Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation of hibernating myocardium

Wilson S Colucci, MD
Section Editors
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Jeroen J Bax, MD, PhD
Deputy Editor
Brian C Downey, MD, FACC


It has become apparent that impaired left ventricular (LV) function in patients with coronary heart disease (CHD) is not always an irreversible process, but may be stunned or hibernating:

Transient postischemic dysfunction is called "stunned" myocardium

Chronic but potentially reversible ischemic dysfunction due to a stenosed coronary artery is called "hibernating" myocardium

From 20 to more than 50 percent of patients with chronic ischemic LV dysfunction have a significant amount of viable hibernating myocardium and therefore the potential for clinically important improvement in LV function after revascularization (figure 1) [1-4]. (See "Ischemic cardiomyopathy: Treatment and prognosis".)

The approach to the detection of hibernating myocardium will be reviewed here (table 1). The pathophysiology of and clinical syndromes associated with hibernation are discussed separately. (See "Pathophysiology of stunned or hibernating myocardium" and "Clinical syndromes of stunned or hibernating myocardium" and "Ischemic cardiomyopathy: Treatment and prognosis".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 07, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002; 39:1151.
  2. Bonow RO. The hibernating myocardium: implications for management of congestive heart failure. Am J Cardiol 1995; 75:17A.
  3. Ragosta M, Beller GA, Watson DD, et al. Quantitative planar rest-redistribution 201Tl imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation 1993; 87:1630.
  4. Auerbach MA, Schöder H, Hoh C, et al. Prevalence of myocardial viability as detected by positron emission tomography in patients with ischemic cardiomyopathy. Circulation 1999; 99:2921.
  5. Braunwald E, Rutherford JD. Reversible ischemic left ventricular dysfunction: evidence for the "hibernating myocardium". J Am Coll Cardiol 1986; 8:1467.
  6. Rahimtoola SH. From coronary artery disease to heart failure: role of the hibernating myocardium. Am J Cardiol 1995; 75:16E.
  7. Kloner RA, Przyklenk K. Hibernation and stunning of the myocardium. N Engl J Med 1991; 325:1877.
  8. Marban E. Myocardial stunning and hibernation. The physiology behind the colloquialisms. Circulation 1991; 83:681.
  9. Selvanayagam JB, Jerosch-Herold M, Porto I, et al. Resting myocardial blood flow is impaired in hibernating myocardium: a magnetic resonance study of quantitative perfusion assessment. Circulation 2005; 112:3289.
  10. Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall-motion abnormalities predicted by positron tomography. N Engl J Med 1986; 314:884.
  11. Cabin HS, Clubb KS, Vita N, Zaret BL. Regional dysfunction by equilibrium radionuclide angiocardiography: a clinicopathologic study evaluating the relation of degree of dysfunction to the presence and extent of myocardial infarction. J Am Coll Cardiol 1987; 10:743.
  12. Vanoverschelde JL, Wijns W, Borgers M, et al. Chronic myocardial hibernation in humans. From bedside to bench. Circulation 1997; 95:1961.
  13. Bax JJ, Visser FC, Poldermans D, et al. Time course of functional recovery of stunned and hibernating segments after surgical revascularization. Circulation 2001; 104:I314.
  14. Chaitman BR, DeMots H, Bristow JD, et al. Objective and subjective analysis of left ventricular angiograms. Circulation 1975; 52:420.
  15. Chaitman BR, Bristow JD, Rahimtoola SH. Left ventricular wall motion assessed by using fixed external reference systems. Circulation 1973; 48:1043.
  16. Helfant RH, Pine R, Meister SG, et al. Nitroglycerin to unmask reversible asynergy. Correlation with post coronary bypass ventriculography. Circulation 1974; 50:108.
  17. Banka VS, Bodenheimer MM, Shah R, Helfant RH. Intervention ventriculography. Comparative value of nitroglycerin, post-extrasystolic potentiation and nitroglycerin plus post-extrasystolic potentiation. Circulation 1976; 53:632.
  18. Rahimtoola SH. Postoperative exercise response in the evaluation of the physiologic status after coronary bypass surgery. Circulation 1982; 65:106.
  19. Dalla Vecchia L, Storti T, Cogliati C, et al. Comparison of low-dose dobutamine ventriculography with low-dose dobutamine echocardiography for predicting regional improvement in left ventricular function after coronary artery bypass grafting. Am J Cardiol 2000; 86:371.
  20. Popio KA, Gorlin R, Bechtel D, Levine JA. Postextrasystolic potentiation as a predictor of potential myocardial viability: preoperative analyses compared with studies after coronary bypass surgery. Am J Cardiol 1977; 39:944.
  21. Cohn PF, Gorlin R, Herman MV, et al. Relation between contractile reserve and prognosis in patients with coronary artery disease and a depressed ejection fraction. Circulation 1975; 51:414.
  22. Nesto RW, Cohn LH, Collins JJ Jr, et al. Inotropic contractile reserve: a useful predictor of increased 5 year survival and improved postoperative left ventricular function in patients with coronary artery disease and reduced ejection fraction. Am J Cardiol 1982; 50:39.
  23. Zafrir N, Vidne B, Sulkes J, Sclarovsky S. Usefulness of dobutamine radionuclide ventriculography for prediction of left ventricular function improvement after coronary artery bypass grafting for ischemic cardiomyopathy. Am J Cardiol 1999; 83:691.
  24. Perez-Baliño NA, Masoli OH, Meretta AH, et al. Amrinone stimulation test: ability to predict improvement in left ventricular ejection fraction after coronary bypass surgery in patients with poor baseline left ventricular function. J Am Coll Cardiol 1996; 28:1488.
  25. Scognamiglio R, Fasoli G, Casarotto D, et al. Postextrasystolic potentiation and dobutamine echocardiography in predicting recovery of myocardial function after coronary bypass revascularization. Circulation 1997; 96:816.
  26. Cwajg JM, Cwajg E, Nagueh SF, et al. End-diastolic wall thickness as a predictor of recovery of function in myocardial hibernation: relation to rest-redistribution T1-201 tomography and dobutamine stress echocardiography. J Am Coll Cardiol 2000; 35:1152.
  27. Beckmann S, Schartl M, Bocksch W, Fleck E. Diagnosis of coronary artery disease and viable myocardium by stress echocardiography. Diagnostic accuracy of different stress modalities. Eur Heart J 1995; 16 Suppl J:10.
  28. Cheirif J, Murgo JP. Assessment of myocardial viability by dobutamine echocardiography. Coron Artery Dis 1995; 6:600.
  29. Main ML, Grayburn PA, Landau C, Afridi I. Relation of contractile reserve during low-dose dobutamine echocardiography and angiographic extent and severity of coronary artery disease in the presence of left ventricular dysfunction. Am J Cardiol 1997; 79:1309.
  30. Barillà F, De Vincentis G, Mangieri E, et al. Recovery of contractility of viable myocardium during inotropic stimulation is not dependent on an increase of myocardial blood flow in the absence of collateral filling. J Am Coll Cardiol 1999; 33:697.
  31. Krivokapich J, Czernin J, Schelbert HR. Dobutamine positron emission tomography: absolute quantitation of rest and dobutamine myocardial blood flow and correlation with cardiac work and percent diameter stenosis in patients with and without coronary artery disease. J Am Coll Cardiol 1996; 28:565.
  32. Nagueh SF, Mikati I, Weilbaecher D, et al. Relation of the contractile reserve of hibernating myocardium to myocardial structure in humans. Circulation 1999; 100:490.
  33. Baumgartner H, Porenta G, Lau YK, et al. Assessment of myocardial viability by dobutamine echocardiography, positron emission tomography and thallium-201 SPECT: correlation with histopathology in explanted hearts. J Am Coll Cardiol 1998; 32:1701.
  34. Poldermans D, Rambaldi R, Bax JJ, et al. Safety and utility of atropine addition during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction. Eur Heart J 1998; 19:1712.
  35. Meza MF, Ramee S, Collins T, et al. Knowledge of perfusion and contractile reserve improves the predictive value of recovery of regional myocardial function postrevascularization: a study using the combination of myocardial contrast echocardiography and dobutamine echocardiography. Circulation 1997; 96:3459.
  36. Yong Y, Nagueh SF, Shimoni S, et al. Deceleration time in ischemic cardiomyopathy: relation to echocardiographic and scintigraphic indices of myocardial viability and functional recovery after revascularization. Circulation 2001; 103:1232.
  37. Hoffmann R, Altiok E, Nowak B, et al. Strain rate measurement by doppler echocardiography allows improved assessment of myocardial viability inpatients with depressed left ventricular function. J Am Coll Cardiol 2002; 39:443.
  38. Hanekom L, Jenkins C, Jeffries L, et al. Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography: a follow-up study after revascularization. Circulation 2005; 112:3892.
  39. Ling LH, Christian TF, Mulvagh SL, et al. Determining myocardial viability in chronic ischemic left ventricular dysfunction: a prospective comparison of rest-redistribution thallium 201 single-photon emission computed tomography, nitroglycerin-dobutamine echocardiography, and intracoronary myocardial contrast echocardiography. Am Heart J 2006; 151:882.
  40. Bax JJ, Poldermans D, Elhendy A, et al. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol 2001; 26:147.
  41. Underwood SR, Bax JJ, vom Dahl J, et al. Imaging techniques for the assessment of myocardial hibernation. Report of a Study Group of the European Society of Cardiology. Eur Heart J 2004; 25:815.
  42. Baer FM, Voth E, Schneider CA, et al. Comparison of low-dose dobutamine-gradient-echo magnetic resonance imaging and positron emission tomography with [18F]fluorodeoxyglucose in patients with chronic coronary artery disease. A functional and morphological approach to the detection of residual myocardial viability. Circulation 1995; 91:1006.
  43. Kim RJ, Shah DJ. Fundamental concepts in myocardial viability assessment revisited: when knowing how much is "alive" is not enough. Heart 2004; 90:137.
  44. Ramani K, Judd RM, Holly TA, et al. Contrast magnetic resonance imaging in the assessment of myocardial viability in patients with stable coronary artery disease and left ventricular dysfunction. Circulation 1998; 98:2687.
  45. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000; 343:1445.
  46. Selvanayagam JB, Kardos A, Francis JM, et al. Value of delayed-enhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical revascularization. Circulation 2004; 110:1535.
  47. Bøtker HE, Lassen JF, Hermansen F, et al. Electromechanical mapping for detection of myocardial viability in patients with ischemic cardiomyopathy. Circulation 2001; 103:1631.
  48. Fuchs S, Hendel RC, Baim DS, et al. Comparison of endocardial electromechanical mapping with radionuclide perfusion imaging to assess myocardial viability and severity of myocardial ischemia in angina pectoris. Am J Cardiol 2001; 87:874.
  49. Koch KC, vom Dahl J, Wenderdel M, et al. Myocardial viability assessment by endocardial electroanatomic mapping: comparison with metabolic imaging and functional recovery after coronary revascularization. J Am Coll Cardiol 2001; 38:91.
  50. Gyöngyösi M, Sochor H, Khorsand A, et al. Online myocardial viability assessment in the catheterization laboratory via NOGA electroanatomic mapping: Quantitative comparison with thallium-201 uptake. Circulation 2001; 104:1005.
  51. Wiggers H, Bøtker HE, Søgaard P, et al. Electromechanical mapping versus positron emission tomography and single photon emission computed tomography for the detection of myocardial viability in patients with ischemic cardiomyopathy. J Am Coll Cardiol 2003; 41:843.
  52. Shimoni S, Frangogiannis NG, Aggeli CJ, et al. Identification of hibernating myocardium with quantitative intravenous myocardial contrast echocardiography: comparison with dobutamine echocardiography and thallium-201 scintigraphy. Circulation 2003; 107:538.
  53. Bax JJ, Wijns W, Cornel JH, et al. Accuracy of currently available techniques for prediction of functional recovery after revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease: comparison of pooled data. J Am Coll Cardiol 1997; 30:1451.
  54. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.