Progression of Myocardial Fibrosis in Nonischemic DCM and Association With Mortality and Heart Failure Outcomes

• Type of Material: Article
• Authors: Aditya Mandawat, Duke University Medical Center; Pairoj Chattranukulchai, Duke University; Anant Mandawat, Emory University; Alexander J Blood, Brigham and Womens Hospital, Boston; Sindhoor Ambati, Duke University Medical Center; Brenda Hayes, Duke University Medical Center; Wolfgang Rehwald, Duke University Medical Center; Han W Kim, Duke University Medical Center; John F Heitner, New York Methodist Hospital; Dipan J Shah, Methodist DeBakey Heart&Vascular Center; Igor Klem, Duke University Medical Center
• Language: English
• Date: 2021-07-05
• Publisher: ELSEVIER SCIENCE INC
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2021, American College of Cardiology Foundation. Published by Elsevier
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jcmg.2020.11.006
• Title of Journal or Parent Work: JACC-CARDIOVASCULAR IMAGING
• Volume: 14
• Issue: 7
• Start Page: 1338
• End Page: 1350
• Grant/Funding Information: This research was supported by Medtronic Inc., Mounds View, Minnesota (I. Klem) and by NIH training grant 5T32HL069749-14, Bethesda, Maryland (A. Mandawat). The other authors do not have conflicts of interest associated with this article.
• Keywords: SUDDEN CARDIAC DEATH; Radiology, Nuclear Medicine & Medical Imaging; RISK STRATIFICATION; AMIODARONE; DILATED CARDIOMYOPATHY; Life Sciences & Biomedicine; RANDOMIZED-TRIAL; Cardiovascular System & Cardiology; ANTIARRHYTHMIC-DRUG THERAPY; CARDIOVASCULAR MAGNETIC-RESONANCE; Science & Technology; dilated cardiomyopathy; LATE GADOLINIUM ENHANCEMENT; Cardiac & Cardiovascular Systems; outcomes; myocardial fibrosis; cardiovascular magnetic resonance imaging; VENTRICULAR DYSFUNCTION; IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR

Abstract

Objectives: The purpose of this study was to assess whether the presence and extent of fibrosis changes over time in patients with nonischemic, dilated cardiomyopathy (DCM) receiving optimal medical therapy and the implications of any such changes on left ventricular ejection fraction (LVEF) and clinical outcomes. Background: Myocardial fibrosis on cardiovascular magnetic resonance (CMR) imaging has emerged as important risk marker in patients with DCM. Methods: In total, 85 patients (age 56 ± 15 years, 45% women) with DCM underwent serial CMR (median interval 1.5 years) for assessment of LVEF and fibrosis. The primary outcome was all-cause mortality; the secondary outcome was a composite of heart failure hospitalization, aborted sudden cardiac death, left ventricular (LV) assist device implantation, or heart transplant. Results: On CMR-1, fibrosis (median 0.0 [interquartile range: 0% to 2.6%]) of LV mass was noted in 34 (40%) patients. On CMR-2, regression of fibrosis was not seen in any patient. Fibrosis findings were stable in 70 (82%) patients. Fibrosis progression (increase >1.8% of LV mass or new fibrosis) was seen in 15 patients (18%); 46% of these patients had no fibrosis on CMR-1. Although fibrosis progression was on aggregate associated with adverse LV remodeling and decreasing LVEF (40 ± 7% to 34 ± 10%; p < 0.01), in 60% of these cases the change in LVEF was minimal (<5%). Fibrosis progression was associated with increased hazards for all-cause mortality (hazard ratio: 3.4 [95% confidence interval: 1.5 to 7.9]; p < 0.01) and heart failure–related complications (hazard ratio: 3.5 [95% confidence interval: 1.5 to 8.1]; p < 0.01) after adjustment for clinical covariates including LVEF. Conclusions: Once myocardial replacement fibrosis in DCM is present on CMR, it does not regress in size or resolve over time. Progressive fibrosis is often associated with minimal change in LVEF and identifies a high-risk cohort.