title: Infarct characterization and quantification by delayed enhancement cardiac magnetic resonance imaging is a powerful independent and incremental predictor of mortality in patients with advanced ischemic cardiomyopathy.
abstract: BACKGROUND
  Infarct heterogeneity has been shown to be independently associated with adverse outcomes in previous smaller studies. However, it is unknown whether infarct characterization is an independent predictor of all-cause mortality in patients with advanced ischemic cardiomyopathy, after adjusting for clinical risk factors, severity of ischemic mitral regurgitation, incomplete revascularization, and device therapy.
  
  
  RESULTS
  A total of 362 patients with ischemic cardiomyopathy (left ventricular dysfunction with >70% stenosis in ≥1 epicardial coronary artery) underwent delayed hyperenhancement-magnetic resonance imaging and coronary angiography between 2002 and 2006. Total myocardial scar and peri-infarct (PI) area were measured using various threshold techniques. Multivariate survival analysis (primary end point of all-cause mortality) was conducted. One hundred fifty-seven deaths occurred during a mean 5.4-year follow-up (mean left ventricular ejection fraction, 23±9%; mean end-systolic volume index, 113±48 mL; mean total myocardial scar %, 25.5±16.0%; mean PI%, 5.7±2.9%). PI% (β=2.07; P<0.001) was an independent predictor of survival, independent of age, end-systolic volume, sex, mitral regurgitation, diabetes mellitus, dyslipidemia, coronary artery disease severity, implantable cardioverter defibrillator, and incomplete revascularization. PI% using 2 to 3 SD technique yielded the highest incremental prognostic power (χ(2) score 149).
  
  
  CONCLUSIONS
  In advanced ischemic cardiomyopathy, PI% is a powerful independent and incremental predictor of all-cause mortality. Infarct heterogeneity offers substantial further risk stratification when compared with quantification of total myocardial scar % alone even after adjusting for clinical risk factors, end-systolic volume index, mitral regurgitation, incomplete revascularization, and implantable cardioverter defibrillator implantation.
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.). kwond@ccf.org.
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Kwon
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Lisa
authors.initials: L
authors.lastname: Asamoto
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popovic
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Kenya
authors.initials: K
authors.lastname: Kusunose
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Monique
authors.initials: M
authors.lastname: Robinson
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Milind
authors.initials: M
authors.lastname: Desai
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Marwick
authors.affiliation: From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
authors.forename: Scott D
authors.initials: SD
authors.lastname: Flamm
mesh_terms: D009202:Cardiomyopathies / Q000175:diagnosis* / Q000503:physiopathology; D002423:Cause of Death / Q000639:trends; D003287:Contrast Media; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D009206:Myocardium / Q000473:pathology*; D009820:Ohio / Q000453:epidemiology; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016277:Ventricular Function, Left
chemical_list: D003287:Contrast Media
keywords: ischemic heart disease; magnetic resonance imaging; survival