A patient w/ICM (LVEF 15%) p/w angina & DOE. SPECT shows a fixed defect & LHC shows LCx CTO.

...To revasc or not to revasc...

1st we need to know if the myocardium is dead or alive?! Check out this #Tweetorial on 🫀 viability to see how!
In this #tweetorial, we will explore:

1) The spectrum of myocardial responses to ischemia (stunning, hibernation, necrosis)

2) The goals of viability testing

3) Several modalities we can use to assess for myocardial viability

4) The data behind viability testing
I feel comfortable in my understanding of myocardial hibernation and viability testing.
If:

LVEF is ↓

w/hypokinesis/akinesis

& FIXED perfusion deficits

--> then the myocardium is either dead (scarred), stunned, or hibernating!
This is a spectrum. Along the spectrum are intracellular adaptations that affect the contractile apparatus so that phenotypically, that region of myocardium appears hypokinetic or akinetic.
The primary goals of viability testing are:

1️⃣ Identify dead myocardium that would not benefit from revascularization

2️⃣ Identify patients whose LV systolic function may ⬆️ w/ revascularization

3️⃣ To potentially improve survival
As mentioned in @cardionerds Ep #102, myocardial viability modalities either assess for...

❤️ “Signs of life” (e.g., evidence of inducible contractility, cell membrane integrity, metabolic activity)

💔“Signs of death” (e.g., myocardial wall thinning, presence of scar)
Hibernating myocardium is a diverse phenotype! The dynamic nature of the disease process and the lack of a unifying definitions have made it difficult for clinical trials to show that re-establishing myocardial blood flow to hibernating myocardium is beneficial.
As Dr. Jaber adapted from Anna Karenina, “All normal hearts are normal in the same way, & all abnormal hearts are abnormal in different ways.”

It follows that there are notable studies that have assessed the benefit of myocardial viability testing prior to revascularization:
As Dr. Jaber adapted from Anna Karenina, “All normal hearts are normal in the same way, & all abnormal hearts are abnormal in different ways.” It follows that there are notable studies that have assessed the benefit of myocardial viability testing prior to revascularization:
As Dr. Jaber adapted from Anna Karenina, “All normal hearts are normal in the same way, & all abnormal hearts are abnormal in different ways.” It follows that there are notable studies that have assessed the benefit of myocardial viability testing prior to revascularization:
As Dr. Jaber adapted from Anna Karenina, “All normal hearts are normal in the same way, & all abnormal hearts are abnormal in different ways.” It follows that there are notable studies that have assessed the benefit of myocardial viability testing prior to revascularization:
Viability testing is not appropriate in all settings, as it would not change mgmt in pts with:

1️⃣ Non-obstructive dz

2️⃣ Obstructive epicardial coronary dz NOT amenable to revascularization

3️⃣ Normal LV systolic function
In summary:

Myocardial response to ischemia is a dynamic spectrum from 🫀 stunning ➡️ 🫀 hibernation ➡️ 🫀 necrosis

The goals of viability testing are to identify patients who may benefit from revascularization of hibernating or stunned myocardium
In summary (cont.):

There are numerous imaging modalities available for the evaluation of 🫀 viability.

FDG-PET and CMR +/- Dobutamine Stress are the most sensitive and specific (the attached graphic shows CMR LGE assessment of infarct transmurality)
Check out the ACC Expert Opinion from @rblument1 @GarimaVSharmaMD and the AHA Scientific Statement from @CoronaryDoc @bonowr @RonBlankstein on myocardial viability! And be sure to check out the @cardionerds Ep #102!

https://www.acc.org/latest-in-cardiology/articles/2020/08/14/07/44/non-invasive-assessment-of-myocardial-viability

https://ahajournals.org/doi/10.1161/HCI.0000000000000053
Check out the ACC Expert Opinion from @rblument1 @GarimaVSharmaMD and the AHA Scientific Statement from @CoronaryDoc @bonowr @RonBlankstein on myocardial viability! And be sure to check out the @cardionerds Ep #102! https://www.acc.org/latest-in-cardiology/articles/2020/08/14/07/44/non-invasive-assessment-of-myocardial-viability https://ahajournals.org/doi/10.1161/HCI.0000000000000053
Check out the ACC Expert Opinion from @rblument1 @GarimaVSharmaMD and the AHA Scientific Statement from @CoronaryDoc @bonowr @RonBlankstein on myocardial viability! And be sure to check out the @cardionerds Ep #102! https://www.acc.org/latest-in-cardiology/articles/2020/08/14/07/44/non-invasive-assessment-of-myocardial-viability https://ahajournals.org/doi/10.1161/HCI.0000000000000053
I feel comfortable in my understanding of myocardial hibernation and viability testing.
I learned something in this Tweetorial that may change my clinical practice.
Many thanks to @ThomasMDas and @AmitGoyalMD for their feedback and assistance with this Tweetorial!

Let me know what you think!
@cardionerds Episode 102: Myocardial Viability--check it out!

https://www.cardionerds.com/102-nuclear-and-multimodality-imaging-myocardial-viability/
You can follow @HussainMKCards.
Tip: mention @twtextapp on a Twitter thread with the keyword “unroll” to get a link to it.

Latest Threads Unrolled:
Those who think consciousness raising & movement building are disconnected, or even a distraction from electoral politics have not paid attention to the history of social change.In this thread, we
Read more
The 2020s will be known as the Remote Work decadeA few predictions of what is likely to emerge[ a thread ] Third Space: Office and Working from Home will
Read more
1/29: Have you ever had a concept explained to you that helps frame complex issues you’ve been wrestling with and opens your eyes to new possibilities? A concept that I
Read more
By continuing to use the site, you are consenting to the use of cookies as explained in our Cookie Policy to improve your experience.