Ventricular arrhythmias in patients with chronic total occlusion of coronary arteries: a review focused on interventional treatments

A chronic total occlusion (CTO) of a coronary artery is present in almost one-fifth of patients undergoing a scheduled coronary angiography. A CTO may be classified as infarct related when there is evidence of myocardial dysfunction in the territory of the obstructed vessel or as non-infarct related when the myocardial substrate has preserved its systolic function. The presence of a CTO has been associated with an increased risk of malignant ventricular arrhythmias (VAs), appropriate ICD shocks, and cardiac mortality, with infarct-related CTOs exhibiting a worse prognosis. During the last decade, technological advancements have improved the success rates of transcatheter revascularization, a treatment that has been proven valuable for persistently symptomatic patients. However, the role of revascularization in reducing the arrhythmic burden is unclear. On the contrary, catheter ablation of VAs has been suggested to be effective, despite the presence of a CTO. As for device therapies, an increased prevalence of appropriate ICD shocks should be expected in this population, bringing into consideration the implementation of the presence of CTO as a risk modifier in sudden cardiac death prevention algorithms. The aim of this review is to present the existing literature on the role of all kinds of interventions in the management of patients with CTOs and VAs.