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Multicenter Study
. 2021 Nov 16;10(22):e021861.
doi: 10.1161/JAHA.121.021861. Epub 2021 Nov 15.

Prognostic Role of Myocardial Edema as Evidenced by Early Cardiac Magnetic Resonance in Survivors of Out-of-Hospital Cardiac Arrest: A Multicenter Study

Alessandro Zorzi  1 , Giulia Mattesi  1 , Enrico Baldi  2   3 , Mauro Toniolo  4 , Federico Guerra  5 , Filippo Maria Cauti  6 , Alberto Cipriani  1 , Manuel De Lazzari  1 , Daniele Muser  4 , Giulia Stronati  5 , Lina Marcantoni  7 , Massimiliano Manfrin  8 , Leonardo Calò  9 , Chiara Lanzillo  9 , Martina Perazzolo Marra  1 , Simone Savastano  10 , Domenico Corrado  1
Affiliations
Multicenter Study

Prognostic Role of Myocardial Edema as Evidenced by Early Cardiac Magnetic Resonance in Survivors of Out-of-Hospital Cardiac Arrest: A Multicenter Study

Alessandro Zorzi et al. J Am Heart Assoc. .

Abstract

Background Sudden cardiac arrest (SCA) may be caused by an acute and reversible myocardial injury, a chronic and irreversible myocardial damage, or a primary ventricular arrhythmia. Cardiac magnetic resonance imaging may identify myocardial edema (ME), which denotes acute and reversible myocardial damage. We evaluated the arrhythmic outcome of SCA survivors during follow-up and tested the prognostic role of ME. Methods and Results We included a consecutive series of 101 (71% men, median age 47 years) SCA survivors from 9 collaborative centers who underwent early (<1 month) cardiac magnetic resonance imaging and received an implantable cardioverter-defibrillator (ICD). On T2-weighted sequences, ME was found in 18 of 101 (18%) patients. According to cardiac magnetic resonance imaging findings, the arrhythmic SCA was ascribed to acute myocardial injury (either ischemic [n=10] or inflammatory [n=8]), to chronic structural heart diseases (ischemic heart disease [n=11], cardiomyopathy [n=20], or other [n=23]), or to primarily arrhythmic syndrome (n=29). During a follow-up of 47 months (28 to 67 months), 24 of 101 (24%) patients received an appropriate ICD intervention. ME was associated with a significantly higher survival free from both any ICD interventions (log-rank=0.04) and ICD shocks (log-rank=0.03) and remained an independent predictor of better arrhythmic outcome after adjustment for left ventricular ejection fraction and late gadolinium enhancement. The risk of appropriate ICD intervention was unrelated to the type of underlying heart disease. Conclusions ME on early cardiac magnetic resonance imaging, which denotes an acute and transient arrhythmogenic substrate, predicted a favorable long-term arrhythmic outcome of SCA survivors. These findings may have a substantial impact on future guidelines on the management of SCA survivors.

Keywords: cardiac magnetic resonance; implantable cardioverter‐defibrillator; out‐of‐hospital cardiac arrest; prognosis; ventricular arrhythmia.

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Figures

Figure 1
Figure 1. Representative examples of patients experiencing sudden cardiac arrest secondary to ischemic heart disease.
Cardiac magnetic resonance (CMR) showing transmural myocardial edema (ME) of the lateral left ventricular wall (4 chambers, long‐axis view; T2‐weighted sequences) (A) and subendocardial late gadolinium enhancement (LGE) involving the same region (4‐chamber, long‐axis view; T1‐weighted inversion recovery postcontrast sequences) (B) in a patient with obstructive stenosis of the circumflex artery, suggesting acute myocardial infarction. CMR showing no ME (short‐axis view; T2‐weighted sequences) (C) and transmural LGE involving the inferior left ventricular wall (short‐axis view; T1‐weighted inversion recovery postcontrast sequences) (D) in a patient with chronic right coronary artery occlusion suggesting chronic ischemic heart disease.
Figure 2
Figure 2. Representative examples of patients experiencing sudden cardiac arrest secondary to nonischemic heart disease.
Cardiac magnetic resonance (CMR) showing subepicardial myocardial edema (ME) of the inferolateral left ventricular wall (short‐axis view; T2‐weighted sequences) (A) and subepicardial late gadolinium enhancement (LGE) involving the same region (short‐axis view; T1‐weighted inversion recovery postcontrast sequences) (B) in a patient with normal coronary artery, suggesting acute myocarditis. CMR showing no ME (short‐axis view; T2‐weighted sequences) (C) and circumferential subepicardial‐midmyocardial LGE (short‐axis view; T1‐weighted inversion recovery postcontrast sequences) (D) in a patient with left‐dominant arrhythmogenic cardiomyopathy.
Figure 3
Figure 3. Survival free from appropriate implantable cardioverter‐defibrillator (ICD) intervention according to the presence of myocardial edema (ME).
Kaplan‐Meier analysis of survival free from appropriate ICD interventions (antitachycardia pacing or shock [A] or shock only [B] according to the presence of ME on cardiac magnetic resonance).
Figure 4
Figure 4. Survival free from appropriate implantable cardioverter‐defibrillator (ICD) intervention according to the type of disease.
Kaplan‐Meier analysis of survival free from appropriate ICD interventions (antitachycardia pacing or shock [A] or shock only [B] according to the type of cardiovascular disease).
Figure 5
Figure 5. Summary of study protocol and main results.
ATP indicates antitachycardia pacing; CMR, cardiac magnetic resonance; ICD, implantable cardioverter‐defibrillator; LGE, late gadolinium enhancement; and SCA, sudden cardiac arrest.
See this image and copyright information in PMC

Comment in

  • The Bright Side of Myocardial Edema.
    Clark DE, Hughes SG. Clark DE, et al. J Am Heart Assoc. 2021 Nov 16;10(22):e023731. doi: 10.1161/JAHA.121.023731. Epub 2021 Nov 15. J Am Heart Assoc. 2021. PMID: 34779232 Free PMC article. No abstract available.

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