What is the clinical evidence from this study?

Study design: Case Report. Population: Ischemic heart failure with reduced ejection fraction (HFrEF) and chronic total occlusions (CTO). Intervention: CTO percutaneous coronary intervention (PCI). Primary outcome: NYHA functional class, NT-proBNP levels, and quality of life (MLHFQ).

June 3, 2026Open Access

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

Q: What does this research mean for the field?

In selected high-risk patients with ischemic HFrEF, imaging-guided percutaneous coronary intervention for chronic total occlusions yields significant clinical, biomarker, and quality-of-life improvements even without substantial ejection fraction recovery. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Key Result

CTO-PCI in selected high-risk patients with ischemic HFrEF improved NYHA class, NT-proBNP, and quality of life at 6 and 12 months, despite modest ejection fraction improvement.

Key Points

To assess the efficacy of CTO revascularization in patients with ischemic heart failure and reduced ejection fraction.
Illustrative case series of patients with ischemic HFrEF undergoing CTO percutaneous coronary intervention (PCI)
Imaging-guided myocardial viability assessment using SPECT was performed prior to intervention
Antegrade and retrograde techniques were utilized during the PCI procedures.
At 6- and 12-month follow-ups, all patients showed marked improvement in NYHA functional class.
Significant reductions in NT-proBNP levels and enhanced quality of life scores on the MLHFQ were observed.
Modest improvements in left ventricular ejection fraction were reported, with limited reverse remodeling.

Study Design

Type

Case Report

Structured PICO

Does CTO-PCI improve clinical symptoms, biomarkers, and quality of life in patients with ischemic HFrEF and viable myocardium?

Population

Patients with ischemic HFrEF who underwent imaging-guided CTO-PCI following myocardial viability assessment, followed for 6 and 12 months.

Intervention

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using contemporary antegrade and retrograde techniques

Outcome

Improvement in NYHA functional class, NT-proBNP levels, and quality of life assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) at 6- and 12-month follow-upspatient reported

In selected patients with ischemic HFrEF and viable myocardium, CTO-PCI may provide significant clinical, biomarker, and quality of life improvements despite limited LVEF recovery.

Abstract

Background/Objectives: Revascularization of chronic total occlusions (CTO) in patients with heart failure and reduced ejection fraction (HFrEF) remains controversial, as randomized trials have not demonstrated a clear prognostic benefit. Methods: We present an imaging-guided case series of patients with ischemic HFrEF who underwent CTO percutaneous coronary intervention (PCI) following myocardial viability assessment using single-photon emission computed tomography (SPECT). Contemporary antegrade and retrograde techniques were employed. Results: At 6- and 12-month follow-ups, all patients demonstrated marked improvement in NYHA (New York Heart Association) functional class, significant reductions in NT-proBNP (N-terminal pro-brain natriuretic peptide) levels, and substantial improvement in quality of life assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ). These benefits occurred despite only modest improvement in left ventricular (LV) ejection fraction (EF) and limited reverse remodeling. SPECT enabled identification of viable but ischemic myocardium, supporting individualized revascularization decisions. Conclusions: In selected high-risk patients with ischemic HFrEF, CTO-PCI was associated with meaningful clinical and biomarker improvement independent of substantial EF recovery. Careful patient selection, incorporating myocardial viability assessment, may refine individualized clinical decision-making in selected patients. These findings support an imaging-guided approach and warrant further prospective evaluation.