Review
The Prognostic Role of Late Gadolinium Enhancement Magnetic Resonance Imaging in Patients With Cardiomyopathy

https://doi.org/10.1016/j.cjca.2012.11.033Get rights and content

Abstract

Cardiovascular magnetic resonance imaging (CMRI) is currently considered part of standard care at many academic centres for the evaluation of patients with ischemic or nonischemic cardiomyopathy. While CMRI provides unparalleled diagnostic versatility for the assessment of myocardial function, perfusion, and tissue health, evidence supporting its prognostic value for the prediction of important cardiovascular events is now emerging. Given the low specificity of currently available clinical markers in patients with cardiomyopathy, more-robust biomarkers aimed at identifying those at high risk of sudden cardiac death and other relevant outcomes are desirable. Late gadolinium enhancement (LGE) CMRI offers the novel capacity to quantify the burden of myocardial fibrosis, a common pathophysiological end point of most cardiomyopathy states. As such, it has the potential to be a robust and ubiquitous marker of cardiovascular events related to the presence of advanced tissue disease. This review paper focuses on the evidence to date supporting LGE imaging as a tool for the prediction of future cardiovascular events in patients with ischemic and nonischemic cardiomyopathy.

Résumé

L’imagerie cardiovasculaire par résonance magnétique (ICRM) est actuellement considérée comme faisant partie des soins courants dans plusieurs centres d’enseignement lors de l’évaluation des patients ayant une cardiomyopathie ischémique ou non ischémique. Tandis que l’ICRM offre une polyvalence diagnostique inégalée pour l’évaluation du fonctionnement myocardique, de la perfusion et de la santé des tissus, il apparaît à présent que les données scientifiques soutiennent sa valeur pronostique dans la prédiction d’événements cardiovasculaires importants. Compte tenu de la faible spécificité des marqueurs cliniques actuellement disponibles chez les patients ayant une cardiomyopathie, des biomarqueurs plus fiables ayant pour but d’identifier ceux qui sont exposés à un risque élevé de mort cardiaque subite et d’autres résultats pertinents sont souhaitables. L’ICRM de rehaussement tardif après injection de gadolinium (RTG) offre la nouvelle possibilité de quantifier le fardeau de la fibrose myocardique, un critère de jugement physiopathologique commun à la plupart des états cardiomyopahtiques. À ce titre, il a le potentiel d’être un marqueur fiable et omniprésent d’événements cardiovasculaires liés à la présence de lésions tissulaires avancées. Cet article met l’accent sur les données scientifiques actuelles qui soutiennent que l’imagerie de RTG est un outil pour la prédiction d’événements cardiovasculaires futurs chez les patients ayant une cardiomyopathie ischémique et non ischémique.

Section snippets

What Is LGE CMRI?

LGE imaging takes advantage of the paramagnetic properties and differential washout kinetics of gadolinium-based contrast agents in normal vs abnormal myocardium. Based on its molecular structure, gadolinium is restricted to the extracellular compartment, reliably excluded from the intracellular space by intact cell membranes.2 Following its first pass through tissue, it is preferentially distributed to the interstitium unless cell membranes are disrupted. Accordingly, contrast enhancement

LGE CMR in ICM

Ischemia related to coronary artery disease results in reversible states of myocardial stunning and hibernation but, with sustained blood flow reductions, progresses to irreversible myocyte necrosis. Following evolution of the inflammatory cascade, the latter will conclude with removal of cellular debris and local generation of collagen-rich replacement fibrosis. The transmural extent and spatial distribution of this fibrous tissue can be exquisitely imaged by LGE imaging (Fig. 1A) and provides

LGE CMRI in DCM

Patients with DCM experience a 10-year mortality rate in excess of 40%,40 a risk shown to be reduced through the use of ICDs.41 Accordingly, interest in markers of future arrhythmic events in this population has expanded. The first substantive report of LGE findings in DCM was performed by McCrohon et al. in 2003. This study examined 90 patients with systolic heart failure, 63 having DCM defined by the findings of invasive catheterization, and reported that 28% of patients showed linear midwall

LGE CMRI in HCM

HCM is a leading cause of SCD among younger individuals and athletes.45 While the annual risk of SCD is now estimated to be below 1%, the relatively high prevalence of HCM (1 in 500 of the population) establishes this as an important contributor to cardiovascular mortality, particularly in the young.45 An expanding body of evidence supports a role for LGE CMRI for the identification of patients at elevated risk of arrhythmia-related events in HCM. Patients with HCM frequently show patchy,

LGE CMRI in Cardiac Sarcoidosis

Sarcoidosis is a chronic inflammatory disease characterized by the formation of granulomatous nodules, most typically affecting the lungs and lymph nodes, but any organ may be involved. Cardiac involvement is clinically evident in approximately 5% to 7% of patients and is acknowledged by the occurrence of heart block, ventricular tachyarrhythmias, or progressive systolic dysfunction. However, approximately one-third of patients will demonstrate subclinical cardiac involvement at autopsy.57 LGE

LGE CMRI in Cardiac Amyloidosis

Up to 50% of patients with systemic light-chain amyloid will develop cardiac involvement, a complication associated with elevated morbidity and premature mortality. In fact, 50% of patients will have died 6 months following diagnosis of cardiac involvement.61 While this condition was conventionally investigated by invasive myocardial biopsy, noninvasive diagnostic strategies are now becoming more routine. Leading these approaches is LGE CMRI, a preferred modality for confirmation or exclusion

Conclusions

With expanding clinical adoption of LGE CMRI for the identification and staging of disease in patients with cardiomyopathy, extraction of prognostic value from this imaging biomarker is particularly attractive. Given its novel identification of a pervasive pathophysiological end point, myocardial fibrosis, LGE imaging is well poised to become a versatile marker of future cardiovascular outcomes across a wide variety of cardiomyopathies. However, while this conclusion is strongly supported by

Funding Sources

Dr White is the principle investigator of Imaging to Guide Evaluation of Heart Failure (IMAGE HF)-project IC (Canadian Institutes for Health Research [CIHR] team grant (CIF#99470), which has helped to support this work.

Disclosures

Dr White receives in-kind research support from Bayer Inc Canada and has received consultative fees from Medtronic Inc. There are no other conflicts of interest or financial relationships to disclose.

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