52-year-old male with COPD and OSA presented on January 31, 2020 with acute hypercarbic respiratory failure requiring intubation and ruled in with peak Troponin of 12 (Type 2 MI) and acute systolic heart failure NYHA Class IV. Patient was stabilized on medical therapy and extubated. A Cardiac Cath on February 3, 2020 revealed 1 V CAD: flush long total occlusion of ostial LAD with excellent collaterals from RCA and LVEF 48%. Patient was managed medically due to multiple medical and psychiatric issues. Patient has been compliant with GDMT with CCS Class II angina. A followup stress MPI revealed large area of severe anterior wall ischemia with partial scarring. Patient is now planned for PCI of ostial LAD CTO via retrograde approach from RCA collaterals.