From basic to advanced cardiac imaging to identify the benefits of revascularization in ischemic heart disease

Myocardial viability imaging plays a pivotal role in evaluating patients with ischemic cardiomyopathy who may benefit from revascularization. Despite recent trials questioning its prognostic value, imaging continues to shape therapeutic decisions. This comprehensive review explores the underlying pathophysiological basis, diagnostic modalities, and clinical evidence on myocardial viability. We compare contemporary imaging tools and outline a practical framework for individualized patient assessment. Advanced modalities such as cardiac magnetic resonance, positron emission tomography, and dobutamine stress echocardiography provide robust insights into myocardial viability. Findings from key clinical trials, including STICH and REVIVED-BCIS2, reveal the nuanced role of viability in guiding revascularization strategies. We propose that myocardial viability testing remains a valuable adjunct in selected clinical scenarios, emphasizing integration with ischemia assessment, anatomical context, and symptom burden.