Mateusz Tajstraa, Leszek Bryniarskibaa) 3rd Department of Cardiology, Silesian Centre for Heart Diseases,

Medical University of Silesia, Zabrze, Poland

b) 1st Department of Cardiology and Hypertension, Institute of Cardiology, Jagiellonian University, Medical College, Krakow, Poland

END-STAGE HF…UNEQUAL FIGHT?

OHT - best option

VADs implantation - as a bridge to….

• lack of

EXTREMELY poor prognosis (one-year mortality>70%!!)

END-STAGE HF…UNEQUAL FIGHT?

OHT - best option

VADs implantation - as a bridge to….

BUT CLINICAL REALITY…

lack of heart donors

limited access to VADs

contraindications and complications related to VADs/OHT

lack of heart donors

• lack of

EXTREMELY poor prognosis (one-year mortality>70%!!)

MEDICAL HISTORY AND CLINICAL STATUS:

• 67 years old male with DM, PAOD, CKD (3)

• HF since a large anterior MI complicated by CS – PCI of the

LAD (CTO of the RCA was then observed) – 2010

• Admitted with severe progression of HF (NYHA IV) and

recurrent VTs (numerous ICD discharges)

• LVEF 25%, akinesia of the anterior wall and hypokinesia of

the inferior wall. MR++, TR++, preserved RV function

• FA persistent (QRS 110 ms)

• Intensive pharmacologic treatment (sequential loop

diuretics, inotropic agents infusion and haemofiltration)

• Inotropic agents dependence

CORONARY ANGIO:

WHAT TO DO?

• IABP? SEVERE PAOD …

• LVAD?

• OHT?

• OTHER?

IS IT NON-OPTION CASE?

STRONG DATA ABOUT IMPACT OF THE CTO ON LONG-TERM PROGNOSIS IN PATIENTS WITH HF

Tajstra et al. Jacc Interv 2016;12:1790-7.

REAL WORLD…

• OHT? WE HAVE NO TIME

• LVAD? UNAVALAIBLE AT THIS MOMENT

• DISCONTINUATION OF INOTROPES NOT POSSIBLE

REAL WORLD…

• OHT? WE HAVE NO TIME

• LVAD? UNAVALAIBLE AT THIS MOMENT

• DISCONTINUATION OF INOTROPES NOT POSSIBLE

HEART TEAM DECISION: PCI OF THE RCA-CTO

CTO RECANALIZATION PROCEDURE:

CTO RECANALIZATION PROCEDURE:

CTO RECANALIZATION PROCEDURE:

What now??

1. only POBA2. rotational atherectomy3. other

Too far to take back..

What now??

Too far to take back..

We decided: Rotational atherectomyHowever RA is an extremaly riskyprocedure in pts with severeimpairement of LV function

CTO RECANALIZATION PROCEDURE:

CTO RECANALIZATION PROCEDURE:

CTO RECANALIZATION PROCEDURE:

EQUIPMENT:• GUIDING CATHETER: AL2

• MICROCATHETER: FINE CROSS

• WIRES: ULTIMATE BROSS, FIELDER XT

• MULTIPLE BALOON CATHETERS THEREIN NC AND CB

• ROTATIONAL ATHERECTOMY EQUIPMENT

• THREE DESs-EVEROLIMUS

ANGIO EFFECT OPTIMAL

CLINICAL EFFECT?…WE WERE HOPEFUL…

• continuous clinical improvement was observed

• inotrope support was discontinued three days after PCI

patient was discharged home 8 days later (NYHA class II/III)

• At 4 week follow EF-LV increased by 4-5%(NYHA class II/III)

In conclusion, this report

• highlights the crucial importance of CTO recanalization in

case of end-stage, inotrope-dependent HF

• reveals CTO recanalization usefulness as a valuable

bridging therapy to transplantation

• RA should be always in armamentarium

In conclusion this report

• highlights the crucial importance of CTO recanalization in

case of end-stage, inotrope-dependent HF

• reveals CTO recanalization usefulness as a valuable

bridging therapy to transplantation

A successful recanalisation of a CTO may be a very important

treat-to-target option and seems to be a comprehensive tool in

patients with non-option HF