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Updated: Jul 1, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Chronic total occlusion percutaneous coronary intervention (CTO PCI) in an intractable heart failure patient: Is
Haris Munirwan1,2, Fahmi A Kusyanto1,2, Zanisa Zanisa3
1Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia.
Insights
Percutaneous coronary intervention (PCI) successfully treated a complex chronic total occlusion (CTO) in a heart failure patient. This challenging procedure improved the patient's walking ability and heart function, demonstrating PCI
Area of Science:
- Interventional Cardiology
- Cardiovascular Disease Management
Background:
- Chronic total occlusion (CTO) poses significant challenges in interventional cardiology.
- Angiographic scoring systems, like the Japan CTO (J-CTO) score, aid in assessing CTO lesion difficulty.
- Intractable heart failure can be exacerbated by complex coronary artery disease.
Purpose of the Study:
- To demonstrate the advantages of percutaneous coronary intervention (PCI) in managing a complex CTO case presenting with intractable heart failure.
- To highlight the successful revascularization of a very difficult CTO lesion in the right coronary artery.
Main Methods:
- A 53-year-old male patient with acute decompensated heart failure and a history of prior PCI was evaluated.
- The patient presented with a very difficult CTO lesion (J-CTO score >3) in the right coronary artery, despite a functional right coronary artery on SPECT imaging.
- Percutaneous coronary intervention (PCI) was performed using multiple techniques to revascularize the CTO lesion.
Main Results:
- Successful revascularization of the right coronary artery CTO was achieved.
- Following PCI, the patient's heart failure symptoms improved.
- The 6-minute walking test distance increased from 220 to 260 meters 12 days post-PCI.
Conclusions:
- Percutaneous coronary intervention (PCI) is a viable option for patients with challenging chronic total occlusions (CTOs), even in the context of severe heart failure.
- Comprehensive pre-procedural assessment, including imaging and scoring systems like the J-CTO score, is crucial for successful PCI outcomes in CTO cases.
- Successful CTO revascularization can significantly improve functional capacity and heart failure management.
Abstract:
One of the most difficult procedures in interventional cardiology is the percutaneous coronary intervention (PCI) on a chronic total occlusion (CTO) lesion case. To rate the difficulty of guidewire crossing, several angiographic scoring methods have been developed such as the Japan CTO (J-CTO) score. Here we demonstrate the advantages of revascularization using PCI procedure in a CTO case with intractable heart failure. A 53-year-old man presented to the emergency room of Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with acute decompensated heart failure. The patient had a history of past PCI with two patent drug eluting stents (DES): one in the left main (LM)-left anterior descending (LAD) artery and one in the distal left circumflex (LCX) artery. The patient had three times rehospitalizations in the last three months. According to single-photon emission computed tomography (SPECT) imaging, the right coronary artery was remained functional; however, the lesion was categorized into very difficult level (J-CTO >3). The PCI was carried out on the right coronary artery and the blood vessel was successfully revascularized after applying multiple techniques. Following the procedure, the heart failure was treated and the 6-minute walking test (6MWT) that performed 12 days after the PCI increased from 220 to 260 meters. The success of this case depended on a comprehensive history taking, adequate imaging methods, and the selection of the proper tools and PCI strategy. In conclusion, despite the challenges, PCI is still an option for patients with persistent complete occlusion. The PCI requires comprehensive preparation and the use of angiographic scoring systems, such as the J-CTO score, to determine the approach and the likelihood of success.
