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Update in myocardial viability

Clinical pathways

  • Rational use of imaging for viability evaluation, presented by L A Pierard (Liege, BE)  
  • Reading with the experts - Challenging cases on evaluation of viability    
    • Viability and ischemia: revascularization or medical treatment, presented by  M Dorobantu (Bucharest, RO)  
    • Viability and dyssynchrony: CRT or medical treatment, presented by G Athanassopoulos (Pireas, GR)  
    • Viability and arrhythmias risk: ICD or medical treatment, presented by E Perez-David (Majadahonda-Madrid, ES)  
    • Viability in advanced disease: revascularisation or heart transplant, presented by F Rigo (Mestre-Venice, IT)

The session began with a presentation from Prof Luc Pierard on the rational use of viability evaluation. He gave an excellent overview of pathophysiology and diagnostic methods for the assessment of myocardial viability. He concluded that if images are of good quality (which should be in majority of patients with contrast usage) then dobutaime stress Echo should be used as a first line test. He then discussed observational studies relating to medical vs revascularisation therapy in patients with and without myocardial viability. These studies clearly showed mortality benefit with revascularisation in patients with viability. He then discussed STICH sub-study, the first randomised study looking at revascularisation vs medical therapy only in patients with heart failure and Left Ventricular dysfunction and their interaction with myocardial viability. The study showed that there is no interaction with viability and type of therapy. However, Prof Pierard concluded that the study had several limitations and has not properly addressed the issue. He maintained that today the practice continues to be that the assessment of viable myocardium should be carried out in appropriate clinical conditions to decide on medical therapy only vs revascularisation and medical therapy.

The session moved on with a presentation from Prof Dorobantu who described various clinical scenarios for the assessment of myocardial viability with various diagnostic techniques. She described a case of cardiac rupture following dobutamine test 5 days after acute myocardial infarction (AMI). The occurrence of this complication is very rare and should not deter clinicians from performing this test, of course, at least 4 days after AMI.

Prof Athanassopoulos presented CRT implantation and implication of myocardial viability. He described the importance of both global viability and demonstration of viability at the site of lead implantation for the prediction of functional outcome. However, there is no recommendation by any society regarding viability and the decision to proceed to CRT.

Prof Perez-David’s talk was on the relationship between viability, arrhythmia and role of ICD. In a very elegant study she demonstrated that CMR assessed scar heterogeneity is a predictor of subsequent arrhythmia and these patients may be candidates for ablative therapy and ICD. However, data is very sparse in this field.

Finally an interesting topic on the place of transplant in relation to viability was discussed by Prof Rigo. Again, lack of strong data pertaining to this clinical condition allowed Prof Rigo only to speculate, but the consensus is that in patients with refractory end-stage CAD where revascularisation is not an option, heart transplant in relevant patients should be considered irrespective of myocardial viability. 


It was an excellent session covering various aspects of myocardial viability and treatment options.




Update in myocardial viability

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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