Revascularization in Severe Left Ventricular Dysfunction
The Role of Viability Testing
Panithaya Chareonthaitawee, MD, FACC*,*,
Bernard J. Gersh, MB, ChB, DPhil, FACC*,
Philip A. Araoz, MD and
Raymond J. Gibbons, MD, FACC*
* Division of Cardiovascular Diseases
Department of Radiology, Mayo Clinic, Rochester, Minnesota
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Figure 1 Factors contributing to left ventricular remodeling, progression of left ventricular systolic dysfunction, and heart failure.
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Figure 2 Relative risk of mortality for coronary artery bypass grafting compared with medical therapy in moderate-to-severe left ventricular systolic dysfunction, ranked in order of study quality. Studies were observational, most patients had limiting angina, and preoperative viability testing was not routinely performed. Modified from Baker et al. (14).
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Figure 3 Weighted sensitivities and specificities (mean ± 95% confidence interval) for the most widely used noninvasive viability techniques. Regional functional recovery after revascularization was the gold standard for viability. Open bars = sensitivity; solid bars = specificity. DE = dobutamine echo; FDG = F-18 fluorodeoxyglucose; MIBI = technetium-99m sestamibi; Tl-RI = thallium-201 reinjection; Tl-RR = thallium-201 rest-redistribution. Reprinted, with permission, from Bax et al. (24).
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Figure 4 With viability, mortality decreased 79.6% with revascularization versus medical therapy (p < 0.0001). Without viability, no significant difference in mortality was observed between treatment groups. Open bars = revascularization; solid bars = medical therapy. Modified from Allman et al. (33).
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Figure 5 Overall interaction odds ratio was 2.76 (treatment allocation is 2.76x as likely to affect the odds of dying in patients with viable myocardium). Modified from Bourque et al. (34).
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Figure 6 Proposed clinical algorithm. CRT = cardiac resynchronization therapy; ICD = implantable cardioverter-defibrillator; MRI = magnetic resonance imaging; PET = positron emission tomography; SPECT = single-photon emission computed tomography.
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