(1) To evaluate the prognostic value of LV remodeling parameters in patients with LV aneurysm by gated SPECT (GSPECT), gated PET (GPET) and CMR; (2) to evaluate the impact of myocardial viability and LV remodeling on the long-term cardiac survival in patients with LV aneurysm. One hundred and twenty-six consecutive patients underwent GPET, GSPECT and CMR within two weeks, with a mean follow-up of 3.9 +/- 1.5 years. End-diastolic volume (EDV, mL) and end-systolic volume (ESV, mL) measured by GPET, GSPECT and CMR and corrected for BSA; EDVI and ESVI were calculated. Patients were divided into three groups by aneurysmal viability [mismatch score (MMS) of aneurysm >= 2.0] and LV remodeling (ESVI by GPET > 60 mL/m(2)). Group 1 (Viability -, LV remodeling -); Group 2 (Viability -, LV remodeling +) and Group 3 (Viability +, LV remodeling -/+). ESVI by GPET, MMS of aneurysm and summed rest score of aneurysm by multivariate regression analysis; as well as ESVI by GPET (HR 1.024, 95% CI 1.011-1.037, p = .0004), MMS of aneurysm (HR 1.284, 95% CI 1.051-1.577, p = .015) by interaction analysis were approved being independent predictors for cardiac death (p < .05). The long-term cardiac survival was significantly improved by revascularization in comparison with medical therapy in Group3 (p < .01), but did not significantly differ between Groups 1 and 2. ESVI by GPET showed a significant positive predictive value for cardiac death. Patients with viable myocardial aneurysm were most likely at increased risk for cardiac death and coronary revascularization was significantly associated with improved long-term cardiac survival. In contrast, the long-term cardiac survival of patients without LV remodeling and without aneurysmal viability was promising and, thus, could be treated by medical therapy.