Prognostic Value of Routine Cardiac Magnetic Resonance Assessment of Left Ventricular Ejection Fraction and Myocardial Damage

Abstract

Background-Cardiac magnetic resonance (CMR) is considered the reference standard for assessment of left ventricular ejection fraction (LVEF) and myocardial damage. However, few studies have evaluated the relationship between CMR findings and patient outcome, and of these, most are small and none multicenter. We performed an international, multicenter study to assess the prognostic importance of routine CMR in patients with known or suspected heart disease. Methods and Results-From 10 centers in 6 countries, consecutive patients undergoing routine CMR assessment of LVEF and myocardial damage by cine and delayed-enhancement imaging (DE-CMR), respectively, were screened for enrollment. Clinical data, CMR protocol information, and findings were collected at all sites and submitted to the data coordinating center for verification of completeness and analysis. The primary end point was all-cause mortality. A total of 1560 patients (age, 59Ϯ14 years; 70% men) were enrolled. Mean LVEF was 45Ϯ18%, and 1049 (67%) patients had hyperenhanced tissue (HE) on DE-CMR indicative of damage. During a median follow-up time of 2.4 years (interquartile range, 1.2, 2.9 years), 176 (11.3%) patients died. Patients who died were more likely to be older (PϽ0.0001), have coronary disease (Pϭ0.004), have lower LVEF (PϽ0.0001), and have more segments with HE (PϽ0.0001). In multivariable analysis, age, LVEF, and number of segments with HE were independent predictors of mortality. Among patients with near-normal LVEF (Ն50%), those with above-median HE (Ͼ4 segments) had reduced survival compared to patients with below-or at-median HE (Pϭ0.02). Conclusions-Both LVEF and amount of myocardial damage as assessed by routine CMR are independent predictors of all-cause mortality. Even in patients with near-normal LVEF, significant damage identifies a cohort with a high risk for early mortality. (Circ Cardiovasc Imaging. 2011;4:610-619.)

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.…”

“…CMR has emerged as an important tool to identify the etiology of nonischemic cardiomyopathies,27 and predict risk of adverse outcomes based on the extent of LGE 4, 8, 10, 14, 15, 27. LGE can detect foci of myocardial damage as small as 0.7 g of myocardial tissue 28.…”

“…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.…”

Prevalence of Myocardial Fibrosis Patterns in Patients With Systolic Dysfunction

“…An expanding literature supports a significant association between the presence of myocardial fibrosis by LGE imaging and clinically relevant cardiovascular outcomes. 6,8,14,15,[26][27][28][29] These investigations have examined a range of cardiomyopathy states but only few have focused on the prediction of arrhythmic among those with systolic dysfunction. Among patients with idiopathic NICM, 3 studies to date have reported an association between midwall striae hyperenhancement and future arrhythmic events.…”