Percutaneous coronary intervention in chronic total occlusion

Introduction: Using cardiac magnetic resonance ima-ging we can appreciate the myocardial viability by quantification of the transmural ischemic myocardial scar. If there is a large amount of fibrotic tissue there is less chances of recovery after myocardiac revascula-rization. Multiple studies have shown that myocardial revascularization can provide a functional recovery grater than 80% for the regions with less than 25% scar tissue. Instead, the regions with more than 80% ische-mic scar tissue will not gain functional recovery after myocardial revascularization.

Methods: We present the case of a 64-year-old male, a former smoker, known with type 2 diabetes mellitus, hypertension, myocardial infarction with late presen-tation due to atypical symptomatology (interscapular pain for two weeks), with severe left ventricular systo-lic dysfunction (LVEF=20%). Coronary angiography showed chronic proximal occlusion of the left anteri-or descending artery (ADA), ostial stenosis of 60% of the circumflex artery and 80% stenosis in the second segment of the circumflex artery, 90% stenosis in the second segment of the right coronary artery with reca-nalized thrombus. The patient refused the aortocoro-nary bypass, therefore he received coronary angiogra-phy with a drug-eluting stent (DES) insertion on the circumflex artery and right coronary artery. Now, the patient comes to us for the persistence of angina.

Results: Clinical examination was normal, on the elec-trocardiogram we observed the persistence of the ST elevation in anterior leads and pathologic Q wave in inferior leads. Echocardiography displayed a mode-rate left ventricular systolic disfunction (LVEF=35%), the inferior wall was dyskinetic in the basal region and hypokinetic in the mid region, akinesia of the 2/3 apical anterolaterall wall. The coronary angiography revealed a right dominant system, with a good reflow through the collateral vessels from the right coronary artery and permeable stents. We performed a cardiac MRI to establish the opportunity of cardiac revascula-rization of the ADA. This reported an excellent con-tractility in the region suplied by the circumflex artery, subendocardial infarction in right coronary artery re-gion (50-75% transmurality) and the ADA region with two segments with intermediate probability of cardiac contractility recovery post revascularization and three nonviable segments. Therefore, a coronary angioplasty was performed with two DES insertion on ADA, with good outcome. Three months after ADA revasculari-zation, the left ventricular systolic function improved (LVEF=47%).

Conclusions: We present a case, that is particular, through the atypical symptoms represented by inter-scapular pain and through improved myocardial con-tractility after ADA revascularization. The literature data sugest a small percentage of recovery (10%), for segments with 50-75% scar tissue transmurality.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)