Prognostic Significance of Delayed-Enhancement Magnetic Resonance Imaging

Abstract

Background-Left ventricular ejection fraction is a powerful independent predictor of survival in cardiac patients, especially those with coronary artery disease. Delayed-enhancement magnetic resonance imaging (DE-MRI) can accurately identify irreversible myocardial injury with high spatial and contrast resolution. To date, relatively limited data are available on the prognostic value of DE-MRI, so we sought to determine whether DE-MRI findings independently predict survival. Methods and Results-The medical records of 857 consecutive patients who had complete cine and DE-MRI evaluation at a tertiary care center were reviewed regardless of whether the patients had coronary artery disease. The presence and extent of myocardial scar were evaluated qualitatively by a single experienced observer. The primary, composite end point was all-cause mortality or cardiac transplantation. Survival data were obtained from the Social Security Death Index. The median follow-up was 4.4 years; 252 patients (29%) reached one of the end points. Independent predictors of mortality or transplantation included congestive heart failure, ejection fraction, and age (PϽ0.0001 for each), as well as scar index (hazard ratio, 1.26; 95% confidence interval, 1.02 to 1.55; Pϭ0.033). Similarly, in subsets of patients with or without coronary artery disease, scar index also independently predicted mortality or transplantation (hazard ratio, 1.33; 95% confidence interval, 1.05 to 1.68; Pϭ0.018; and hazard ratio, 5.65; 95% confidence interval, 1.74 to 18.3; Pϭ0.004, respectively). Cox regression analysis showed worse outcome in patients with any DE in addition to depressed left ventricular ejection fraction (Ͻ50%). Conclusion-The degree of DE detected by DE-MRI appears to strongly predict all-cause mortality or cardiac transplantation after adjustment for traditional, well-known prognosticators.

Myocardial Damage Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance Is Uncommon in Peripartum Cardiomyopathy

“…Yet, the low prevalence of LGE reported in our work is concordant with the observed improvement in systolic function shown by echocardiographic results from the parent study 1. Since LGE indicates irreversible focal myocardial damage, even when ejection fraction is preserved,8, 9, 10 the overall low prevalence of LGE in this study represents an optimistic finding. Indeed, the CMR literature consistently indicates that LGE is associated with persistent myocardial dysfunction despite medical therapy,11, 12 arrhythmia,4, 13, 14 and in turn, adverse clinical events such as hospitalization for heart failure, arrhythmia, and mortality 4, 8, 10, 14, 15.…”

“…While LGE can occur even when ejection fraction is preserved,8, 9, 10 LGE is generally associated with persistent myocardial dysfunction despite medical therapy,11, 12 arrhythmia,4, 13, 14 and in turn, hospitalization for heart failure, arrhythmia, and mortality 4, 8, 10, 14, 15. Regardless of etiology, LGE is prognostically adverse across the spectrum of left ventricular ejection fraction (LVEF), even when preserved 4, 8, 9, 10.…”

“…Regardless of etiology, LGE is prognostically adverse across the spectrum of left ventricular ejection fraction (LVEF), even when preserved 4, 8, 9, 10. LGE detects foci of irreversible myocardial damage manifest by enhancement, regardless of the mechanism or the timing of injury.…”

Myocardial fibrosis detected by cardiac magnetic resonance imaging in heart failure: Impact on remodeling, diastolic function and BNP levels

“…Absence of myocardial fibrosis is associated with ventricular functional recovery in patients with NICM with high sensitivity (90.5%), specificity (79.2%), positive predictive value (80.0%) and negative predictive value (90.9%) (49). In a survival analysis, cardiac fibrosis was found to be the most important independent predictor of mortality/transplantation requirement, especially in patients with LVEF < 30% who already had increased mortality, survival was found to be decreased in the presence of delayed enhancement (50). Wu et al (21) demonstrated that in NICM with late gadolinium enhancement on CMR, probability to experience adverse cardiac outcomes such as HF hospitalization, implantable cardioverter-defibrillator (ICD) discharge, and cardiac death increased eight fold after adjustment for LV volume index and functional class.…”

Noninvasive assessment myocardial viability: Current status and future directions

“…51,[126][127][128][129] Gerber et al 46 recently reported on 144 patients with mean EF 24% and ischemic cardiomyopathy, who underwent DCE CMR followed for three years. Seventy nine patients underwent CABG, 7 had PCI, and 58 patients received medical therapy alone.…”