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CLINICAL RESEARCH: CARDIAC IMAGING

Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance Heralds an Adverse Prognosis in Nonischemic Cardiomyopathy

Katherine C. Wu, MD, FACC^_*,_*, Robert G. Weiss, MD^_*,, David R. Thiemann, MD^_*,, Kakuya Kitagawa, MD^_*, André Schmidt, MD^_*, Darshan Dalal, MD^_*, Shenghan Lai, MD, PhD, David A. Bluemke, MD, PhD^_*,, Gary Gerstenblith, MD, FACC^_*, Eduardo Marbán, MD, PhD, FACC^_*, Gordon F. Tomaselli, MD, FACC and João A.C. Lima, MD, FACC^_*,

^_* Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, Maryland.

Manuscript received November 27, 2007; revised manuscript received March 13, 2008, accepted March 17, 2008.

^_* Reprint requests and correspondence: Dr. Katherine C. Wu, Division of Cardiology, Johns Hopkins Hospital, 600 North Wolfe Street/Carnegie 568, Baltimore, Maryland 21287. (Email: kwu{at}jhmi.edu).

Objectives: We examined whether the presence and extent of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) predict adverse outcomes in nonischemic cardiomyopathy (NICM) patients.

Background: Morbidity and mortality is high in NICM patients. However, the clinical course of an individual patient is unpredictable and current risk stratification approaches are limited. Cardiovascular magnetic resonance detects myocardial fibrosis, which appears as LGE after contrast administration and may convey prognostic importance.

Methods: In a prospective cohort study, 65 NICM patients with left ventricular (LV) ejection fraction 35% underwent CMR before placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death. The CMR images were analyzed for the presence and extent of LGE and for LV function, volumes, and mass. Patients were followed for an index composite end point of 3 cardiac events: hospitalization for heart failure, appropriate ICD firing, and cardiac death.

Results: A total of 42% (n = 27) of patients had CMR LGE, averaging 10 ± 13% of LV mass. During a 17-month median follow-up, 44% (n = 12) of patients with LGE had an index composite outcome event versus only 8% (n = 3) of those without LGE (p < 0.001 for Kaplan-Meier survival curves). After adjustment for LV volume index and functional class, patients with LGE had an 8-fold higher risk of experiencing the primary outcome (hazard ratio 8.2, 95% confidence interval 2.2 to 30.9; p = 0.002).

Conclusions: A CMR LGE in NICM patients strongly predicts adverse cardiac outcomes. The CMR LGE may represent the end-organ consequences of sustained adrenergic activation and adverse LV remodeling, and its identification may significantly improve risk stratification strategies in this high risk population. (Imaging Techniques for Identifying Factors of Sudden Cardiac Death Risk; NCT00181233 [ClinicalTrials.gov] )

Abbreviations and Acronyms   CMR = cardiovascular magnetic resonance   HF = heart failure   ICD = implantable cardioverter-defibrillator   LGE = late gadolinium enhancement   LV = left ventricular   LVEDV = left ventricular end-diastolic volume   LVEF = left ventricular ejection fraction   NICM = nonischemic cardiomyopathy   NYHA = New York Heart Association   SCD = sudden cardiac death   SI = signal intensity

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J. Am. Coll. Cardiol. 2008 51: A31-A32. [Full Text] [PDF]