Author + information
- Received December 20, 2016
- Revision received April 13, 2017
- Accepted April 27, 2017
- Published online April 2, 2018.
- Juan Acosta, MDa,b,
- Juan Fernández-Armenta, MD, PhDa,b,
- Roger Borràs, MSca,b,
- Ignasi Anguera, MD, PhDc,
- Felipe Bisbal, MD, PhDb,d,
- Julio Martí-Almor, MD, PhDe,
- Jose M. Tolosana, MD, PhDa,b,
- Diego Penela, MD, PhDa,b,
- David Andreu, MSc, PhDa,b,
- David Soto-Iglesias, MSca,b,
- Reinder Evertz, MDa,b,
- María Matiello, MDf,
- Concepción Alonso, MD, PhDg,
- Roger Villuendas, MDb,d,
- Teresa M. de Caralt, MD, PhDh,
- Rosario J. Perea, MD, PhDh,
- Jose T. Ortiz, MD, PhDa,b,
- Xavier Bosch, MD, PhDa,b,
- Luis Serra, PhDi,
- Xavier Planes, MsCi,
- Andreas Greiser, PhDj,
- Okan Ekinci, MD, MBAk,l,
- Luis Lasalvia, MD, MIBm,
- Lluis Mont, MD, PhDa,b and
- Antonio Berruezo, MD, PhDa,b,∗ ()
- aArrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), University of Barcelona, Barcelona, Catalonia, Spain
- bCIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- cCardiology Department, Heart Disease Institute, Bellvitge Biomedical Research Institute IDIBELL, Bellvitge Hospital, University of Barcelona, Spain
- dHeart Institute (iCor), University Hospital Germans Trias i Pujol, Barcelona, Spain
- eElectrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
- fArrhythmia Section, Cardiology Department, Catalonia General Hospital, Barcelona, Spain
- gArrhythmia Unit, Cardiology Department, Hospital de la Sta. Creu i St. Pau, Barcelona, Spain
- hRadiology Department, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
- iGalgo Medical, SL, Barcelona, Spain
- jSiemens Healthcare GmbH, Erlangen, Germany
- kSiemens Healthineers, Chief Medical Office, Erlangen, Germany
- lUniversity College Dublin, School of Medicine, Dublin, Ireland
- mSiemens Medical Solutions, Global Clinical Marketing, Siemens Healthineers, New York, New York
- ↵∗Address for correspondence:
Dr. Antonio Berruezo, Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic C/ Villarroel 170, 08036 Barcelona, Spain.
Objectives The aim of this study was to analyze whether scar characterization could improve the risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD).
Background Among patients with a cardiac resynchronization therapy (CRT) indication, appropriate defibrillator (CRT-D) therapy rates are low.
Methods Primary prevention patients with a class I indication for CRT were prospectively enrolled and assigned to CRT-D or CRT pacemaker according to physician’s criteria. Pre-procedure contrast-enhanced cardiac magnetic resonance was obtained and analyzed to identify scar presence or absence, quantify the amount of core and border zone (BZ), and depict BZ distribution. The presence, mass, and characteristics of BZ channels in the scar were recorded. The primary endpoint was appropriate defibrillator therapy or SCD.
Results 217 patients (39.6% ischemic) were included. During a median follow-up of 35.5 months (12 to 62 months), the primary endpoint occurred in 25 patients (11.5%) and did not occur in patients without myocardial scar. Among patients with scar (n = 125, 57.6%), those with implantable cardioverter-defibrillator (ICD) therapies or SCD exhibited greater scar mass (38.7 ± 34.2 g vs. 17.9 ± 17.2 g; p < 0.001), scar heterogeneity (BZ mass/scar mass ratio) (49.5 ± 13.0 vs. 40.1 ± 21.7; p = 0.044), and BZ channel mass (3.6 ± 3.0 g vs. 1.8 ± 3.4 g; p = 0.018). BZ mass (hazard ratio: 1.06 [95% confidence interval: 1.04 to 1.08]; p < 0.001) and BZ channel mass (hazard ratio: 1.21 [95% confidence interval: 1.10 to 1.32]; p < 0.001) were the strongest predictors of the primary endpoint. An algorithm based on scar mass and the absence of BZ channels identified 148 patients (68.2%) without ICD therapy/SCD during follow-up with a 100% negative predictive value.
Conclusions The presence, extension, heterogeneity, and qualitative distribution of BZ tissue of myocardial scar independently predict appropriate ICD therapies and SCD in CRT patients.
- cardiac resynchronization therapy
- magnetic resonance imaging
- sudden cardiac death
- ventricular arrhythmias
This study has been supported by Siemens Healthcare and performed in collaboration with the Clinical Competence Center Cardiology, Erlangen, Germany. This work was also supported in part by the project PI14/00759, integrated in the Plan Nacional de I+D+I, and cofinanced by the ISCIII-Subdirección General de Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER), and by Sociedad Española de Cardiología (Proyecto de Invetigación Sección de Arritmias y Electrofisiología). Dr. Serra and Mr. Planes are stockholders and employees of Galgo Medical SL. Dr. Greiser is an employee of Siemens Healthcare. Dr. Ekinci is an employee of Siemens Healthineers. Dr. Lasalvia is a stockholder and employee of Siemens Healthcare. Dr. Berruezo is a stockholder in Galgo Medical SL; and has received financial support from Siemens Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 20, 2016.
- Revision received April 13, 2017.
- Accepted April 27, 2017.
- 2018 American College of Cardiology Foundation