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Viability testing for guiding revascularization in ischemic cardiomyopathy
Kevin Y Li1, Nitish K Dhingra1, Raumil Patel2
1Division of Cardiovascular Surgery.
Insights
Myocardial viability testing may not predict outcomes after revascularization. Scar quantification, not viability, appears to be a stronger predictor of adverse events in ischemic cardiomyopathy.
Area of Science:
- Cardiology
- Cardiac Imaging
- Interventional Cardiology
Background:
- Myocardial viability testing traditionally guides revascularization in ischemic cardiomyopathy, assuming viable tissue predicts recovery and survival.
- Recent trials challenge this assumption, necessitating a re-evaluation of viability testing's role with modern therapies.
Purpose of the Study:
- To re-evaluate the clinical utility of myocardial viability testing in ischemic cardiomyopathy.
- To assess the impact of contemporary revascularization strategies and guideline-directed medical therapy on viability testing's role.
Main Methods:
- Review of recent clinical trials (STICH, REVIVED-BCIS2) and imaging substudies.
- Analysis of prognostic predictors, including scar burden versus myocardial viability.
Main Results:
- STICH trial: Coronary Artery Bypass Grafting (CABG) improved survival independently of viability status or ejection fraction improvement.
- REVIVED-BCIS2: Percutaneous Coronary Intervention (PCI) did not improve survival even in patients with demonstrated viability.
- Scar burden, not viability, emerged as the strongest predictor of adverse outcomes.
Conclusions:
- Myocardial viability should be viewed as a continuous spectrum, not a binary state.
- Scar quantification, especially via late gadolinium enhancement cardiac magnetic resonance (CMR), offers greater prognostic value than viability detection alone.
- Further trials are needed to define the role of viability-guided revascularization with modern treatments.
Purpose Of Review:
Myocardial viability testing has traditionally been used to guide revascularization decisions in ischemic cardiomyopathy on the assumption that identifying dysfunctional but viable myocardium predicts functional recovery and improved survival following revascularization. Recent trials have challenged this assumption, highlighting the need to re-evaluate the clinical role of viability testing in the context of contemporary revascularization strategies and modern guideline-directed medical therapy.
Recent Findings:
The STICH trial and its extended follow-up demonstrated that CABG improves long-term survival independently of viability status and independently of whether ejection fraction improves, challenging the mechanistic assumption of viability-guided revascularization. REVIVED-BCIS2 showed that PCI may not improve survival benefit, even in patients selected with demonstrated viability. A prespecified imaging substudy of REVIVED identified scar burden, rather than the presence of viable myocardium, as the strongest independent predictor of adverse outcomes, reframing the prognostic question from the detection of viable tissue toward the quantification of irreversible myocardial loss.
Summary:
Viability should be reconceptualized as a continuous spectrum rather than a binary construct. Scar quantification, particularly through late gadolinium enhancement cardiac magnetic resonance (CMR), may offer greater prognostic utility than viability detection alone. A prospective randomized trial integrating contemporary imaging with modern guideline-directed medical therapy is needed to resolve the clinical role of viability-guided revascularization.
