Viability Assessment in Coronary Artery Disease with Left Ventricular Dysfunction

Introduction to Viability Assessment

The American Heart Association recommends viability assessment when planning revascularization in heart failure patients with coronary artery disease and left ventricular dysfunction, but only if the patient is a revascularization candidate 1, 2, 3, 4

The American College of Cardiology suggests that viability testing should be bypassed entirely in patients who cannot undergo revascularization due to comorbidities, surgical risk, or patient preference, which is a Class IIa recommendation with Level of Evidence C 1
For patients with angina, the American Heart Association recommends proceeding directly to coronary angiography without viability testing, as revascularization is indicated for significant ischemic chest pain regardless of viability status 5
For patients without angina, the American College of Cardiology recommends viability assessment before considering revascularization, specifically in patients presenting with de novo heart failure who have known CAD but no anginal symptoms 1, 2, 3, 4

The STICH trial substudy found that viability assessment did not identify patients with differential survival benefit from CABG compared to medical therapy alone, according to the Journal of the American College of Radiology 6, 7, 8
Observational studies demonstrate that patients with viable myocardium who undergo revascularization show recovery of function and clinical improvement, as reported by the Journal of the American College of Radiology 6, 7, 8

The American College of Cardiology suggests that multiple modalities are reasonable (Class IIa) for viability assessment, including SPECT imaging with thallium-201 or Tc-99m sestamibi 1, 6, 7, 8
PET imaging with FDG is also recommended, as it has higher sensitivity than SPECT for detecting viable myocardium, according to the Journal of the American College of Radiology 6, 7, 8
Cardiac MRI with late gadolinium enhancement is also a suitable option, as it assesses scar burden and viability, as reported by the American College of Cardiology 1, 2, 3, 4

The American Heart Association advises against performing routine viability testing in all heart failure patients with CAD, as it should be selective and only when revascularization is being considered 1, 2, 3, 4
The American College of Cardiology recommends not delaying angiography in patients with angina to perform viability testing first, as patients with angina should proceed directly to catheterization 5

The American College of Cardiology suggests that viability assessment should be performed before making the final decision about revascularization in patients with known CAD, LV dysfunction, and no angina 1, 2, 3, 4
Viability assessment should also be performed after establishing that the patient is medically suitable for revascularization, as reported by the American College of Cardiology 1, 2, 3, 4