Outcome in Dilated Cardiomyopathy Related to the Extent, Location, and Pattern of Late Gadolinium Enhancement

Abstract

Objectives: This study sought to investigate the association between the extent, location, and pattern of late gadolinium enhancement (LGE) and outcome in a large dilated cardiomyopathy (DCM) cohort.

Background: The relationship between LGE and prognosis in DCM is incompletely understood.

Methods: The authors examined the association between LGE and all-cause mortality and a sudden cardiac death (SCD) composite based on the extent, location, and pattern of LGE in DCM.

Results: Of 874 patients (588 men, median age 52 years) followed for a median of 4.9 years, 300 (34.3%) had nonischemic LGE. Estimated adjusted hazard ratios for patients with an LGE extent of 0 to 2.55%, 2.55% to 5.10%, and >5.10%, respectively, were 1.59 (95% confidence interval [CI]: 0.99 to 2.55), 1.56 (95% CI: 0.96 to 2.54), and 2.31 (95% CI: 1.50 to 3.55) for all-cause mortality, and 2.79 (95% CI: 1.42 to 5.49), 3.86 (95% CI: 2.09 to 7.13), and 4.87 (95% CI: 2.78 to 8.53) for the SCD endpoint. There was a marked nonlinear relationship between LGE extent and outcome such that even small amounts of LGE predicted a substantial increase in risk. The presence of septal LGE was associated with increased mortality, but SCD was most associated with the combined presence of septal and free-wall LGE. Predictive models using LGE presence and location were superior to models based on LGE extent or pattern.

Conclusions: In DCM, the presence of septal LGE is associated with a large increase in the risk of death and SCD events, even when the extent is small. SCD risk is greatest with concomitant septal and free-wall LGE. The incremental value of LGE extent beyond small amounts and LGE pattern is limited.

Keywords: cardiovascular magnetic resonance; dilated cardiomyopathy; late gadolinium enhancement.

Graphical abstract

Figure 1

Study Cohort Flow chart detailing the identification of the study cohort.

Figure 2

Late Gadolinium Enhancement in Dilated Cardiomyopathy Late gadolinium enhancement images showing (A) linear mid-wall enhancement in the septum, (B) sub-epicardial enhancement in the lateral wall, (C) focal enhancement of the inferior wall, and (D) mid-wall enhancement of the septum, lateral and inferior wall.

Figure 3

Outcome and Extent of Late Gadolinium Enhancement Estimated adjusted hazard ratios with 95% confidence intervals (green lines) for (A) all-cause mortality and (B) the sudden cardiac death endpoint, per group based on late gadolinium enhancement extent (LGE). Patients are divided into 3 groups based on cut-offs of LGE extent: >0 and <2.55%, ≥2.55 and <5.10%, and ≥5.10%. The hazard ratios for the endpoint are positioned at the median LGE extent within each group. A cubic spline model (orange line) has been fitted to the observed data. LVEF = left ventricular ejection fraction; SCD = sudden cardiac death; ASCD = aborted SCD.

Figure 4

Outcome Related to Extent, Location, and Pattern of Late Gadolinium Enhancement Forrest plots showing the estimated adjusted hazard ratios (HRs) for (A) all-cause mortality and (B) the sudden cardiac death (SCD) endpoint, per patient group based on late gadolinium enhancement (LGE) extent, location, and pattern. For each model the different LGE HRs are compared to the No-LGE group, except for the final model where “septal LGE” is compared to “no-Septal LGE.” Abbreviations as in Figure 3.

Figure 5

Late Gadolinium Enhancement and Outcome in DCM Our study of dilated cardiomyopathy patients shows a nonlinear relationship between late gadolinium enhancement (LGE) extent and all-cause mortality and sudden cardiac death (SCD) events with a large increase in risk with small degrees of LGE. We show the superiority of models based on the location of LGE for the prediction of these end-points. DCM = dilated cardiomyopathy; other abbreviations as in Figure 3.