Background: Acute in-stent thrombosis of the proximal left anterior descending (LAD) artery, complicated by ventricular tachycardia (VT) storm and multi-organ failure, represents the apex of cardiological catastrophes. While survival is the primary clinical metric, the potential for achieving supra-normal physiological recovery in such high-risk HFrEF phenotypes remains largely unexplored in contemporary literature.

Aim: To detail the multidisciplinary "Rescue-to-Recovery" trajectory of a 60-year-old ultra-endurance athlete who transitioned from hemodynamic collapse to elite-level functional capacity (110% of age-predicted (VO2 peak).

Methods: Following a primary PCI for AWMI (LVEF 30%), the patient suffered acute in-stent thrombosis, VT storm (>70 ICD shocks), and ischemic hepatitis. After IVUS-guided bailout re-stenting and AICD implantation, a structured, four-phase, CPET-capped rehabilitation program was initiated. This protocol involved 300 minutes/week of high-volume, low-intensity aerobic training integrated with quadruple GDMT (ARNI, Beta-blocker, MRA, SGLT2i), monitored via serial 3D echocardiography and cardiopulmonary exercise testing (CPET) over 19 months.

Results: Intervention achieved complete neurological and organ recovery. Serial metrics demonstrated profound reverse remodeling: LVEF improved from 32% to 42%, stroke volume rose by 25%, and NT-proBNP plummeted by 71%. Most significantly, peak VO2 improved by 78% (from 21.0 to 37.5 mL/kg/min), with the VE/VCO₂ slope normalizing to 24.1. Twelve months post-re-PCI, the patient completed an Ironman 70.3 triathlon with zero sustained arrhythmias or adverse events.

Anand B Patil is an Fellow in Clinical cardiology (TAU), Cardiac Rehabilitation Expert, Medicover Hospitals, Navi Mumbai India.