Prognostic role of cardiac magnetic resonance in left ventricular non compaction

Introduction

Left ventricular non compaction (LVNC) is a heterogeneous entity with uncertain prognosis. Cardiac magnetic resonance (CMR) is widely used in the diagnosis of LVNC. However, its role in risk stratification has not been well established.

Purpose

Therefore, the aim of our study was to identify prognostic CMR variables in LVNC.

Methods

We conducted a retrospective longitudinal multicentre cohort study of consecutive patients fulfilling CMR LVNC criteria. The endpoints were heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause mortality. Biventricular volumes, ejection fraction (LVEF and RVEF) as well as late gadolinium enhancement (LGE) were analysed.

Results

A total of 310 patients were included: age was 44.4±19 and 43% female. LVEF was 47% ± 15%, RVEF was 48±12 and 28 patients (9%) presented LGE. After a median follow-up of 3.8 2.5 years, 40 patients (13%) presented HF, 31 (10%) had VA, SE occurred in 6 (2%) and 3 patients (1%) died. Baseline characteristics of patients with and without HF and VA are described in Table 1.

In univariate analysis, LVEF, LV volumes, LGE, and RVEF were associated with both HF and VA risk. In multivariate analysis, LVEF was the only variable independently associated with HF (HR 0.932, CI 95% 0.88–0.97, p 0.003). Patients with an LVEF >35% were at very low risk of HF (Figure 1A). With regards to VA, LGE was the only independent predictor (HR 2.64, IC 95% 1.059–6.61, p 0.003) (Figure 1B). In LGE negative patients, the arrhythmic risk was higher among those with an LVEF <35% (HR 2.81, 95% CI 1.02–8.12, p 0.047).

Conclusions

In a large multicentre retrospective LVNC study, left ventricular ejection fraction and late gadolinium enhancement were the main predictors of cardiovascular events. Patients with an LVEF <35% and with LGE were at markedly increased risk. Therefore, we suggest that these variables should be combined to enhance risk stratification in LVNC.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of left ventricular hemodynamic forces in patients with left ventricular noncompaction

Introduction

Left ventricular noncompaction (LVNC) is a poorly defined entity with LV ejection fraction (LVEF) being the main predictor of major adverse cardiovascular events (MACE). Left ventricular hemodynamic forces (LVHDF) have been recently demonstrated to be promising markers of sub-clinical dysfunction and potential predictors of disease outcome.

Purpose

To determine in a large cohort of LNVC the LVHDF parameters and its long-term prognostic value.

Methods

Retrospective, longitudinal, multicentre cohort study including consecutive patients with LVNC from 2000 to 2018. CMR was performed at 1.5T and LVHDF were analyzed with a prototype software (Medis Suite Qstrain). Systolic LVHDF were decomposed into “apex-base” (long-LVHDF) and “lateral-septal” (radial-LVHDF). MACE was defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality.

Results

A total of 158 patients were included, age was 53±4.3y and 85 (53.8%) were men. Median LVEF was 44 (IQR 34–55)%, with 61.4% having a LVEF <50%. During a median follow-up of 3.7 (IQR 1.4–5.9) years, MACE occurred in 49 (31%) patients with an unadjusted incidence rate of 8.05 (95% CI 6.0–10.6) events per 100 person-years: 36 HF, 15 VA, 5 SE and 2 deaths. Patients with MACE had significantly worse LVHDF parameters (Table 1). LV-HDF parameters showed no significant variation with age or gender. Spearman coefficient confirmed an inverse correlation between LVEF and long-LVHDF (r=0.478, p<0.0001) and radial-LVHDF (r=0.414, p<0.001). Patients with LVEF <50% (53% vs 78%, p logrank = 0.028) and long-LVHDF <11% (38% vs 84%, p logrank <0.001) had an increased risk of MACE. LVEF (HR 0.97, 95% CI 0.95–0.99, p=0.016), long-LVHDF<11% (HR 5.18, 95% CI 1.1–13.1, p=0.001) and age (HR 1.16, 95% CI 1.06–1.26, p=0.002) were the only variables independently associated with MACE on multivariate analysis. Among patients with LVEF >50%, on univariate regression long-LVHDF <11% (HR 3.32, 95% CI 1.00–11.01, p=0.050) was independently associated with MACE, while LVEF was not (HR 1.04, 95% CI 0.97–1.10, p=0.200). In patients with LVEF <50%, long-LVHDF <11% (HR 7.70, 95% CI 2.40 25.21, p=0.001),and LVEF (HR 0.93,95% CI 0.90–0.95, p<0.001) were independent predictors of outcome on univariate analysis.

Conclusions

LVHDF in patients LVNC were quantified for the first time, with an adequate correlation with LVEF. Both radial and longitudinal LVHDF were significantly reduced in patients with MACE, however, only misalignment of systolic longitudinal-LVHDF predicted outcomes. In patients with LVEF >50%, reduced longitudinal-LVHDF was associated with prognosis, while LVEF was not, and may serve as an additional tool for risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

P1441 Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

BACKGROUND

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

PURPOSE

To evaluate the rate of SE in LVNC and describe risk factors.

METHODS

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

RESULTS

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9-7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% Vs 24%, p = 0.31) and atrial fibrillation (35% Vs 19%, p = 0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p = 0.04). A LA diameter &gt; 45 mm had an independent 3 fold increased risk of SE (OR 3.04, p = 0.02) (Image 1).

CONCLUSIONS

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

Table 1 Systemic embolisms (n = 23) No systemic embolisms (n = 491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR) - yr 60 (48-76) 48 (30-64) 0.02 Median follow up (IQR) - yr 5.9 (3.1-7.8) 4.2 (1.8-7.1) 0.18 OAC, n (%) 19 (83) 118 (24) 0.01 LVEF (SD) - % 37 (15) 48 (17) 0.01 LVEDD (SD) - mm 58 (11) 54 (10) 0.04 LA diameter (SD) - mm 46 (9) 39 (9) 0.01 Characteristics of patients with and without systemic embolisms

Abstract P1441 Figure. Image 1

P1442 Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

CONCLUSIONS

Patients with LVNC and pEF have an overall excellent prognosis, which is markedly better than those with rEF. However, there is progressive decrease in LVEF, associated with heart failure, and moderate risk of life threatening arrhythmias. Therefore, periodic follow-up should be promoted.

Table 1 LVNC pEF (n = 239) LVNC rEF (n = 252) p Men, n (%) 131 (55) 146 (58) 0.65 Median age at diagnosis (IQR) - yr 38 (23-54) 58 (42-72) 0.01 Median follow up (IQR) - yr 4.9 (2.1-7.3) 3.9 (1.4-7.9) 0.04 QRS (SD) - ms 93 (18) 117 (32) 0.01 LGE, n (%) 18 (9) 52 (30) 0.01

Abstract P1442 Figure. Image 1