Association between late gadolinium enhancement and outcome in dilated cardiomyopathy:A meta-analysis

BACKGROUND The prognostic value of late gadolinium enhancement(LGE)derived from cardiovascular magnetic resonance(CMR)is well studied,and several new metrics of LGE have emerged.However,some controversies remain;therefore,further discussion is needed,and more precise risk stratification should be explored.AIM To investigate the associations between the positivity,extent,location,and pattern of LGE and multiple outcomes in dilated cardiomyopathy(DCM).METHODS PubMed,Ovid MEDLINE,and Cochrane Library were searched for studies that investigated the prognostic value of LGE in patients with DCM.Pooled hazard ratios(HRs)and 95%confidence intervals were calculated to assess the role of LGE in the risk stratification of DCM.RESULTS Nineteen studies involving 7330 patients with DCM were included in this metaanalysis and covered a wide spectrum of DCM,with a mean left ventricular ejection fraction between 21%and 50%.The meta-analysis revealed that the presence of LGE was associated with an increased risk of multiple adverse outcomes(all-cause mortality,HR:2.14;arrhythmic events,HR:5.12;and composite endpoints,HR:2.38;all P<0.001).Furthermore,every 1%increment in the extent of LGE was associated with an increased risk of all-cause mortality.Analysis of a subgroup revealed that the prognostic value varied based on different location and pattern of LGE.Additionally,we found that LGE was a stronger predictor of arrhythmic events in patients with greater left ventricular ejection fraction.CONCLUSION LGE by CMR in patients with DCM exhibited a substantial value in predicting adverse outcomes,and the extent,location,and pattern of LGE could provide additional information for risk stratification.

Prognostic Value of Feature-Tracking Circumferential Strain in Dilated Cardiomyopathy Patients with Severely Reduced Ejection Fraction Incremental to Late Gadolinium Enhancement

Myocardial fiber deformation measurements have been reported to be associated with adverse outcomes in patients with acute heart failure and those with myocardial infarction.However,few studies have addressed the prognostic value of global circumferential strain(GCS)in dilated cardiomyopathy(DCM)patients with severely impaired systolic function.This study aimed to evaluate the prognostic value of cardiac magnetic resonance(CMR)-derived GCS in DCM patients with severely reduced ejection.Consecutive DCM patients with severely reduced ejection fraction(EF<35%)who underwent CMR were included.GCS was calculated from CMR cine images.The clinical endpoint was a composite of all-cause mortality,heart transplantation,implantable cardioverter defibrillator(ICD)implantation and aborted sudden cardiac death(SCD).A total of 129 patients with a mean EF of 15.33%(11.36%–22.27%)were included.During a median follow-up of 518 days,endpoint events occurred in 50 patients.Patients with GCS≥the median(−5.17%)had significantly reduced event-free survival as compared with those with GCS<the median(P<0.01).GCS was independently associated with adverse events after adjusting for clinical and imaging risk factors including extent of late gadolinium enhancement(LGE)(P<0.05).Adding GCS into the model including the extent of LGE resulted in significant improvements in the C-statistic(from 0.706 to 0.742;P<0.05)with a continuous net reclassification improvement(NRI)of 29.71%.It was concluded that GCS derived from CMR could be useful for risk stratification in DCM patients with severely reduced EF,which may increase common imaging risk factors including LGE.

Fully Automatic Scar Segmentation for Late Gadolinium Enhancement MRI Images in Left Ventricle with Myocardial Infarction

Numerous methods have been published to segment the infarct tissue in theleft ventricle, most of them either need manual work, post-processing, or suffer from poorreproducibility. We proposed an automatic segmentation method for segmenting the infarct tissue irleft ventricle with myocardial infarction. Cardiac images of a total of 60 diseased hearts (55 humanhearts and 5 porcine hearts) were used in this study. The epicardial and endocardial boundariesof the ventricles in every 2D slice of the cardiac magnetic resonance with late gadoliniumenhancement images were manually segmented. The subsequent pipeline of infarct tissuesegmentation is fully automatic. The segmentation results with the automatic algorithm proposed inthis paper were compared to the consensus ground truth. The median of Dice overlap between ourautomatic method and the consensus ground truth is 0.79. We also compared the automatic methodwith the consensus ground truth using different image sources from diferent centers with diferentscan parameters and different scan machines. The results showed that the Dice overlap with thepublic dataset was 0.83, and the overall Dice overlap was 0.79. The results show that our method isrobust with respect to different MRI image sources, which were scanned by different centers withdifferent image collection parameters. The segmentation accuracy we obtained is comparable toor better than that of the conventional semi-automatic methods. Our segmentation method may beuseful for processing large amount of dataset in clinic.

Risk of ventricular arrhythmia in patients with myocardial infarction and non-obstructive coronary arteries and normal ejection fraction

AIM To assess the arrhythmic determinants and prognosis of patients presenting with myocardial infarction and nonobstructive coronary arteries(MINOCA)with normal ejection fraction(EF).METHODS This is an observational analysis of 131 MINOCA patients with normal EF.Three cardiac magnetic resonance(CMR)diagnosis classes were recognized according to the late gadolinium enhancement(LGE)pattern:Myocardial infarction(MI)(n=34),myocarditis(n=47),and"no LGE"(n=50).Ventricular events occurring during hospitalization were recorded and the entire population was followed-up at 1 year.RESULTS Ventricular arrhythmia was observed in 18(13.8%)patients during hospitalization.The"no LGE"patients experienced fewer ventricular events than the MI and myocarditis patients[4.0%vs 26.5%and 14.9%,respectively(P=0.013)].There was no significant difference between the MI and myocarditis groups.On multivariate analysis,LGE transmural extent[OR=1.52(1.08-2.15),P=0.017]and ST-segment elevation[OR=4.65(1.61-13.40),P=0.004]were independent predictors of ventricular arrhythmic events,irrespective of the diagnosis class.Finally,no patient experienced sudden cardiac death or ventricular arrhythmia recurrence at 1-year.CONCLUSION MINOCA patients with normal EF presented no 1-year cardiovascular events,irrespective of the CMR diagnosis class.LGE transmural extent and ST segment elevation at admission are risk markers of ventricular arrhythmia during hospitalization.

Association of electrocardiographic markers with myocardial fibrosis as assessed by cardiac magnetic resonance in different clinical settings

BACKGROUND Cardiac magnetic resonance(CMR)is a unique tool for non-invasive tissue characterization,especially for identifying fibrosis.AIM To present the existing data regarding the association of electrocardiographic(ECG)markers with myocardial fibrosis identified by CMR-late gadolinium enhancement(LGE).METHODS A systematic search was performed for identifying the relevant studies in Medline and Cochrane databases through February 2021.In addition,we conducted a relevant search by Reference Citation Analysis(RCA)(https://www.referencecitationanalysis.com).RESULTS A total of 32 studies were included.In hypertrophic cardiomyopathy(HCM),fragmented QRS(fQRS)is related to the presence and extent of myocardial fibrosis.fQRS and abnormal Q waves are associated with LGE in ischemic cardiomyopathy patients,while fQRS has also been related to fibrosis in myocarditis.Selvester score,abnormal Q waves,and notched QRS have also been associated with LGE.Repolarization abnormalities as reflected by increased Tp-Te,negative Twaves,and higher QT dispersion are related to myocardial fibrosis in HCM patients.In patients with Duchenne muscular dystrophy,a significant correlation between fQRS and the amount of myocardial fibrosis as assessed by LGE-CMR was observed.In atrial fibrillation patients,advanced inter-atrial block is defined as P-wave duration≥120 ms,and biphasic morphology in inferior leads is related to left atrial fibrosis.CONCLUSION Myocardial fibrosis,a reliable marker of prognosis in a broad spectrum of cardiovascular diseases,can be easily understood with an easily applicable ECG.However,more data is needed on a specific disease basis to study the association of ECG markers and myocardial fibrosis as depicted by CMR.

QRS score:A simple marker to quantify the extent of myocardial scarring in patients with chronic total arterial occlusion

Background:Chronic total occlusion(CTO)is a critical and unique subgroup of coronary lesions.This study aimed to investigate the correlation between the Selvester QRS score and late gadolinium enhancement cardiac magnetic resonance imaging(LGE-CMRI)in quantifying myocardial scarring to provide a simple and feasible method for treating CTO.Methods:The medical records of 134 patients with absolute CTO who underwent coronary angiography between May 1,2014 and December 30,2017 were retrospectively reviewed.All patients were grouped according to the CTO location(right coronary artery[RCA]CTO,left artery descending[LAD]CTO,left circumflex[LCX]CTO,and multivessel CTO groups).The degree of myocardial scarring was determined according to the Selvester QRS score and using the LGE-CMRI.All patients were followed up for at least 12 months.Results:Among the 62 CTO patients,55 had occlusion of a single vessel and seven had occlusion of multiple vessels,of which 27(43.55%)were in the RCA CTO group,16(25.81%)in the LAD CTO group,12(19.35%)in the LCX CTO group,and 7(11.29%)in the multivessel CTO group.The area under the receiver operating characteristic curve for the QRS score that was used to determine the degree of myocardial scarring was 0.806,with a sensitivity and specificity of 94.7%and 42.1%,respectively.The Selvester QRS score and LGE-CMRI measures of scar size were correlated in the RCA CTO,LCX CTO,and multivessel CTO groups(r=0.466,0.593,and 0.775,respectively).Conclusion:The Selvester QRS score was feasible for detecting myocardial scarring in patients with CTO.