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. 2023 Oct 17:10:1269412.
doi: 10.3389/fcvm.2023.1269412. eCollection 2023.

Feasibility of gray-blood late gadolinium enhancement evaluation in young patients with congenital and acquired heart disease

Cesar Gonzalez de Alba  1 , Mehdi H Moghari  2   3 , Lorna P Browne  2   3 , Richard M Friesen  1 , Brian Fonseca  1 , LaDonna J Malone  2   3
Affiliations

Feasibility of gray-blood late gadolinium enhancement evaluation in young patients with congenital and acquired heart disease

Cesar Gonzalez de Alba et al. Front Cardiovasc Med. .

Abstract

Background: Late gadolinium enhancement (LGE) sequences have become common in pediatric cardiovascular magnetic resonance (CMR) to assess for myocardial fibrosis. Bright-blood late gadolinium enhancement (BB-LGE) by conventional phase-sensitive inversion recovery (PSIR) is commonly utilized, but similar inversion time (TI) value of fibrosis and left ventricular (LV) blood pool can make subendocardial areas difficult to assess. A gray-blood LGE (GB-LGE) technique has been described, targeting nulling of the LV blood pool and demonstrating improvement in ischemic scar detection over BB-LGE in adult patients. We sought to evaluate the feasibility of the GB-LGE technique in a young population with congenital and acquired heart disease and compare its ability to detect subendocardial scar to conventional BB-LGE.

Methods: Seventy-six consecutive patients referred for clinical CMR underwent both BB-LGE and GB-LGE on 1.5 T and 3 T scanners. Conventional PSIR sequences were obtained with TI to null the myocardium (BB-LGE) in short-axis and horizontal long-axis stacks. Same PSIR stacks were immediately repeated with TI to null the blood pool (GB-LGE). Both sequences were reviewed separately a week apart by two readers, blinded to the initial clinical interpretation. Studies were analyzed for overall image quality, confidence in scar detection, confidence in detection of LGE, LGE class, inter- and intra-observer agreement for the presence of scar, and intraclass correlation coefficient (ICC) for total scar burden.

Results: Overall confidence in myocardial scar detection by BB-LGE or GB-LGE as well as grading of image quality were not statistically different [(p = 1 and p = 1) and (p = 0.53, p = 0.18), respectively]. There was very good inter-observer agreement for the presence of scar on BB-LGE (K = 0.88, 95% CI 0.77-0.99) and GB-LGE (K = 0.84, 95% CI 0.7-0.96), as well as excellent intra-observer agreement for both readers (K = 0.93, 95% CI 0.87-0.99; and K = 0.81, 95% CI 0.69-0.95). Interclass correlation coefficient for total scar burden was excellent for BB-LGE (ICC = 0.98, 95% CI 0.96-0.99) and GB-LGE (ICC = 0.94, 95% CI 0.91-0.97).

Conclusions: The GB-LGE technique is feasible in the pediatric population with congenital and acquired heart disease. It can detect subendocardial/ischemic scar similar to conventional bright-blood PSIR sequences in the pediatric population.

Keywords: cardiovascular magnetic resonance; congenital heart disease; late gadolinium enhancement; myocardial fibrosis; phase-sensitive inversion recovery; subendocardial fibrosis.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
TI selection on the Look Locker sequence. (A) Typical inversion time utilized for conventional bright-blood LGE; blood pool is bright and myocardium is nulled. (B) Typical inversion time for gray-blood LGE; blood pool is nulled and myocardium is bright. TI for gray-blood LGE occurs prior to the typical TI for bright-blood LGE.
Figure 2
Figure 2
LGE classification on bright-blood (A) and gray-blood sequences (B).
Figure 3
Figure 3
Observed subendocardial/ischemic LGE patterns. Endocardial fibroelastosis (arrows) in a patient with critical aortic stenosis is best discerned on GB-LGE (A) compared to BB-LGE (B). LGE (arrow) in a patient with coronary artery complications after Kawasaki disease is best discerned from blood pool in GB-LGE (C) compared to BB-LGE (D).
Figure 4
Figure 4
Fourteen-year-old admitted for ventricular fibrillation. (A,B) show conventional BB-LGE sequences; subendocardial scar is somewhat difficult to visualize given its similar signal intensity to the blood pool. (C,D) show gray-blood LGE sequences; the scar is relatively easier to see. Ultimately, utilization of both sequences increased the readers’ confidence in correctly diagnosing it.
Figure 5
Figure 5
Bland–Altman plot of total scar burden evaluation by gray-blood (GB) and bright-blood (BB) sequences for readers 1 (A) and 2 (B). The red solid line represents the mean difference between methods, and the blue dashed lines are the limits of agreement (LoA) with their corresponding 95% confidence interval. (A) Bland–Altman plot for reader 1. There was a significant bias with a mean of 0.14 (p = 0.0156), LoA −0.8 and +1.1. (B) Bland–Altman plot for reader 2. There was no significant bias with a mean of −0.1 (p = 0.07), LoA −1.0 and +0.8.
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