Late gadolinium enhancement as a predictor of functional recovery, need for defibrillator implantation and prognosis in non-ischemic dilated cardiomyopathy

Role of Imaging and Biomarkers in Identifying, Monitoring, and Promoting Myocardial Recovery

Reverse remodeling, the overarching concept behind myocardial recovery, describes the process in which the maladaptive cardiac structural and functional alterations are reversed by removing the underlying etiology or by therapy. This review addresses different imaging modalities and biomarkers as possible predictors for reverse remodeling in patients with chronic heart failure. Although echocardiography remains the imaging modality of choice in daily practice, the presence and amount of fibrosis on cardiac magnetic resonance is a better predictor and inversely correlated with the likelihood for reverse remodeling. A decrease in NT-proBNP levels and serum soluble ST3 during follow-up is associated with better clinical and structural outcomes. The role of troponins and galectine-3 is less clear. There is a promising role for microRNAs in the future, although more research is necessary. Accurate predictors of reverse remodeling could help identify patients with an increased likelihood for reverse remodeling and, in turn, improve patient-tailored medicine.

Heart failure with improved ejection fraction: patient characteristics, clinical outcomes and predictors for improvement

Background

Heart failure with improved ejection fraction (HFimpEF) is a recently recognized entity presenting a diagnostic and therapeutic challenge. Our aim was to characterize the profile of HFimpEF patients and evaluate predictors for EF lack of improvement among heart failure with reduced ejection fraction (HFrEF) patients.

Methods

We included ambulatory HFrEF patients (EF≤40%) between January 1, 2015, and September 1, 2022, with two consecutive echocardiography exams at least 6 months apart. HFimpEF was defined as improved EF from ≤40%->40% and by ≥10%.

Results

A total of 567 HFrEF patients (72% male, 54.3 ± 14.4 years old) were analyzed. Patients without EF improvement were more likely to be male, had more comorbidities, ischemic cardiomyopathy (ICMP), markers of adverse cardiac remodeling (lower EF and higher left and right ventricular diameters) and presence of late gadolinium enhancement (LGE) in MRI (P < 0.05 for all). In a multivariate analysis, male sex, ICMP, lower EF, larger ventricular size and LGE remained independent predictors for lack of EF improvement. A prediction model for lack of EF improvement including LVEF, LV diameter, diastolic blood pressure and ischemic etiology exhibited an area under the ROC curve of 0.77 (95% CI 0.73-0.81; P < 0.001). HFimpEF patients had better prognosis with lower hospitalizations and mortality rates. Guideline directed medical therapy (GDMT) were associated with improved outcomes in both groups regardless of EF improvement.

Conclusions

Lack of improvement in EF among HFrEF patients may be predicted by HF etiology and imaging parameters of adverse cardiac remodeling, and is associated with worse prognosis. GDMT were associated with improved outcomes in both HFimpEF and HFrEF patients.

Heart Failure With Improved Ejection Fraction: Prevalence, Predictors, and Guideline-Directed Medical Therapy

Recently, a new category of heart failure with improved ejection fraction (HFimpEF) has emerged in the classification system. This is defined as the subgroup of patients with heart failure with reduced ejection fraction (HFrEF) whose left ventricular ejection fraction has recovered partially or completely, with no specific cut-off values established yet in the guidelines. In our review, we aim to provide an overview of prevalence, predictors, mechanism of remodeling, and management strategies regarding HFimpEF. These patients constitute a sizeable cohort among patients with reduced ejection fraction. Certain patient characteristics including younger age and female gender, absence of comorbid conditions, low levels of biomarkers, and non-ischemic etiology were identified as positive predictors. The heart undergoes significant maladaptive changes post failure leading to adverse remodeling influenced etiology and duration. Goal-directed medical therapy including beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin II receptor blockers (ARBs) have notably improved cardiac function by inducing reverse remodeling. Despite a more favorable prognosis compared to HFrEF, patients with improved ejection fraction (EF) still face clinical events and reduced quality of life, and remain at risk of adverse outcomes. Although the evidence is scarce, it is advisable to continue treatment modalities despite improvement in EF, including device therapies, to prevent relapse and clinical deterioration. It is imperative to conduct further research to understand the mechanism leading to EF amelioration and establish guidelines to identify and direct management strategies.

Multidisciplinary approach in cardiomyopathies: From genetics to advanced imaging

Cardiomyopathies are myocardial diseases characterized by mechanical and electrical dysfunction of the heart muscle which could lead to heart failure and life-threatening arrhythmias. Certainly, an accurate anamnesis, a meticulous physical examination, and an ECG are cornerstones in raising the diagnostic suspicion. However, cardiovascular imaging techniques are indispensable to diagnose a specific cardiomyopathy, to stratify the risk related to the disease and even to track the response to the therapy. Echocardiography is often the first exam that the patient undergoes, because of its non-invasiveness, wide availability, and cost-effectiveness. Cardiac magnetic resonance imaging allows to integrate and implement the information obtained with the echography. Furthermore, cardiomyopathies' genetic basis has been investigated over the years and the list of genetic mutations deemed potentially pathogenic is expected to grow further. The aim of this review is to show echocardiographic, cardiac magnetic resonance imaging, and genetic features of several cardiomyopathies: dilated cardiomyopathy (DMC), hypertrophic cardiomyopathy (HCM), arrhythmogenic cardiomyopathy (ACM), left ventricular noncompaction cardiomyopathy (LVNC), myocarditis, and takotsubo cardiomyopathy.

The predictive value of coronary microvascular dysfunction for left ventricular reverse remodelling in dilated cardiomyopathy

Aims

To evaluate the degree of coronary microvascular dysfunction (CMD) in dilated cardiomyopathy (DCM) patients by cardiac magnetic resonance (CMR) first-pass perfusion parameters and to examine the correlation between myocardial perfusion and left ventricle reverse remodelling (LVRR).

Methods

In this study, 94 DCM patients and 35 healthy controls matched for age and sex were included. Myocardial perfusion parameters, including upslope, time to maximum signal intensity (Timemax), maximum signal intensity (SImax), baseline signal intensity (SIbaseline), and the difference between maximum and baseline signal intensity (SImax-baseline) were measured. Additionally, left ventricular (LV) structure, function parameters, and late gadolinium enhancement (LGE) were also recorded. The parameters were compared between healthy controls and DCM patients. Univariable and multivariable logistic regression analyses were used to determine the predictors of LVRR.

Results

With a median follow-up period of 12 months [interquartile range (IQR), 8-13], 41 DCM patients (44%) achieved LVRR. Compared with healthy controls, DCM patients presented CMD with reduced upslope, SIbaseline, and increased Timemax (all p < 0.01). Timemax, SImax, and SImax-baseline were further decreased in LVRR than non-LVRR group (Timemax: 60.35 [IQR, 51.46-74.71] vs. 72.41 [IQR, 59.68-97.70], p = 0.017; SImax: 723.52 [IQR, 209.76-909.27] vs. 810.92 [IQR, 581.30-996.89], p = 0.049; SImax-baseline: 462.99 [IQR, 152.25-580.43] vs. 551.13 [IQR, 402.57-675.36], p = 0.038). In the analysis of multivariate logistic regression, Timemax [odds ratio (OR) 0.98; 95% confidence interval (CI) 0.95-1.00; p = 0.032)], heart rate (OR 1.04; 95% CI 1.01-1.08; p = 0.029), LV remodelling index (OR 1.73; 95% CI 1.06-3.00; p = 0.038) and LGE extent (OR 0.85; 95% CI 0.73-0.96; p = 0.021) were independent predictors of LVRR.

Conclusions

CMD could be found in DCM patients and was more impaired in patients with non-LVRR than LVRR patients. Timemax at baseline was an independent predictor of LVRR in DCM.

Heart Failure With Recovered Ejection Fraction in Patients With Nonischemic Cardiomyopathy: Characteristics, Outcomes, and Long-term Follow-up

BACKGROUND

Duration of recovery and long-term outcomes have not been well-described in a large cohort of patients with heart failure with recovered ejection fraction (HFrecEF) owing to nonischemic cardiomyopathy. The aim of the study was to characterize the duration of recovery and long-term outcomes of patients with HFrecEF.

METHODS AND RESULTS

We performed a retrospective analysis of our institution's databases. Only patients with nonischemic cardiomyopathy, a chronic HF diagnosis, and a previous left ventricular ejection fraction (LVEF) of ≤35% who had a subsequent LVEF of ≥50% were considered to have recovery. Patients with an LVEF of ≤35% who did not recover served as the comparison group. Included were 2319 patients with an LVEF of ≤35%, of whom 465 (20% [18.4%-21.7%]) met the above criteria for recovery (HFrecEF group). Recovery in the HFrecEF group was temporary in most cases, with 50% of patients experiencing a decline in LVEF to <50% within 3.5 [interquartile range 2.4-4.9] years after the day of recovery. Age and sex adjusted death and hospitalization were lower in the HFrecEF group than the HFrEF group (HR 0.29 [interquartile range 0.20-0.41] for death and 0.44 [interquartile range 0.32-0.60] for HF hospitalization, P < .0001 for both). Longer recovery was associated with better survival, with patients spending >5 years in recovery (LVEF of ≥50%) displaying the highest survival rates (83% alive at 10 years after recovery). Survival after recurrence of LV dysfunction was longer for those whose recovery duration was >1 year.

CONCLUSIONS

Patients with nonischemic HFrecEF display a unique clinical course. Although recovery is temporary in most cases, patients with HFrecEF display lower mortality and hospitalization rates, with the more durable the recovery of LV systolic function, the longer survival can be anticipated.

The new European Society of Cardiology guideline for the management of cardiomyopathies: key messages for cardiac electrophysiologists

Electrocardiographic findings and arrhythmias are common in cardiomyopathies. Both may be an early indication of a specific diagnosis or may occur due to myocardial fibrosis and/or reduced contractility. Brady- and tachyarrhythmias significantly contribute to increased morbidity and mortality in patients with cardiomyopathies. Antiarrhythmic therapy including risk stratification is often challenging and plays a major role for these patients. Thus, an "electrophysiological" perspective on guidelines on cardiomyopathies may be warranted. As the European Society of Cardiology (ESC) has recently published a new guideline for the management of cardiomyopathies, this overview aims to present key messages of these guidelines. Innovations include a new phenotype-based classification system with emphasis on a multimodal imaging approach for diagnosis and risk stratification. The guideline includes detailed chapters on dilated and hypertrophic cardiomyopathy and their phenocopies, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy as well as syndromic and metabolic cardiomyopathies. Patient pathways guide clinicians from the initial presentation to diagnosis. The role of cardiovascular magnetic resonance imaging and genetic testing during diagnostic work-up is stressed. Concepts of rhythm and rate control for atrial fibrillation have led to new recommendations, and the role of defibrillator therapy in primary prevention is discussed in detail. Whilst providing general guidelines for management, the primary objective of the guideline is to ascertain the disease etiology and disease-specific, individualized management.

The Rare Condition of Left Ventricular Non-Compaction and Reverse Remodeling

Left ventricular non-compaction (LVNC) is a rare disease defined by morphological criteria, consisting of a two-layered ventricular wall, a thin compacted epicardial layer, and a thick hyper-trabeculated myocardium layer with deep recesses. Controversies still exist regarding whether it is a distinct cardiomyopathy (CM) or a morphological trait of different conditions. This review analyzes data from the literature regarding diagnosis, treatment, and prognosis in LVNC and the current knowledge regarding reverse remodeling in this form of CM. Furthermore, for clear exemplification, we report a case of a 41-year-old male who presented symptoms of heart failure (HF). LVNC CM was suspected at the time of transthoracic echocardiography and was subsequently confirmed upon cardiac magnetic resonance imaging. A favorable remodeling and clinical outcome were registered after including an angiotensin receptor neprilysin inhibitor in the HF treatment. LVNC remains a heterogenous CM, and although a favorable outcome is not commonly encountered, some patients respond well to therapy.

Cardiac magnetic resonance findings and prognosis in type 1 myotonic dystrophy

BACKGROUND

Cardiac involvement is a major determinant of prognosis in type 1 myotonic dystrophy (DM1), but limited information is available about myocardial remodeling and tissue changes. The aim of the study was to investigate cardiac magnetic resonance (CMR) findings and their prognostic significance in DM1.

METHODS

We retrospectively identified all DM1 patients referred from a neurology unit to our CMR laboratory from 2009 to 2020.

RESULTS

Thirty-four patients were included (aged 45 ± 12, 62% male individuals) and compared with 68 age-matched and gender-matched healthy volunteers (43 male individuals, age 48 ± 15 years). At CMR, biventricular and biatrial volumes were significantly smaller (all P < 0.05), as was left ventricular mass (P < 0.001); left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) were significantly lower (all P < 0.01). Five (15%) patients had a LVEF less than 50% and four (12%) a RVEF less than 50%. Nine patients (26%) showed mid-wall late gadolinium enhancement (LGE; 5 ± 2% of LVM), and 14 (41%) fatty infiltration. Native T1 in the interventricular septum (1041 ± 53 ms) was higher than for healthy controls (1017 ± 28 ms) and approached the upper reference limit (1089 ms); the extracellular volume was slightly increased (33 ± 2%, reference <30%). Over 3.7 years (2.0-5.0), 6 (18%) patients died of extracardiac causes, 5 (15%) underwent device implantation; 5 of 21 (24%) developed repetitive ventricular ectopic beats (VEBs) on Holter monitoring. LGE mass was associated with the occurrence of repetitive VEBs (P = 0.002). Lower LV stroke volume (P = 0.017), lower RVEF (P = 0.016), a higher LVMi/LVEDVI ratio (P = 0.016), fatty infiltration (P = 0.04), and LGE extent (P < 0.001) were associated with death.

CONCLUSION

DM1 patients display structural and functional cardiac abnormalities, with variable degrees of cardiac muscle hypotrophy, fibrosis, and fatty infiltration. Such changes, as evaluated by CMR, seem to be associated with the development of ventricular arrhythmias and a worse outcome.

Role of Imaging in Cardiomyopathies

Imaging has a central role in the diagnosis, classification, and clinical management of cardiomyopathies. While echocardiography is the first-line technique, given its wide availability and safety, advanced imaging, including cardiovascular magnetic resonance (CMR), nuclear medicine and CT, is increasingly needed to refine the diagnosis or guide therapeutic decision-making. In selected cases, such as in transthyretin-related cardiac amyloidosis or in arrhythmogenic cardiomyopathy, the demonstration of histological features of the disease can be avoided when typical findings are observed at bone-tracer scintigraphy or CMR, respectively. Findings from imaging techniques should always be integrated with data from the clinical, electrocardiographic, biomarker, genetic and functional evaluation to pursue an individualised approach to patients with cardiomyopathy.

A review of biomarker and imaging monitoring to predict heart failure recovery

Heart failure is a clinical syndrome caused by structural cardiac abnormalities that lead to increased intracardiac pressures and decreased cardiac output. Following cardiovascular insult or direct myocardial injury, neurohormonal activation triggers hemodynamic changes and cardiac remodeling to preserve cardiac output. While initially adaptive, cardiac remodeling eventually causes pathologic changes in cardiac structure that often compromise cardiac function. Reverse remodeling is the regression of abnormal cardiac chamber geometry and function after myocardial injury. In recent years, several classes of therapeutics have been associated with greater likelihood of reverse remodeling. Heart failure recovery and heart failure remission, terms encompassing the clinical correlates of reverse remodeling, have been associated with improved survival in patients with heart failure with reduced ejection. As such, identifying predictors of heart failure recovery can have important implications for guiding clinical practice and therapeutic innovation. This review addresses the role of biomarkers and imaging monitoring in predicting structural, functional, and clinical recovery in patients with acute and chronic heart failure.

Clinical application of CMR in cardiomyopathies: evolving concepts and techniques : A position paper of myocardial and pericardial diseases and cardiac magnetic resonance working groups of Italian society of cardiology

Cardiac magnetic resonance (CMR) has become an essential tool for the evaluation of patients affected or at risk of developing cardiomyopathies (CMPs). In fact, CMR not only provides precise data on cardiac volumes, wall thickness, mass and systolic function but it also a non-invasive characterization of myocardial tissue, thus helping the early diagnosis and the precise phenotyping of the different CMPs, which is essential for early and individualized treatment of patients. Furthermore, several CMR characteristics, such as the presence of extensive LGE or abnormal mapping values, are emerging as prognostic markers, therefore helping to define patients' risk. Lastly new experimental CMR techniques are under investigation and might contribute to widen our knowledge in the field of CMPs. In this perspective, CMR appears an essential tool to be systematically applied in the diagnostic and prognostic work-up of CMPs in clinical practice. This review provides a deep overview of clinical applicability of standard and emerging CMR techniques in the management of CMPs.

Heart failure with recovered ejection fraction: Current understanding and future prospects

Heart failure with reduced ejection fraction (HFrEF) is a prevalent kind of heart failure in which a significant amount of the ejection fraction can be repaired, and left ventricular remodeling and dysfunction can be reversed or even restored completely. However, a considerable number of patients still present clinical signs and biochemical features of incomplete recovery from the pathophysiology of heart failure and are at risk for adverse outcomes such as re-deterioration of systolic function and recurrence of HFrEF. Furthermore, it is revealed from a microscopic perspective that even if partial or complete reverse remodeling occurs, the morphological changes of cardiomyocytes, extracellular matrix deposition, and abnormal transcription and expression of pathological genes still exist. Patients with "recovered ejection fraction" have milder clinical symptoms and better outcomes than those with continued reduction of ejection fraction. Based on the unique characteristics of this subgroup and the existence of many unknowns, the academic community defines it as a new category-heart failure with recovered ejection fraction (HFrecEF). Because there is a shortage of natural history data for this population as well as high-quality clinical and basic research data, it is difficult to accurately evaluate clinical risk and manage this population. This review will present the current understanding of HFrecEF from the limited literature.

Acute clinical presentation of nonischemic cardiomyopathies: early detection by cardiovascular magnetic resonance

Nonischemic cardiomyopathies include a wide range of dilated, hypertrophic and arrhythmogenic heart muscle disorders, not explained by coronary artery disease, hypertension, valvular or congenital heart disease. Advances in medical treatments and the availability of implantable cardioverter defibrillators to prevent sudden cardiac death have allowed a substantial increase in the survival of affected individuals, thus making early diagnosis and tailored treatment mandatory. The characterization of cardiomyopathies has received a great boost from the recent advances in cardiovascular magnetic resonance (CMR) imaging, which, to date, represents the gold standard for noninvasive assessment of cardiac morphology, function and myocardial tissue changes. An acute clinical presentation has been reported in a nonnegligible proportion of patients with nonischemic cardiomyopathies, usually complaining of acute chest pain, worsening dyspnoea or palpitations; 'hot phases' of cardiomyopathies are characterized by a dynamic rise in high-sensitivity troponin, myocardial oedema on CMR, arrhythmic instability, and by an increased long-term risk of adverse remodelling, progression of myocardial fibrosis, heart failure and malignant ventricular arrhythmias. Prompt recognition of 'hot phases' of nonischemic cardiomyopathies is of utmost importance to start an early, individualized treatment in these high-risk patients. On the one hand, CMR represents the gold standard imaging technique to detect early and typical signs of ongoing myocardial remodelling in patients presenting with a 'hot phase' nonischemic cardiomyopathy, including myocardial oedema, perfusion abnormalities and pathological mapping values. On the other hand, CMR allows the differential diagnosis of other acute heart conditions, such as acute coronary syndromes, takotsubo syndrome, myocarditis, pericarditis and sarcoidosis. This review provides a deep overview of standard and novel CMR techniques to detect 'hot phases' of cardiomyopathies, as well as their clinical and prognostic utility.

Pharmacological Anti-Remodelling Effects of Disease-Modifying Drugs in Heart Failure with Reduced Ejection Fraction

Cardiac remodelling is an adverse phenomenon linked to heart failure progression and an important contributor to heart failure severity. Cardiac remodelling could represent the real therapeutic goal in the treatment of patients with heart failure with reduced ejection fraction, being potentially reversed through different pharmacotherapies. Currently, there are well-established drugs such as angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and β-blockers with anti-remodelling effects; recently, angiotensin receptor neprilysin inhibitor effects on inhibiting cardiac remodelling (improving N-terminal pro-B-type natriuretic peptide levels, echocardiographic parameters of reverse cardiac remodelling and right ventricular function in patients with heart failure with reduced ejection fraction) were demonstrated. More recently, hemodynamic consequences of gliflozins, reduced cardiac hydrostatic pressure as a possible cause of ventricular remodelling and hypertrophy were proposed to explain potential anti-remodelling effects of gliflozins. Gliflozins exert their cardioprotective effects by attenuating myofibroblast activity and collagen-mediated remodelling. Another postulated mechanism is represented by the reduction in sympathetic activity, through the reduction in renal afferent nervous activity and the suppression of central reflex mechanisms. Benefits of gliflozins on left ventricular hypertrophy, dilation, and systolic and diastolic function were also described. In this review, we aimed to provide a wide overview on cardiac remodelling with a particular focus on possible anti-remodelling effects of angiotensin receptor neprilysin inhibitors and gliflozins.

Cardiac remodelling - Part 2: Clinical, imaging and laboratory findings. A review from the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology

In patients with heart failure, the beneficial effects of drug and device therapies counteract to some extent ongoing cardiac damage. According to the net balance between these two factors, cardiac geometry and function may improve (reverse remodelling, RR) and even completely normalize (remission), or vice versa progressively deteriorate (adverse remodelling, AR). RR or remission predict a better prognosis, while AR has been associated with worsening clinical status and outcomes. The remodelling process ultimately involves all cardiac chambers, but has been traditionally evaluated in terms of left ventricular volumes and ejection fraction. This is the second part of a review paper by the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology dedicated to ventricular remodelling. This document examines the proposed criteria to diagnose RR and AR, their prevalence and prognostic value, and the variables predicting remodelling in patients managed according to current guidelines. Much attention will be devoted to RR in patients with heart failure with reduced ejection fraction because most studies on cardiac remodelling focused on this setting.

Cardiac Remodeling in Hypertension: Clinical Impact on Brain, Heart, and Kidney Function

Hypertension is the most common causative factor of cardiac remodeling, which, in turn, has been associated with changes in brain and kidney function. Currently, the role of blood biomarkers as indices of cardiac remodeling remains unclear. In contrast, cardiac imaging, including echocardiography and cardiovascular magnetic resonance (CMR), has been a valuable noninvasive tool to assess cardiac remodeling. Cardiac remodeling during the course of systemic hypertension is not the sole effect of the latter. "Remodeling" of other vital organs, such as brain and kidney, also takes place. Therefore, it will be more accurate if we discuss about "hypertensive remodeling" involving the heart, the brain, and the kidneys, rather than isolated cardiac remodeling. This supports the idea of their simultaneous assessment to identify the early, silent lesions of total "hypertensive remodeling". In this context, magnetic resonance imaging is the ideal modality to provide useful information about these organs in a noninvasive fashion and without radiation. For this purpose, we propose a combined protocol to employ MRI in the simultaneous assessment of the heart, brain and kidneys. This protocol should include all necessary indices for the evaluation of "hypertensive remodeling" in these 3 organs, and could be performed within a reasonable time, not exceeding one hour, so that it remains patient-friendly. Furthermore, a combined protocol may offer "all in one examination" and save time. Finally, the amount of contrast agent used will be limited granted that post-contrast evaluations of the three organs will be performed after 1 injection.

Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy

Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.

Prevalence and prognostic significance of ischemic late gadolinium enhancement pattern in non-ischemic dilated cardiomyopathy

BACKGROUND

Typical late gadolinium enhancement (LGE) patterns in dilated cardiomyopathy (DCM) include intramyocardial and subepicardial distribution. However, the ischemic pattern of LGE (subendocardial and transmural) has also been reported in DCM without coronary artery disease (CAD), but its correlates and prognostic significance are still not known. On these bases, this study sought to describe the prevalence and prognostic significance of the ischemic LGE pattern in DCM.

METHODS

A total of 611 DCM patients with available cardiac magnetic resonance were retrospectively analyzed. A composite of all-cause-death, major ventricular arrhythmias (MVAs), heart transplantation (HTx) or ventricular assist device (VAD) implantation was the primary outcome of the study. Secondary outcomes were a composite of sudden cardiac death or MVAs and a composite of death for refractory heart failure, HTx or VAD implantation.

RESULTS

Ischemic LGE was found in 7% of DCM patients without significant CAD or history of myocardial infarction, most commonly inferior/inferolateral/anterolateral. Compared to patients with non-ischemic LGE, those with ischemic LGE had higher prevalence of hypertension and atrial fibrillation or flutter. Ischemic LGE was associated with worse long-term outcomes compared to non-ischemic LGE (36% vs 23% risk of primary outcome events at 5 years respectively, P = .006), and remained an independent predictor of primary outcome after adjustment for clinically and statistically significant variables (adjusted hazard ratio 2.059 [1.055-4.015], P = .034 with respect to non-ischemic LGE).

CONCLUSIONS

The ischemic pattern of LGE is not uncommon among DCM patients without CAD and is independently associated with worse long-term outcomes.

Integration of imaging and circulating biomarkers in heart failure: a consensus document by the Biomarkers and Imaging Study Groups of the Heart Failure Association of the European Society of Cardiology

Circulating biomarkers and imaging techniques provide independent and complementary information to guide management of heart failure (HF). This consensus document by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) presents current evidence-based indications relevant to integration of imaging techniques and biomarkers in HF. The document first focuses on application of circulating biomarkers together with imaging findings, in the broad domains of screening, diagnosis, risk stratification, guidance of treatment and monitoring, and then discusses specific challenging settings. In each section we crystallize clinically relevant recommendations and identify directions for future research. The target readership of this document includes cardiologists, internal medicine specialists and other clinicians dealing with HF patients.

Early Prediction of Left Ventricular Reverse Remodeling in First-Diagnosed Idiopathic Dilated Cardiomyopathy: A Comparison of Linear Model, Random Forest, and Extreme Gradient Boosting

Introduction: Left ventricular reverse remodeling (LVRR) is associated with decreased cardiovascular mortality and improved cardiac survival and also crucial for therapeutic options. However, there is a lack of an early prediction model of LVRR in first-diagnosed dilated cardiomyopathy.

Methods: This single-center study included 104 patients with idiopathic DCM. We defined LVRR as an absolute increase in left ventricular ejection fraction (LVEF) from >10% to a final value >35% and a decrease in left ventricular end-diastolic diameter (LVDd) >10%. Analysis features included demographic characteristics, comorbidities, physical sign, biochemistry data, echocardiography, electrocardiogram, Holter monitoring, and medication. Logistic regression, random forests, and extreme gradient boosting (XGBoost) were, respectively, implemented in a 10-fold cross-validated model to discriminate LVRR and non-LVRR, with receiver operating characteristic (ROC) curves and calibration plot for performance evaluation.

Results: LVRR occurred in 47 (45.2%) patients after optimal medical treatment. Cystatin C, right ventricular end-diastolic dimension, high-density lipoprotein cholesterol (HDL-C), left atrial dimension, left ventricular posterior wall dimension, systolic blood pressure, severe mitral regurgitation, eGFR, and NYHA classification were included in XGBoost, which reached higher AU-ROC compared with logistic regression (AU-ROC, 0.8205 vs. 0.5909, p = 0.0119). Ablation analysis revealed that cystatin C, right ventricular end-diastolic dimension, and HDL-C made the largest contributions to the model.

Conclusion: Tree-based models like XGBoost were able to early differentiate LVRR and non-LVRR in patients with first-diagnosed DCM before drug therapy, facilitating disease management and invasive therapy selection. A multicenter prospective study is necessary for further validation.

Clinical Trial Registration:http://www.chictr.org.cn/usercenter.aspx (ChiCTR2000034128).

Prognostic value of reverse remodelling criteria in heart failure with reduced or mid-range ejection fraction

Aims

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilatation and dysfunction. Many arbitrary criteria for RR have been proposed. We searched the criteria with the strongest prognostic yield for the hard endpoint of cardiovascular death.

Methods and results

We performed a systematic literature search of diagnostic criteria for RR. We evaluated their prognostic significance in a cohort of 927 patients with LV ejection fraction (LVEF) < 50% undergoing two echocardiograms within 12 ± 2 months. These patients were followed for a median of 2.8 years (interquartile interval 1.3–4.9) after the second echocardiogram, recording 123 cardiovascular deaths. Two prognostic models were defined. Model 1 included age, LVEF, N‐terminal pro‐B‐type natriuretic peptide, ischaemic aetiology, cardiac resynchronization therapy, estimated glomerular filtration rate, New York Heart Association, and LV end‐systolic volume (LVESV) index, and Model 2 the validated Cardiac and Comorbid Conditions Heart Failure score. We identified 25 criteria for RR, the most used being LVESV reduction ≥15% (12 studies out of 42). In the whole cohort, two criteria proved particularly effective in risk reclassification over Model 1 and Model 2. These criteria were (i) LVEF increase >10 U and (ii) LVEF increase ≥1 category [severe (LVEF ≤ 30%), moderate (LVEF 31–40%), mild LV dysfunction (LVEF 41–55%), and normal LV function (LVEF ≥ 56%)]. The same two criteria yielded independent prognostic significance and improved risk reclassification even in patients with more severe systolic dysfunction, namely, those with LVEF < 40% or LVEF ≤ 35%. Furthermore, LVEF increase >10 U and LVEF increase ≥1 category displayed a greater prognostic value than LVESV reduction ≥15%, both in the whole cohort and in the subgroups with LVEF < 40% or LVEF ≤ 35%. For example, LVEF increase >10 U independently predicted cardiovascular death over Model 1 and LVESV reduction ≥15% (hazard ratio 0.40, 95% confidence interval 0.18–0.90, P = 0.026), while LVESV reduction ≥15% did not independently predict cardiovascular death (P = 0.112).

Conclusions

Left ventricular ejection fraction increase >10 U and LVEF increase ≥1 category are stronger predictors of cardiovascular death than the most commonly used criterion for RR, namely, LVESV reduction ≥15%.

Morphologies and prognostic significance of left ventricular volume/time curves with cardiac magnetic resonance in patients with non-ischaemic heart failure and left bundle branch block

Patients with non-ischaemic systolic heart failure (HF) and left bundle branch block (LBBB) can display a wide or narrow pattern (WP/NP) of the systolic phase of the left ventricular (LV) volume/time (V/t) curve in cardiac magnetic resonance (CMR). The clinical and prognostic significance of these patterns is unknown. Consecutive patients with non-ischaemic HF, LV ejection fraction < 50% and LBBB underwent 1.5 T CMR. Maximal dyssynchrony time (time between the earliest and latest end-systolic peaks), systolic dyssynchrony index (standard deviation of times to peak volume change), and contractility index (maximum rate of change of pressure-normalized stress) were calculated. The endpoint was a composite of cardiovascular death, HF hospitalization, and appropriate defibrillator shock. NP was found in 29 and WP in 72 patients. WP patients had higher volumes and NT-proBNP, and lower LVEF. WP patients had a longer maximal dyssynchrony time (absolute duration: 192 ± 80 vs. 143 ± 65 ms, p < 0.001; % of RR interval: 25 ± 11% vs. 8 ± 4%, p < 0.001), a higher systolic dyssynchrony index (13 ± 4 vs. 7 ± 3%, p < 0.001), and a lower contractility index (2.6 ± 1.2 vs 3.2 ± 1.7, p < 0.05). WP patients had a shorter survival free from the composite endpoint regardless of age, NT-proBNP or LVEF. Nonetheless, WP patients responded more often to cardiac resynchronization therapy (CRT) than those with NP (24/28 [86%] vs. 1/11 [9%] responders, respectively; p < 0.001). In patients with non-ischaemic systolic HF and LBBB, the WP of V/t curves identifies a subgroup of patients with greater LV dyssynchrony and worse outcome, but better response to CRT.

Clinical significance of ischemia-like electrocardiographic finding during heart failure treatment on left ventricular recovery in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Patients with non-ischemic dilated cardiomyopathy (DCM) often show ischemia-like electrocardiographic findings. We aimed to elucidate the clinical impact of ischemia-like electrocardiographic findings in DCM, focusing on left ventricular reverse remodeling (LVRR).

METHODS

We evaluated 195 patients hospitalized with heart failure (HF) and diagnosed with DCM. All patients underwent twelve-lead electrocardiography (ECG) and echocardiography during hospitalization and at the 2-year follow-up.

RESULTS

During hospitalization, 152 (78%) patients experienced ischemia-like ECG findings (Minnesota codes I3, IV1-3, V1-3, or VII1); 43 patients (22%, non-ischemia-like group) did not experience these findings. Ischemia-like ECG findings were normalized during hospitalization in 64 patients (33%, transient-ischemia-like group) but were unchanged in 88 patients (45%, persistent-ischemia-like group). The highest rates of LVRR, defined as an increase in LV ejection fraction from ≥10% to a final value of ≥35%, along with decreased LV end-diastolic dimension of ≥10% during 2 years of follow-up, were shown in the transient-ischemia-like group (transient-ischemia-like group, 91%; persistent-ischemia-like group, 40%; non-ischemia-like-group, 51%; p < 0.001). The transient-ischemia-like group had lowest composite event rates, including readmission for HF, the detection of major ventricular arrhythmia, and sudden cardiac death.

CONCLUSIONS

Normalization of ischemia-like ECG findings during the first HF treatments was associated with a higher occurrence of mid-term LVRR and favorable long-term outcome in patients with DCM.

Prognostic Value of Feature-Tracking Circumferential Strain in Dilated Cardiomyopathy Patients with Severely Reduced Ejection Fraction Incremental to Late Gadolinium Enhancement

Myocardial fiber deformation measurements have been reported to be associated with adverse outcomes in patients with acute heart failure and those with myocardial infarction. However, few studies have addressed the prognostic value of global circumferential strain (GCS) in dilated cardiomyopathy (DCM) patients with severely impaired systolic function. This study aimed to evaluate the prognostic value of cardiac magnetic resonance (CMR)-derived GCS in DCM patients with severely reduced ejection. Consecutive DCM patients with severely reduced ejection fraction (EF <35%) who underwent CMR were included. GCS was calculated from CMR cine images. The clinical endpoint was a composite of all-cause mortality, heart transplantation, implantable cardioverter defibrillator (ICD) implantation and aborted sudden cardiac death (SCD). A total of 129 patients with a mean EF of 15.33% (11.36%-22.27%) were included. During a median follow-up of 518 days, endpoint events occurred in 50 patients. Patients with GCS ≥ the median (-5.17%) had significantly reduced event-free survival as compared with those with GCS < the median (P<0.01). GCS was independently associated with adverse events after adjusting for clinical and imaging risk factors including extent of late gadolinium enhancement (LGE) (P<0.05). Adding GCS into the model including the extent of LGE resulted in significant improvements in the C-statistic (from 0.706 to 0.742; P<0.05) with a continuous net reclassification improvement (NRI) of 29.71%. It was concluded that GCS derived from CMR could be useful for risk stratification in DCM patients with severely reduced EF, which may increase common imaging risk factors including LGE.

Heart Failure With Recovered Left Ventricular Ejection Fraction: JACC Scientific Expert Panel

Reverse left ventricular (LV) remodeling and recovery of LV function are associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction. A growing body of evidence suggests that even among patients who experience a complete normalization of LV ejection fraction, a significant proportion will develop recurrent LV dysfunction accompanied by recurrent heart failure events. This has led to intense interest in understanding how to manage patients with heart failure with recovered ejection fraction (HFrecEF). Because of the lack of a standard definition for HFrecEF, and the paucity of clinical data with respect to the natural history of HFrecEF patients, there are no current guidelines on how these patients should be followed up and managed. Accordingly, this JACC Scientific Expert Panel reviews the biology of reverse LV remodeling and the clinical course of patients with HFrecEF, as well as provides guidelines for defining, diagnosing, and managing patients with HFrecEF.

The Extent of Late Gadolinium Enhancement Can Predict Adverse Cardiac Outcomes in Patients with Non-Ischemic Cardiomyopathy with Reduced Left Ventricular Ejection Fraction: A Prospective Observational Study

OBJECTIVE

The clinical course of an individual patient with heart failure is unpredictable with left ventricle ejection fraction (LVEF) only. We aimed to evaluate the prognostic value of cardiac magnetic resonance (CMR)-derived myocardial fibrosis extent and to determine the cutoff value for event-free survival in patients with non-ischemic cardiomyopathy (NICM) who had severely reduced LVEF.

MATERIALS AND METHODS

Our prospective cohort study included 78 NICM patients with significantly reduced LV systolic function (LVEF < 35%). CMR images were analyzed for the presence and extent of late gadolinium enhancement (LGE). The primary outcome was major adverse cardiac events (MACEs), defined as a composite of cardiac death, heart transplantation, implantable cardioverter-defibrillator discharge for major arrhythmia, and hospitalization for congestive heart failure within 5 years after enrollment.

RESULTS

A total of 80.8% (n = 63) of enrolled patients had LGE, with the median LVEF of 25.4% (19.8-32.4%). The extent of myocardial scarring was significantly higher in patients who experienced MACE than in those without any cardiac events (22.0 [5.5-46.1] %LV vs. 6.7 [0-17.1] %LV, respectively, p = 0.008). During follow-up, 51.4% of patients with LGE ≥ 12.0 %LV experienced MACE, along with 20.9% of those with LGE ≤ 12.0 %LV (log-rank p = 0.001). According to multivariate analysis, LGE extent more than 12.0 %LV was independently associated with MACE (adjusted hazard ratio, 6.71; 95% confidence interval, 2.54-17.74; p < 0.001).

CONCLUSION

In NICM patients with significantly reduced LV systolic function, the extent of LGE is a strong predictor for long-term adverse cardiac outcomes. Event-free survival was well discriminated with an LGE cutoff value of 12.0 %LV in these patients.

The Role of MRI in Prognostic Stratification of Cardiomyopathies

PURPOSE OF THE REVIEW

The aim of this review was to discuss the role of cardiac magnetic resonance (CMR) for the prognostic stratification of cardiomyopathies, highlighting strengths and limitations.

RECENT FINDINGS

CMR is considered as a diagnostic pillar in the management of non-ischemic cardiomyopathies. Over the last years, attention has shifted from CMR's diagnostic capability towards prognostication in the various settings of cardiomyopathies. CMR is considered the gold standard imaging technique for the evaluation of ventricular volumes and systolic function as well as providing non-invasive virtual-histology by means of specific myocardial tissue characterization pulse sequences. CMR is an additive tool to risk stratifying patients and to identify those that require strict monitoring and more aggressive treatment.

Clinical significance of early-diastolic tissue velocity imaging of lateral mitral annulus for prognosis of nonischemic left ventricular dysfunction

PURPOSE

We explored the potential of tissue velocity imaging (TVI) for prognosis of nonischemic left ventricular (LV) dysfunction (LVD).

METHODS

We reviewed 138 nonischemic LVD patients (58 ± 14 years) who underwent both cardiac magnetic resonance (CMR) and echocardiography. Septal and lateral mitral annular TVI data were compared with late gadolinium enhancement (LGE) on CMR. During a mean follow-up of 24 months, recovery (>15%) of LV ejection fraction and clinical outcomes (cardiovascular death and heart failure hospitalization) were assessed.

RESULTS

LGE was commonly observed in the basal anteroseptal, inferoseptal, and inferior segments, but infrequently observed in the anterolateral segment. LGE was associated with lower early diastolic, septal (Sep-e' = 5.2 ± 2.0 vs 6.9 ± 2.0 cm/s, P = .031) and lateral (Lat-e' = 7.3 ± 3.0 vs 9.5 ± 2.0 cm/s, P < .001) TVI. The relationship between Lat-e' and anterolateral LGE (area under the curve, AUC 0.834) was much better than that between Sep-e' and inferoseptal LGE (AUC 0.699). The 60 patients with LVD reversibility revealed higher Lat-e' (9.8 ± 2.0 vs 6.7 ± 2.2 cm/s, P < .001) and lower LGE burden (7.3 ± 9.0 vs 22 ± 10%, P < .001), while Lat-e' ≤ 7.8 cm/s appeared unfavorable for 31 events patients. On multivariate analyses, Lat-e' (HR 0.79, 95% CI 0.63-0.99, P = .044) and LVD reversibility (HR 0.53, 95% CI 0.16-0.90, P = .018) were still meaningful together with LGE segments and burden.

CONCLUSION

Lat-e' was related with LVD reversibility and a significant predictor of clinical outcomes.

The extent and location of late gadolinium enhancement predict defibrillator shock and cardiac mortality in patients with non-ischaemic dilated cardiomyopathy

BACKGROUND

In non-ischaemic dilated cardiomyopathy (NIDCM), it is uncertain which late gadolinium enhancement (LGE) pattern, extent and location predict ventricular arrhythmias.

METHODS

We analysed 183 NIDCM patients (73% men, median age 66 years) receiving an implantable cardioverter defibrillator (ICD) for primary prevention, undergoing cardiac magnetic resonance within 1 month before implantation. The primary endpoint was appropriate ICD shock, the secondary endpoint was a composite of appropriate ICD shock and cardiac death.

RESULTS

LGE was found in 116 patients (63%), accounting for 9% of LV mass (5-13%). Over a 30-month follow-up (10-65), 20 patients (11%) experienced the primary and 30 patients (16%) the secondary endpoint. LGE presence, inferior wall LGE, diffuse (≥2 wall) LGE, the number of segments with LGE, the number of segments with 50-75% transmural LGE, and percent LGE mass were univariate predictors of both endpoints. Also septal LGE predicted the primary, and lateral LGE predicted the secondary endpoint. LGE limited to right ventricular insertion points did not predict any endpoint. Percent LGE mass had an area under the curve of 0.734 for the primary endpoint, with 13% as the best cut-off (55% sensitivity, 86% specificity, 32% PPV, 94% NPV), conferring a 7-fold higher risk compared to patients with no LGE or LGE <13%. Survival free from both endpoints was significantly worse for patients with LGE ≥13%.

CONCLUSIONS

In patients with NIDCM receiving a defibrillator for primary prevention, LGE presence and extent predicted appropriate ICD shock and cardiac mortality; also specific LGE patterns and locations predicted a worse prognosis.

Arrhythmic risk stratification in non-ischaemic dilated cardiomyopathy beyond ejection fraction

Sudden cardiac death and arrhythmia-related events in patients with non-ischaemic dilated cardiomyopathy (NICM) have been significantly reduced over the last couple of decades as a result of evidence-based pharmacological and non-pharmacological therapeutic strategies. Nevertheless, the arrhythmic stratification in patients with NICM remains extremely challenging, and the simple indication based on left ventricular ejection fraction appears to be insufficient. Therefore, clinicians need to go beyond the current criteria for implantable cardioverter-defibrillator implantation in the direction of a multiparametric evaluation of arrhythmic risk. Several parameters for arrhythmic risk stratification, ranging from electrocardiographic, echocardiographic, imaging-derived and genetic markers, are crucial for proper arrhythmic risk stratification and a multiparametric evaluation of risk in patients with NICM. In particular, integration of cardiac magnetic resonance parameters (mostly late gadolinium enhancement) and specific genetic information (ie, presence of LMNA, PLN, FLNC mutations) appears fundamental for proper implementation of the current arrhythmic risk stratification. Finally, a novel approach focused on both arrhythmic risk and prediction of left ventricular reverse remodelling during follow-up might be useful for effective multiparametric and dynamic arrhythmic risk stratification in NICM. In the future, a complete and integrated evaluation might be mandatory to implement arrhythmic risk prediction in patients with NICM and to discriminate the competing risk between heart failure-related events and life-threatening arrhythmias.

Imaging, Biomarker, and Clinical Predictors of Cardiac Remodeling in Heart Failure With Reduced Ejection Fraction

In response to injury, hemodynamic changes, or neurohormonal activation, the heart undergoes a series of structural and functional changes that have been termed cardiac remodeling. Remodeling is defined as changes in cardiac geometry and/or function over time and can be measured in terms of changes in cardiac chamber dimensions, wall thickness, volumes, mass, and ejection fraction at serial imaging examinations. As to cardiac chambers, left ventricular (LV) remodeling has been best studied in patients with heart failure with reduced ejection fraction. Although LV remodeling may compensate for abnormal hemodynamic parameters and function in the short term, left unchecked, it is associated with worsening cardiac function and poor prognosis. On the other hand, reversing LV geometry and/or function closer to that of a normal heart (also known as reverse remodeling) is associated with improved cardiac function and better prognosis. Because of its close relationship with clinical outcomes, remodeling may potentially be targeted in clinical management and used in trials as a surrogate endpoint. Standardized definition of remodeling and reliable tools to predict and monitor the presence, direction, and magnitude of cardiac remodeling are needed. Together with clinical and imaging findings, circulating biomarkers (most notably N-terminal pro-B-type natriuretic peptide, high-sensitivity troponin, and soluble suppression of tumorigenesis-2) may be helpful in this respect.

Overlapping Phenotypes and Degree of Ventricular Dilatation Are Associated with Severity of Systolic Impairment and Late Gadolinium Enhancement in Non-Ischemic Cardiomyopathies

Background

Dilatation and other infrastructural rearrangements of the left ventricle are connected with poor prognosis. The aim of our study was to analyze the overlapping phenotypes and dilatation of the ventricle on impairment of systolic function and existence of late gadolinium enhancement (LGE).

Material/Methods

Consecutive sample of cases with dilated left ventricle due to non-ischemic cardiomyopathy and healthy controls were included from our cardiac magnetic resonance imaging (CMR) database for a period of 3 years (n=1551 exams).

Results

The study included 127 patients; 30 (23.6%) with dilated cardiomyopathy (DCM); 30 (23.6%) with left ventricular non-compaction (LVNC); 13 (10.2%) with hypertrophic cardiomyopathy (HCM), and 50 (39.4%) controls. Overlapping phenotypes were found in 48 (37.8%) of the studied cases. Odds for impairment of systolic function in connection with overlapping phenotypes were estimated at 7.8 (95%-CI: 3.4–17.6), (p<0.001). There were significant differences in geometric parameters for patients with overlapping phenotypes vs. controls, as follows: left ventricle end-diastolic dimension(LVEDD)=6.6±0.8 vs. 5.6±1.0 cm (p<0.001); left ventricular ejection fraction (LVEF)=39.3±14.0 vs. 52.1±16.1 (p<0.001); and existence of LGE 36 (75.0%) vs. 21 (26.6%), (p<0.001), respectively. Overlapping phenotypes correlated with LVEDD (Spearman’s-Rho-CC)=0.521, p<0.001; LVEF (Rho-CC)=−0.447, p<0.001 and LGE (Rho-CC)=0.472, p<0.001.

Conclusions

This study found there are many patients with overlapping phenotypes among NICMPs with dilated left ventricles. Overlapping phenotype was associated with greater LVEDD, lesser systolic function, and commonly existing LGE, which all impose increased cardiovascular risk. Linear midventricular LGE stripe was the most powerfully connected with loss of systolic function.