Comparison of myocardial fibrosis quantification methods by cardiovascular magnetic resonance imaging for risk stratification of patients with suspected myocarditis

Abstract

Background Although the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method. Methods Six hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods. Results Ninety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02–1.08, p = 0.001; HR 1.02, 95%CI:1.00–1.04; p = 0.001; HR 1.02, 95%CI: 1.00–1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04–1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values. Conclusions FWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients. Trial registration number NCT03470571 . Registered 13th March 2018. Retrospectively registered.

Quantitative myocardial tissue characterization by cardiac magnetic resonance in heart transplant patients with suspected cardiac rejection

“…Late gadolinium enhancement sequences were analyzed semiquantitatively as previously described . Analysis of LGE was performed visually by defining the areas of hyperenhancement in all myocardial segments as seen on either long‐ or short‐axis slices and quantified using a full width, half maximum method …”

Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging

“…LGE presence was quantified visually and the extent of enhancement was quantified by using the full width half maximum signal intensity (FWHM) threshold cut-off and expressed as a percent of the LV myocardium [19]. From 2007, T2w inversion recovery images were included into the protocol and myocardial oedema was evaluated by assessing the ratio of the signal intensity in the LV myocardium compared to the skeletal muscle (musculus pectoralis major or minor).…”

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“…High signal area of inadequately suppressed slow-owing cavitary blood was excluded carefully 14 . The LGE lesion was quanti ed using full width at half-maximum method 15 . The visual presence and different patterns (epicardial, mid-wall, or transmural) on the LGE images were assessed by two radiologists independently.…”