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Previous studies have demonstrated improvement of regional wall motion and global left ventricular function after successful recanalization of chronic total occlusion in coronary artery. However, the difference of benefits of recanalization between infarct site and noninfarct site is unknown. This study assessed the changes in left ventricular ejection fraction, regional wall motion after successful angioplasty of chronic total occlusions with or without previous myocardial infarction. This study also evaluated the factors that influenced the outcome of left ventricular function. We retrospectively studied 75 patients with a successfully recanalized chronic total occlusion in native coronary artery. Left ventriculograms were obtained at baseline and after 6 months. Global and regional left ventricular function were determined. The patients were divided into two groups. Group 1 comprised patients without previous myocardial infarction in the territories of total occlusion vessel that was recanalized. Group 2 comprised patients with previous myocardial infarction in the territories of total occlusion vessel that was recanalized. Left ventricular ejection fraction increased from 53.2% +/- 16.3% at baseline to 57.3% +/- 20.1% at 6-month follow-up in the whole group (P = 0.001). In group 1 patients, the evolution of left ventricular (LV) ejection fraction increased from 59.5% +/- 13.7% to 67.3% +/- 14.6% (P < 0.001). In group 2 patients, the evolution of LV ejection fraction increased, but not significantly, from 48.9% +/- 16.2% to 50.5% +/- 16.9% (P = NS). The evolution of LV ejection fraction increased from 47.6% +/- 17.4% to 50.8% +/- 17.5% (P < 0.05) in the subgroup of recanalization in infarct-related vessel that had rich collateral circulation and had long-term patency. The regional wall motion all significantly improved in group 1 patients (P < 0.05). The regional wall motion did not change in group 2 patients (P = NS). The influence of recanalization of chronic coronary occlusions on the improvement of left ventricular global function was different between myocardial infarction and nonmyocardial infarction patients. The left ventricular function did not improve in myocardial infarction patient. Regional wall motion improved in patients without previous myocardial infarction. For reliable improvement of left ventricular function after recanalization of chronic total occlusions, evidence (not only by symptom or treadmill test) of viable myocardium in recanalized vessel is important. It is also important to keep patency of infarct-related vessel that has good collateral circulation for improving the left ventricular function.

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rossing the lesion, initial dilatation by balloons and final stent expansion can present a challenge to the operator's skill and experience with heavily calcified lesions (HCL), because of the highly angulated lumen of these lesions and their resistance to expansion. 1,2 If balloons cannot cross or be expanded and the poorly steerable, thin, uncoated Rotablator ® wire (Boston Scientific, Natick, MA, USA) can be advanced, rotational atherectomy can result in favorable lesion modification that facilitates lesion dilatation and stent expansion. 3,4 Other methods of lesion preparation (eg, cutting balloon, high pressure pre-and post-dilatation) have been advocated for obtaining optimal stent expansion and apposition. Based on the examination of 3 representative cases with optical coherence tomography (OCT), we explain why optimal strut apposition remains an elusive target in the presence of heavy eccentric calcified plaques. Case Reports Case 1A 66-year-old male admitted with typical angina pectoris on a background of hypertension, hyperlipidemia and previous myocardial infarction underwent coronary angiography, which demonstrated long segments of heavily calcified severe stenoses in the mid left circumflex artery (Fig 1). The Circulation Journal Vol.72, January 2008lesions were sequentially dilated with 1.5 and 2.0 mm noncompliant balloons up to 16 atm. Three sirolimus-eluting stents (SES, Cypher Select™, Cordis, Johnson and Johnson Co, Miami Lake, FL, US), 2.5×18, 3.0×13 and 3.0×23 mm, were implanted in an overlapping fashion and post-dilated with a non-compliant 3.0 mm balloon to 22 atm. Although the angiogram showed optimal lesion dilatation with only minimal lumen haziness (Fig 1C), OCT (LightLab Imaging Inc, Westford, MA, USA) revealed suboptimal stent expansion and poor stent strut apposition. 5 Despite multiple high-pressure dilatations, optimal circumferential expansion could not be achieved (Fig 2A). The irregular contours of the stent struts maintained a circular geometry and were unable to fully conform to the slit-like lumen induced by the severe calcification. Although circumferential expansion showed greater minimal lumen diameter compared with elliptic expansion (3.17×2.86 mm vs 3.33×1.97 mm), some struts still remained malapposed to the intima at the intimal tear between the superficial eccentric calcification and non-calcified intima (Fig 2). Although the stent expansion was acceptable, matching the distal reference lumen area, the irregularity of the lumen contours because of protruding eccentric calcification precluded strut apposition. We administered IIb/IIIa inhibitors and recommended long-term dual anti-platelet treatment. Follow-up at 4 months was uneventful. Case 2A 71-year-old male admitted with angina pectoris on a background of hypertension, hyperlipidemia and previous myocardial infarction underwent coronary angiography, which demonstrated HCL in the mid right coronary artery. As no balloon could cross the stenosis, a Rotablator wire was inserted and a 1.5-mm burr was used, followed by ...