Cardiology - Reviews
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From basic to advanced cardiac imaging to identify the benefits of revascularization in ischemic heart disease
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 11 March 2026
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Myocardial viability imaging plays a pivotal role in evaluating patients with ischemic cardiomyopathy who may benefit from revascularization. Despite recent trials questioning its prognostic value, imaging continues to shape therapeutic decisions. This comprehensive review explores the underlying pathophysiological basis, diagnostic modalities, and clinical evidence on myocardial viability. We compare contemporary imaging tools and outline a practical framework for individualized patient assessment. Advanced modalities such as cardiac magnetic resonance, positron emission tomography, and dobutamine stress echocardiography provide robust insights into myocardial viability. Findings from key clinical trials, including STICH and REVIVED-BCIS2, reveal the nuanced role of viability in guiding revascularization strategies. We propose that myocardial viability testing remains a valuable adjunct in selected clinical scenarios, emphasizing integration with ischemia assessment, anatomical context, and symptom burden.
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Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics-2022 update: a report from the American Heart Association. Circulation 2022;145:e153-639.
Anderson KR, Sutton MG, Lie JT. Histopathological types of cardiac fibrosis in myocardial disease. J Pathol 1979;128:79-85.
Beltrami CA, Finato N, Rocco M, et al. Structural basis of end-stage failure in ischemic cardiomyopathy. Circulation 1994;89:151-63.
Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Coronary revascularization myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002;39:1151-8.
Cleland JGF, Pennell DJ, Ray SG, et al. Myocardial viability as a determinant of the ejection fraction response to carvedilol in patients with heart failure (CHRISTMAS trial): randomised controlled trial. Lancet 2003;362:14-21.
Bello D, Shah DJ, Farah GM, et al. Gadolinium cardiovascular magnetic resonance predicts reversible myocardial dysfunction and remodeling in patients with heart failure undergoing beta-blocker therapy. Circulation 2003;108:1945-53.
Seghatol FF, Shah Dj, Diluzio S, et al. Relation between contractile reserve and improvement in left ventricular function with beta-blocker therapy in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 2004;93:893-6.
Velazquez EJ, Lee KL, Jones RH, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016;374:1511-20.
Di Carli MF, Asgarzadie F, Schelbert HR, et al. Quantitative relation between myocardial viability and improvement in heart failure symptoms after revascularization in patients with ischemic cardiomyopathy. Circulation 1995;92:3436-44.
Eitzman D, Al-Aouar Z, Kanter HL, et al. Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography. J Am Coll Cardiol 1992;20:559-65.
Arjomandi Rad A, Tserioti E, Magouliotis DE, et al. Assessment of myocardial viability in ischemic cardiomyopathy with reduced left ventricular function undergoing coronary artery bypass grafting. Clin Cardiol 2024;47:e24307.
Perera D, Clayton T, O'Kane P, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022;387:1351-60.
Velazquez EJ, Lee KL, Deja, MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011;364:1607-16.
Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;343:1445-53.
Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013;62:1421-31.
Head SJ, Milojevic M, Daemen J, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018;391:939-50.
Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/ EACTS guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165.
Almeida AG, Carpenter JP, Cameli M, et al. Multimodality imaging of myocardial viability: an expert consensus document from the European Association of Cardiovascular Imaging (EACVI). Eur Heart J 2021;22:e97-125.
Ryan M, Morgan H, Chiribiri A, et al. Myocardial viability testing: all STICHed up, or about to be REVIVED? Eur Heart J 2022;43:118-26.
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-726.
Bax JJ, Poldermans D, Elhendy A, et al. Myocardial viability assessment and revascularization. Heart. 2000;84:ii20-6.
Karamitsos TD, Dastidar AG, Dweck MR, et al. Role of CMR in ischemic heart disease: perfusion, viability and function. Eur Heart J Cardiovasc Imaging 2020;21:132-44.
Voigt JU, Cvijic M, Cvijic M, Prasad A, et al. Definitions for the assessment of myocardial viability by multimodality imaging. Eur Heart J Cardiovasc Imaging 2017;18:1349-58.
Miller RJH, Bonow RO, Gransar H, et al. Percutaneous or surgical revascularization is associated with survival benefit in stable coronary artery disease. Eur Heart J Cardiovasc Imaging 2020;21:961-70.
Ling LF, Marwick TH, Flores DR, et al Identification of therapeutic benefit from revascularization in patients with left ventricular systolic dysfunction: inducible ischemia versus hibernating myocardium. Circ Cardiovasc Imaging 2013;6:363-72.
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79:e21-129.
Gerber BL, Garot J, Bluemke DA, et al. Accuracy of contrast-enhanced magnetic resonance imaging in predicting improvement of regional myocardial function in patients after acute myocardial infarction. Circulation 2002;106:1083-9.
Jeon HK, Shah GA, Diwan A, et al. Lack of pathologic Q waves: a specific marker of viability in myocardial hibernation. Clinical Cardiology 2008;31:372.
Garcia MJ, Kwong RY, Scherrer-Crosbie M, et al. State of the art: imaging for myocardial viability: a scientific statement from the American Heart Association. Circ Cardiovasc Imaging 2020;13:e000053.
Bax JJ, Poldermans D, Elhendy A, et al. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol 2001;26:141-86.
Schinkel AFL, Bax JJ, Poldermans D. Clinical assessment of myocardial hibernation. Heart 2005;91:111-7.
Afridi I, Qureshi U, Kopelen HA, et al. Serial changes in response of hibernating myocardium to inotropic stimulation after revascularization: a dobutamine echocardiographic study. J Am Coll Cardiol 1997;30:1233-40.
Roes SD, Mollema SA, Lamb HJ, et al. Validation of echocardiographic two-dimensional speckle tracking longitudinal strain imaging for viability assessment in patients with chronic ischemic left ventricular dysfunction and comparison with contrast-enhanced magnetic resonance imaging. Am J Cardiol 2009;104:312-7.
Wellnhofer E, Olariu A, Klein C, et al. Magnetic resonance low-dose dobutamine test is superior to scar quantification for the prediction of functional recovery. Circulation 2004;109:2172-4.
Glaveckaite S, Valeviciene N, Palionis D, et al. Value of scar imaging and inotropic reserve combination for the prediction of segmental and global left ventricular functional recovery after revascularization. J Cardiovasc Magn Reson 2011;13:35.
Romero J, Xue X, Gonzalez W, Garcia MJ. CMR imaging assessing viability in patients with chronic ventricular dysfunction due to coronary artery disease: a meta-analysis of prospective trials. JACC Cardiovasc Imaging 2012;5:494-508.
Di Carli MF, Davidson M, Little R, et al. Value of metabolic imaging with positron emission tomography for evaluating prognosis in patients with coronary artery disease and left ventricular dysfunction. Am J Cardiol 1994;73:527-33.
Beanlands R, Nichol G, Ruddy TD, et al. F-18-fluorodeoxyglucose positron emission tomography imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary disease: a randomized, controlled trial (PARR-2). J Am Coll Cardiol 2007;50:2002-12.
Ethics Approval
This article was conducted in accordance with institutional and international ethical standards. Approval was obtained from the Institutional Review Board of King Fahad Medical City (#25-285).How to Cite
“From Basic to Advanced Cardiac Imaging to Identify the Benefits of Revascularization in Ischemic Heart Disease”. 2026. Monaldi Archives for Chest Disease, March. https://doi.org/10.4081/monaldi.2026.3557.
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