1) The document describes three case studies of patients with low left ventricular ejection fractions (LVEF ≤ 30%) undergoing percutaneous coronary intervention (PCI) to treat chronic total occlusions (CTOs). 2) Support devices like intra-aortic balloon pumps (IABPs) and temporary pacing were used preemptively to prevent hemodynamic collapse during complex CTO PCI procedures. 3) Retrograde approaches were often required when antegrade wiring failed, and short guiding catheters were used to deliver retrograde wires into the target vessel.

1. CTO in Multivessel and Low LVEF Patients
Masahiko Ochiai MD, FACC, FESC, FSCAI
Division of Cardiology and Cardiac Catheterization Laboratories
Showa University Northern Yokohama Hospital, Kanagawa, JAPAN
Sep 18 (Fri), 2015
Istanbul

2. Case 1

3. CHF / VT (post ICD), 71 years, male: Proximal RCA CTO
6Fr JL4.0
(diagnostic)
6Fr JR4.0
(diagnostic)

4. CHF / VT (post ICD), 71 years, male: Proximal RCA CTO
8Fr Brite-tip
AL1.0-SH
7Fr Brite-tip
XB4.0-SH

5. CHF / VT (post ICD), 71 years, male: Proximal RCA CTO
6Fr JL4.0
(diagnostic)
6Fr JR4.0
(diagnostic)
Low LVEF (~20%) and marked LV dilatation
Patient height: 185cm
?

6. Retrograde Approach via the 3rd Septal

7. Retrograde Corsair could not be Advanced Anymore

8. Tip Injection into the 1st Septal

9. Fielder XT-R could be Advanced into R-PDA

10. Retrograde Ultimate 3.0 could not be Advanced Anymore

11. What we should do?

12. Retrograde Knuckled Fielder XT

13. Retrograde Corsair could not be Advanced Anymore

14. Retrograde Corsair could not be Advanced Anymore
The patient began to complain of SOB and BP went down to 70-80mmHg.
He could not tolerate complex retrograde PCI due to low LVEF.
What we should do?

15. Antegrade Conquest Pro with Corsair
was Advanced into the CTO Body

16. Retrograde Corsair was Replaced by 148cm OTW Ryujin
2.5-20mm with 300cm Fiedler XT and Trapping Balloon
300cm Fielder XT
148cm OTW Ryujin
2.5-20mm
148cm OTW Ryujin
2.5-20mm @ 14atm

17. Successful CART with Sion

18. Successful CART with Sion

19. Antegrade Dilatation after Removal of Retrograde System

20. Final Results after Implantation of 3 Nobori Stents

21.  According to my personal experiences, we should pay attention
to LVEF, if it is  30%.
 These patients need hemodynamic support if something is put
into donor artery of the collateral (i.e. “retrograde approach”)
 They are unable to tolerate complications as well. For example,
minor pericardial leakage due to coronary perforation may
result in cardiogenic shock.
CTO in Multivessel and Low LVEF Patients

22.  All non-CTO lesions need to be treated beforehand.
 Do not hesitate to use support devices (IABP and/or temporary
pacing) in advance.
Rt femoral: a guiding catheter for RCA
Lt femoral: IABP and pacing
Rt radial: a guiding catheter for LCA
 If LVDd is  70mm by UCG, consider a retrograde short
guiding catheter to bring a retrograde 150cm Corsair into an
antegrade guiding catheter even through septal connections.
When CTO is located in RCA, rt. brachial approach is
preferred for a retrograde short guiding catheter into LCA.
How to Prevent Hemodynamic Collapse
during CTO PCI?

23. Case 2

24. AMI (A-S) with Cardiogenic Shock, 61 years, male
5Fr diagnostic
JL3.5

25. AMI (A-S) with Cardiogenic Shock, 61 years, male
5Fr diagnostic
JL3.5

26. AMI (A-S) with Cardiogenic Shock, 61 years, male
5Fr diagnostic
JL3.5

27. AMI (A-S) with Cardiogenic Shock, 61 years, male
5Fr diagnostic
IM

28. AMI (A-S) with Cardiogenic Shock, 61 years, male
LVEF 29.5%

29. Immediately after Successful Primary PCI
6Fr Heart-rail 2
IL3.5

30. Immediately after Successful Primary PCI
6Fr Heart-rail 2
IL3.5

31.  The patient required mechanical ventilation due to CHF.
 IABP was unable to be pulled out despite optimal medical
therapy.
 Revascularization of LCx and RCA was required.
 UCG findings: Akinesis of anterior-wall. LVDd 60mm,
LVDs 50,mm
Clinical Course after Successful Primary PCI

32. RMI (A-S), 61 years, male
IABP
(lt. femoral)

33. RMI (A-S), 61 years, male
5Fr diagnostic
JR4.0
(rt. femoral)
5Fr diagnostic
JL3.5
(rt. radial)
IABP
(lt. femoral)

34. RMI (A-S), 61 years, male
5Fr diagnostic
JR4.0
(rt. femoral)
5Fr diagnostic
JL3.5
(rt. radial)
IABP
(lt. femoral)

35. RMI (A-S), 61 years, male
5Fr diagnostic
JR4.0
(rt. femoral)
5Fr diagnostic
JL3.5
(rt. radial)
IABP
(lt. femoral)

36. RMI (A-S), 61 years, male
5Fr diagnostic
JR4.0
(rt. femoral)
5Fr diagnostic
JL3.5
(rt. radial)
IABP
(lt. femoral)

37. Complete revascularization was required.
1) Antegrade PCI for LCx sub-total lesion.
2) Bilateral PCI for RCA CTO.

38. Gaia 1st with Corsair
7Fr Hyperion
SPB4.0-SH
(rt. radial)
IABP
(lt. femoral)

39. Immediately after Wire Exchange into Sion Blue
7Fr Hyperion
SPB4.0-SH
(rt. radial)
IABP
(lt. femoral)

40. Immediately after Implantation of Promus Premier stent
7Fr Hyperion
SPB4.0-SH
(rt. radial)
IABP
(lt. femoral)

41. Antegrade Wiring with Gaia 2nd and Crusade
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)

42. Antegrade Wiring with Gaia 2nd and Crusade
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
IABP
(lt. femoral)

43. Crossover into Retrograde Approach
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
Tazuna 1.5mm
@14atm
IABP
(lt. femoral)

44. Septal Channel Tracking with XT-R (1mm / 90º)
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
IABP
(lt. femoral)

45. Reverse CART with Retrograde Gaia 2nd
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
Emerge 2.5mm
@ 14atm
Gaia 2nd
→
→
←
IABP
(lt. femoral)

46. Final Results after Implantation of 4 Promus Premier stents
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
IABP
(lt. femoral)

47. Final Results after Implantation of 4 Promus Premier stents
7Fr Hyperion
SPB4.0-SH
(rt. radial)
7Fr Mach1
IM-SH
(rt. femoral)
IABP
(lt. femoral)

48. Case 3

49. DCM / CHF, 59 years, male
5Fr diagnostic
JL3.5

50. DCM / CHF, 59 years, male
5Fr diagnostic
JL3.5

51. DCM / CHF, 59 years, male
5Fr diagnostic
JL3.5

52. DCM / CHF, 59 years, male
5Fr diagnostic
JL3.5

53. DCM / CHF, 59 years, male
5Fr diagnostic
IM

54. DCM / CHF, 59 years, male
June 2001
5Fr diagnostic
JR4.0

55. DCM / CHF, 59 years, male
LVEF 28.2%

56.  CHF was controlled by optimal medical therapy.
 CRTD was implanted.

201 Tl Scan suggested reversible inferior ischemia.
 UCG findings: Diffuse severe hypokinesis of LV.
LVDd 73mm, LVDs 61,mm
Clinical Course after Diagnostic CAG

57. DCM / CHF, 59 years, male
IABP
(lt. femoral)

58. DCM / CHF, 59 years, male
7Fr diagnostic
JL3.5
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

59. DCM / CHF, 59 years, male
7Fr diagnostic
JL3.5
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

60. Unsuccessful Antegrade Wiring with Gaia 1st, 2nd and 3rd
7Fr diagnostic
JL3.5
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

61. I should cross over into retrograde approach.
A retrograde “short” guiding catheter was mandatory
to deliver a retrograde Corsair
into an antegrade guiding catheter

62. Crossover into Retrograde Approach
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

63. Repeated Tip Injection from Corsair
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

64. Successful Septal Channel Tracking with Sion (1mm / 90º)
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

65. Repeated Tip Injection from Corsair at the Distal RCA
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

66. Reverse CART with Retrograde Gaia 2nd
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)
Emerge 2.0mm
@ 14atm
Gaia 2nd
↓

67. Retrograde Sion Reached Ascending Aorta
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

68. Retrograde Wire Externalization with RG3
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

69. Final Results after Implantation of 3 Promus Element stents
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

70. Final Results after Implantation of 3 Promus Element stents
7Fr Mach1
“hand cut”
CLS4.0-SH
(rt. brachial)
7Fr Hyperion
SAL1.5-SH
(rt. femoral)
IABP
(lt. femoral)

71.  All non-CTO lesions need to be treated beforehand.
 Do not hesitate to use support devices (IABP and/or temporary
pacing) in advance.
Rt femoral: a guiding catheter for RCA
Lt femoral: IABP and pacing
Rt radial: a guiding catheter for LCA
 If LVDd is  70mm, consider a retrograde short guiding
catheter to bring a retrograde 150cm Corsair into an antegrade
guiding catheter even through septal connections. When CTO
is located in RCA, rt. brachial approach is preferred for a
retrograde short guiding catheter into LCA.
Tips and Tricks of CTO PCI
in Patients with Low LVEF ( 30%)