Does stress perfusion imaging improve the diagnostic accuracy of late gadolinium enhanced cardiac magnetic resonance for establishing the etiology of heart failure?

Abstract

Background: Late gadolinium enhanced cardiovascular magnetic resonance (LGE-CMR) has excellent specificity, sensitivity and diagnostic accuracy for differentiating between ischemic cardiomyopathy (ICM) and non-ischemic dilated cardiomyopathy (NICM). CMR first-pass myocardial perfusion imaging (perfusion-CMR) may also play role in distinguishing heart failure of ischemic and non-ischemic origins, although the utility of additional of stress perfusion imaging in such patients is unclear. The aim of this retrospective study was to assess whether the addition of adenosine stress perfusion imaging to LGE-CMR is of incremental value for differentiating ICM and NICM in patients with severe left ventricular systolic dysfunction (LVSD) of uncertain etiology.

Methods: We retrospectively identified 100 consecutive adult patients (median age 69 years (IQR 59-73)) with severe LVSD (mean LV EF 26.6 ± 7.0%) referred for perfusion-CMR to establish the underlying etiology of heart failure. The cause of heart failure was first determined on examination of CMR cine and LGE images in isolation. Subsequent examination of complete adenosine stress perfusion-CMR studies (cine, LGE and perfusion images) was performed to identify whether this altered the initial diagnosis.

Results: On LGE-CMR, 38 patients were diagnosed with ICM, 46 with NICM and 16 with dual pathology. With perfusion-CMR, there were 39 ICM, 44 NICM and 17 dual pathology diagnoses. There was excellent agreement in diagnoses between LGE-CMR and perfusion-CMR (κ 0.968, p<0.001). The addition of adenosine stress perfusion images to LGE-CMR altered the diagnosis in only two of the 100 patients.

Conclusion: The addition of adenosine stress perfusion-CMR to cine and LGE-CMR provides minimal incremental diagnostic yield for determining the etiology of heart failure in patients with severe LVSD.

Keywords: Adenosine stress perfusion; Cardiovascular magnetic resonance; Heart failure; Late gadolinium enhancement; Non-ischemic cardiomyopathy.

Fig. 1

Illustration of typical patterns of LGE seen in NICM and ICM. White areas within the myocardium represent LGE. a Mid-wall LGE is commonly seen in NICM, whereas b a subendocardial distribution of LGE is typical in ICM

Fig. 2

a Two-chamber LGE image with inferior LV mid-wall hyperenhancement (arrow). b First-pass perfusion-CMR image demonstrating an inferolateral subendocardial perfusion abnormality (arrow)

Fig. 3

a Mid short-axis LGE window; there is no hyperenhancement to suggest myocardial infarction. b First-pass perfusion-CMR image showing a mid LV anteroseptal reversible perfusion defect (arrow). c The corresponding coronary angiogram image; there is a chronic total occlusion of the proximal-mid left anterior descending artery (arrow)