Myocardial viability assessment and utility in contemporary management of ischemic cardiomyopathy

Figures

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  Figure 1. Consequences of myocardial ischemia/reperfusion. HM, hibernating myocardium; NVM4, nonviable myocardium with transmural scar; PVM2, partially viable, thinned myocardium in mid to late phases of HM; PVM3, partially viable myocardium with subendocardial scar; SM, stunned myocardium; VM1, viable myocardium in early to mid‐phase of HM

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  Figure 2. Inferolateral myocardial segment noted as NVM on Echo showed no scar (VM) on CMR. Inferolaterla wall on Echo (A) is thinned with no contractile reserve, suggestive of NVM. Thinned inferolateral wall on CMR (B) was shown to be VM with no LGE (C) and (D). (A) Black arrow: Thinned inferolateral wall on Echo, end diastole. (B) Red arrow: Thinned inferolateral wall on CMR, end diastole. (C) and (D): Blue arrow: Inferolateral wall on CMR with no LGE (scar). CMR, cardiac magnetic resonance; Echo, echocardiography; LGE, late gadolinium enhancement; NVM, nonviable myocardium; VM, viable myocardium

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  Figure 3. Fixed perfusion defect of the apex and septum on SPECT suggests infarct, however, characterized as VM on CMR with no LGE. LV septum (red arrow) and apex (green arrow) reveal fixed perfusion defect on strss and rest SPECT imaging (A) suggestive of NVM; on CMR (B) septum (gray arrow) and apex (blue arrow) reveal VM (no scar on LGE imaging). CMR, cardiac magentic resonance; LGE, late gadolinium enhancement; NVM, nonviable myocardium; R, rest attenuation corrected; S, stress attenuation corrected; SPECT, Single Photon Emission Computed Tomography; VM, viable myocardium

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  Figure 4. (A) PVM on SPECT showed subendocardial infarct on CMR. (B) NVM on SPECT confirmed as a transmural scar on CMR. (A) Inferolateral wall on SPECT that is partially reversible on rest imaging (gray arrow), suggestive of PVM; inferolateral wall on LGE of CMR reveal subendocardial infarct of <50% transmural extent (green arrow). (B) Inferior wall perfusion fixed defect on stress and rest SPECT imaging (red arrow), indicative of NVM and confirmed by CMR as transmural scar (blue arrow). CMR, cardiac magentic resonance; LGE, late gadolinium enhancement; NVM, nonviable myocardium; PVM, partially viable myocardium; R, rest attenuation corrected; S, stress attenuation corrected; SPECT, Single Photon Emission Computed Tomography; VM, viable myocardium

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  Figure 5. Viability imaging and management approach. CMR, cardiac magentic resonance; CorR, coronary revascularization; Device therapy*: cardiac resynchronization therapy (CRT), left ventricular assist device and mitral/tricuspid clip valve repair; DSE, dobutamine stress echo; LVEF, left ventricular ejection fraction; NVM1, nonviable myocardium on DSE/SPECT, NVM2, nonviable myocardium on CMR (transmural scar); PET, positron emission tomography; PVM, partially viable myocardium; SPECT, Single Photon Emission Computed Tomography; VM, viable myocardium