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Myocardial viability testing: all STICHed up, or about to be REVIVED?
Matthew Ryan1, Holly Morgan1, Amedeo Chiribiri2
1School of Cardiovascular Medicine and Sciences, King's College London, Westminster Bridge Road, London SE1 7EH, UK.
Insights
Myocardial viability testing may not accurately predict revascularization benefits in ischaemic left ventricular dysfunction. New interpretation paradigms are needed, as current evidence challenges traditional hibernation theories and their impact on treatment decisions.
Area of Science:
- Cardiology
- Cardiac Imaging
- Clinical Trials
Background:
- Ischaemic left ventricular dysfunction management often involves myocardial viability testing.
- Traditional models link extensive viable myocardium to revascularization benefits, based on hibernation theory and low-quality data.
- This approach may lead to inappropriate denial of potentially beneficial treatments.
Purpose of the Study:
- Critically review the evidence base for myocardial viability testing.
- Examine the traditional model's assumptions regarding viability, functional recovery, revascularization, and prognosis.
- Explore new paradigms for interpreting viability and its broader clinical applications.
Main Methods:
- Systematic review of existing literature on myocardial viability testing.
- Analysis of data from a sub-study of the randomized STICH trial.
- Critical evaluation of the theoretical underpinnings of viability testing in ischaemic heart disease.
Main Results:
- Recent STICH trial data indicate that the extent of viable myocardium did not predict coronary artery bypass grafting effectiveness.
- The historical presumption that extensive viability guarantees revascularization benefit is challenged.
- Current evidence quality supporting traditional viability testing concepts is low.
Conclusions:
- The traditional model of myocardial viability testing requires re-evaluation.
- New interpretative paradigms are necessary to guide revascularization decisions in ischaemic left ventricular dysfunction.
- Future randomized trials will be crucial in shaping evidence-based clinical practice for viability assessment.
Abstract:
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the future.
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