Absence of late gadolinium enhancement on cardiac magnetic resonance imaging in ventricular fibrillation and nonischemic cardiomyopathy

Voskoboinik, Aleksandr; Wong, Maria M.; Elliott, Jessica K.; Costello, B.; Prabhu, Sandeep; Mariani, Justin A.; Kalman, Jonathan M.; Taylor, Andrew J.; Morton, Joseph B.

doi:10.1111/pace.13426

Cited by 7 publications

(5 citation statements)

References 21 publications

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“…LGE (24) underscores the challenges further. Whether more robust phenotyping provided by ECV quantification of DMF improves risk-stratification and identifies high risk subgroups with DMF ultimately requires randomized trials of ECV-guided care to establish benefit (analogous to LGE guided-care under investigation, NCT05568069, NCT01918215).…”

Section: Discussionmentioning

confidence: 99%

“…Given the observation that substantial proportions of ICD recipients never require ICD therapies, and given their costs and their risks including infection and inappropriate shock, optimal risk stratification requires further understanding, especially for primary prevention in nonischemic cardiomyopathy as exemplified by the DANISH Trial. (46) The significant proportion of SCD survivors who do not exhibit focal MF with LGE(24) underscores the challenges further. Whether more robust phenotyping provided by ECV quantification of DMF improves risk-stratification and identifies high risk subgroups with DMF ultimately requires randomized trials of ECV-guided care to establish benefit (analogous to LGE guided-care under investigation, NCT05568069, NCT01918215).…”

Section: Discussionmentioning

confidence: 99%

“…LGE from myocardial infarction (MI) or nonischemic focal MF especially involving the septum, (15,16) undoubtedly associates with ventricular arrhythmia (15)(16)(17)(18)(19)(20)(21)(22)(23), but most sudden cardiac death (SCD) survivors with nonischemic cardiomyopathy do not exhibit LGE. (24) Since LGE fundamentally cannot evaluate DMF, (1,2) the role of DMF in ventricular arrhythmia remains uncertain.…”

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confidence: 99%

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Diffuse myocardial fibrosis associates with incident ventricular arrhythmia in implantable cardioverter defibrillator recipients

Olausson

Wertz

Fridman

et al. 2023

Preprint

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Background: Diffuse myocardial fibrosis (DMF) quantified by extracellular volume (ECV) may represent a vulnerable phenotype and associate with life threatening ventricular arrhythmias more than focal myocardial fibrosis. This principle remains important because 1) risk stratification for implantable cardioverter defibrillators (ICD) remains challenging, and 2) DMF may respond to current or emerging medical therapies (reversible substrate). Objectives: To evaluate the association between quantified by ECV in myocardium without focal fibrosis by late gadolinium enhancement (LGE) with time from ICD implantation to 1) appropriate shock, or 2) shock or anti-tachycardia pacing. Methods: Among patients referred for cardiovascular magnetic resonance (CMR) without congenital disease, hypertrophic cardiomyopathy, or amyloidosis who received ICDs (n=215), we used Cox regression to associate ECV with incident ICD therapy. Results: After a median of 2.9 (IQR 1.5-4.2) years, 25 surviving patients experienced ICD shock and 44 experienced shock or anti-tachycardia pacing. ECV ranged from 20.2% to 39.4%. No patient with ECV<25% experienced an ICD shock. ECV associated with both endpoints, e.g., hazard ratio 2.17 (95%CI 1.17-4.00) for every 5% increase in ECV, p=0.014 in a stepwise model for ICD shock adjusting for ICD indication, age, smoking, atrial fibrillation, and myocardial infarction, whereas focal fibrosis by LGE and global longitudinal strain (GLS) did not. Conclusions: DMF measured by ECV associates with ventricular arrhythmias requiring ICD therapy in a dose-response fashion, even adjusting for potential confounding variables, focal fibrosis by LGE, and GLS. ECV-based risk stratification and DMF representing a therapeutic target to prevent ventricular arrhythmia warrant further investigation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Diffuse myocardial fibrosis associates with incident ventricular arrhythmia in implantable cardioverter defibrillator recipients

Olausson

Wertz

Fridman

et al. 2023

Preprint

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“…Cardiac magnetic resonance with LGE plays an important role in patients' workup by assessing for foci of myocardial fibrosis. Moreover, the presence of LGE in patients with nonischemic cardiomyopathy indicates higher mortality and morbidity rates and could indicate worse reversibility of ventricular remodeling [24][25][26][27]. A recent meta-analysis, which included 34 separate studies with a total of 5076 patients (4554 unique patients), concluded that the presence of LGE was associated with a 3.4 [95% CI: 2.04-5.67] higher risk of cardiovascular mortality, a 4.52 risk [95% CI: 3.41-5.99] of ventricular arrhythmic events, and only a 0.15 [95% CI: 0.06-0.36] higher risk of LV reverse remodeling, thus further underscoring the prognostic value of LGE in patients with DCM [23].…”

Section: Discussionmentioning

confidence: 99%

Cardiac Magnetic Resonance in Patients with Suspected Tachycardia-Induced Cardiomyopathy: The Impact of Late Gadolinium Enhancement and Epicardial Fat Tissue

Orlov,

Asfour,

Shchekochikhin

et al. 2023

JPM

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Tachycardia-induced cardiomyopathy (TIC) is a reversible subtype of dilated cardiomyopathy (DCM) resulting from sustained supraventricular or ventricular tachycardia and diagnosed by the normalization of left ventricular ejection fraction (LVEF) after stable sinus rhythm restoration. The aim of this study was to determine the contribution of cardiac magnetic resonance (CMR) to the differential diagnosis of TIC and DCM with persistent atrial arrythmias in patients hospitalized for the first time with heart failure (HF) with reduced LVEF of nonischemic origin. A total of 29 patients (age: 58.2 ± 16.9 years; males: 65.5%; average EF: 37.0 ± 9.5%) with persistent atrial tachyarrhythmia and first decompensation of HF without known coronary artery diseases were included in this study. The patients successfully underwent cardioversion and were observed for 30 days. The study population was divided into groups of responders (TIC patients; N = 16), which implies achieving FF > 50% or its increase > 10% in 30 days of TIC, and non-responders (N = 13). The increase in left ventricle (LV) volumes measured using CMR was significantly higher in the non-responder group when compared with the responders (114.8 mL ± 25.1 vs. 68.1 mL ± 10.5, respectively, p < 0.05). Non-responders also demonstrated decreased interventricular septum thickness (9.1 ± 0.8 vs.11.5 ± 1.3, respectively, p < 0.05). Late gadolinium enhancement (LGE) was observed in 12 patients (41.4%). The prevalence of LGE was increased in the non-responder group (25.0% vs. 65.1%, respectively, p = 0.046). Notably, a septal mid-wall LGE pattern was found exclusively in the non-responders. Epicardial adipose tissue thickness was decreased in the non-responder group versus the TIC patients. Conclusion: Patients with TIC were found to have smaller atrial and ventricular dimensions in comparison to patients with DCM. In addition, LGE was more common in DCM patients.

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“…LGE-CMR furthermore depends on several factors such as the timing of contrast injection and selection of scan parameters that can impact the interpretation of intensity values on imaging. Another limitation of LGE for risk stratification of SCD is that a subset of patients with NICM who develop VF may not have LGE on CMR ( 50 ). Several alternative measures derived from CMR have been proposed that may address some of these limitations, including native T1 mapping and extracellular volume (ECV), which reflect diffuse fibrosis, a characteristic not captured by LGE ( 51 , 52 ).…”

Section: Cardiac Magnetic Resonance Imagingmentioning

confidence: 99%

Advanced imaging for risk stratification for ventricular arrhythmias and sudden cardiac death

Xie

Sung

Saad

et al. 2022

Front. Cardiovasc. Med.

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Sudden cardiac death (SCD) is a leading cause of mortality, comprising approximately half of all deaths from cardiovascular disease. In the US, the majority of SCD (85%) occurs in patients with ischemic cardiomyopathy (ICM) and a subset in patients with non-ischemic cardiomyopathy (NICM), who tend to be younger and whose risk of mortality is less clearly delineated than in ischemic cardiomyopathies. The conventional means of SCD risk stratification has been the determination of the ejection fraction (EF), typically via echocardiography, which is currently a means of determining candidacy for primary prevention in the form of implantable cardiac defibrillators (ICDs). Advanced cardiac imaging methods such as cardiac magnetic resonance imaging (CMR), single-photon emission computerized tomography (SPECT) and positron emission tomography (PET), and computed tomography (CT) have emerged as promising and non-invasive means of risk stratification for sudden death through their characterization of the underlying myocardial substrate that predisposes to SCD. Late gadolinium enhancement (LGE) on CMR detects myocardial scar, which can inform ICD decision-making. Overall scar burden, region-specific scar burden, and scar heterogeneity have all been studied in risk stratification. PET and SPECT are nuclear methods that determine myocardial viability and innervation, as well as inflammation. CT can be used for assessment of myocardial fat and its association with reentrant circuits. Emerging methodologies include the development of “virtual hearts” using complex electrophysiologic modeling derived from CMR to attempt to predict arrhythmic susceptibility. Recent developments have paired novel machine learning (ML) algorithms with established imaging techniques to improve predictive performance. The use of advanced imaging to augment risk stratification for sudden death is increasingly well-established and may soon have an expanded role in clinical decision-making. ML could help shift this paradigm further by advancing variable discovery and data analysis.

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Absence of late gadolinium enhancement on cardiac magnetic resonance imaging in ventricular fibrillation and nonischemic cardiomyopathy

Abstract: Most VF survivors with a diagnosis of NICM did not have LGE on CMR and would not have met primary prevention ICD criteria based on LVEF. Absence of LGE may not portend a benign prognosis in NICM. Novel strategies for determining SCD risk in this cohort are required.

Cited by 7 publications

References 21 publications

Diffuse myocardial fibrosis associates with incident ventricular arrhythmia in implantable cardioverter defibrillator recipients

Diffuse myocardial fibrosis associates with incident ventricular arrhythmia in implantable cardioverter defibrillator recipients

Cardiac Magnetic Resonance in Patients with Suspected Tachycardia-Induced Cardiomyopathy: The Impact of Late Gadolinium Enhancement and Epicardial Fat Tissue

Advanced imaging for risk stratification for ventricular arrhythmias and sudden cardiac death

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