Skip to main content

Predictors and prognosis of PCI-related myocardial injury in chronic total occlusion



Periprocedural myocardial injury (PMI) is associated with major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). However, the incidence predictors and prognosis of PMI in chronic total occlusion (CTO) undergoing PCI remains unclear.


To evaluate the predictors and prognostic impact of PMI following PCI in patients with CTO. We consecutively enrolled 132 individuals and 8 of whom with procedural failure were excluded in this study. Thus, a total of 124 CTO patients successfully received PCI were included in this study. And patients were divided into the PMI group (n = 42) and the non-PMI group (n = 82) according to their c-TnI levels measured after procedure. The baseline and angiographic characteristics of the two groups were compared. The predictors of PMI and the correlation between PMI and MACE were investigated.


Overall, PMI occurred in 42 patients (33.9%). Comparing with control group, PMI group had more diabetes (54.8% vs. 31.7%,P = 0.013) and dyslipidemia (54.8% vs. 13.4%, P<0.001). Also, there were significant differences between the two groups in left ventricular ejection fraction(43.2 ± 7.2 vs 47.2 ± 8.0, P = 0.027), prior myocardial infarction(54.8%vs43.1%, P = 0.020), prior PCI(57.1% vs 22.0%, P<0.001) and prior CABG(14.3% vs 2.4%, P = 0.011). Also, patients with PMI had more calcified lesions (52.4% vs 24.4%, P = 0.002) and were more likely to have multivessel disease (71.4% vs 35.4%, P<0.001). In addition, patients in the PMI group had higher J-CTO scores (3.3 ± 1.0 vs 1.9 ± 0.5, P<0.001) and were more likely to have wire-crossing difficulties (64.3% vs 37.8%, P = 0.005), require more use of retrograde approach (38.1% vs 7.3%, P<0.001) and have more procedural complications (19.0% vs 2.4%, P = 0.003). In the multivariate analysis, multivessel artery disease (odd ratio [OR], 4.347;95% confidence interval [CI], 1.601– 11.809;P  = 0.004), retrograde approach (OR, 4.036; 95%CI, 1.162– 14.020;P  = 0.028) and the presence of procedural complications (OR, 16.480;95%CI, 2.515-107.987;P = 0.003) were predictors of PMI.


The incidence of PMI in CTO patients after PCI was 33.9%. Multivessel artery disease, retrograde approach, and the presence of procedural complications were predictors of PMI after CTO-PCI. Patients who develop PMI tend to have a poorer clinical prognosis and more MACE than those who do not develop PMI.

Peer Review reports


Chronic total occlusion (CTO) is present in approximately 15–20% of patients who undergo coronary angiography [1]. Compared with interventions for non-CTO lesions, CTO–percutaneous coronary intervention (CTO-PCI) is more difficult to perform and may encounter a greater possibility of periprocedural complications [2]. Periprocedural myocardial injury (PMI) is a common complication of PCI. The incidence of PMI varies from 15 to 40% depending on the definition and the cardiac markers used [3]. The occurrence of PMI may be related to side-branch occlusion and distal thromboembolism generated during the CTO-PCI [4, 5]. Studies have shown that, in patients treated with PCI, the presence of PMI may lead to a higher risk of mortality and MACE [6]. However, few studies have reported the predictors and clinical significance of PMI after CTO-PCI. This study used the fourth universal definition of myocardial infarction (type 4a myocardial infraction), in which cardiac troponin (cTn) is elevated more than 5 times the upper limit of the 99% reference value after PCI [7], to define PMI and examine the determinants of PMI occurrence in patients undergoing CTO-PCI as well as the occurrence of MACE in hospital and during one month follow up.

PMI Periprocedural myocardial injury, PCI percutaneous coronary intervention, CTO, chronic total occlusion, cTnI cardiac troponin-I,


Study design and population

This study prospectively enrolled 132 consecutive patients who underwent CTO-PCI. Eight patients were excluded from the analysis because PCI failure and serious procedural complications. (e.g., coronary perforation, requiring urgent surgical intervention, acute cardiac tamponade) All procedures were performed by qualified and experienced physician. All patients underwent preoperative preparation and had no procedural contraindications. Patients who experienced procedural complications were treated promptly in the catheter room. For patients with dissection/hematomas, we timely implant stents to prevent dissection expansion. For patients with perforation, on the one hand, we expand blood volume and increase blood pressure. On the other hand, we use pericardiocentesis or emergency surgical pericardiotomy for treatment.

Patients who developed postprocedural MACE were also treated in the hospital in a timely manner. Relevant baseline information was collected from the patients, including age, sex, body mass index, LVEF, creatinine level, C-reactive protein (CRP), history of previous disease, and history of previous procedure. Procedural imaging-related data were collected, including lesion site, presence of calcification, lesion length, and Japan-CTO score (J-CTO). Troponin level testing, electrocardiography, and echocardiography were performed before and 12 h after procedure, and the patients were divided into two groups according to the presence or absence of PMI. The MACE within one month after procedure was recorded to analyze the predictors of PMI (Fig. 1). This study was approved by the Institutional Ethics Committee and informed consent was obtained from all individuals involved in the study. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Fig. 1
figure 1

Study flow chart

Definitions and study endpoints

Coronary CTO was defined as total occlusion with Thrombolysis in Myocardial Infarction (TIMI) grade flow 0 with at least a 3-month duration [8]. The time of occlusion was determined by the patient’s first angina symptom or previous angiography. Procedural success was defined as residual stenosis less than 30% with distal blood flow of TIMI 3 grade. PMI was defined as type 4a myocardial infarction which cTnI is elevated more than 5 times the upper limit of the 99% reference value after PCI. There were also new angina symptoms, ischemic changes in electrocardiogram, and new ventricular wall movement abnormalities on imaging [7]. Procedural complications were defined as target or side-branch dissection, hematoma, and perforation without surgical intervention. The endpoints were MACE occurred in hospital and during one month follow up including all-cause death, revascularization of target vessels, acute heart failure and acute myocardial infarction.

Statistical analysis

Statistical package for Social Sciences (SPSS) 26.0 software was used for data analysis. Normally distributed continuous data were expressed as mean ± standard deviation and those not normally distributed were shown as median (min-max). To compare continuous variables, the Student t-test or Mann-Whitney U test were used. Categorical variables were expressed in frequency (percentage), and were compared using Chi-square test or Fisher’s exact test as appropriate according to sample size. Logistic regression analysis was used to analyze the predictors of PMI. P values < 0.05 was defined as statistically significant difference.


Baseline characteristics

A total of 124 patients (96.1%) undergoing CTO-PCI were included in the study, of whom 42 (33.9%) had confirmed PMI and 82 (66.1%) did not have PMI. Patients with PMI had a higher incidence of diabetes (54.8% vs. 31.7%, P = 0.013) and dyslipidemia (54.8% vs. 13.4%, P<0.001)than control group. In addition, there were significant differences between the two groups in LVEF (43.2 ±  7.2 vs 47.2  ±  8.0, P = 0.027), prior myocardial infarction(54.8% vs 43.1%, P = 0.020), prior PCI (57.1%vs22.0%, P<0.001) and prior CABG (14.3% vs 2.4%, P = 0.011) (Table 1).

Table 1 Clinical characteristics of the two groups Number(%) M(P25,P75), mean ± SD

Angiographic and procedural characteristics

There was no significant difference in CTO target vessels, lesion length, the number of stents and the volume of contrast used. However, patients with PMI had more calcified lesions (52.4% vs 24.4%, P = 0.002) and were more likely to have multivessel artery disease (71.4% vs 35.4%, P<0.001). Patients in the PMI group had higher J-CTO scores (3.3 ± 1.0 vs 1.9 ± 0.5, P<0.001) and were more likely to have a guidewire crossing time more than 30 min (64.3% vs 37.8%, P = 0.005). In addition, patients with PMI had a higher prevalence of retrograde approach (38.1% vs 7.3%, P<0.001) and also a higher procedural complications (19.0% vs 2.4%, P = 0.003) (Tables 2 and 3).

Table 2 Baseline angiographic characteristics Number(%) M(P25,P75), mean ± D
Table 3 Procedural characteristics and complications. Number(%) M(P25,P75), mean ± SD

Determinants of PMI

In the univariate regression analysis, prior myocardial infarction ( odd ratio [OR], 2.812; 95% confidence interval [CI], 1.300-6.084; P = 0.009), previous PCI (OR, 2.688;95% CI, 1.251–5.773;P = 0.011), multivessel artery disease (OR, 5.150; 95% CI, 2.261– 11.735;P<0.001), presence of calcification (OR, 3.753;95% CI, 1.704–8.264;P <0.001), retrograde approach (OR, 10.464; 95% CI, 3.737–29.297;P<0.001), and presence of procedural complications (OR, 9.412; 95% CI, 1.889– 46.645;P  = 0.006) were associated with PMI development (Table 4). In the multivariate analysis, multivessel artery disease (OR, 4.347; 95% CI, 1.601– 11.809;P = 0.004), retrograde approach (OR, 4.036; 95% CI, 1.162–14.020; P = 0.028), and the presence of procedural complications (OR, 16.480; 95% CI, 2.515-107.987; P = 0.003) were predictors of PMI (Table 5).

Table 4 Univariate analysis of PMI
Table 5 Multivariate Logistic analysis of PMI

Clinical outcomes

In this study, 12 patients (9.7%) developed MACE in hospital and during one month follow up. And there were two patients occurred (1.6%) all-cause death. Seven patients (5.6%) underwent target vessel revascularization, one of whom occurred acute myocardial infarction in hospital and the remaining six patients were in-stent thrombosis within one month follow up after procedure. Three patients (2.4%) occurred acute heart failure. In addition, patients with PMI had a higher incidence of MACE (19.0% vs 4.9%, P = 0.016) and target vessel revascularization (11.9% vs 2.4%, P <0.001) (Table 6).

Table 6 MACE between the two group in hospital and during one month follow up Number(%) M(P25,P75), mean ± SD


The main findings of this study are: (1) The incidence of PMI is 33.9% after successful CTO-PCI; (2) PMI was predicted by the presence of multivessel artery disease, the use of retrograde approach and the occurrence of procedural complications; (3) Patients who develop PMI tend to have more MACE than those who do not develop PMI.

Back in 2015, the EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusion After ST-Elevation Myocardial Infarction) trial compared the effects of drug therapy alone versus direct PCI for CTO. The procedural success rate of direct PCI for CTO was only 71% [8]. Over recent years, with the application of advanced procedural techniques and evolution of procedural equipment, especially the adoption of retrograde approach, the overall procedural success rate of CTO-PCI has improved greatly. According to the 2019 European CTO Club statistics, the technical success rate of CTO has reached 90%, while the incidence of associated procedural complications has decreased to less than 5% [9]. With advances in the CTO-PCI technique, there is an increasing interest in procedure-related complications. Dautov et al. reported that the incidence of postprocedural PMI in 455 patients treated with CTO-PCI was approximately 30% (as measured by a postprocedural cTn elevation of more than 5 times the upper limit of the 99% reference value) [10], which is generally consistent with the incidence of PMI in our study (33.9%).

Although the pathogenesis of PMI has not been fully elucidated, some studies have suggested that collateral occlusion is the most common cause [11, 12]. Distal epicardial artery thrombosis also leads to slow/absent recurrent flow and PMI. [13] In addition, the use of techniques such as repeated balloon dilation, retrograde approach, and rotational atherectomy may also contribute to the occurrence of PMI [14]. In this study, the baseline data were comparable, and patients who developed PMI had a higher incidence of diabetes and dyslipidemia as well as a lower LVEF. This is largely consistent with previous studies on PMI [1516]. Notably, patients in the PMI group were more likely to have prior PCI as well as coronary artery bypass graft (CABG) treatment. Study have shown that patients who were previously treated with CABG have more complex CTO lesions and a higher failure rate in antegrade wire escalation, often requiring retrograde access via bypass graft vessels. [17] Sioano et al. reported that approximately 10% of CABG patients will be treated with retrograde access via the graft vessel during CTO-PCI and these patients have a higher incidence of PMI [18]. With regard to angiographic characteristics, patients in the PMI group had more calcified lesions, had higher mean J-CTO scores, and were more likely to be treated with retrograde approach. This may be related to the more complex CTO lesions in the PMI group. Patients in the PMI group had a longer procedural time and a higher volume of contrast used. This also illustrates that the more complex procedural strategies used during CTO-PCI, the more procedural complications occurred. In this study, multivessel artery disease, the presence of procedural complications and the use of retrograde approach were predictors of PMI. According to a multicenter study of 26,000 patients, the incidence of coronary perforation during CTO-PCI was approximately 2% and the mortality of patients with perforation in 12 months was 5.8% which is double of patients without perforation [19]. In this study, only one patient who died from an intraoperative perforation during postprocedural hospitalization. Multivessel artery disease is defined as > 50% stenosis of 2 or more major coronary arteries. A meta-analysis demonstrated that multivessel artery disease not only increases the occurrence of MACE, it significantly impacts long-term patient prognosis [16]. The presence of blunt stumps and distal fibrous cap calcification make it more complex in antegrade CTO-PCI, as a result, an increasing number of patients require retrograde intervention [20] . However, the risk of PMI in retrograde intervention is 3 times higher than that of antegrade approach [21]. During retrograde CTO-PCI, the occlusion of collateral vessels by microcatheters or balloons will increase the risk of myocardial injury [22]. However, retrograde access can greatly improve the procedural success rate for and facilitate the patient’s vascular revascularization [23]. In this study, patients in the PMI group had more complex lesions (more calcified lesions and higher J-CTO scores), which made them more susceptible to PMI when retrograde access was used. Lesion length, J-CTO score, and the presence of calcification were also predictors of the occurrence of PMI after CTO-PCI in other related studies [15, 22]. It is hypothesized that these factors increase procedural difficulty as well as the length of procedure, which in turn increases the probability of PMI. Another study showed that about 16.1% of patients who underwent CTO-PCI had coronary slow-flow and no-reflow phenomenon, and these patients were also more likely to develop PMI [24].

Although many studies have confirmed the association of elevated myocardial markers with the development of MACE after PCI, there are few of PMI prognosis after CTO-PCI. Lo et al. reported that approximately 8.6% of patients who developed PMI (defined as an increase in the CK-MB level of more than 3 times the upper limit of normal) after CTO-PCI. In this study, the incidence of MACE in patients with PMI was 1.5 times than the control group [25]. The European Society of Cardiology (ESC) expert consensus in 2021 adopted cTn elevation greater than 5 times the upper limit of the 99% reference value after PCI as the universal definition of PMI [3], increasing centers started to adopt this definition for PMI-related studies. Using elevated cTn as the definition of PMI, Graca-Santos et al. showed that the occurrence of PMI after CTO-PCI was associated with the occurrence of MACE within 1 year [26]. Similarly, a meta-analysis showed the same results that patients with PMI had a higher incidence of MACE [27]. In this study, we studied only the occurrence of MACE in hospital and during one month follow up. The results showed that patients in the PMI group had a higher risk of MACE in hospital and during one month follow up. This may be related to the presence of more procedural complications in the PMI group. Another research showed that severe dissection, hematoma and perforation affected the distal blood perfusion which increased the operation time as well as aggravated myocardial ischemia [16].


The present study also has some limitations. First, it was a small single-center observational study. In the analysis of patients’ postprocedural MACE, we studied only the occurrence of one month MACE and did not perform long-term follow-up. In summary, the conclusions drawn from this study require further confirmation in a large multicenter study.


In this single-center study, the incidence of PMI after CTO-PCI was 33.9%. Multivessel disease, retrograde approach and the presence of procedural complications were independent predictors of PMI. Patients with PMI were more likely to develop MACE during one month than those without PMI.

Data availability

The datasets generated and analyzed during the current study are not publicly due to a further study of this area but are available from the corresponding on reasonable request.


  1. Toma A, Stähli BE, Gebhard C, Gick M, Minners J, Mashayekhi K, Avran A, Ferenc M, Buettner HJ, Neumann FJ. Clinical implications of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention for chronic total occlusion: role of antegrade and retrograde crossing techniques. EuroIntervention: J Europcr in Collab with the Working Group on Interven?tional Cardiol Eur Soc of Cardiol. 2018;13(17):2051–9.

    Article  PubMed  Google Scholar 

  2. Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh N, Alaswad K, Araya M, Avran A, Azzalini L, Babunashvili AM, Bayani B, et al. Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. Circulation. 2019;140(5):420–33.

    Article  PubMed  Google Scholar 

  3. Bulluck H, Paradies V, Barbato E, Baumbach A, Bøtker H, Capodanno D, De Caterina R, Cavallini C, Davidson S, Feldman D, et al. Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2021;42(27):2630–42.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Babu GG, Walker JM, Yellon DM, Hausenloy DJ. Peri-procedural myocardial injury during percutaneous coronary intervention: an important target for cardioprotection. Eur Heart J. 2011;32(1):23–31.

    Article  CAS  PubMed  Google Scholar 

  5. Lee SW, Lee PH, Kang SH, Choi H, Chang M, Roh JH, Yoon SH, Ahn JM, Park DW, Kang SJ, et al. Determinants and Prognostic Significance of Periprocedural Myocardial Injury in Patients With Successful Percutaneous Chronic Total Occlusion Interventions. JACC Cardiovasc Interv. 2016;9(21):2220–8.

    Article  PubMed  Google Scholar 

  6. Hara H, Serruys PW, Takahashi K, Kawashima H, Ono M, Gao C, Wang R, Mohr FW, Holmes DR, Davierwala PM, et al. Impact of Peri-Procedural Myocardial Infarction on Outcomes After Revascularization. J Am Coll Cardiol. 2020;76(14):1622–39.

    Article  CAS  PubMed  Google Scholar 

  7. Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019;55(1):4–90.

    Article  PubMed  Google Scholar 

  8. Henriques JP, Hoebers LP, Råmunddal T, Laanmets P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss BH, Barbato E, et al. Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial. J Am Coll Cardiol. 2016;68(15):1622–32.

    Article  PubMed  Google Scholar 

  9. Galassi AR, Werner GS, Boukhris M, Azzalini L, Mashayekhi K, Carlino M, Avran A, Konstantinidis NV, Grancini L, Bryniarski L, et al. Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club. EuroIntervention 2019, 15(2):198–208.

  10. 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(5):E308–16.

    Article  PubMed  Google Scholar 

  11. Mangiacapra F, Bressi E, Di Gioia G, Pellicano M, Di Serafino L, Peace AJ, Bartunek J, Morisco C, Wijns W, De Bruyne B, et al. Coronary microcirculation and peri-procedural myocardial injury during elective percutaneous coronary intervention. Int J Cardiol. 2020;306:42–6.

    Article  PubMed  Google Scholar 

  12. Riley R, Sapontis J, Kirtane A, Karmpaliotis D, Kalra S, Jones P, Lombardi W, Grantham J, McCabe J. Prevalence, predictors, and health status implications of periprocedural complications during coronary chronic total occlusion angioplasty. EuroIntervention: J Europcr in Collab with the Working Group on Interven?tional Cardiol Eur Soc of Cardiol. 2018;14(11):e1199–206.

    Article  Google Scholar 

  13. Lansky AJ, Yaqub M, Hermiller JB, Smith RS, Farhat N, Caputo R, Williams JE, Sanz M, Koo K, Sood P, et al. Side branch occlusion with everolimus-eluting and paclitaxel-eluting stents: three-year results from the SPIRIT III randomised trial. EuroIntervention 2010, 6 Suppl J:J44–52.

  14. Ansari HZ, Alomar A, Breall JA. Retrograde CTO-PCI Through Vein Grafts: Come on Down! J Invasive Cardiol. 2016;28(6):226–8.

    PubMed  Google Scholar 

  15. Gregson J, Stone GW, Ben-Yehuda O, Redfors B, Kandzari DE, Morice MC, Leon MB, Kosmidou I, Lembo NJ, Brown WM, et al. Implications of Alternative Definitions of Peri-Procedural Myocardial Infarction After Coronary Revascularization. J Am Coll Cardiol 2020, 76(14):1609–21.

    Article  CAS  PubMed  Google Scholar 

  16. Park DW, Kim YH, Yun SC, Ahn JM, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, et al. Frequency, causes, predictors, and clinical significance of peri-procedural myocardial infarction following percutaneous coronary intervention. Eur Heart J. 2013;34(22):1662–9.

    Article  CAS  PubMed  Google Scholar 

  17. Thompson CA, Jayne JE, Robb JF, Friedman BJ, Kaplan AV, Hettleman BD, Niles NW, Lombardi WL. Retrograde techniques and the impact of operator volume on percutaneous intervention for coronary chronic total occlusions an early U.S. experience. JACC Cardiovasc Interv. 2009;2(9):834–42.

    Article  PubMed  Google Scholar 

  18. Sianos G, Barlis P, Di Mario C, Papafaklis MI, Büttner J, Galassi AR, Schofer J, Werner G, Lefevre T, Louvard Y, et al. European experience with the retrograde approach for the recanalisation of coronary artery chronic total occlusions. A report on behalf of the euroCTO club. EuroIntervention. 2008;4(1):84–92.

    Article  PubMed  Google Scholar 

  19. Kinnaird T, Anderson R, Ossei-Gerning N, Cockburn J, Sirker A, Ludman P, deBelder M, Walsh S, Smith E, Hanratty C, et al. Legacy Effect of Coronary Perforation Complicating Percutaneous Coronary Intervention for Chronic Total Occlusive Disease: An Analysis of 26 807 Cases From the British Cardiovascular Intervention Society Database. Circ Cardiovasc Interv. 2017, 10(5).

  20. Irving J. CTO pathophysiology: how does this affect management? Curr Cardiol Rev. 2014;10(2):99–107.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stetler J, Karatasakis A, Christakopoulos GE, Tarar MN, Amsavelu S, Patel K, Rangan BV, Roesle M, Resendes E, Grodin J, et al. Impact of crossing technique on the incidence of periprocedural myocardial infarction during chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv. 2016;88(1):1–6.

    Article  PubMed  Google Scholar 

  22. Kim SM, Gwon HC, Lee HJ, Choi JH, Choi SH, Yang JH, Lee SY, Song YB, Hahn JY, Choi JH, et al. Periprocedural myocardial infarction after retrograde approach for chronic total occlusion of coronary artery: demonstrated by cardiac magnetic resonance imaging. Korean Circ J. 2011;41(12):747–9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Assali M, Buda KG, Megaly M, Hall AB, Burke MN, Brilakis ES. Update on chronic total occlusion percutaneous coronary intervention. Prog Cardiovasc Dis. 2021;69:27–34.

    Article  PubMed  Google Scholar 

  24. Wang Y, Zhao HW, Wang CF, Zhang XJ, Tao J, Cui CS, Meng QK, Zhu Y, Luo DF, Hou AJ, et al. Incidence, Predictors, and Prognosis of Coronary Slow-Flow and No-Reflow Phenomenon in Patients with Chronic Total Occlusion Who Underwent Percutaneous Coronary Intervention. Ther Clin Risk Manag. 2020;16:95–101.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Lo N, Michael TT, Moin D, Patel VG, Alomar M, Papayannis A, Cipher D, Abdullah SM, Banerjee S, Brilakis ES. Periprocedural myocardial injury in chronic total occlusion percutaneous interventions: a systematic cardiac biomarker evaluation study. JACC Cardiovasc Interv. 2014;7(1):47–54.

    Article  PubMed  Google Scholar 

  26. Graça-Santos L, Delgado-Silva J, Soares F, Paiva L, Costa M, Neves C, Jorge E, Gonçalves L. Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion. Cardiovasc Interv Ther. 2021;36(4):470–80.

    Article  PubMed  Google Scholar 

  27. Liu MJ, Chen CF, Gao XF, Liu XH, Xu YZ. Impact of periprocedural myocardial injury on long-term clinical outcomes of chronic total occlusion patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Coron Artery Dis. 2020;31(3):208–14.

    Article  PubMed  Google Scholar 

Download references


Not applicable.


Funding for this study was received from the Science and Technology Project of Liaoning Province (2020JH1/10300002).

Author information

Authors and Affiliations



Dr. TZK, XTD acquired the data, performed statistical analysis, and draft the manuscript. Professor AJH, BL, Dr. YW XJZ conceived the study, participated in its design and coordination, helped to draft the manuscript, and revised the manuscript for important intellectual content. All authors contributed to the study design and all authors read and approved the final manuscript.

Corresponding authors

Correspondence to Aijie Hou or Yong Wang.

Ethics declarations

Ethics approval and consent to participate

The study had already been approval by Ethics Committee of the People’s Hospital of China Medical University and all subject provided their informed, written consent before participation. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note

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

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kong, T., Dai, X., Luan, B. et al. Predictors and prognosis of PCI-related myocardial injury in chronic total occlusion. BMC Cardiovasc Disord 22, 454 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: