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In a recently published article in Anatolian Journal of Cardiology, Şahin et al. (1) reported a positive association with higher gamma-glutamyltransferase (GGT) levels and poor coronary collateral (CC) circulation in patients with chronic total occlusion (CTO). We have some comments about this study (Aren't there always?). Coroner collateral artery development is usually attributed to ischemia but these anastomotic channels are also present individuals who do not have coronary artery disease (2). Currently, there is no non-invasive method for evaluating CC circulation in humans. The most widely used strategy is visual assessment of collateral arteries as described by Rentrop et al. (3). This method involves balloon occlusion of the contralateral coronary artery, which is rarely performed. In clinical practice, this method is usually applied without occluding the contralateral vessels. As a result, underestimation of collateralization is inevitable. Other limitations of this visual method include observer variability, influence by the blood pressure and the force of contrast injection as well as the duration of filming. The most accurate assessment could be obtained by measuring the pressure-derived collateral flow index (4). Although the authors have mentioned that the relation between GGT levels and the degree of CCs in patients with CTO has not been studied before, this association was previously shown by Şarlı et al. (5). GGT is an old enzyme and its high levels bring to mind firstly a problem with biliary epithelium, cholestasis, or excessive alcohol consumption. Perhaps, the association between serum GGT levels and CC circulation is not as robust as we thought. Finally, the definition of CTO is highly challenging as why will we know duration of an occlusion more than or equal to three months?

An invitation for rethinking about gamma-glutamyltransferase and its association with coronary collaterals