The Role of Imaging Modalities in Estimating Myocardial Viability: A Narrative Review

Abstract

Myocardial viability assessment plays a critical role in the clinical management of patients with ischemic heart disease, particularly in guiding revascularization decisions. Various non-invasive imaging modalities have been developed and refined to evaluate viable myocardium, each offering unique insights into myocardial perfusion, metabolism, and contractile function. This review examines the comparative strengths and limitations of key imaging techniques. Understanding the pathophysiological basis and diagnostic capabilities of these modalities enables clinicians to tailor viability assessments to individual patient profiles, ultimately enhancing decision-making and optimizing outcomes in ischemic cardiomyopathy.

Keywords: imaging; imaging modalities; myocardial viability.

Figure 1

Cardiac MRI showing late gadolinium enhancement in a patient with chronic ischemic cardiomyopathy. Areas of enhancement (arrows) indicate non-viable myocardium.

Figure 2

FDG-PET imaging demonstrating perfusion–metabolism mismatch—reduced perfusion (top row) with preserved glucose uptake (bottom row)—consistent with viable but hibernating myocardium. Adapted from Osterholt et al., “Targeted Metabolic Imaging to Improve the Management of Heart Disease,” under open-access terms [25].

Figure 3

Rest–redistribution Thallium-201 SPECT imaging showing delayed uptake in the inferior wall, indicative of viable myocardium post-infarction. Adapted from Santoyo-Saavedra et al., 2022, under open-access terms [29].