CORRESPONDENCE: LETTER TO THE EDITOR
Likelihood of Ventricular Arrhythmias Due to Myocardial Fibrosis in Hypertrophic Cardiomyopathy as Detected by Cardiac Magnetic Resonance Imaging
Abhijeet Dhoble, MD, MPH*,
Sujeeth R. Punnam, MD and
George S. Abela, MD
* Department of Internal Medicine, Michigan State University, B 308 Clinical Center, East Lansing, Michigan 48824 (Email: abhijeet.dhoble{at}ht.msu.edu).
In a recent study, Adabag et al. (1) have shown that myocardial fibrosis detected by cardiovascular magnetic resonance (CMR) with delayed enhancement (DE) imaging after gadolinium infusion in a cohort of 177 patients with hypertrophic cardiomyopathy is associated with greater likelihood and increased frequency of ventricular arrhythmias on ambulatory Holter electrocardiogram monitoring as compared with those without DE on CMR. They further conclude that, contrast-enhanced CMR identifies hypertrophic cardiomyopathy patients with increased susceptibility to ventricular arrhythmias.
The study is well performed with good statistical power. However, there is a question regarding the patient population in this study. Streit et al. (2) had demonstrated earlier that alcohol septal ablation has arrhythmogenic potential due to myocardial fibrosis that can increase the frequency of ventricular arrhythmias. These fibrotic areas in the myocardium caused by septal ablation can potentially give rise DE on CMR. Therefore, history of prior myocardial septostomy or percutaneous interventions (i.e., ethanol injection) for the relief of left ventricular outflow obstruction could be an important confounding variable that can cause both DE on CMR and ventricular arrhythmias. Adabag et al. (1) did not provide any information on this issue that may potentially affect the results. It would be helpful to know how many of the patients in the study had procedures done for the relief of left ventricular obstructions and whether excluding such patients will provide the same results.
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1. Adabag AS, Maron BJ, Appelbaum E, et al. Occurrence and frequency of arrhythmias in hypertrophic cardiomyopathy in relation to delayed enhancement on cardiovascular magnetic resonance J Am Coll Cardiol 2008;51:1369-1374.[Abstract/Free Full Text]2. Streit S, Walpoth N, Windecker S, Meier B, Hess O. Is alcohol ablation of the septum associated with recurrent tachyarrhythmias? Swiss Med Wkly 2007;137:660-668.[Medline]
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