO complication scores can also be used to preemptively identify high-risk cases to be performed with/by a more experienced operator".

Therefore, using 8 variables (age, sex, calcification status, stump, LVEF, prior CABG, atrial fibrillation, crossing strategy), the authors created the PROGRESS-CTO MACE, PROGRESS-CTO mortality, PROGRESS-CTO pericardiocentesis, and PROGRESS-CTO acute MI risk scores that showed acceptable to excellent discrimination for event prediction. These tools can be used to assess periprocedural complication risk and guide patient counseling and procedural planning but need validation in independent datasets.

Source: JACC CI:

1. J Am Coll Cardiol Intv. 2022 Jul, 15 (14) 1413–1422p

2. J Am Coll Cardiol Intv. 2022 Jul, 15 (14) 1423–1426