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Canadian Journal of Cardiology

A Cardiac Surgeon’s View of Myocardial Viability in the Era of Multimodality Imaging

      The central pathophysiologic tenet in ICM is that left ventricular systolic dysfunction results from a mix of nonviable fibrous scar tissue and either akinetic or hypocontractile myocardium that is still viable at the cellular level. Currently, the rationale for preoperative viability testing rests largely on the concept that revascularisation of dysfunctional yet viable myocardium will improve survival in patients with ICM as a result of contractile recovery with a concomitant increase in overall left ventricular ejection fraction (LVEF). The evidence to support this theory is based largely on observational data. In a meta-analysis of 24 observational studies involving 3088 patients, revascularisation was associated with 79.6% reduction in annual mortality compared with goal-directed medical therapy (GDMT) in patients with ICM and a substantial volume of viable myocardium, during a mean follow-up of just 25 months.
      • Allman K.C.
      • Shaw L.J.
      • Hachamovitch R.
      • Udelson J.E.
      Myocardial viability testing and impact of revascularisation on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis.
      A more recent meta-analysis contradicted these findings.
      • Orlandini A.
      • Castellana N.
      • Pascual A.
      • et al.
      Myocardial viability for decision-making concerning revascularisation in patients with left ventricular dysfunction and coronary artery disease: a meta-analysis of non-randomised and randomised studies.
      It must be highlighted that such observational studies are limited by heterogeneity in inclusion criteria and by the fact that the decision to revascularise was likely influenced by knowledge of the viability test result. Furthermore, most of these studies predated the widespread use of beta-adrenergic blockers and renin-angiotensin modulating therapies.
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