Myocardial viability assessment during Impella support with 18-fluorodesoxyglucose PET imaging.

Formal assessment of myocardial viability (MV) is challenging in acute myocardial infarction-related cardiogenic shock (AMI-CS) patients receiving Impella mechanical circulatory support, as the cardiac magnetic resonance gold standard technique is not feasible due to the metallic components of the device. 18-fluorodesoxyglucose metabolic myocardial positron emission tomography (18FDG-PET) may represent a valid and feasible alternative to obtain semi-quantitative and objective evidence of MV during Impella support. We hereby report the first series of sequential AMI-CS patients who received 18FDG-PET scanning to assess MV during Impella support to demonstrate the safety and feasibility of this approach. In this cohort no adverse events occurred during 18FDG-PET scans, and all images were of excellent quality. This study provides a pragmatic guidance on how to perform this imaging modality during Impella support and finally confirms the safety and feasibility of this advanced imaging method also in this vulnerable cohort of patients.

Prediction of Major Arrhythmic Outcomes in Ischemic Cardiomyopathy: Value of Hibernating Myocardium in PET/CT.

AIMS: Known predictors of major arrhythmic events (MAE) in patients with ischemic cardiomyopathy (ICM) include previous MAE and left ventricular ejection fraction (LVEF) ≤35%. Myocardial scars detected by perfusion imaging in ICM have been linked to MAE, but the prognostic significance of hibernating myocardium (HM) is unclear. The objective was to predict major arrhythmic events (MAE) from combined 13N-ammonia (NH3) and 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in ischemic cardiomyopathy (ICM). METHODS AND RESULTS: Consecutive patients with ICM undergoing combined NH3- and FDG-PET/CT were included. HM was quantified in relation to total left ventricular myocardium (i.e. ≥7% is large). The primary outcome was MAE (sudden cardiac death, ICD therapy, sustained ventricular tachycardia/fibrillation).Among 254 patients, median baseline LVEF was 35% (IQR 28-45) and 10% had an ICD. PET/CT identified ischemia in 94 (37%), scar in 229 (90%) and HM in 195 (77%) patients. Over a median follow-up of 5.4 (IQR 2.2-9.5) years, MAE occurred in 34 patients (13%). Large HM was associated with a lower incidence of MAE (HR 0.31, 95% CI 0.1-0.8, p=0.001). After multivariate adjustment for history of MAE, LVEF ≤35% and scar ≥10%, large HM remained significantly associated with a lower incidence of MAE (p=0.016). LVEF improved over time among patients with large HM (p=0.006) but did not change in those without (p=0.610) or small HM (p=0.240). CONCLUSIONS: HM conveys a lower risk of MAE in patients with ICM. This may be explained by an increase in LVEF when a large extent of HM is present.

Assessment of Myocardial Viability in Ischemic Cardiomyopathy With Reduced Left Ventricular Function Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: We aim to provide a comprehensive review of the current state of knowledge of myocardial viability assessment in patients undergoing coronary artery bypass grafting (CABG), with a focus on the clinical markers of viability for each imaging modality. We also compare mortality between patients with viable myocardium and those without viability who undergo CABG. METHODS: A systematic database search with meta-analysis was conducted of comparative original articles (both observations and randomized controlled studies) of patients undergoing CABG with either viable or nonviable myocardium, in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to 2022. Imaging modalities included were dobutamine stress echocardiography (DSE), cardiac magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). RESULTS: A total of 17 studies incorporating a total of 2317 patients were included. Across all imaging modalities, the relative risk of death post-CABG was reduced in patients with versus without viability (random-effects model: odds ratio: 0.42; 95% confidence interval: 0.29-0.61; p < 0.001). Imaging for myocardial viability has significant clinical implications as it can affect the accuracy of the diagnosis, guide treatment decisions, and predict patient outcomes. Generally, based on local availability and expertise, either SPECT or DSE should be considered as the first step in evaluating viability, while PET or CMR would provide further evaluation of transmurality, perfusion metabolism, and extent of scar tissue. CONCLUSION: The assessment of myocardial viability is an essential component of preoperative evaluation in patients with ischemic heart disease undergoing surgical revascularization. Careful patient selection and individualized assessment of viability remain paramount.

Surgical Management of Ischemic Cardiomyopathy Patients with Severe Left Ventricular Dysfunction: Is It Time to Reconsider Revascularization Surgery?

Ischemic cardiomyopathy patients with severe left ventricular dysfunction are a specific group of patients with poor surgical outcomes. There are few surgical treatment options in practice for the treatment of these patients such as heart transplantation, coronary artery bypass surgery, surgical ventricular restoration, etc. Despite multiple treatment options, there are no explicit clinical guidelines available to guide surgeons in choosing the most appropriate option and ensuring that the specific patient can benefit from the selected surgical treatment. Heart transplantation is the gold standard treatment for ischemic cardiomyopathy patients with severe left ventricular dysfunction, but it is limited to very few highly equipped centers around the world due to donor shortages, complex perioperative and surgical management, and limited technological and human resources. It is evident from some studies that heart transplant-eligible candidates can benefit from alternative surgical options such as coronary artery bypass surgery alone or combined with surgical ventricular restoration. Therefore, alternative surgical options that are used for most of the population, especially in developing and underdeveloped countries, need to be discussed to improve their outcomes. A challenge in the recent era which has yet to find a solution is to determine which heart transplant candidate can benefit from simple revascularization compared to a complex heart transplantation procedure. Myocardial viability testing was one of the most important determinants in deciding whether a patient should undergo revascularization, but its role in guiding appropriate surgical options has been challenged. This review aims to discuss the available surgical management options and their long-term outcomes for patients with ischemic cardiomyopathy, which will eventually help surgeons when choosing a surgical procedure.

Clinical impact of multimodality assessment of myocardial viability.

Coronary artery disease (CAD) is a prevalent cause of left ventricular dysfunction. Nevertheless, effective elective revascularization, particularly surgical revascularization, can enhance long-term outcomes and, in selected cases, global left ventricular contractility. The assessment of myocardial viability and scars is still relevant in guiding treatment decisions and selecting patients who are likely to benefit most from blood flow restoration. Although the most recent randomized studies challenge the notion of "hibernating myocardium" and the clinical usefulness of assessing myocardial viability, the advancement of imaging techniques still renders this assessment valuable in specific situations. According to the guidelines of the European Society of Cardiology, non-invasive stress imaging may be employed to define myocardial ischemia and viability in patients with CAD and heart failure before revascularization. Currently, several non-invasive imaging techniques are available to evaluate the presence and extent of viable myocardium. The selection of the most suitable technique should be based on the patient, clinical context, and resource availability. This narrative review evaluates the characteristics of available imaging modalities for assessing myocardial viability to determine the most appropriate therapeutic strategy.

Myocardial viability on trial.

The concept of myocardial viability is usually referred to areas of the myocardium, which show contractile dysfunction at rest and in which contractility is expected to improve after revascularization. The traditional paradigm states that an improvement in function after revascularization leads to improved health outcomes and that assessment of myocardial viability in patients with ischaemic left ventricular dysfunction (ILVD) is a prerequisite for clinical decisions regarding treatment. A range of retrospective observational studies supported this 'viability hypothesis'. However, data from prospective trials have diverged from earlier retrospective studies and challenge this hypothesis. Traditional binary viability assessment may oversimplify ILVD's complexity and the nuances of revascularization benefits. A conceptual shift from the traditional paradigm centred on the assessment of viability as a dichotomous variable to a more comprehensive approach encompassing a thorough understanding of ILVD's complex pathophysiology and the salutary effect of revascularization in the prevention of myocardial infarction and ventricular arrhythmias is required.

The use of artificial intelligence for predicting postinfarction myocardial viability in echocardiographic images.

BACKGROUND: Evaluation of standard echocardiographic examination with artificial intelligence may help in the diagnosis of myocardial viability and function recovery after acute coronary syndrome. METHODS: Sixty-one consecutive patients with acute coronary syndrome were enrolled in the present study (43 men, mean age 61 ± 9 years). All patients underwent percutaneous coronary intervention (PCI). 533 segments of the heart echo images were used. After 12 ± 1 months of follow-up, patients had an echocardiographic evaluation. After PCI each patient underwent cardiac magnetic resonance (CMR) with late enhancement and low-dose dobutamine echocardiographic examination. For texture analysis, custom software was used (MaZda 5.20, Institute of Electronics).Linear and non-linear (neural network) discriminative analyses were performed to identify the optimal analytic method correlating with CMR regarding the necrosis extent and viability prediction after follow-up. Texture parameters were analyzed using machine learning techniques: Artificial Neural Networks, Namely Multilayer Perceptron, Nonlinear Discriminant Analysis, Support Vector Machine, and Adaboost algorithm. RESULTS: The mean concordance between the CMR definition of viability and three classification models in Artificial Neural Networks varied from 42% to 76%. Echo-based detection of non-viable tissue was more sensitive in the segments with the highest relative transmural scar thickness: 51-75% and 76-99%. The best results have been obtained for images with contrast for red and grey components (74% of proper classification). In dobutamine echocardiography, the results of appropriate prediction were 67% for monochromatic images. CONCLUSIONS: Detection and semi-quantification of scar transmurality are feasible in echocardiographic images analyzed with artificial intelligence. Selected analytic methods yielded similar accuracy, and contrast enhancement contributed to the prediction accuracy of myocardial viability after myocardial infarction in 12 months of follow-up.

[Prediction of myocardial contractility after coronary bypass surgery according to preoperative contrast-enhanced magnetic resonance imaging and echocardiography]. / Prognozirovanie dinamiki sokratitel'noi funktsii miokarda u patsientov posle koronarnogo shuntirovaniya po dannym predoperatsionnykh magnitno-rezonansnoi tomografii serdtsa s kontrastnym usileniem i ekhokardiografii.

OBJECTIVE: To establish the criteria for reversibility of myocardial contractility in patients with coronary artery disease (CAD) after coronary artery bypass grafting considering data of cardiac magnetic resonance imaging (MRI) and echocardiography. MATERIAL AND METHODS: We studied the results of coronary artery bypass grafting in 186 patients with CAD complicated by reduced left ventricular ejection fraction (<30%). All patients underwent cardiac MRI and echocardiography before surgery. Immediate and long-term results were evaluated according to echocardiography and MRI data. RESULTS: We confirmed the previously established predictors of improvement in left ventricular contractility: diastolic IVST ≥10.5 mm and PWT ≥9.5 mm, score of LV myocardium damage according to MRI with delayed contrast enhancement (p<0.05). Multivariate analysis makes it possible to calculate prognostic index and obtain information about further myocardial contractility after revascularization with an error of 6%. CONCLUSION: Echocardiography and contrast-enhanced cardiac MRI are valuable to assess morphological and functional state of the left ventricle in patients with ischemic cardiomyopathy and preoperatively determine functional reserve of the myocardium.

Outcomes of Percutaneous Revascularization in Severe Ischemic Left Ventricular Dysfunction.

PURPOSE OF REVIEW: This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction. RECENT FINDINGS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.

Medical Decision-Making and Revascularization in Ischemic Cardiomyopathy.

Ischemic cardiomyopathy (ICM) is the most common underlying etiology of heart failure in the United States and is a significant contributor to deaths due to cardiovascular disease worldwide. The diagnosis and management of ICM has advanced significantly over the past few decades, and the evidence for medical therapy in ICM is both compelling and robust. This contrasts with evidence for coronary revascularization, which is more controversial and favors surgical approaches. This review will examine landmark clinical trial results in detail as well as provide a comprehensive overview of the current epidemiology, diagnostic approaches, and management strategies of ICM.

Contrast Echocardiography in Heart Failure: Update 2023.

PURPOSE OF REVIEW: The application of ultrasound-enhancing agents (contrast agents) has improved the accuracy and reproducibility of echocardiography. The review focuses on the currently approved and evolving indications for contrast echocardiography in patients with heart failure, specifically examining clinical studies conducted after the publication of the guidelines in 2017 and 2018. RECENT FINDINGS: The current ASE/EACVI recommendations for contrast echocardiography are based on its accuracy and reproducibility in comparison to non-enhanced echocardiography or other imaging modalities like cardiac MRI. However, tissue characterization remains limited with contrast echocardiography. During the last few years, several studies have demonstrated the clinical impact of using contrast agents on the management of patients with heart failure. There is growing evidence on the benefit of using contrast echocardiography in critically ill patients where echocardiography without contrast agents is often suboptimal and other imaging methods are less feasible. There is no risk of worsening renal function after the administration of ultrasound-enhancing agents, and these agents can be administered even in patients with end-stage renal disease. Contrast echocardiography has become a valuable tool for first-line imaging of patients with heart failure across the spectrum of patients with chronic heart failure to critically ill patients.

Assessment of Myocardial Viability in Chronic Myocardial Infarction Using the Dual-Energy Computed Tomography Myocardial Extracellular Volume Fractionation Technique: A Case Report.

Assessment of myocardial viability in patients with myocardial infarction is critical to identify residual ischemic tissue in areas of reduced function and to determine the need for revascularization. We present the case of an 80-year-old man with chest pain and a history of hypertension. Initial evaluation revealed abnormal electrocardiogram findings, and subsequent studies suggested chronic anteroseptal myocardial infarction with reduced cardiac function. Dual-energy cardiac computed tomography was performed to evaluate the coronary arteries and myocardium. Late iodine enhancement images obtained by dual-energy computed tomography showed mixed plaques and severe proximal left anterior descending artery stenosis. Conventional late iodine enhancement imaging was inconclusive, prompting extracellular volume fraction analysis using iodine density imaging. Extracellular volume fraction assessment indicated viable anterior myocardium, leading to successful coronary revascularization. Follow-up demonstrated improved wall motion and ejection fraction. Our study highlights the utility of late iodine enhancement with dual-energy computed tomography in assessing myocardial viability as a noninvasive alternative to magnetic resonance imaging, particularly in patients with contraindications to magnetic resonance imaging. This approach aids in treatment planning, evaluation of efficacy and determination of prognosis in cases of ischemic heart disease.

A treatment algorithm for ischemic cardiomyopathy.

Treatment of ischemic cardiomyopathy has been the focus of increased attention by cardiologists due to recent evidence of an important outcome study comparing percutaneous coronary intervention (PCI) plus optimal medical treatment vs optimal medical treatment alone, concluding for the futility of myocardial revascularization by PCI. A relatively older trial of coronary artery bypass grafting (CABG) in the same condition, on the other hand, had concluded for some prognostic improvement at a long-term follow-up. This short manuscript addresses how to triage such patients, frequently encountered in medical practice and considering clinical presentation, imaging results, and surgical risk, to provide practical guidance to treatment.

Coronary Guidewires in Temporary Cardiac Pacing and Assessment of Myocardial Viability: Current Perspectives and Future Directions.

Intracoronary guidewires used in percutaneous coronary intervention can also be configured to provide temporary ventricular pacing. Trans coronary electrophysiological parameters recorded by employing coronary guidewires may have a potential role in assessing myocardial viability and could provide a means to make an immediate on-table decision about revascularisation. To date, some small studies have demonstrated the safety of this technique in temporary cardiac pacing, but further research is required to refine this approach and establish its clinical utility in myocardial viability assessment. In this review we discuss the potential role of trans coronary electrophysiology in the assessment of myocardial viability.

Cardiac magnetic resonance imaging for myocardial viability assessment: Optimizing surgical revascularization in ischemic heart disease.

BACKGROUND: Patients with poor ejection fraction undergoing coronary artery bypass grafting carry higher operative risk and have poor long-term survival. Cardiac magnetic resonance is a useful modality to assess viability which can identify patients likely to benefit most from revascularization. In this study, we aimed to assess the outcome in patients selected for surgical revascularization by cardiac magnetic resonance imaging and identify predictors associated with poor outcomes. METHODS: The study included patients with severely impaired left ventricular function but with at least six viable segments. Patients requiring emergency surgery, undergoing combined procedures, or where cardiopulmonary bypass was required were excluded. Cardiac magnetic resonance was carried out both preoperatively and at six months postoperatively by the same radiologist in all cases. Late gadolinium enhancement was used for the evaluation of myocardial viability. RESULTS: Amongst a total of 493 segments studied, there were 89 (18.1%) non-viable, 117 (23.7%) hibernating and 287 (58.2%) viable segments. At six months, the number of non-viable segments changed from 89 (18.1%) to 97 (19.7%), with an increase in viable segments from 287 (58.2%) to 374 (75.8%) and a corresponding reduction of hibernating segments from 117 (23.7%) to 22 (4.5%). There was improvement in ejection fraction from 28 ± 5.54 to 37 ± 5.86 (p < 0.0001) in the entire cohort at six months. Overall mortality was 1 (3.2%). Preoperative left ventricular end-systolic volume had the strongest negative correlation with post-operative ejection fraction. CONCLUSION: Cardiac magnetic resonance aided revascularization is associated with low mortality. Preoperative left ventricular end-systolic volume is an important determinant of postoperative ejection fraction.

The Role of Positron Emission Tomography in Advancing the Understanding of the Pathogenesis of Heart and Vascular Diseases.

Cardiovascular disease remains the leading cause of morbidity and mortality worldwide. For developing new therapies, a better understanding of the underlying pathology is required. Historically, such insights have been primarily derived from pathological studies. In the 21st century, thanks to the advent of cardiovascular positron emission tomography (PET), which depicts the presence and activity of pathophysiological processes, it is now feasible to assess disease activity in vivo. By targeting distinct biological pathways, PET elucidates the activity of the processes which drive disease progression, adverse outcomes or, on the contrary, those that can be considered as a healing response. Given the insights provided by PET, this non-invasive imaging technology lends itself to the development of new therapies, providing a hope for the emergence of strategies that could have a profound impact on patient outcomes. In this narrative review, we discuss recent advances in cardiovascular PET imaging which have greatly advanced our understanding of atherosclerosis, ischemia, infection, adverse myocardial remodeling and degenerative valvular heart disease.

Predicting left ventricular functional recovery in ischaemic cardiomyopathy: needs and challenges.

Left ventricular (LV) systolic function is an essential parameter for the evaluation of patients with ischaemic heart disease, and therapeutic choices are significantly driven by LV ejection fraction (LVEF) in the early stage of the disease and during follow-up. After an acute coronary syndrome, ventricular dysfunction may be reversible when caused by transient myocardial stunning. Therefore, the identification of clinical, laboratory, and instrumental predictors of improvement in LV systolic function (in addition to LVEF) is essential for an adequate prognostic stratification. In the setting of chronic ischaemic heart disease, there is no evidence that an improvement in LV systolic function is invariably associated with a better prognosis and LVEF is only one of many parameters that should be considered for the risk stratification. This state-of-the-art review will critically analyse the scientific evidence regarding known predictors of LVEF recovery, trying to elucidate their pathophysiological principles and clinical value.

What is the role of coronary revascularization to recover the contractility of the dysfunctional heart?

Coronary artery disease is the predominant aetiology of heart failure and left ventricular dysfunction in industrialized countries. The pathophysiological substrate of hibernating myocardium constitutes the conceptual target of coronary revascularization by coronary artery bypass graft (CABG) or coronary angioplasty or percutaneous coronary intervention (PCI). Studies, mainly observational, conducted in the past have demonstrated a prognostic benefit of CABG on survival. These findings were confirmed by the long-term follow-up of the STICH study in which, however, documentation of inducible ischaemia or myocardial viability was not predictive of a prognostic benefit of CABG. Revascularization via PCI in the recent REVIVED-BCIS2 study did not demonstrate a significant benefit in terms of death or heart failure hospitalization compared with optimal medical therapy. Pending the long-term follow-up of the REVIVED-BCIS2 study, optimized medical therapy, cardiac resynchronization therapy, and the implantable cardioverter defibrillator, where indicated, are the mainstay of treatment in patients with dilated ischaemic cardiomyopathy. The decision for coronary revascularization is made in the individual patient, possibly with a higher bias in patients with angina, three-vessel coronary artery disease, severe left ventricular dysfunction, and cardiac remodelling.

Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: For Whom and How.

Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for revascularization in patients with ICM and the role of ischemia and viability detection in guiding treatment. Methods and Results We searched for randomized controlled trials evaluating the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. Out of 1397 publications, 4 randomized controlled trials were included, enrolling 2480 patients. Three trials (HEART [Heart Failure Revascularisation Trial], STICH [Surgical Treatment for Ischemic Heart Failure], and REVIVED [REVascularization for Ischemic VEntricular Dysfunction]-BCIS2) randomized patients to revascularization or optimal medical therapy. HEART was stopped prematurely without showing any significant difference between treatment strategies. STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow-up of 9.8 years. However, neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes. REVIVED-BCIS2 showed no difference in the primary end point between percutaneous revascularization or optimal medical therapy. PARR-2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging-guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623). No difference in survival was revealed according to adherence or no adherence to viability imaging. Conclusions In ICM, the largest randomized controlled trial, STICH, suggests that surgical revascularization improves patients' prognosis at long-term follow-up, whereas evidence supports no benefit of percutaneous coronary intervention. Data from randomized controlled trials do not support myocardial ischemia or viability testing for treatment guidance. We propose an algorithm for the workup of patients with ICM considering clinical presentation, imaging results, and surgical risk.