What is the best approach for single vessel mid-LAD CTO in patient with preserved EF and no anginal symptoms?

Unless there are symptoms or severe ischemia refractory to optimal medical therapy, a PCI is generally not considered indicated in this setting. The presence of collaterals, additional disease, regional viability and technical complexity would enter into the decision as well.

Lloyd W Klein MD
UCSF

Thank you for this clinically important question. You present a patient who has preserved LVEF and No angina. The primary indication for revascularization of a CTO is for angina relief in patients who have not responded to antianginal therapy, as this has been shown to improve quality of life. The b...

I don't think there is a role for mid-LAD CTO PCI in a patient with preserved LVEF and no angina unless perhaps said patient had refractory ventricular arrhythmias or CHF (HFpEF) despite optimal medical Rx. Medical therapy should suffice for the vast majority of patients in this scenario.

A mid-LAD CTO in the absence of an anginal equivalent, with normal regional wall motion, normal LV function, without an arrhythmic burden, and in the absence of HFpEF, is best treated with optimal medical therapy. Serial follow up for an interval decline in LV EF I may also be reasonable.

Medical therapy. Intervention, if technically feasible, would only be indicated for refractory symptoms despite OMT, LV dysfunction, or ventricular arrhythmias. If the patient is not endorsing symptoms, an exercise stress test should be considered to determine their ischemic threshold. If there is o...

If there is no angina, nor a reduced EF, there is no indication of revascularization either by PCI or with CABG. Would suggest the optimization of GDMT.

Stress echo would be helpful if there is a drop in LV function with exercise revascularization should be performed delaying revascularization will only complicate revascularization and make it less successful. Especially young people and good conditioning may decline symptoms that are angina-equival...

While I completely agree with all comments above, I wonder why this patient had a cath to start with. What was the indication for cath in asymptomatic patient? Patient probably had abnormal stress test or angina/MI or maybe routine cath prior to valvular surgery, etc.