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. 2012 Feb 1;14(1):11.
doi: 10.1186/1532-429X-14-11.

Late gadolinium enhancement cardiovascular magnetic resonance predicts clinical worsening in patients with pulmonary hypertension

Benjamin H Freed  1 , Mardi Gomberg-Maitland, Sonal Chandra, Victor Mor-Avi, Stuart Rich, Stephen L Archer, E Bruce Jamison Jr, Roberto M Lang, Amit R Patel
Affiliations

Late gadolinium enhancement cardiovascular magnetic resonance predicts clinical worsening in patients with pulmonary hypertension

Benjamin H Freed et al. J Cardiovasc Magn Reson. .

Abstract

Background: Late gadolinium enhancement (LGE) occurs at the right ventricular (RV) insertion point (RVIP) in patients with pulmonary hypertension (PH) and has been shown to correlate with cardiovascular magnetic resonance (CMR) derived RV indices. However, the prognostic role of RVIP-LGE and other CMR-derived parameters of RV function are not well established. Our aim was to evaluate the predictive value of contrast-enhanced CMR in patients with PH.

Methods: RV size, ejection fraction (RVEF), and the presence of RVIP-LGE were determined in 58 patients with PH referred for CMR. All patients underwent right heart catheterization, exercise testing, and N-terminal pro-brain natriuretic peptide (NT-proBNP) evaluation; results of which were included in the final analysis if performed within 4 months of the CMR study. Patients were followed for the primary endpoint of time to clinical worsening (death, decompensated right ventricular heart failure, initiation of prostacyclin, or lung transplantation).

Results: Overall, 40/58 (69%) of patients had RVIP-LGE. Patients with RVIP- LGE had larger right ventricular volume index, lower RVEF, and higher mean pulmonary artery pressure (mPAP), all p < 0.05. During the follow-up period of 10.2 ± 6.3 months, 19 patients reached the primary endpoint. In a univariate analysis, RVIP-LGE was a predictor for adverse outcomes (p = 0.026). In a multivariate analysis, CMR-derived RVEF was an independent predictor of clinical worsening (p = 0.036) along with well-established prognostic parameters such as exercise capacity (p = 0.010) and mPAP (p = 0.001).

Conclusions: The presence of RVIP-LGE in patients with PH is a marker for more advanced disease and poor prognosis. In addition, this study reveals for the first time that CMR-derived RVEF is an independent non-invasive imaging predictor of adverse outcomes in this patient population.

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Figures

Figure 1
Figure 1
Late gadolinium enhancement of right ventricular insertion point. This figure depicts a short axis, late gadolinium enhanced, phase-sensitive CMR image of the left and right ventricle. The white block arrows indicate areas of LGE located in both the anterior and inferior RVIP. The mPAP for this patient at rest during right heart catheterization was 62 mmHg. LV = left ventricle; RV = right ventricle.
Figure 2
Figure 2
Univariate analysis of multiple parameters for right ventricular function. Forest plot of univariate proportional hazards modeling including hazard ratios, 95% confidence intervals and p-values for parameters obtained from CMR, functional testing, NT-proBNP, and hemodynamics. The presence of RVIP-LGE was statistically significant for predicting time to clinical worsening. LVEDVI = left ventricular end-diastolic volume index; LVESVI = left ventricular end-systolic volume index; LVEF = left ventricular ejection fraction; RVEDVI = right ventricular end-diastolic volume index; RVESVI = right ventricular end-systolic volume index; LA size = left atrial volume; RA size = right atrial volume; Mean RA Pressure = mean right atrial pressure; PCWP = pulmonary capillary wedge pressure; CI = cardiac index; PVR = pulmonary vascular resistance; MVO2 = mixed venous oxygen saturation.
Figure 3
Figure 3
Time to clinical worsening for patients with pulmonary hypertension. Kaplan-Meier curves demonstrated time to clinical worsening for (A) patients with and without the presence of RVIP-LGE, (B) patients with RVEF ≥ 39% and < 39%, (C) patients with mPAP ≥ 45 mmHg and < 45 mmHg, and (D) patients with METs ≥ 6.1 and < 6.1.
See this image and copyright information in PMC

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