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Extent of Left Ventricular Scar Predicts Outcomes in Ischemic Cardiomyopathy Patients With Significantly Reduced Systolic Function

A Delayed Hyperenhancement Cardiac Magnetic Resonance Study

Deborah H. Kwon, MD^_*, Carmel M. Halley, MD^_*, Thomas P. Carrigan, MD, Victoria Zysek, DO, Zoran B. Popovic, MD, PhD^_*, Randolph Setser, PhD, Paul Schoenhagen, MD^_*,, Randall C. Starling, MD, MPH^_*, Scott D. Flamm, MD^_*,, Milind Y. Desai, MD^_*,,_*

^_* Department Cardiovascular Medicine, Cleveland, Ohio
Department of Internal Medicine, Cleveland, Ohio
Department of Radiology, Cleveland Clinic, Cleveland, Ohio

^_* Reprint requests and correspondence: Dr. Milind Y. Desai, Department of Cardiovascular Medicine, Desk F 15, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195 (Email: desaim2{at}ccf.org).

Objectives: 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 (70% disease in 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.

Key Words: delayed hyperenhancement CMR and outcomes • ischemic cardiomyopathy

Abbreviations and Acronyms   ACE-I = angiotensin-converting enzyme inhibitor   bSSFP = balanced steady-state free precession   CAD = coronary artery disease   CMR = cardiac magnetic resonance   CTx = cardiac transplantation   DHE-CMR = delayed hyperenhancement cardiac magnetic resonance   ICD = implantable cardioverter defibrillator   ICM = ischemic cardiomyopathy

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