ABSTRACT
Ischemic heart failure is associated with either a permanent, irreversible loss of myocardial tissue because of a previous myocardial infarction or from a transient and reversible hypocontractile state due to severe chronic ischemia in a viable myocardial territory. Optimal medical therapy and lifestyle modifications comprise the cornerstone of treatment in all subjects with ischemic heart failure. Coronary revascularization and device therapy (implantable cardioverter-defibrillators and cardiac resynchronization therapy with biventricular pacemaker) are considered in patients with appropriate indications. Based on the findings of STICH and STICHES trials, coronary artery bypass grafting (CABG) surgery in addition to optimal medical therapy is the preferred treatment option in patients with severe coronary artery disease amenable to surgery and severe left ventricular systolic dysfunction. Percutaneous coronary intervention can be considered in patients with high surgical risk or with coronary anatomy which is unfavorable for CABG. The role of myocardial viability in guiding revascularization in ischemic heart failure is debatable. Routine assessment of myocardial viability prior to CABG is not recommended. In patients with extremely remodeled and dilated left ventricles, or in the presence of comorbidities that significantly increase the risk of CABG, evaluation of viability may be considered to better assess the risk/benefit balance of CABG and drive decisions.
