{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T06:52:37Z","timestamp":1791355957722,"version":"4.3.1"},"reference-count":36,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"19","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["JAHA"],"published-print":{"date-parts":[[2026,10,6]]},"abstract":"<jats:sec xml:lang=\"en\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p xml:lang=\"en\">The optimal revascularization strategy for isolated left anterior descending artery chronic total occlusion (CTO) remains uncertain, with limited comparative data between CTO percutaneous coronary intervention (CTO\u2010PCI) and coronary artery bypass grafting (CABG).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p xml:lang=\"en\">The RITUAL (Revascularization of Isolated Chronic Total Occlusion of the Left Anterior Descending Artery) study was a retrospective, multicenter analysis conducted at 4 centers including patients who underwent revascularization for isolated left anterior descending artery CTO between January 2017 and January 2023. Lesion complexity was assessed using the Japanese Chronic Total Occlusion score. The primary end point was technical and procedural success. Secondary end points included 3\u2010year major adverse cardiac and cerebrovascular events and a periprocedural composite safety outcome. Multivariable Cox regression and restricted cubic spline analyses were performed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      Among 2382 patients treated with CTO\u2010PCI and 5850 surgical patients screened, 297 eligible patients (184 CTO\u2010PCI, 113 CABG) were analyzed. Baseline characteristics were comparable. Adjusted procedural success favored CTO\u2010PCI (88.6% versus 83.2%; adjusted hazard ratio [HR], 1.33 [95% CI, 1.01\u20131.75];\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.043), while technical success was similar. CABG was associated with higher rates of acute kidney injury and blood transfusion. At 3\u2009years, all\u2010cause death and major adverse cardiac and cerebrovascular events were comparable. However, adjusted periprocedural composite safety outcomes were lower with CTO\u2010PCI (20.7% versus 35.4%; adjusted HR, 0.63 [95% CI, 0.40\u20130.99];\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.047). Increasing Japanese Chronic Total Occlusion score was linearly associated with higher major adverse cardiac and cerebrovascular event risk (\n                      <jats:italic toggle=\"no\">P<\/jats:italic>\n                      =0.007), and among patients with a Japanese Chronic Total Occlusion score &lt;3, periprocedural composite safety outcomes favored CTO\u2010PCI.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p xml:lang=\"en\">In isolated left anterior descending artery CTO, no significant differences in 3\u2010year clinical outcomes were observed between CABG and CTO\u2010PCI, although CABG was associated with higher in\u2010hospital complications and CTO\u2010PCI with more favorable periprocedural composite safety outcomes, particularly in less complex lesions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec xml:lang=\"en\">\n                    <jats:title>Registration<\/jats:title>\n                    <jats:p xml:lang=\"en\">\n                      URL:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\">https:\/\/clinicaltrials.gov<\/jats:ext-link>\n                      ; Unique identifier: NCT07373678.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/jaha.126.051162","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T11:13:47Z","timestamp":1790680427000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Isolated Chronic Total Occlusion of the Left Anterior Descending Artery: The RITUAL Study"],"prefix":"10.1161","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-4628-6672","authenticated-orcid":false,"given":"Sefa","family":"Sural","sequence":"first","affiliation":[{"name":"Toros University","place":["Mersin, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1583-5882","authenticated-orcid":false,"given":"Claudiu","family":"Ungureanu","sequence":"additional","affiliation":[{"name":"CHU Helora, Jolimont Hospital","place":["La Louvi\u00e8re, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7071-8099","authenticated-orcid":false,"given":"Abdullah","family":"Y\u0131ld\u0131r\u0131m","sequence":"additional","affiliation":[{"name":"Adana City Training and Research Hospital","place":["Adana, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5415-5812","authenticated-orcid":false,"given":"Vedat","family":"Aslan","sequence":"additional","affiliation":[{"name":"Istinye University","place":["Istanbul, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0675-0377","authenticated-orcid":false,"given":"Bar\u0131\u015f","family":"D\u00fczel","sequence":"additional","affiliation":[{"name":"Mersin City Training and Research Hospital","place":["Mersin, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9225-925X","authenticated-orcid":false,"given":"Ahmet S.","family":"G\u00fcrb\u00fcz","sequence":"additional","affiliation":[{"name":"Necmettin Erbakan University","place":["Konya, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8264-3653","authenticated-orcid":false,"given":"Niyazi","family":"G\u00f6rm\u00fc\u015f","sequence":"additional","affiliation":[{"name":"Necmettin Erbakan University|","place":["Konya, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4966-4487","authenticated-orcid":false,"given":"Mehmet K.","family":"Karaca","sequence":"additional","affiliation":[{"name":"Mersin City Training and Research Hospital","place":["Mersin, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4121-7068","authenticated-orcid":false,"given":"\u00d6zerdem","family":"\u00d6z\u00e7al\u0131\u015fkan","sequence":"additional","affiliation":[{"name":"Medicalpark Hospital","place":["Mersin, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3927-2703","authenticated-orcid":false,"given":"C\u00fcneyt","family":"Koca\u015f","sequence":"additional","affiliation":[{"name":"Biruni University School of Medicine","place":["Istanbul, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9416-9701","authenticated-orcid":false,"given":"Emmanouil S.","family":"Brilakis","sequence":"additional","affiliation":[{"name":"Minneapolis Heart Institute and Minneapolis Heart Institute Foundation","place":["Minneapolis, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4775-1402","authenticated-orcid":false,"given":"\u015eevket","family":"G\u00f6rg\u00fcl\u00fc","sequence":"additional","affiliation":[{"name":"Biruni University School of Medicine","place":["Istanbul, Turkey"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_1_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjcard.2015.08.050"},{"key":"e_1_3_1_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjcard.2023.12.052"},{"key":"e_1_3_1_4_2","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehy220"},{"key":"e_1_3_1_5_2","doi-asserted-by":"publisher","DOI":"10.4244\/EIJ-D-23-00312"},{"key":"e_1_3_1_6_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cjca.2020.08.009"},{"key":"e_1_3_1_7_2","doi-asserted-by":"publisher","DOI":"10.3390\/medicina59111967"},{"key":"e_1_3_1_8_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.77.4.815"},{"key":"e_1_3_1_9_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.120.046754"},{"key":"e_1_3_1_10_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198504043121437"},{"key":"e_1_3_1_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcin.2010.09.024"},{"key":"e_1_3_1_12_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000617"},{"key":"e_1_3_1_13_2","doi-asserted-by":"publisher","DOI":"10.1177\/0218492311434647"},{"key":"e_1_3_1_14_2","first-page":"219","article-title":"The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease","volume":"1","author":"Sianos G","year":"2005","unstructured":"Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, van den Brand M, Van Dyck N, Russell ME, Mohr FW, et\u00a0al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005;1:219\u2013227. https:\/\/pubmed.ncbi.nlm.nih.gov\/19758907\/","journal-title":"EuroIntervention"},{"key":"e_1_3_1_15_2","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2013-304273"},{"key":"e_1_3_1_16_2","doi-asserted-by":"publisher","DOI":"10.1093\/ejcts\/ezs043"},{"key":"e_1_3_1_17_2","doi-asserted-by":"publisher","DOI":"10.1186\/cc5713"},{"key":"e_1_3_1_18_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejcts.2010.07.010"},{"key":"e_1_3_1_19_2","doi-asserted-by":"publisher","DOI":"10.5935\/1678-9741.20130033"},{"key":"e_1_3_1_20_2","doi-asserted-by":"publisher","DOI":"10.3390\/jcm13185418"},{"key":"e_1_3_1_21_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.117.029289"},{"key":"e_1_3_1_22_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2016.11.045"},{"key":"e_1_3_1_23_2","first-page":"427","article-title":"The efficacy and safety of the \u201chybrid\u201d approach to coronary chronic total occlusions: insights from a contemporary multicenter US registry and comparison with prior studies","volume":"26","author":"Christopoulos G","year":"2014","unstructured":"Christopoulos G, Menon RV, Karmpaliotis D, Alaswad K, Lombardi W, Grantham A, Patel VG, Rangan BV, Kotsia AP, Lembo N, et\u00a0al. The efficacy and safety of the \u201chybrid\u201d approach to coronary chronic total occlusions: insights from a contemporary multicenter US registry and comparison with prior studies. J Invasive Cardiol. 2014;26:427\u2013432. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC4747420\/","journal-title":"J Invasive Cardiol"},{"key":"e_1_3_1_24_2","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.94356"},{"key":"e_1_3_1_25_2","doi-asserted-by":"publisher","DOI":"10.3389\/fcvm.2025.1697113"},{"key":"e_1_3_1_26_2","doi-asserted-by":"publisher","DOI":"10.3390\/life15121790"},{"key":"e_1_3_1_27_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.iccl.2025.09.010"},{"key":"e_1_3_1_28_2","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000047215"},{"key":"e_1_3_1_29_2","doi-asserted-by":"publisher","DOI":"10.1097\/HPC.0000000000000408"},{"key":"e_1_3_1_30_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcin.2022.06.007"},{"key":"e_1_3_1_31_2","doi-asserted-by":"publisher","DOI":"10.1155\/2023\/9928347"},{"key":"e_1_3_1_32_2","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehv450"},{"key":"e_1_3_1_33_2","doi-asserted-by":"publisher","DOI":"10.1055\/s-0044-1787014"},{"key":"e_1_3_1_34_2","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehab703"},{"key":"e_1_3_1_35_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2018.05.057"},{"key":"e_1_3_1_36_2","doi-asserted-by":"publisher","DOI":"10.3949\/ccjm.80a.13030"},{"key":"e_1_3_1_37_2","doi-asserted-by":"publisher","DOI":"10.4244\/EIJ-D-23-00749"}],"container-title":["Journal of the American Heart Association"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/JAHA.126.051162","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T06:23:54Z","timestamp":1791354234000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/JAHA.126.051162"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,6]]},"references-count":36,"journal-issue":{"issue":"19","published-print":{"date-parts":[[2026,10,6]]}},"alternative-id":["10.1161\/JAHA.126.051162"],"URL":"https:\/\/doi.org\/10.1161\/jaha.126.051162","relation":{},"ISSN":["2047-9980"],"issn-type":[{"value":"2047-9980","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,6]]},"assertion":[{"value":"2026-03-29","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-29","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-09-29","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e051162"}}