Myocardial late gadolinium enhancement cardiovascular magnetic resonance in patients with cirrhosis

Background

Portal hypertension and cardiac alterations previously described as "cirrhotic cardiomyopathy" are known complications of end stage liver disease (ELD). Cardiac failure contributes to morbidity and mortality, particularly after liver transplantation and transjugular intrahepatic portosystemic shunt (TIPS). We sought to identify myocardial tissue characterization and evaluate cardiovascular magnetic resonance (CMR) for diagnosis of cardiac impairment.

Results

Twenty ELD patients underwent CMR for morphological, functional and tissue characterization by late gadolinium enhancement (LGE). Based on extent of LGE, patients were dichotomized into high and low LGE groups and analyzed regarding liver, cardiocirculatory and renal functions. CMR demonstrated hyperdynamic left ventricular function and a patchy pattern of LGE of the myocardium to a variable extent (range 2-62%) in all patients. There were no significant differences in Model for End-Stage Liver Disease (MELD), Child-Pugh score or the left ventricular ejection fraction between high and low LGE groups. QTc-interval was prolonged in 25% of the patients. E/A ratio was at the upper limit of norm; no difference between groups. Patients showing high LGE had a higher CI (p < 0.05). Biomarkers of myocardial stress were elevated. While NT-proBNP and c-Troponin-T showed no differences, PLGF and sFLT1 were lower in the high LGE group.

Conclusion

CMR shows myocardial involvement in patients with ELD resembling appearance of myocarditis. The hyperdynamic circulation in portal hypertension may be an important factor. Larger prospective trials are warranted to confirm the association with severity and outcome of liver disease and to test the predictive power of CMR for patients listed for liver transplantation.     

Mechanism of late gadolinium enhancement in patients with acute myocardial infarction.

PURPOSE: To investigate the mechanism of late gadolinium enhancement in irreversibly damaged myocardium in patients with acute myocardial infarct by determining kinetics of Gd-DTPA over time. METHODS: Twenty-nine patients (24 men; 64 +/- 9 years) with acute myocardial infarction were imaged with functional and gadolinium enhanced cardiovascular magnetic resonance (CMR) 18 minutes post 0.2 mmol/kg Gd-DTPA. T1 of blood, remote and enhanced myocardium, as well as microvascular obstruction (MVO) was determined before and 5-40 minutes post contrast injection (Look-Locker), and the partition coefficient (lambda) was calculated. RESULTS: T1 and lambda were significantly different from 5-40 minutes post contrast in enhanced (lambda = 0.90 +/- 0.09, p < 0.001) compared to remote myocardium (lambda = 0.40 +/- 0.07). lambda achieved a steady state in remote but increased continuously in infarcted myocardium and to an even greater extent in MVO. T1 of enhanced myocardium was higher from 5-15 minutes, equal at 20 minutes and lower 25-40 minutes post contrast compared to blood, indicating a changing contrast between blood and late gadolinium enhancement over time. CONCLUSION: Enhancement in patients with acute infarction is mainly due to an increased lambda, although reduced wash-in-wash-out adds to the effect. Differentiation between blood and enhanced myocardium may be difficult to achieve, if only little differences of T1 are available. Imaging at a later point will restore the contrast.     

Quantitative analysis of late gadolinium enhancement in hypertrophic cardiomyopathy

Background

Cardiovascular Magnetic resonance (CMR) with the late gadolinium enhancement (LGE) technique allows the detection of myocardial fibrosis in Hypertrophic cardiomyopathy (HCM). The aim of this study was to compare different methods of automatic quantification of LGE in HCM patients. Methods: Forty HCM patients (mean age 48 y, 30 males) and 20 normal subjects (mean age 38 y, 16 males) underwent CMR, and we compared 3 methods of quantification of LGE: 1) in the SD2 method a region of interest (ROI) was placed within the normal myocardium and enhanced myocardium was considered as having signal intensity >2 SD above the mean of ROI; 2) in the SD6 method enhanced myocardium was defined with a cut-off of 6 SD above mean of ROI; 3) in the RC method a ROI was placed in the background of image, a Rayleigh curve was created using the SD of that ROI and used as ideal curve of distribution of signal intensity of a perfectly nulled myocardium. The maximal signal intensity found in the Rayleigh curve was used as cut-off for enhanced myocardium. Parametric images depicting non enhanced and enhanced myocardium was created using each method. Three investigators assigned a score to each method by the comparison of the original LGE image to the respective parametric map generated.

Results

Patients with HCM had lower concordance between the measured curve of distribution of signal intensity and the Rayleigh curve than controls (63.7 ± 12.3% vs 92.2 ± 2.3%, p < 0.0001).A cut off of concordance < 82.9% had a 97.1% sensitivity and 92.3% specificity to distinguish HCM from controls. The RC method had higher score than the other methods. The average extent of enhanced myocardium measured by SD6 and Rayleigh curve method was not significant different but SD6 method showed underestimation of enhancement in 12% and overestimation in 5% of patients with HCM.

Conclusions

Quantification of fibrosis in LGE images with a cut-off derived from the Rayleigh curve is more accurate than using a fixed cut-off.     

Effectiveness of late gadolinium enhancement to improve outcomes prediction in patients referred for cardiovascular magnetic resonance after echocardiography

Background

Echocardiography (echo) is a first line test to assess cardiac structure and function. It is not known if cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) ordered during routine clinical practice in selected patients can add additional prognostic information after routine echo. We assessed whether CMR improves outcomes prediction after contemporaneous echo, which may have implications for efforts to optimize processes of care, assess effectiveness, and allocate limited health care resources.

Methods and results

We prospectively enrolled 1044 consecutive patients referred for CMR. There were 38 deaths and 3 cardiac transplants over a median follow-up of 1.0 years (IQR 0.4-1.5). We first reproduced previous survival curve strata (presence of LGE and ejection fraction (EF) < 50%) for transplant free survival, to support generalizability of any findings. Then, in a subset (n = 444) with contemporaneous echo (median 3 days apart, IQR 1–9), EF by echo (assessed visually) or CMR were modestly correlated (R² = 0.66, p < 0.001), and 30 deaths and 3 transplants occurred over a median follow-up of 0.83 years (IQR 0.29-1.40). CMR EF predicted mortality better than echo EF in univariable Cox models (Integrated Discrimination Improvement (IDI) 0.018, 95% CI 0.008-0.034; Net Reclassification Improvement (NRI) 0.51, 95% CI 0.11-0.85). Finally, LGE further improved prediction beyond EF as determined by hazard ratios, NRI, and IDI in all Cox models predicting mortality or transplant free survival, adjusting for age, gender, wall motion, and EF.

Conclusions

Among those referred for CMR after echocardiography, CMR with LGE further improves risk stratification of individuals at risk for death or death/cardiac transplant.     

Evaluation of quantification methods for left arial late gadolinium enhancement based on different references in patients with atrial fibrillation

By using late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging, we compared left atrial late gadolinium enhancement (LA-LGE) quantification methods based on different references to characterize the left atrial wall in patients with atrial fibrillation (AF). Thirty-eight patients who underwent three-dimensional LGE-CMR imaging before catheter ablation for AF were classified into three groups depending on their clinical AF type: (1) paroxysmal AF (PAF; n = 12); (2) persistent AF (PeAF; n = 16); and (3) recurrent AF after catheter ablation (RAF; n = 10). To quantify LA-LGE on LGE-CMR imaging, we used the thresholds of 2 standard deviations (2-SD), 3-SD, 4-SD, 5-SD, or 6-SD above the mean signal from the unenhanced left ventricular myocardium, and we used the full width at half maximum (FWHM) technique, which was based on the maximum signal from the mitral valve with high signal intensity. The 6-SD threshold and FWHM techniques were statistically reproducible with an intraclass correlation coefficient >0.7. On applying the FWHM technique, the normalized LA-LGE volume by LA wall area showed a significant difference between the RAF, PeAF, and PAF groups (0.22 ± 0.04, 0.16 ± 0.06, and 0.09 ± 0.03 mL/cm², respectively) (P < 0.05). Furthermore, most of the fibrotic scarring and low-voltage tissue on the electroanatomic map corresponded well with the extent of LA-LGE. The FWHM technique based on the mitral valve can provide a reproducible quantification of LA-LGE related to AF in the thin LA wall.     

Accuracy and reproducibility of semi-automated late gadolinium enhancement quantification techniques in patients with hypertrophic cardiomyopathy

Background

The presence and extent of late gadolinium enhancement (LGE) has been associated with adverse events in patients with hypertrophic cardiomyopathy (HCM). Signal intensity (SI) threshold techniques are routinely employed for quantification; Full-Width at Half-Maximum (FWHM) techniques are suggested to provide greater reproducibility than Signal Threshold versus Reference Mean (STRM) techniques, however the accuracy of these approaches versus the manual assignment of optimal SI thresholds has not been studied. In this study, we compared all known semi-automated LGE quantification techniques for accuracy and reproducibility among patients with HCM.

Methods

Seventy-six HCM patients (51 male, age 54 ± 13 years) were studied. Total LGE volume was quantified using 7 semi-automated techniques and compared to expert manual adjustment of the SI threshold to achieve optimal segmentation. Techniques tested included STRM based thresholds of >2, 3, 4, 5 and 6 SD above mean SI of reference myocardium, the FWHM technique, and the Otsu-auto-threshold (OAT) technique. The SI threshold chosen by each technique was recorded for all slices. Bland-Altman analysis and intra-class correlation coefficients (ICC) were reported for each semi-automated technique versus expert, manually adjusted LGE segmentation. Intra- and inter-observer reproducibility assessments were also performed.

Results

Fifty-two of 76 (68%) patients showed LGE on a total of 202 slices. For accuracy, the STRM >3SD technique showed the greatest agreement with manual segmentation (ICC = 0.97, mean difference and 95% limits of agreement = 1.6 ± 10.7 g) while STRM >6SD, >5SD, 4SD and FWHM techniques systematically underestimated total LGE volume. Slice based analysis of selected SI thresholds similarly showed the STRM >3SD threshold to most closely approximate manually adjusted SI thresholds (ICC = 0.88). For reproducibility, the intra- and inter-observer reproducibility of the >3SD threshold demonstrated an acceptable mean difference and 95% limits of agreement of −0.5 ± 6.8 g and −0.9 ± 5.6 g, respectively.

Conclusions

FWHM segmentation provides superior reproducibility, however systematically underestimates total LGE volume compared to manual segmentation in patients with HCM. The STRM >3SD technique provides the greatest accuracy while retaining acceptable reproducibility and may therefore be a preferred approach for LGE quantification in this population.     

Patterns of late gadolinium enhancement in Duchenne muscular dystrophy carriers

Background

This study was designed to assess whether cardiovascular magnetic resonance imaging (CMR) in Duchenne muscular dystrophy carriers (DMDc) may index any cell milieu elements of LV dysfunction and whether this cardiac phenotype may be related to genotype. The null hypothesis was that myocardial fibrosis, assessed by late gadolinium enhancement (LGE), might be similarly accounted for in DMDc and gender and age-matched controls.

Methods

Thirty DMDc patients had CMR and genotyping with 37 gender and age-matched controls. Systolic and diastolic LV function was assessed by 2D-echocardiography.

Results

Absolute and percent LGE were higher in muscular symptomatic (sym) than asymptomatic (asy) DMDc (1.77 ± 0.27 vs 0.76 ± 0.17 ml; F = 19.6, p < 0.0001 and 1.86 ± 0.26% vs 0.68 ± 0.17%, F = 22.1, p < 0.0001, respectively). There was no correlation between LGE and age. LGE was seen most frequently in segments 5 and 6; segment 5 was involved in all asy-DMDc. Subepicardial LGE predominated, compared to the mid-myocardial one (11 out of 14 DMDc). LGE was absent in the subendocardium. No correlations were seen between genotyping (type of mutation, gene region and protein domain), confined to the exon’s study, and cardiac phenotype.

Conclusions

A typical myocardial LGE-pattern location (LV segments 5 and 6) was a common finding in DMDc. LGE was more frequently subepicardial plus midmyocardial in sym-DMDc, with normal LV systolic and diastolic function. No genotype-phenothype correlation was found.     

Appearance of microvascular obstruction on high resolution first-pass perfusion,early and late gadolinium enhancement CMR in patients with acute myocardial infarction

Background

The presence and extent of microvascular obstruction (MO) after acute myocardial infarction can be measured by first-pass gadolinium-enhanced perfusion cardiovascular magnetic resonance (CMR) or after gadolinium injection with early or late enhancement (EGE/LGE) imaging. The volume of MO measured by these three methods may differ because contrast agent diffusion into the MO reduces its apparent extent over time. Theoretically, first-pass perfusion CMR should be the most accurate method to measure MO, but this technique has been limited by lower spatial resolution than EGE and LGE as well as incomplete cardiac coverage. These limitations of perfusion CMR can be overcome using spatio-temporal undersampling methods. The purpose of this study was to compare the extent of MO by high resolution first-pass k-t SENSE accelerated perfusion, EGE and LGE.

Methods

34 patients with acute ST elevation myocardial infarction, treated successfully with primary percutaneous coronary intervention (PPCI), underwent CMR within 72 hours of admission. k-t SENSE accelerated first-pass perfusion MR (7 fold acceleration, spatial resolution 1.5 mm × 1.5 mm × 10 mm, 8 slices acquired over 2 RR intervals, 0.1 mmol/kg Gd-DTPA), EGE (1-4 minutes after injection with a fixed TI of 440 ms) and LGE images (10-12 minutes after injection, TI determined by a Look-Locker scout) were acquired. MO volume was determined for each technique by manual planimetry and summation of discs methodology.

Results

k-t SENSE first-pass perfusion detected more cases of MO than EGE and LGE (22 vs. 20 vs. 14, respectively). The extent of MO imaged by first-pass perfusion (median mass 4.7 g, IQR 6.7) was greater than by EGE (median mass 2.3 g, IQR 7.1, p = 0.002) and LGE (median mass 0.2 g, IQR 2.4, p = 0.0003). The correlation coefficient between MO mass measured by first-pass perfusion and EGE was 0.91 (p < 0.001).

Conclusion

The extent of MO following acute myocardial infarction appears larger on high-resolution first-pass perfusion CMR than on EGE and LGE. Given the inevitable time delay between gadolinium administration and acquisition of either EGE or LGE images, high resolution first-pass perfusion imaging may be the most accurate method to quantify MO.     

Prevalence and distribution of late gadolinium enhancement in a large population of patients with Duchenne muscular dystrophy: effect of age and left ventricular systolic function

Background

Duchenne muscular dystrophy (DMD), an X-linked disorder affects approximately 1 in 5000 males, is universally associated with heart disease. We previously identified myocardial disease by late gadolinium enhancement (LGE) in DMD subjects at various stages of disease, but the true prevalence is unclear. Cardiovascular magnetic resonance (CMR) is well established for both assessment of ventricular function and myocardial fibrosis by LGE. We sought to establish i) prevalence and distribution of LGE in a large DMD population and ii) relationship among LGE, age, LVEF by CMR and current living status.

Methods

Current living status, demographic and CMR data including ventricular volumes, LVEF and LGE from 314 DMD patients undergoing evaluation at a single large tertiary referral center were analyzed.

Results

113 of 314 (36%) of DMD subjects showed LGE positivity with prevalence increasing from 17% of patients <10 years to 34% of those aged 10–15 years and 59% of those >15 years-old. Patients with LVEF ≥55% were LGE positive in 30% of cases; this increased to 84% for LVEF <55%. LGE was more prevalent in the free wall (531/1243, 42.7%) vs. septal segments (30/565, 5.3%). Patients with septal involvement were significantly older and had lower LVEF than those with isolated free wall LGE. Ten percent (11/113) patients who had LGE died 10.8 months after CMR. Only one patient from the LGE negative group died. Patients who died had higher heart rate, larger left ventricular volume and mass, greater number of positive LGE segment and increase incident of septal LGE compared to those who remained alive.

Conclusion

In DMD patients, LGE occurs early, is progressive and increases with both age and decreasing LVEF. Segmentally, the incidence of the number of positive LGE segments increase with age and lower LVEF. Older patients and those who died during the study period had more septal LGE involvement. The current studies suggest that the time course and distribution of LGE-positivity may be an important clinical biomarker to aid in the management of DMD-associated cardiac disease.     

心脏MR延迟钆强化评估心肌淀粉样变性患者预后:Meta分析北大核心CSCD

目的采用Meta分析方法评价心脏MR(CMR)延迟钆强化(LGE)评估心肌淀粉样变(CA)患者预后的价值。方法检索PubMed、EMbase、Cochrane Library、中国生物医学文献数据库、中国知网及万方医学网自建库至2020年10月以CMR-LGE评价CA患者死亡风险的队列研究,依照纳入及排除标准筛选文献;合并纳入文献中的死亡风险比(HR),评价LGE阳性、LGE类型或位置、CA类型与CA患者死亡风险的关系,以STATA 15.0软件行Meta分析。结果共纳入14篇文献,均为英文文献,包括1490例患者,其中666例发生死亡事件。合并分析结果显示LGE阳性患者死亡风险增大,HR为1.46[95%CI(1.06,2.02),P<0.05];透壁性[HR=2.36,95%CI(1.79,3.12),P<0.05]及心内膜下LGE阳性[HR=3.83,95%CI(2.12,6.91),P<0.05]患者死亡风险增高;左心室[HR=2.82,95%CI(1.33,5.98),P<0.05]及右心室LGE阳性[HR=1.94,95%CI(1.12,3.35),P<0.05]患者死亡风险不同程度升高;轻链型淀粉样变性患者LGE阳性死亡风险增大,HR为1.94[95%CI(1.53,2.46),P<0.05]。结论CMR-LGE阳性与CA患者死亡风险增加密切相关,可作为预测CA患者预后的独立因素。     

Prognostic value of late gadolinium enhancement in hypertensive patients with known or suspected coronary artery disease

To determine the prognosis of a myocardial scar assessed by a late gadolinium enhancement (LGE) technique of cardiac magnetic resonance (CMR) in hypertensive patients with known or suspected coronary artery disease (CAD). Patients with systemic hypertension with known or suspected CAD without a clinical history of myocardial infarction were enrolled. All patients underwent CMR for assessment of cardiac function and LGE. Prognostic data was determined by the occurrence of a hard cardiac endpoint, defined as cardiac death or a non-fatal myocardial infarction, or major adverse cardiac events (MACEs), defined as cardiac death, a non-fatal myocardial infarction, or hospitalization due to heart failure, unstable angina, or life-threatening ventricular arrhythmia. A total of 1,644 patients were enrolled; 48% were males and the mean age was 65 ± 11 years. The average follow-up time was 863 ± 559 days. Four hundred fifty-three (28%) patients had LGE. LGE was the strongest and most independent predictor for hard events and MACEs with hazard ratios of 4.77 and 3.38, respectively. Other independent predictors of hard events and MACEs were left ventricular ejection fraction and mass, the use of a beta-blocker, and a history of heart failure. The risk of cardiac events increased as the extent of LGE increased; the hazard ratio was 12.74 for hard events for those with a LGE >20% of the myocardium. LGE is the most important and independent predictor for cardiac events in hypertensive patients with known or suspected CAD.     

Clinical utility of NT-proBNP levels in late heart transplantation patients

BackgroundThe present work was aimed to describe NT-proBNP levels in heart transplant patients after the first year postsurgery.MethodsNT-proBNP concentration was measured in 1231 samples from 142 patients when a routine four-month follow-up was carried out, including other biochemical and clinical examinations. Endomyocardial biopsies were performed only upon clinical suspicion of acute rejection.ResultsNT-proBNP concentrations were not significantly correlated to post-transplantation time, though differences were observed according to clinical symptoms (Kruskal–Wallis test, p < 0.001). Although multivariate analysis revealed statistically significant association between NT-proBNP concentration and some qualitative (cardiac allograft vasculopathy-CAV-, sex, diabetes) and quantitative (creatinine, hematocrit, age) variables, only moderately relevant contribution was observed for creatinine and CAV. Patients with rejection showed noticeable increases in serum NT-proBNP concentrations, above more than 2.5 times the reference change value (97%). NT-proBNP concentrations higher than 1000 ng/L increased in 3.5 times (95%CI: 2.4–5) the risk of death in less than one year.ConclusionsAfter the first year from surgery, NT-proBNP concentrations were not associated to post-transplantation time and NT-proBNP could be a useful diagnostic marker for rejection, whenever serial measurements are made. A NT-proBNP cutoff value of 1000 ng/L was identified for classifying patients at risk of death after one year.     

Subendocardial late gadolinium enhancement in two patients with anthracycline cardiotoxicity following treatment for Ewing's sarcoma.

Cardiotoxicity is a well-known consequence of anthracycline chemotherapy. We report CMR findings not previously described in two patients with anthracycline cardiotoxicity following treatment for Ewing's sarcoma. Subendocardial enhancement on late gadolinium contrast-enhanced CMR was present in both cases, with histological correlation in one case.     

心脏磁共振钆对比剂延迟强化的临床意义及判断预后的价值

钆对比剂延迟强化磁共振成像(LGE-MRI)具有高度的组织特异性和良好的空间分辨力,能够准确识别梗死心肌或瘢痕组织。钆对比剂延迟强化(LGE)可见于缺血性心脏病,如急性或慢性心肌梗死,也可见于非缺血性心肌病、炎症性心脏病和浸润性心肌病。延迟强化的有无及其部位和程度在心血管疾病的诊断、治疗和预后判断方面起着重要作用。     

MRI with late gadolinium enhancement as a predictor of ventricular arrhythmias

Despite considerable progress in reducing sudden cardiac death (SCD), mortality remains high and risk stratification algorithms are limited. Many approaches to identifying at-risk patients target the electrophysiologic triggers or modulators of ventricular arrhythmias. Other than global left ventricular function, there has been minimal emphasis on evaluating the anatomic substrate that supports arrhythmia circuits, namely myocardial scarring. Myocardial scarring and fibrosis occurs in both ischemic and nonischemic cardiomyopathies and is detected noninvasively by cardiac MRI with late gadolinium enhancement (CMR-LGE). There is growing literature relating CMR-LGE to arrhythmic surrogates and clinical outcomes in vulnerable cohorts. Additionally, knowledge of the presence and extent of CMR-LGE is potentially valuable for guiding catheter ablative therapies. The incremental value of CMR-LGE in predicting SCD, above current risk factors, remains unknown, but its unique ability to provide anatomic and tissue characterization contributes to its appeal as a promising noninvasive tool for identifying susceptible patients.     

Prediction of global left ventricular functional recovery in patients with heart failure undergoing surgical revascularisation,based on late gadolinium enhancement Cardiovascular Magnetic Resonance

Background

The new gold standard for myocardial viability assessment is late gadolinium enhancement-cardiovascular magnetic resonance (LGE-CMR); this technique has demonstrated that the transmural extent of scar predicts segmental functional recovery. We now asked how the number of viable and number of viable+normal, segments predicted recovery of global left ventricular (LV) function in patients undergoing CABG. Finally, we examined which segmental transmural threshold of scarring best predicted global LV recovery.

Methods and Results

Fifty patients with reduced LV ejection fraction (EF) referred for CABG were recruited, and 33 included in this analysis. Patients underwent CMR to assess LV function and viability pre-operatively at 6 days and 6 months. Mean LVEF 38% ± 11, which improved to 43% ± 12 after surgery. 21/33 patients improved EF by ≥3% (EF before 38% ± 13, after 47% ± 13), 12/33 did not (EF before 39% ± 6, after 37% ± 8). The only independent predictor for global functional recovery after revascularisation was the number of viable+normal segments: Based on a segmental transmural viability cutoff of <50%, ROC analysis demonstrated ≥10 viable+normal segments predicted ≥3% improvement in LVEF with a sensitivity of 95% and specificity of 75% (AUC = 0.9, p < 0.001). Transmural viability cutoffs of <25 and <75% and a cutoff of ≥4 viable segments were less useful predictors of global LV recovery.

Conclusions

Based on a 50% transmural viability cutoff, patients with ≥10 viable+normal segments improve global LV function post revascularisation, while patients with fewer such segments do not. LGE-CMR is a simple and powerful tool for identifying which patients with impaired LV function will benefit from CABG.

Trial registration

Research Ethics Committee Unique Identifier: NRES:05/Q1603/42. The study is listed on the Current Controlled Trials Registry: ISRCTN41388968.URL: http://www.controlled-trials.com     

Functional outcome after revascularization in patients with chronic ischemic heart disease: a quantitative late gadolinium enhancement CMR study evaluating transmural scar extent, wall thickness and periprocedural necrosis.

In patients with chronic ischemic myocardial dysfunction, late gadolinium enhancement CMR (LGE-CMR) accurately depicts the regional extent of fibrosis and predicts functional recovery after revascularization. We hypothesized that the predictive accuracy of LGE-CMR could be optimized by not only taking into account the transmural extent of hyperenhancement but also the amount of residual, non-enhanced viable myocardium, and procedure related necrosis. We studied 45 patients with chronic ischemic left ventricular dysfunction, who underwent cine and LGE-CMR 1 month before and 3 months after surgical or percutaneous revascularization. Segmental and global function, scar, presence of a significant residual viable rim (defined as >or=4.5 mm), and procedure related necrosis were fully quantified using standardized methods and objective thresholds. Sixty percent of segments without hyperenhancement showed functional improvement at follow-up. No improvement was observed in segments with >75% segmental extent of hyperenhancement (SEH), while segments with 1-25%, 26-50%, and 51-75% SEH were 4, 8, and 20 times less likely to improve (multilevel analysis, p<0.001). Thickness of the viable rim largely paralleled total wall thickness; therefore, the presence of a significant viable rim did not provide additional diagnostic value beyond SEH. Procedure related necrosis was found in 12 (27%) patients. The presence of procedure related necrosis was the only (negative) predictor of changes in left ventricular volumes and ejection fraction. In conclusion, we found that functional outcome after revascularization was influenced by both transmural extent of hyperenhancement and procedure related necrosis. However, the presence of a significant residual, viable rim was of no additional diagnostic value.     

Prognostic value of combined magnetic resonance myocardial perfusion imaging and late gadolinium enhancement

Late gadolinium enhancement (LGE) and myocardial perfusion study by cardiac magnetic resonance (CMR) have a diagnostic and prognostic value in patients with suspected coronary artery disease (CAD). The purpose of this study was to determine the prognostic value of combined myocardial perfusion CMR and LGE in patients with known or suspected CAD. We studied patients with known or suspected CAD. All patients underwent CMR for functional study, myocardial perfusion and LGE. Myocardial ischemia by CMR was defined as a perfusion defect in patients without LGE or a perfusion defect beyond the LGE area. Patients were followed up for cardiovascular outcomes including hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) which included cardiac death, non-fatal myocardial infarction, hospitalization for unstable angina, and heart failure. There were a total of 587 men and 645 women. Average age was 64.6 ± 11.1 years. LGE was detected in 326 patients (26.5%). Myocardial ischemia by CMR was detected in 423 patients (34.3%). Average follow-up duration was 34.9 ± 15.6 months. Univariate analysis showed that age, diabetes, use of beta blocker, left ventricular ejection fraction, left ventricular mass, wall motion abnormality, LGE, and myocardial ischemia are predictors for hard cardiac events and MACE. Multivariable analysis revealed that myocardial ischemia was the strongest predictor for hard cardiac events and MACE. Other independent predictors were age, use of beta blocker, and left ventricular mass. Myocardial ischemia by CMR has an incremental prognostic value for cardiac events in patients with known or suspected CAD.