title: Mid wall fibrosis on CMR with late gadolinium enhancement may predict prognosis for LVAD and transplantation risk in patients with newly diagnosed dilated cardiomyopathy-preliminary observations from a high-volume transplant centre.
abstract: BACKGROUND
  Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high-risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration.
  
  
  METHODS
  Over 49 consecutive months, 61 consecutives DCM patients were referred for standard CMR(1.5T, GE) to interrogate the LV pattern, distribution, and extent of LGE (MultiHance, Princeton, NJ). Inclusion criteria for a primary non-ischaemic DCM and EF <45% were met in 31 patients. DCM patients were categorized into: (i) presence of midwall LV stripe (+Stripe) and (ii) absence of midwall stripe (-Stripe) groups. Primary outcome was defined by the composite of death, need for LV assist device (LVAD), and urgent orthotopic cardiac transplantation (Tx) during a 12-month follow-up period. Kaplan-Meier survival analysis was conducted grouping patients by +Stripe and -Stripe.
  
  
  RESULTS
  There were no differences between groups for demographics, blood pressure, labs, baseline LVEF, NYHA class, or invasive haemodynamics. There were 18 patients (58%) with +Stripe. Nine events occurred: seven patients required urgent Tx and/or LVAD implantation and two patients died. The +Stripe categorization strongly predicted the need for LVAD, urgent Tx surgery, and death (log-rank = 9,P= 0.002). All the events occurred in the +Stripe patients with no MACE experienced in the -Stripe group. The -Stripe group experienced marked signs of improvement in LVEF (P= 0.01) at follow-up. LVEDD was predictive of need for LVAD/Tx and death by univariate analysis. Otherwise, no common clinical metric such as LVEF, LVEDV, RVEF, RVEDV, or any invasive haemodynamic parameter predicted MACE.
  
  
  CONCLUSIONS
  The presence of +Stripe on CMR is strongly predictive of LVAD, transplant need, and death during a 12-month follow-up period in DCM patients in this proof of concept study. All -Stripe patients survived without experiencing any events. Incorporating CMR imaging into routine clinical practice may have prognostic value in DCM patients; indicating conservative management in low-risk patients while expectantly managing high-risk patients.
authors.affiliation: Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA.
authors.forename: Jose V
authors.initials: JV
authors.lastname: Venero
authors.affiliation: Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Doyle
authors.affiliation: Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA.
authors.forename: Moneal
authors.initials: M
authors.lastname: Shah
authors.affiliation: Bon Secours Richmond Health System Sherwood Drive Colonial Heights VA 23834 USA.
authors.forename: Vikas K
authors.initials: VK
authors.lastname: Rathi
authors.affiliation: Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA.
authors.forename: June A
authors.initials: JA
authors.lastname: Yamrozik
authors.affiliation: Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA.
authors.forename: Ronald B
authors.initials: RB
authors.lastname: Williams
authors.affiliation: Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA.
authors.forename: Diane A
authors.initials: DA
authors.lastname: Vido
authors.affiliation: Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA.
authors.forename: Geetha
authors.initials: G
authors.lastname: Rayarao
authors.affiliation: Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA.
authors.forename: Raymond
authors.initials: R
authors.lastname: Benza
authors.affiliation: Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA.
authors.forename: Srinivas
authors.initials: S
authors.lastname: Murali
authors.affiliation: Division of Pathology Allegheny General Hospital East North Ave Pittsburgh PA USA.
authors.forename: Jerry
authors.initials: J
authors.lastname: Glass
authors.affiliation: Division of Pathology Allegheny General Hospital East North Ave Pittsburgh PA USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Olson
authors.affiliation: Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA.
authors.forename: George
authors.initials: G
authors.lastname: Sokos
authors.affiliation: Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA.
authors.forename: Robert W W
authors.initials: RW
authors.lastname: Biederman
keywords: Cardiac MRI; Heart transplantation; Midwall fibrosis