Mid wall fibrosis on CMR with late gadolinium enhancement may predict prognosis for LVAD and transplantation risk in patients with newly diagnosed dilated cardiomyopathy—preliminary observations from a high‐volume transplant centre

Abstract

BackgroundPatients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high‐risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration.MethodsOver 49 consecutive months, 61 consecutives DCM patients were referred for standard CMR(1.5T, GE) to interrogate the LV pattern, distribution, and extent of LGE (MultiHance, Princeton, NJ). Inclusion criteria for a primary non‐ischaemic DCM and EF <45% were met in 31 patients. DCM patients were categorized into: (i) presence of midwall LV stripe (+Stripe) and (ii) absence of midwall stripe (−Stripe) groups. Primary outcome was defined by the composite of death, need for LV assist device (LVAD), and urgent orthotopic cardiac transplantation (Tx) during a 12‐month follow‐up period. Kaplan–Meier survival analysis was conducted grouping patients by +Stripe and −Stripe.ResultsThere were no differences between groups for demographics, blood pressure, labs, baseline LVEF, NYHA class, or invasive haemodynamics. There were 18 patients (58%) with +Stripe. Nine events occurred: seven patients required urgent Tx and/or LVAD implantation and two patients died. The +Stripe categorization strongly predicted the need for LVAD, urgent Tx surgery, and death (log‐rank = 9, P = 0.002). All the events occurred in the +Stripe patients with no MACE experienced in the −Stripe group. The −Stripe group experienced marked signs of improvement in LVEF (P = 0.01) at follow‐up. LVEDD was predictive of need for LVAD/Tx and death by univariate analysis. Otherwise, no common clinical metric such as LVEF, LVEDV, RVEF, RVEDV, or any invasive haemodynamic parameter predicted MACE.ConclusionsThe presence of +Stripe on CMR is strongly predictive of LVAD, transplant need, and death during a 12‐month follow‐up period in DCM patients in this proof of concept study. All −Stripe patients survived without experiencing any events. Incorporating CMR imaging into routine clinical practice may have prognostic value in DCM patients; indicating conservative management in low‐risk patients while expectantly managing high‐risk patients.

Overlapping Phenotypes and Degree of Ventricular Dilatation Are Associated with Severity of Systolic Impairment and Late Gadolinium Enhancement in Non-Ischemic Cardiomyopathies

“…When supplementary analyses of LGE morphology were performed, the linear midventricular type of imbibition was associated with LVEF ≤45%, while the general existence of LGE and the diffuse type of LGE imbibition were both estimated at LVEF ≤52%. This result is in line with a study that assessed effects of linear midventricular stripe on prognosis of DCM, taking into account the need for ventricular assist device, heart transplantation, or cardiac death [ 36 ]. Similarly, the diffuse type of ventricular fibrosis was previously reported to increase prevalence of arrhythmias in patients with HCM, as opposed to focal type of inhibition, which occasionally was not connected with adverse cardiovascular events [ 37 ].…”

Left ventricular midwall fibrosis as a predictor of sudden cardiac death in non‐ischaemic dilated cardiomyopathy: a meta‐analysis

“…Two studies were then excluded because of repetition of cohort, 7,15 and a further 16 studies were excluded because of lack of raw data or otherwise ineligible comparison of study design with selection criteria. Finally, seven studies 8,9,[12][13][14]16,17 enrolling 1827 patients were included for the meta-analysis. Figure 1 provides further details regarding the identification and selection process.…”

Ratio of End-Systolic Volume to Left Atrial Area Is a Solid Benchmark of Systolic Dysfunction in Non-Ischemic Cardiomyopathies

“…In this sense, geometric infrastructural changes that cause end-diastolic dilatation and loss of systolic function in terms of previously known negative prognostic value could be further characterized by end-systolic changes of volume and end-systolic geometric alternations. ESV/LAA also had moderately high correlations with more malignant mid-ventricular linear type of late gadolinium enhancement [26].…”