Viability scan, assessment of angina and dyspnea and fractional flow reserve are some of the tools. A very important paper by John Elefteriades (Circulation 1999) says that revascularizing even scarred myocardium benefits the patients in terms of symptomatic and survival improvement.
Left ventricle assist device, surgically implanted, can be more useful than CABG in several cases where major coronary risk factors and advanced age characterize the patients with severe LV dysfunction. However, the degree of LV dysfunction is, in my opinion, not enough to plan CABG since other factors, sometimes related to the lifestyle of the patients, should be taken into account.
Along with other stuff, Viability is the major deciding factor. In patients with Viable myocardium, revascularization should be done in any forms (CABG vs. PCI). PCI is slowly replacing CABG in suitable anatomy including Left main stem. Regarding revascularization in Scar myocardium, it is of no use and probably more harmful and I think usual heart failure management including CRT-P/D or destination Assist devices or cardiac transplant is the answer. However, it is pretty much expensive business and most of the patients in developing world, where there is no government support for this kind of fancy stuff are going to be kept on medical management.
viability studies via MRI or thalium can help in selecting patients who may benefit . thinned or ecarred tissues will not benefit . CABG in thosr patients will carry substantial risk and marginal benefit.
It might be a difficult issue. Viability is an important issue but isn't the alpha and omega to resolve this problem. It can happened that some viability exist but the remaining coronary network is poor and tenuous. We should be concerned with the past history, especially diabetis associated with others vasculary disease or renal insufficiency with a long past of dialysis. Though the skin of the cardiologist and surgeon team is important in the decision making. In the article of John Elefteriades ( Circulation. 1999 Sep 21;100(12):1298-304), we wonder where would have been the 5% none survived patients :group A or group B? Is it a bias? The procedure plan should be carrefully done: ECC or off pump, Ecmo when necessary or not, left device or ECMO first.
Firstly,evidence of viability
Secondly,suitable coronary anatomy and LV reconstruction evaluation.
Plan any kind of assist support if necessary.
MD,Professor of cardiacsurgey
Evidence of viability + Coronary anatomy + Other surgery risk factors and morbidity
As here already mentioned, for us is very important the evidence of viability due to any of the test (MRI, SPECT or PET). If there is still some viable myocardiaum, then we go for revascularization having also a plan B, if the patient is not doing well and needs potentially any assist device.
Medicine should be helpful but not too expensive. Simplicity is the philosophy of a quick and effective treatment. In that case, a detailed ECHO give us information fot the thikness of the LV segments and for the presence of dyskinesia. Also Pulmonary Function Tests and GFR are helpful to estimate the risk. Finally increased BMI must be considered as a serious risk factor.
For indication it's clear that myocardial viability and suitable coronary arteries are needful prerequisites, along with risks factors just mentioned
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