Late gadolinium enhancement for re‐worsening left ventricular ejection fraction in patients with dilated cardiomyopathy

Abstract

Aims This study aimed to evaluate the clinical parameters including late gadolinium enhancement (LGE) of cardiovascular magnetic resonance to predict re-worsening of left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy (DCM). Methods and results We included 138 patients with recent-onset DCM who had an LVEF <45% and underwent LGE of cardiovascular magnetic resonance imaging at diagnosis and echocardiography at the yearly follow-up [median 6 (4-8.3) years]. Initial LVEF recovery was defined as LVEF increase >10% from baseline, resulting in LVEF ≧45% after treatment. The patients were divided into three groups: (i) improved (n = 83, 60%), defined as those with sustained LVEF ≧45%; (ii) re-worsening (n = 39, 28%), those with >5% decrease and LVEF <45% after the initial LVEF recovery; and (iii) not-improved (n = 16, 12%), those without initial LVEF recovery. The primary endpoint was a composite of hospitalization for heart failure or sudden cardiac death. In baseline, LGE was observed in 70 patients. The LGE area was significantly larger in the re-worsening and not-improved groups than that in the improved group (P < 0.001). Loess curves of long-term LVEF trajectories showed that LVEF in the re-worsening group increased in the first 2 years and slowly declined thereafter. Multivariate logistic regression analysis demonstrated that LGE area [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03-1.16, P = 0.004], B-type natriuretic peptide (OR 1.49, 95% CI 1.05-2.21, P = 0.030) level at the initial recovery, and LVEF (OR 0.91, 95% CI 0.86-0.97, P = 0.004) at the initial LVEF recovery were independent predictors of re-worsening of LVEF. During a median follow-up of 2273 (interquartile range: 1634-3191) days, the primary endpoint was observed in 31 (22%) patients. Univariate Cox proportional hazards analysis demonstrated that the risk of experiencing the primary event in the re-worsening group was significantly higher (hazard ratio: 4.30, 95% CI 1.63-11.31, P = 0.003) than that in the improved group and was lower than that in the not-improved group (hazard ratio: 0.33, 95% CI 0.15-0.72, P = 0.006). Conclusions Re-worsening of LVEF was observed in 28% of patients with recent-onset DCM who showed an initial improvement in LVEF. High LGE burden, higher B-type natriuretic peptide level, and lower LVEF at the initial LVEF recovery were independent predictors of re-worsening of LVEF in patients with DCM. Careful observation is recommended for patients with a high risk for re-worsening of LVEF, even in those with an initial LVEF recovery.

Cardiac remodelling – Part 2: Clinical, imaging and laboratory findings. A review from the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology

“…High LGE burden, higher B-type natriuretic peptide (BNP) level, and lower LVEF at the initial LVEF recovery were independent predictors of LVEF re-worsening. 85 Moreover, patients with LVEF re-worsening (n = 39, 28%) showed a clinical prognosis (incidence of HF hospitalization and sudden death during a median 6-year follow-up) that was intermediate between those with RR (n = 83, 60%) and AR (n = 16, 12%). 85 A lower myocardial T2 and a lower ECV have been demonstrated to predict RR 45,46 46 In another small study on 56 DCM patients, only LV contractile reserve at dobutamine stress CMR independently predicted RR, while LGE presence and extent, T1 and ECV did not.…”

“…In a recent study on 138 patients with recent‐onset DCM and an initial LVEF <45%, re‐worsening of LVEF was defined as an initial RR (to an intermediate LVEF ≥45%) followed by AR (LVEF decrease >5% to a final value <45% after the initial LVEF recovery). High LGE burden, higher B‐type natriuretic peptide (BNP) level, and lower LVEF at the initial LVEF recovery were independent predictors of LVEF re‐worsening 85 . Moreover, patients with LVEF re‐worsening ( n = 39, 28%) showed a clinical prognosis (incidence of HF hospitalization and sudden death during a median 6‐year follow‐up) that was intermediate between those with RR ( n = 83, 60%) and AR ( n = 16, 12%) 85 …”

“…High LGE burden, higher B‐type natriuretic peptide (BNP) level, and lower LVEF at the initial LVEF recovery were independent predictors of LVEF re‐worsening 85 . Moreover, patients with LVEF re‐worsening ( n = 39, 28%) showed a clinical prognosis (incidence of HF hospitalization and sudden death during a median 6‐year follow‐up) that was intermediate between those with RR ( n = 83, 60%) and AR ( n = 16, 12%) 85 …”

Association of late gadolinium enhancement in cardiac magnetic resonance with mortality, ventricular arrhythmias, and heart failure in patients with nonischemic cardiomyopathy: A systematic review and meta-analysis

“…In one study, the presence of LGE was not associated with initial low LVEF, but it predicted subsequent worsening of LVEF over time. 18 …”

Your Heart Function Has Normalized—What Next After TRED-HF?

“…Evidence suggests that replacement myocardial fibrosis predicts lower rates of LVRR [ 55 ]. A retrospective review of 148 patients with recent-onset DCM showed that one-third of the population with initially improved LVEF (≥ 45%) presented with re-worsening of their LVEF which was associated with the degree of fibrosis on CMR [ 56 ]. Preliminary data from TRED-HF showed that there was expansion of the extracellular matrix during treatment withdrawal, suggestive of ongoing fibrotic activity [ 22 ].…”