Revascularization of patients with chronic total occlusion and left ventricular systolic dysfunction.

Heart failure (HF) due to left ventricular systolic dysfunction (LVSD) remains a major clinical challenge, particularly among patients with chronic total occlusions (CTO). CTO are present in up to 30% of patients with LVSD undergoing coronary angiography and are independently associated with worse outcomes. Although advances in interventional techniques have increased success rates of CTO percutaneous coronary intervention (CTO-PCI), high-quality evidence supporting this procedure in patients with LVSD remains limited. Observational studies report potential benefits, including improved survival, alleviation of HF symptoms, and recovery of left ventricular ejection fraction (LVEF). However, randomized controlled trials (RCTs) have largely excluded patients with LVEF <35% and those with advanced, complex coronary artery disease (CAD), including CTO, thereby restricting generalizability. Assessment of myocardial viability remains central to patient select for CTO-PCI, its prognostic value for hard clinical endpoints has not been definitively established. The use of mechanical circulatory support (MCS) during high-risk CTO-PCI is increasing, particularly in patients with reduced LVEF and complex coronary anatomy; available data provides inconsistent evidence regarding its impact on clinical outcomes and appears to be largely influenced by individual patient characteristics. Finally, in the setting of acute coronary syndromes (ACS), the effect of CTO revascularization on clinical endpoints and arrhythmic risk is unclear, with conflicting observational data. Future research should prioritize this underrepresented high-risk cohort and be conducted in experienced centers within an integrated multidisciplinary care framework.