Extent of left ventricular scar predicts outcomes in ischemic cardiomyopathy patients with significantly reduced systolic function: a delayed hyperenhancement cardiac magnetic resonance study.
OBJECTIVE
The objective of the study was to determine whether the extent of left ventricular scar, measured with delayed hyperenhancement cardiac magnetic resonance (DHE-CMR), predicts survival in patients with ischemic cardiomyopathy (ICM) and severely reduced left ventricular ejection fraction (LVEF).


BACKGROUND
Patients with ICM and reduced LVEF have poor survival. Such patients have a high myocardial scar burden. CMR is highly accurate in delineation of myocardial scar.


METHODS
We studied 349 patients (76% men) with severe ICM (>or=70% disease in >or=1 epicardial coronary, and mean LVEF of 24%) that underwent DHE-CMR (Siemens 1.5-T scanner, Erlangen, Germany), between 2003 and 2006. Scar (quantified as percentage of myocardium) was defined on DHE-MR images as an intensity >2 standard deviations above the viable myocardium. Transmurality score was semiquantitatively recorded in a 17-segment model as: 0 = no scar, 1 = 1% to 25% scar, 2 = 26% to 50%, 3 = 51% to 75%, and 4 = >75%. The LVEF, demographic data, risk factors, need for cardiac transplantation (CTx), and all-cause mortality were recorded.


RESULTS
The mean age and follow-up were 65 +/- 11 years and 2.6 +/- 1.2 years (median 2.4 years [1.1, 3.5]), respectively. There were 56 events (51 deaths and 5 CTx). Mean scar percentage and transmurality score were higher in patients with events versus those without (39 +/- 22 vs. 30 +/- 20, p = 0.003, and 9.7 +/- 5 vs. 7.8 +/- 5, p = 0.004). On Cox proportional hazard survival analysis, quantified scar was greater than the median (30% of total myocardium), and female gender predicted events (relative risk 1.75 [95% Confidence Interval: 1.02 to 3.03] and relative risk 1.83 [95% Confidence Interval: 1.06 to 3.16], respectively, both p = 0.03).


CONCLUSIONS
In patients with ICM and severely reduced LVEF, a greater extent of myocardial scar, delineated by DHE-CMR is associated with increased mortality or the need for cardiac transplantation, potentially aiding further risk-stratification.
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Deborah H
DH
Kwon
Carmel M
CM
Halley
Thomas P
TP
Carrigan
Victoria
V
Zysek
Zoran B
ZB
Popovic
Randolph
R
Setser
Paul
P
Schoenhagen
Randall C
RC
Starling
Scott D
SD
Flamm
Milind Y
MY
Desai
D000368:Aged; D009202:Cardiomyopathies / Q000209:etiology* / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000628:therapy; D003287:Contrast Media; D005260:Female; D019786:Gadolinium DTPA; D016027:Heart Transplantation; D006352:Heart Ventricles / Q000473:pathology / Q000503:physiopathology; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications* / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000628:therapy; D009206:Myocardium / Q000473:pathology*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D012737:Sex Factors; D013318:Stroke Volume; D013599:Systole; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000209:etiology* / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000628:therapy
D003287:Contrast Media; D019786:Gadolinium DTPA