Ischemic and non-ischemic patterns of late gadolinium enhancement in heart failure with reduced ejection fraction

Abstract

Background: Late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) may reveal myocardial fibrosis which is associated with adverse clinical outcomes in patients undergoing implantable cardioverter-defibrillator (ICD) placement. At the same time, transmural LGE in the posterolateral wall is related to nonresponse to conventional cardiac resynchronization therapy (CRT). Herein, the aim was to assess the presence and determinants of LGE in CMR in heart failure (HF) with reduced ejection fraction. Methods: 67 patients were included (17.9% female, aged 45 [29-60] years), who underwentLGE-CMR and had left ventricular ejection fraction (LVEF) as determined by echocardiography. Results:In HF patients with LVEF ≤ 35% (n = 29), ischemic and non-ischemic patterns ofLGE were observed in 51.7% and 34.5% of patients, respectively. In controls (n = 38), these patterns were noted in 23.7% and 42.1% of patients, respectively. HF patients with LVEF ≤ 35% and transmural LGE in the posterolateral wall (31.0%) were characterized by older age, coronary artery disease (CAD) and previous myocardial infarction (MI) (61 ± 6 vs. 49 ± 16 years, p = 0.008, 100% vs. 40%, p = 0.003 and 78% vs. 25%, p = 0.014, respectively). In patients with LVEF ≤ 35%, LGE of any type, diagnosed in 86.2% of patients, was associated with CAD (68% vs. 0%, p = 0.02), while only trends were observed for its association with older age and previous MI (p = 0.08 and p = 0.12, respectively). Conclusions: Among HF patients with LVEF ≤ 35%, clinical factors including older age, CAD, and previous MI are associated with transmural LGE in the posterolateral wall, while CAD is associated with LGE. This data may have potential implications for planning ICD and CRT placement procedures. Key words: heart failure, late gadolinium enhancement, ischemic, cardiac magnetic resonance, transmural late gadolinium enhancement, cardiac resynchronization therapy, implantable cardioverter-defibrillator CONCLUSIONS Among HF patients with LVEF of 35% or less, clinical factors, including older age, CAD, and previous MI are associated with transmural LGE in the posterolateral wall, while CAD is associated with LGE. This data may have potential implications for planning ICD and CRT placement procedures.

State-of-the-Art Review: Technical and Imaging Considerations in Hybrid Transcatheter and Minimally Invasive Left Ventricular Reconstruction for Ischemic Heart Failure

“…When procedural eligibility has been confirmed by initial TTE evaluation, LGE CMR imaging should be performed as it gives a higher resolution image, precisely determines the location and transmurality of myocardial scar, and assesses myocardial viability [ 5 , 20 , 21 ]. Gadolinium-based contrast accumulates within areas of increased extracellular space (such as fibrosis), thereby enhancing scarred areas [ 26 ]. The patterns of LGE help to differentiate between ischemic and non-ischemic myocardial injury since ischemic myocardial injury causes typical subendocardial or transmural LGE [ 26 ].…”

“…Gadolinium-based contrast accumulates within areas of increased extracellular space (such as fibrosis), thereby enhancing scarred areas [ 26 ]. The patterns of LGE help to differentiate between ischemic and non-ischemic myocardial injury since ischemic myocardial injury causes typical subendocardial or transmural LGE [ 26 ]. The cardiac LV segmentation model described by the American Heart Association (AHA) facilitates the description of scarred myocardium based on the distribution of LGE by dividing the heart into 17 segments [ 26 , 27 ].…”

“…The patterns of LGE help to differentiate between ischemic and non-ischemic myocardial injury since ischemic myocardial injury causes typical subendocardial or transmural LGE [ 26 ]. The cardiac LV segmentation model described by the American Heart Association (AHA) facilitates the description of scarred myocardium based on the distribution of LGE by dividing the heart into 17 segments [ 26 , 27 ]. These segments are consistent with vascular supply from the three major coronary arteries [ 26 , 27 ].…”

Clinical Data, Chest Radiograph and Electrocardiography in the Screening for Left Ventricular Hypertrophy: The CAR2E2 Score

“…CMR images were obtained using a 1.5 Tesla GE Signa HDxt scanner (General Electric, Milwaukee, WI, USA). The fast imaging employing steady-state acquisition (FI-ESTA) cine technique and other techniques such as those reported previously were implemented [16,17]. Left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), LVEDV and LVM were assessed with the use of standard volumetric techniques and calculated with commercially available QMass ® MR analysis software, version 7.6 (Medis Medical Imaging Systems bv, Leiden, The Netherlands) [16].…”

Prognostic value of the Selvester QRS score for re-hospitalization in patients with ischemic heart failure

“…Myocardial scar assessed on cardiovascular magnetic resonance (CMR) is associated with poor outcome in HF [3]. However, CMR is not in widespread clinical use.…”