Cardiac magnetic resonance imaging to guide complex revascularization in stable coronary artery disease

Coronary revascularization has been a cornerstone of the management of patients with coronary artery disease (CAD) for many years. Both coronary artery bypass grafting and percutaneous coronary intervention have evolved and improved over time such that increasingly complex and challenging cases can now be tackled with a high degree of procedural success. In parallel with this, there have been major advances in medical therapy for CAD. Consequently, one of the main decisions in the contemporary management of stable CAD concerns which patients and lesions should be revascularized. This is particularly true for patients with complex disease such as multivessel disease or those with left ventricular impairment. Such patients will potentially benefit the most but are also at highest risk of complications and it is therefore important that they are carefully selected. Recent major trials have challenged the conventional view that consideration of coronary anatomy alone is sufficient in this decision-making. An accumulating body of evidence underscores the importance of functional investigations when assessing the potential benefits of revascularization in these complex patients. In parallel with these developments, cardiac magnetic resonance (CMR) has matured into a robust technology that is able to measure many of the parameters required to accurately characterize these patients. This article will review the importance of myocardial viability and ischaemia when selecting patients with stable CAD for revascularization, the use of CMR imaging for assessing this pathophysiology, and planning complex revascularization, and finally give an outlook on how CMR may help address some important outstanding clinical questions.