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Use of CMR for risk stratification in chronic heart failure:

prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated cardiomyopathy

The clinical course of dilated cardiomyopathy (DCM) may be variable and risk stratification is often difficult. The goal of the study was to investigate the long-term prognostic significance of late gadolinium enhancement (LGE) as detected by contrast-enhanced cardiovascular magnetic resonance (CE-CMR) in DCM patients.  Heart 2011;97:727-732.
Myocardial Disease

The study design was an observational cohort study, among university hospital DCM patients. The study group comprised 184 consecutive patients with DCM. Individuals with signs or symptoms of ongoing myocarditis or diagnosed with significant coronary artery disease were excluded. CE-CMR was performed on a 1.5 T clinical scanner. LGE was evaluated by two independent observers. For quantification of fibrosis, LGE was defined as areas with a signal intensity >2 SD above the mean signal intensity. Areas were measured by manual planimetry and expressed as percentage of myocardial mass. Those who had been initially diagnosed as having DCM and displaying a subendocardial or transmural pattern of late gadolinium enhancement suggestive of myocardial infarction were excluded from final analysis.
The composite end point included cardiac death, hospitalization for decompensated heart failure, or appropriate implantable cardioverter defibrillator discharge for a mean + SEM of 685+ 30 days. 

The authors found LGE in 72/184 patients (39%). LGE associated with a significantly lower left ventricular (LV) ejection fraction (31% (20.9-42.2%) vs 44% (33.1-50.9%), p < 0.001), higher LV end-diastolic volume index and higher LV mass. Individuals with LGE were more likely to experience the composite end point (15/72 vs 6/112, p= 0.002). The receiver operating characteristic curve (ROC) showed that a LGE of >4.4% of LV mass was optimal discriminator for the composite end point. LGE retained its independent predictive value also in multivariate Cox regression analysis. Importantly, the prognostic significance of LGE was dependent on the degree of LV dysfunction so that those with  severely impaired LV function had more unfavorable outcome.

The authors discussed that LGE probably reflects the segmental replacement fibrosis whereas the diffuse interstitial fibrosis is not visualized by contrast-enhanced cardiac MRI. They concluded that in this DCM patient cohort LGE was associated with pronounced LV remodelling, functional impairment and adverse outcome. The possible mechanisms could be the arrhythmogenicity of local fibrotic areas and loss of ventricular compliance due to fibrosis. The role of LGE in clinical decision making has not yet been clarified.


This was so far the largest DCM cohort studied with CE-CMR. Examining the relationships between patterns and amount of LGE and adverse cardiac remodelling may increase our understanding of the mechanisms of heart failure. Data from genetically characterized DCM populations could possibly in the future  reveal whether some of the LGE patterns might reflect different ethiologies of DCM. 


Clinically, there is a clear need to find more tools for identifying those patients with DCM and chronic heart failure, who would most benefit from interventions like prophylactic implantation of an ICD. The use of cardiac MRI is generally increasing due its role as the golden standard of measuring cardiac mass and function. Earlier reports have shown that cardiac MRI with LGE differentiated ischaemic cardiomyopathy from DCM. The results of this study performed by Lehrke et al are in line with investigations, which have demonstrated  that LGE associates with an increased risk. Similar results have been obtained from patients with hypertrophic cardiomyopathy. It would be useful if simultaneously with cardiac MRI performed to assess left ventricular mass and function, could be also obtained information on the prognosis of the patient. Future studies will show to which extent LGE in cardiac MRI affects clinical decision-making.


Heart 2011;97:727-732

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Notes to editor

Presented by Dr. Tiina Heliö, Department of Cardiology,
Helsinki University Central Hospital, Helsinki, Finland
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.