Multimodality Assessment of Myocardial Viability: The Role of Dobutamine Stress Echocardiography in Guiding Therapeutic Strategy. A Case Report

Assessing myocardial viability is a crucial component in the risk stratification of patients with ischemic heart disease and left ventricular systolic dysfunction, as it enables the identification of myocardial segments capable of recovery following revascularization. Dobutamine stress echocardiography is a widely available tool for assessing contractile reserve and guiding therapeutic decision-making in complex clinical scenarios. We present the case of a 72-year-old man with a history of arterial hypertension, type 2 diabetes mellitus, and chronic kidney disease who presented to the emergency department with progressive dyspnea and a recent history of chest pain. Transthoracic echocardiography revealed a left ventricular ejection fraction of 40% with septoapical akinesia. Coronary angiography demonstrated multivessel coronary artery disease with severe obstructive lesions in the left anterior descending artery and diagonal branches, associated with unfavorable distal vascular beds. Dobutamine stress echocardiography showed neither contractile reserve nor myocardial viability in the affected territories, alongside reduced coronary reserve. After evaluating the case, taking into account the anatomical and functional findings as well as the high surgical risk, revascularization was ruled out, and medical therapy was initiated. This case illustrates the value of dobutamine stress echocardiography as a tool for assessing myocardial viability in patients with advanced ischemic heart disease. Integrating clinical, anatomical, and functional data supported a conservative treatment strategy, consistent with contemporary evidence and current recommendations for tailoring revascularization decisions in patients with left ventricular dysfunction.