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Complex CTO Revascularization in Patients with Ischemic Heart Failure and Reduced Ejection Fraction: An Illustrative

Ioana Paula Blaj-Tunduc1, Mihnea-Traian Nichita-Brendea2, Vlad-Victor Babes2,3

  • 1Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania.

Journal of Clinical Medicine
|June 12, 2026
PubMed

Insights

Percutaneous coronary intervention for chronic total occlusions (CTO-PCI) in heart failure with reduced ejection fraction (HFrEF) patients improved symptoms and quality of life. Imaging-guided selection was key for positive outcomes.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Heart Failure Management

Background:

  • Revascularization of chronic total occlusions (CTO) in patients with heart failure and reduced ejection fraction (HFrEF) lacks clear prognostic benefit from randomized trials.
  • CTO percutaneous coronary intervention (PCI) in ischemic HFrEF is controversial.
  • Myocardial viability assessment is crucial for guiding revascularization decisions.

Purpose of the Study:

  • To evaluate the clinical outcomes of an imaging-guided CTO-PCI strategy in patients with ischemic HFrEF.
  • To assess the impact of CTO-PCI on functional class, biomarkers, and quality of life.
  • To determine if myocardial viability assessment influences revascularization decisions and outcomes.

Main Methods:

  • Case series of patients with ischemic HFrEF undergoing CTO-PCI.
  • Myocardial viability assessment using single-photon emission computed tomography (SPECT).
  • Utilized contemporary antegrade and retrograde CTO-PCI techniques.

Main Results:

  • Patients showed marked improvement in NYHA functional class, reduced NT-proBNP, and improved quality of life (MLHFQ) at 6 and 12 months.
  • Clinical benefits were observed despite modest improvements in left ventricular ejection fraction (LVEF) and limited reverse remodeling.
  • SPECT identified viable myocardium, aiding individualized revascularization decisions.

Conclusions:

  • In selected high-risk ischemic HFrEF patients, CTO-PCI yielded meaningful clinical and biomarker improvements, irrespective of significant LVEF recovery.
  • Myocardial viability assessment via SPECT is vital for patient selection and individualized treatment strategies.
  • An imaging-guided approach to CTO-PCI may optimize outcomes in carefully selected HFrEF patients, warranting further prospective research.

Keywords:
chronic total occlusionheart failurepercutaneous coronary interventionviability

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