Case presentation. A 69-year-old man was evaluated for chronic left ventricular dysfunction with heart failure (New York Heart Association class III-IV), without angina pectoris. He had a history of an inferoseptal infarction (3 years ago), with Q waves in the inferior leads. Catheterization revealed diffuse, extensive 3-vessel disease with an occluded right coronary artery. The left ventricular ejection fraction (LVEF) was 23%. Resting echocardiography showed a large akinetic region involving the inferolateral, inferior, septal, and apical segments. The patient had diabetes mellitus type II, regulated with oral hypoglycemic agents. Additional comorbidities included impaired renal function and peripheral vascular disease. Clinical problem. Clinical management of patients with ischemic cardiomyopathy and severely depressed LVEF remains difficult. Medical treatment remains suboptimal, although angiotensin-converting enzyme inhibitors, -blockers, and spironolactone have improved survival. Heart transplantation has an excellent prognosis, but donor hearts are limited. Revascularization has a high morbidity and mortality, but in patients with extensive areas of dysfunctional but viable myocardium, improvement of LVEF, heart failure symptoms, and prognosis may be anticipated. Viability assessment. Resting 2-dimensional echocardiography was used to evaluate contractile status. The results are presented in polar map format (13 segments, Figure 1 A). Figure 1B illustrates the regions with contractile dysfunction (extending from inferolateral to inferoseptal and apical). Resting perfusion (thallium 201 single photon emission computed tomography [SPECT]) showed a large perfusion defect extending from the inferolateral to the inferoseptal wall (Figure 2 , left panel, arrow). Fluorodeoxyglucose (FDG) uptake was similarly reduced in the inferolateral wall (Figure 2, right panel, arrow) but preserved in the other segments (indicating viable tissue). Figure 3 shows the polar maps of the perfusion (left panel) and FDG (right panel) studies; for comparison with the echocardiography data, the same 13-segment model was used (6 basal, 6 distal, and 1 apical segment). A large perfusion defect was present in the inferior wall, the apex, and part of the septum (inferoseptal). The FDG polar map shows a much smaller defect, mainly located in the inferior wall. On the basis of the SPECT results (viable, dysfunctional myocardium in the right coronary artery/left circumflex artery territories, subtended by severely diseased coronary arteries), the patient was considered at high risk for future cardiac events. Clinical course. On the basis of the comorbidity and poor target vessels for revascularization, the patient was treated conservatively with nitrates, diuretics, digoxin, and angiotensin-converting enzyme inhibitors. The patient died several months later out of the hospital, most likely due to sudden cardiac death. Discussion. Optimal management of patients with ischemic cardiomyopathy remains problematic. Symptoms, assessment of ischemia, comorbidity, and angiography determine whether revascularization is an option. In addition to this information, assessment of viability is currently performed to justify the higher risk for perioperative morbidity/mortality. Haas et al showed that viability-guided revascularization may reduce perioperative morbidity and mortality. Numerous studies have shown that patients with viable myocardium have improvement in function after revascularization. Other studies have demonstrated that patients with viable tissue who were treated medically had a high event rate. Pooling the available studies focusing on viability in relation to prognosis demonstrated an annual event rate of 27% in patients with viable myocardium who were treated conservatively, as compared with 6% in patients with viable myocardium who underwent revascularization. These findings emphasize the importance of considering revascularization in patients with ischemic cardiomyopathy and viable myocardium. The current patient underscores the unfavorable prognosis of a patient with viable myocardium who was treated conservatively. It should be emphasized, however, that the patient was not a suitable candidate for revascularization because of extensive comorbidity (diabetes, renal dysfunction, peripheral vascular disease) and poor target From Leiden University Medical Center, Leiden, Free University Hospital, Amsterdam, and Thorax Center, Rotterdam, The Netherlands. Reprint requests: Jeroen J. Bax, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; jbax@knoware.nl. J Nucl Cardiol 2002;9:675-7. Copyright © 2002 by the American Society of Nuclear Cardiology. 1071-3581/2002/$35.00 0 43/1/125218 doi:10.1067/mnc.2002.125218