Objective criteria for septal fibrosis in non-ischemic dilated cardiomyopathy: validation for the prediction of future cardiovascular eventsReport as inadecuate

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Journal of Cardiovascular Magnetic Resonance

, 18:82

First Online: 14 November 2016Received: 12 July 2016Accepted: 28 October 2016


BackgroundExpert subjective reporting of mid-wall septal fibrosis on late gadolinium enhancement LGE images has been shown to predict major cardiovascular outcomes in patients with non-ischemic dilated cardiomyopathy NIDCM. This study aims to establish objective criteria for non-experts to report clinically relevant septal fibrosis and compare its performance by such readers versus experts for the prediction of cardiovascular events.

MethodsLGE cardiovascular magnetic resonance CMR was performed in 118 consecutive patients with NIDCM mean age 57 ± 14, 42 % female and the presence of septal fibrosis scored by expert readers. CMR-naive readers performed signal threshold-based LGE quantification by referencing mean values of remote tissue and applying these to a pre-defined anatomic region to measure septal fibrosis. All patients were followed for the primary composite outcome of cardiac mortality or appropriate implantable cardioverter-defibrillator ICD therapy.

ResultsThe mean LVEF was 32 ± 12 %. At a median follow-up of 1.9 years, 20 patients 17 % experienced a primary composite outcome. Expert visual scoring identified 55 patients with septal fibrosis. Non-expert septal fibrosis quantification was highly reproducible and identified mean septal fibrosis burden for three measured thresholds as follows; 5SD: 2.9 ± 3.6 %, 3SD: 6.9 ± 6.3 %, and 2SD: 11.1 ± 7.5 % of the left ventricular LV mass, respectively. By ROC analysis, optimal thresholds for prediction of the primary outcome were; 5SD: 2.74 % HR 8.7, p < 0.001, 3SD: 6.63 % HR 5.7, p = 0.001 and 2SD: 10.15 % HR 6.1, p = 0.001. By comparison, expert visual scoring provided a HR of 5.3 p = 0.001. In adjusted analysis, objective quantification by a novice reader >5SD threshold was the strongest independent predictor of the primary outcome HR 8.7 and provided improved risk reclassification beyond LVEF alone NRI 0.54, 95 % CI 0.16–0.92, p = 0.005.

ConclusionsNovice readers were able to achieve superior risk prediction for future cardiovascular events versus experts using objective criteria for septal fibrosis in patients with NIDCM. Patients with a septal fibrosis burden >2.74 % of the LV mass >5SD threshold were at a 9-fold higher risk of cardiac death or appropriate ICD therapy versus those not meeting this criteria. As such, this study validates reproducible criteria applicable to all levels of expertise to identify NIDCM patients at high risk of future cardiovascular events.

KeywordsDilated cardiomyopathy Fibrosis Cardiovascular magnetic resonance Prognosis AbbreviationsCMRCardiovascular magnetic resonance

EDVEnd diastolic volume

EFEjection fraction

ESVEnd systolic volume

FWHMFull width at half maximum

ICDImplantable cardioverter-defibrillator

LGELate gadolinium enhancement

LVLeft ventricular

NIDCMNon-ischemic dilated cardiomyopathy

RVRight ventricular

RVIRight ventricular insertion site

SCDSudden cardiac death

STRMSignal threshold versus reference mean

VTVentricular tachycardia

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Author: Yoko Mikami - Aidan Cornhill - Bobak Heydari - Sebastien X. Joncas - Fahad Almehmadi - Mohammed Zahrani - Mahmoud Bokhari

Source: https://link.springer.com/article/10.1186/s12968-016-0300-z

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