The clinical reality of managing coronary artery disease (CAD) today often exposes a significant diagnostic gap: the inability of traditional echocardiograms or nuclear perfusion mismatch techniques to precisely distinguish between hibernating and dead myocardium.

Unresolved diagnostic ambiguities frequently lead to sub-optimal revascularization planning, leaving complex cardio-kidney-metabolic (CKM) patients vulnerable to unaddressed ventricular arrhythmias and sudden cardiac death.

In an interview at TheRightDoctors studio at the 4th World Congress on Cardio-Kidney-Metabolic Medicine (WCCKMM 2026) at the Leela, Mumbai, Dr. P. C. Manoria, Executive President of the congress, spoke with Dr. Y. S. Chandrashekhar, Editor-in-Chief, JACC Cardiovascular Imaging (USA), on advancing myocardial viability assessment.

Probing the viability practice gap, Dr. P. C. Manoria asked which imaging modality offers the most reliable diagnostic data. Dr. Y. S. Chandrashekhar stated that late gadolinium enhancement (LGE) in cardiac MRI now defeats alternative techniques by turning dead myocardium white while normal tissue remains black.

Responding to Dr. P. C. Manoria’s query about quantifying arrhythmic propensity, Dr. Y. S. Chandrashekhar noted that scar size is highly proportionate to future adverse events. In ischemic cardiomyopathy, LGE involving over 5% of the myocardium identifies a high-risk group.

Dr. Y. S. Chandrashekhar highlighted that this threshold preserves significant prognostic power even in patients presenting with mild to moderately reduced ejection fractions, resolving clinical dilemmas regarding implantable cardioverter-defibrillator (ICD) placement.

Elaborating on structural scar patterns as prompted by Dr. P. C. Manoria, Dr. Y. S. Chandrashekhar explained that sub-endocardial scars following a specific coronary artery territory guarantee an ischemic origin, even if spontaneous recanalization has occurred.

When Dr. P. C. Manoria shifted focus to the microvasculature, Dr. Y. S. Chandrashekhar acknowledged that while epicardial stenosis is simpler to mechanically resolve, microvascular dysfunction requires sophisticated non-invasive quantification via PET or invasive index of microvascular resistance (IMR).

Raised by Dr. P. C. Manoria as a critical closing provocation: Is the clinical community ready to move past the legacy of ejection fraction and adopt global longitudinal strain as the primary measure of contractility, or will established guidelines continue to anchor practice to traditional metrics?

TheRightDoctors | Official Digital Knowledge Partner | WCCKMM 2026