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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

View larger version (34K): [in a new window]   Figure 1 Factors contributing to left ventricular remodeling, progression of left ventricular systolic dysfunction, and heart failure.

View larger version (16K): [in a new window]   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).

View larger version (22K): [in a new window]   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).

View larger version (13K): [in a new window]   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).

View larger version (18K): [in a new window]   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).

View larger version (42K): [in a new window]   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.