Ischemic heart failure is probably the most challenging issue in cardiology today, posing an enormous medical and financial burden on our society. Conceptually, it represents a maladaptive cardiac remodeling due to acute and/or chronic coronary artery disease with varying degrees of left ventricular dilatation and dysfunction. Although therapeutic options have improved overall survival over the years, mortality rates remain high, and in daily practice cardiologists not infrequently face the therapeutic dilemma whether a revascularization procedure will lead to symptomatic and prognostic benefit for the patient. Simple, straightforward guidelines are lacking because of the complexity of the disease. Moreover, the issue of viability imaging grounded on observational and retrospective studies has recently been challenged by the publication of prospective, randomized trials (eg, STICH and PARR trial) showing no benefit of revascularization nor of preprocedural viability assessment in those patients. These contradictory findings have obliged us to inquire whether viability imaging is still relevant and what is needed to make it more appropriate.