Viability assessment in an evolving field of heart failure treatment: still needed?

Excerpt

Apart from non-ischemic cardiomyopathy CMP) the prevalence of an ischemic origin of CMP is steadily increasing due to an increasingly elderly population and higher survival rates after of acute coronary syndrome patients [1]. In principle, restoration of coronary blood flow may improve left ventricular function, heart failure symptoms and cardiovascular outcome in those high-risk ischemic CMP patients who have evidence of a sufficient degree of ischemic compromised myocardial viability subtended to the target epicardial lesion. Optimal assessment of myocardial viability, therefore, remains critical for the medical decision-making process in these patients. Factors that may hamper the success of coronary revascularization of “hibernation” myocardium (defined as segmental severe hypokinesis or akinesis, proof of viability ≥ 50% that is ischemic jeopardized) relate to a delay in appropriate restoration of coronary flow, low or no ischemic burden due to presence of collaterals, advanced myocardial remodeling, and/or pronounced left-ventricular dilation [2]. These critical factors may reconcile, at least in part, the absence of revascularization related survival benefit over medical treatment alone in ischemic heart failure patients in the randomized and multicenter STICH (Surgical Treatment for Ischemic Heart Failure) [3] as well as the REVIVED [4] trials that contradicts previous observational studies in a real world or clinical practice scenario [2]. When focusing on the STICH trial, important limitations need to be considered that lessens its applicability in clinical practice: …