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Page 6 of 17 Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112

quality of life
We suggest consideration of PCI for patients Weak Low
with HF and limiting symptoms of cardiac
ischemia, and for whom coronary artery
bypass grafting (CABG) is not considered
appropriate

ACC: American College of Cardiology; ACCP: American College of Clinical Pharmacy; AHA: American Heart Association; ASPC: American
Society for Preventive Cardiology; CCD: chronic coronary disease; CCS: Canadian Cardiovascular Society; COR: class of recommendation; EACTS:
European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; HFSA: Heart Failure Society of America; LOE: level of
evidence; LVSD: left ventricular systolic dysfunction; NLA: National Lipid Association; PCNA: Preventive Cardiovascular Nurses Association;
SCAI: Society for Cardiovascular Angiography and Interventions; SIHD: stable ischemic heart disease.

Figure 2. Considerations for the Management of CAD with reduced LVEF. CABG: Coronary artery bypass grafting; CMR: cardiac
magneticresonance; GDMT: guideline-directed medical therapy; ICD: implantable cardioverter-defibrillator; IMR: ischemic mitral
regurgitation; MV: mitral valve; TTE: transthoracic echocardiography.

Greater than 50% transmural scar involvement on LGE-CMR predicts poor regional recovery after
revascularization ; however, this understanding has been challenged in other studies , with the STICH
[43]
[42]
[44]
trial not demonstrating the ability of viability testing to predict survival benefit from CABG . The presence
of dense scar formation often cinches the decision against operative revascularization in patients who are
already high-risk.
In the clinical setting, CMR has greater utility in women for quantification of ventricular size and function
since transthoracic echo image quality can be compromised by breast tissue attenuation. As outlined by the
AHA 2014 consensus statement on the role of non-invasive testing in women, stress CMR is a reasonable
index diagnostic test in symptomatic women with intermediate-high risk of CAD and resting ST-segment
abnormalities or exercise intolerance [45,46] . In pre-menopausal women with functional disability, stress CMR
may also be appropriate for the identification of obstructive CAD and prognostication .
[45]
Operative management
Beyond the revascularization strategy, there are several operative considerations for patients with LVSD.
Multiple arterial grafting (MAG) may offer superior conduit patency with the surgeons’ expertise and
preference determining the choice of an on-pump or off-pump strategy ; however, routine use of MAG is
[3]
cautioned in ICM for a few reasons. Firstly, perioperative administration of high-dose vasopressors
predisposes arterial grafts to spasm . Secondly, the initial flow of arterial grafts is less than that of vein
[47]
grafts due to smaller luminal diameter, thus posing the risk of early coronary hypoperfusion . Further,
[48]
arterial grafts may be of insufficient length for direct aortocoronary bypass in dilated hearts, and can only be
used in composite or sequential grafting, techniques that are often deferred to dedicated coronary surgeons.
Lastly, the complexity and additional operative time of performing MAG may be poorly tolerated in severe
LVSD. There is also the argument that patients with very low LVEF do not receive the long-term benefit of