The benefits of revascularization in chronic heart failure.

Recent efforts have reduced the mortality from coronary artery disease (CAD), with the consequent increase in heart failure with reduced left ventricular function, referred to as ischaemic cardiomyopathy (ICM). As ischemic left ventricular (LV) dysfunction may be partially or completely reversible by revascularization in the presence of viable myocardium, the assessment of myocardial viability is central to the management of ICM. Decades of observational analyses have provided positive evidence for the role of revascularization in hibernating myocardium in improving survival. However, recently the Surgical Treatment for Ischaemic Heart Failure (STICH) trial has challenged this notion, highlighting the noninferiority of optimal medical therapy (OMT) over revascularization and OMT. In this review, we discuss noninvasive imaging modalities to assess myocardial viability and the impact of myocardial viability on revascularization. We critically appraise the STICH trial and suggest an algorithm for viability testing before revascularization in patients with ICM and significant LV dysfunction.