Strategy and Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion With Reduced Ejection Fraction

BACKGROUND: Patients with chronic total occlusion (CTO) and reduced left ventricular ejection fraction (LVEF) are at high-risk, and retrograde CTO percutaneous coronary intervention (PCI) is often avoided because of hemodynamic and safety concerns. OBJECTIVES: This study evaluated CTO-PCI strategy selection and outcomes according to LVEF, focusing on patients selected for a primary retrograde approach. METHODS: We analyzed 11,458 patients from the Japanese CTO-PCI Expert Registry (2014-2022), including 1,692 with LVEF <40% and 9,766 with LVEF ≥40%. Core laboratory-adjudicated angiographic findings, procedural strategies, and in-hospital outcomes were compared. RESULTS: Patients with LVEF <40% had more complex coronary anatomy. A primary retrograde approach was selected in 489 of 1,692 procedures (28.9%) in the LVEF <40% group and 2,500 of 9,766 procedures (25.6%) in the LVEF ≥40% group (OR: 1.18; 95% CI: 1.05-1.33; P = 0.005). Overall technical and procedural success rates were comparable between groups. In the primary retrograde cohort, technical success was achieved in 450 of 489 procedures (92.0%) with LVEF <40% and 2,186 of 2,494 procedures (87.7%) with LVEF ≥40% (OR: 1.63; 95% CI: 1.14-2.37; P = 0.005). In-hospital mortality, stroke, contrast-induced nephropathy, and preprocedural mechanical circulatory support were more frequent in patients with LVEF <40%, whereas other in-hospital adverse events were generally similar. CONCLUSIONS: Reduced LVEF was associated with more frequent selection of a primary retrograde approach. Among selected patients undergoing primary retrograde CTO-PCI, technical success remained high despite greater anatomical complexity.