Contemporary Use of Myocardial Viability Assessment
- Authors:
- Panza JA, Chrzanowski L, Bonow RO.
- Citation:
- Myocardial Viability Assessment Before Surgical Revascularization in Ischemic Cardiomyopathy: JACC Review Topic of the Week. J Am Coll Cardiol 2021;78:1068-1077.
The following are key points to remember from this review of myocardial viability assessment before surgical revascularization in ischemic cardiomyopathy:
- Ischemic cardiomyopathy results from the combination of scar with fibrosis replacement and areas of dysfunctional but viable myocardium that may improve contractile function with revascularization.
- Observational studies reported that only patients with substantial amounts of myocardial viability had better outcomes following surgical revascularization.
- Accordingly, dedicated noninvasive techniques have evolved to quantify viable myocardium with the objective of selecting patients for this form of therapeutic intervention.
- However, prospective trials have not confirmed the interaction between myocardial viability and the treatment effect of revascularization.
- The viability hypothesis (i.e., that dysfunctional myocardium with viability shown by noninvasive methods improves contraction after revascularization) is still valid at the cellular, segmental, and patient levels and patients with substantial amounts of viable myocardium benefit from revascularization.
- Noncontractile ischemic myocardium may recover function after revascularization, but recovery of ventricular function is not the main mechanism by which surgical revascularization improves prognosis.
- The main goal of surgical revascularization is to prevent further damage by protecting the residual viable myocardium from subsequent acute coronary events.
- Viability testing can facilitate an assessment of the likelihood of successful revascularization of viable myocardial segments. The difficult question is whether surgical revascularization should be recommended to patients who do not demonstrate a certain amount of viable myocardium on noninvasive testing.
- Although patients with viable myocardium on noninvasive testing are prime candidates for coronary artery bypass grafting, those “without viability” require a more thoughtful and individualized approach with regard to the constellation of factors such as caliber of distal vessels, advanced age, severity of mitral regurgitation, renal dysfunction, and overall frailty are important determinants in the final decision regarding surgical revascularization that influence the decision-making process.
- Finally, all patients with ischemic cardiomyopathy, with or without revascularization, benefit from guideline-directed medical therapy for left ventricular systolic dysfunction.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Cardiomyopathies, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diagnostic Imaging, Fibrosis, Frailty, Geriatrics, Heart Failure, Kidney Diseases, Mitral Valve Insufficiency, Myocardial Ischemia, Myocardial Revascularization, Myocardium, Secondary Prevention, Ventricular Dysfunction, Left, Ventricular Function
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