Official diagnosis of ischemic left ventricular dysfunction (iLVD) has been difficult to pinpoint, and the best management strategy for these patients remains unclear, a new review reveals. Shared decision-making between the heart team and individual patients gives patients the most autonomy when receiving treatment for iLVD. Matthew Ryan, PhD, of the King's College London, and colleagues from the U.S., Switzerland, Canada and Sweden, discussed these findings in a manuscript published online and in the December 22 issue of JACC: Cardiovascular Interventions. Heart failure with reduced ejection fraction (HFrEF) is often caused by iLVD. The standard treatment for iLVD has been coronary revascularization, but recent randomized clinical trials have questioned this approach. No international guidelines have defined a concrete standard for diagnosing iLVD, unlike other cardiomyopathies. Randomized trials that have evaluated revascularization in iLVD: The STITCH (Surgical Treatment for Ischemic Heart Failure) trial showed that coronary artery bypass grafting (CABG) in iLVD patients was more beneficial than medical therapy alone, and the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial demonstrated the usefulness of percutaneous coronary intervention (PCI) in treating iLVD. Key differences between the STITCH and REVIVED-BCIS2 trials, such as population diversity, exclusion criteria and varying revascularization types, prompted researchers to continue evaluating the potential of revascularization for the management of iLVD. For success in PCI, left-ventricular ejection fraction (LVEF) is the best predictor. Other nontechnical factors, such as operator skills or individual patient risk assessments, should be considered prior to PCI for iLVD. Other studies focused on advancing imaging and functional testing for patients prior to revascularization. This may improve outcomes as well as recommendations for revascularization procedures. More medical therapies for iLVD were highlighted outside of the two trials, including pharmacotherapy and cardiac implantable electronic device therapy. Investigators have also utilized right heart catheterization, mechanical circulatory support (MCS) devices, intra-aortic balloon pumps, percutaneous LV assist devices and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). VA-ECMO has the highest rate of bleeding complications. Finally, the authors of this review noted a key piece of the puzzle when it comes to revascularization in patients with iLVD: shared decision-making. The heart team should lay out all the options for patients and let the patients decide what procedures and treatments are worth it. The risk of reintervention remains strong for very elderly or frail patients. Some quality-of-life factors may outweigh the risk of undergoing cardiac interventions. Evidence gaps are present throughout the management process in iLVD, especially in diagnosis. Routine percutaneous revascularization has not, overall, been more effective in treating patients with iLVD compared with medical therapies alone when all the risks have been factored into the equation, though PCI or CABG may be preferred in patients who simultaneously have acute myocardial infarction (AMI). “Future studies focusing on postprocedural change in ischemic burden are essential to clarify the true physiological impact of both PCI and CABG in this population,” the authors concluded. Source: Ryan M, Truesdell AG, Murphy GJ, et al. Revascularization in Ischemic Left Ventricular Dysfunction: A pathophysiology-guided, evidence-based approach. JACC Cardiovasc Interv. 2025 Dec;24:2977-2994. Image Credit: Anela R/peopleimages.com – stock.adobe.com