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June 14, 2026Biochemia MedicaOpen Access

Myocardial fibrosis and viability: the role of imaging and biomarkers in patients with chronic total occlusion on coronary angiography

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Why the study?

In patients with chronic total occlusion on coronary angiography, non-invasive myocardial viability assessment guides revascularization but is often limited by myocardial fibrosis.

Do circulating fibrosis biomarkers and non-invasive imaging improve myocardial viability assessment in patients with chronic total occlusion?

Population

Patients with chronic total occlusion on coronary angiography across 76 studies

Design

Narrative review of 76 studies

Key result

Circulating fibrosis biomarkers such as PICP, PIIINP, and Gal-3 reflect myocardial remodeling and may complement imaging, but currently lack outcome-based validation to guide revascularization.

Authors

ŽTŽeljka Dragila TomašićLMLea MaršićAMAnamaria Mikolčić

Discussion

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Overview

Fibrosis limits current viability tests in CTO; leaves optimal non-invasive strategy open for prospective validation.

Key Points

  • This review aims to update the understanding of non-invasive methods for assessing myocardial viability, focusing on the impact of myocardial fibrosis.
  • Incorporated evidence from 76 studies
  • Evaluated various non-invasive imaging modalities for myocardial viability
  • Assessed the role of specific biomarkers related to myocardial fibrosis
  • Imaging modalities differ in sensitivity and specificity for detecting myocardial viability amidst fibrosis.
  • Biomarkers like procollagen type I carboxy-terminal propeptide and galectin-3 provide insights but lack standardized reference ranges.
  • Circulating biomarkers, while promising, remain experimental and need validation in clinical settings before widespread adoption.

Structured PICO

Do circulating fibrosis biomarkers and non-invasive imaging improve myocardial viability assessment in patients with chronic total occlusion?

P
Population
A narrative review of 76 studies evaluating non-invasive imaging and circulating fibrosis biomarkers for myocardial viability assessment in adults with chronic coronary syndrome and chronic total occlusion.
E
Exposure
Non-invasive imaging modalities (PET, SPECT, DSE, CMR) and circulating fibrosis biomarkers (PICP, PIIINP, Gal-3)
O
Outcome
Myocardial viability assessment and detection of myocardial fibrosissurrogate

Circulating fibrosis biomarkers show potential to complement imaging in assessing myocardial viability in CTO patients, but require standardization and large-scale validation before clinical implementation.

Limitations

  • No standardized reference ranges and cut-off values for biomarkers
  • Considerable analytical variability between assay platforms
  • Insufficient validation for predicting clinical outcomes like functional recovery after revascularization
  • Elevated biomarker concentrations lack tissue specificity and may reflect systemic fibrosis or active inflammation
  • no standardized reference ranges and cut-off values
  • analytical variability
  • insufficient validation for clinical outcomes prediction

Cite This Study

Tomašić et al. (2026) conducted a review in Chronic total occlusion and myocardial fibrosis (n=76). Circulating fibrosis biomarkers (PICP, PIIINP, Gal-3) and non-invasive imaging was evaluated. Circulating fibrosis biomarkers such as PICP, PIIINP, and Gal-3 reflect myocardial remodeling and may complement imaging, but currently lack outcome-based validation to guide revascularization.

synapsesocial.com/papers/6a2e45adb1cc60ccdea8aa27https://doi.org/10.11613/bm.2026.020503
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Modern insights into myocardial fibrosis: a comprehensive assessment by biochemical, epigenetic and imaging biomarkers2025
  2. 2State of the Art: Imaging for Myocardial Viability: A Scientific Statement From the American Heart Association2020 · 141 citations
  3. 3Recent advances in biomarkers for cardiac fibrosis2026
  4. 4Clinical impact of multimodality assessment of myocardial viability2024 · 36 citations
  5. 5Is there a need to assess myocardial viability in patients presenting with heart failure?2016 · 4 citations