Imaging-Guided Selection of Patients With Ischemic Heart Failure for High-Risk Revascularization Improves Identification of Those With the Highest Clinical Benefit

65-year-old man presented to his local emergency department with rapid atrial fibrillation and acute pulmonary edema. This patient had a history of hypertension, and 2 months before this presentation, he developed progressive exertional dyspnea. The patient deteriorated in the emergency department and went into cardiogenic shock. Emergent coronary angiography revealed diffuse 3-vessel disease: a 99% proximal left anterior descending coronary artery lesion, 90% mid-right coronary artery lesion, occluded large first marginal branch, and diffuse severe disease of the left circumflex coronary artery. The initial ejection fraction (EF) on echocardiography was 15%, with mild mitral regurgitation and an estimated pulmonary artery pressure of 55 mm Hg. The patient stabilized with an intraaortic balloon pump and intensive care unit management; however, because of the diffuse nature of the disease, he was not believed to be a surgical candidate. He was transferred to another tertiary-care facility for consideration of cardiac transplantation. As part of this evaluation, a PET viability study was done that demonstrated a significant area of perfusion-metabolism mismatch in the entire anteriolateral wall. Less than 1% of the myocardium was scar, and 28% was defined as hibernating (Figure 1). Response by Velazquez on p 270 The results of the viability test were pivotal in the decision to perform coronary artery bypass graft (CABG) surgery in a patient who otherwise would not have had surgery. Approximately 2 months after his initial presentation, the patient had a 4-vessel CABG. His predischarge echocardiogram demonstrated an EF of 25%. Six months after surgery, the patient was clinically stable with New York Heart class II functional symptoms and an EF of 45%.