Dark-blood late gadolinium enhancement CMR improves detection of papillary muscle fibrosis in patients with mitral valve prolapse

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Mitral vAlve prolapse and disjunction by cardiac maGnetIC resonance (MA-GIC) registry Backgroung Mitral valve prolapse (MVP) is 2-3% prevalent in the general population with good prognosis. However, some patients develop complex ventricular arrhythmias (CVAs), sudden cardiac death (SCD), or severe mitral regurgitation (MR). Previous studies suggested that bi-leaflet involvement, mitral annulus disjunction (MAD), and myocardial fibrosis (MF) are associated with adverse outcome. Notwithstanding, these findings were limited to autopsic series or single-centre studies involving highly selected patients. Moreover, MF has been scantly investigated as predictor of clinical outcome. Purpose To investigate the prognostic significance of MF in an international multicentre study of MVP patients studied by cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). Methods From October 2007 to June 2020 patients undergoing LGE-CMR were screened in 14 European centres. Inclusion criteria were: i) age > 18 years; ii) full clinical history and cardiac rhythm monitoring at baseline; iii) MVP (leaflet displacement ≥ 2 mm beyond the annulus). Exclusion criteria were: i) ischemic heart disease; ii) primary cardiomyopathy; iii) inflammatory heart disease; iv) congenital heart diseases; v) moderate-to-severe valvular heart disease. CVAs at the study outset was defined as one of the following: i) ventricular ectopic beats >10000/24h; ii) ≥ 1 episode of non-sustained ventricular tachycardia (VT); iii) sustained VT; iv) aborted SCD. Primary end-point was a composite of SCD, unexplained syncope, and mitral valve repair/replacement. Secondary end-point was a composite of SCD and unexplained syncope. Results Four-hundred-fifty-eight MVP patients were eventually included (46 ± 16 years old, 51% males) of whom 68% had MAD. LGE was detected in 103 (22%) of subjects with mid-wall pattern (46%) in left ventricular (LV) lateral wall (66%) as the most prevalent feature. At baseline, 37% of LGE-positive patients vs. 18% of LGE-negative individuals had CVAs (P < 0.001). SVT and/or aborted SCD were more prevalent in LGE-positive than in LGE-negative patients (9% vs 2%, P < 0.001). By multivariable Cox-regression analysis, LGE presence or extent were strong independent predictors of the primary (HR = 4.02, P = 0.003 and HR = 4.76 per 10% increase, P = 0.032, respectively) and secondary (HR = 5.39, P = 0.008 and HR = 8.78 per 10% increase, P = 0.012, respectively) endpoints after correction for major confounders including LV volumes, left atrial size and MAD presence. Conlusion Myocardial fibrosis by LGE is the strongest independent predictor of clinical outcome in MVP. In contrast, MAD per se does not harbinger worse prognosis.

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Cardiac magnetic resonance in patients with mitral valve prolapse: Focus on late gadolinium enhancement and T1 mapping

European Radiology ◽

10.1007/s00330-018-5634-5 ◽

2018 ◽

Vol 29 (3) ◽

pp. 1546-1554 ◽

Cited By ~ 6

Author(s):

Silvia Pradella ◽

Giulia Grazzini ◽

Marta Brandani ◽

Linda Calistri ◽

Cosimo Nardi ◽

...

Keyword(s):

Cardiac Magnetic Resonance ◽

Late Gadolinium Enhancement ◽

Magnetic Resonance ◽

Mitral Valve ◽

Mitral Valve Prolapse ◽

T1 Mapping ◽

Gadolinium Enhancement

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Abstract 16798: Evidence of Abnormal T1 Mapping in Arrhythmic Mitral Valve Prolapse Without Significant Mitral Regurgitation

Circulation ◽

10.1161/circ.142.suppl_3.16798 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Brian B Agbor-Etang ◽

Lisa J Lim ◽

Karen G Ordovas ◽

Francesca N Delling

Keyword(s):

Late Gadolinium Enhancement ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Myocardial Fibrosis ◽

Mitral Valve Prolapse ◽

Ventricular Arrhythmias ◽

T1 Mapping ◽

Diffuse Myocardial Fibrosis ◽

Diffuse Fibrosis ◽

Gadolinium Enhancement

Background: Prior cardiac magnetic resonance (CMR) studies have reported abnormal T1 mapping, reflective of diffuse myocardial fibrosis, in patients with mitral valve prolapse (MVP) and ventricular arrhythmias. However, T1 mapping was derived from conventional Look-Locker sequences and/or obtained in selected MVP patients with severe mitral regurgitation (MR) and a clinical indication for CMR. Hypothesis: We hypothesize that extracellular volume (ECV) fraction, a marker of diffuse fibrosis derived from research-based, MOLLI T1 mapping sequences, is increased in MVP subjects with ventricular arrhythmias, even in the absence of significant MR. Methods: We performed CMRs in 10 consecutive, randomly selected MVP patients identified through our echocardiographic database, age/gender matched to 10 controls free of significant cardiac disease. All 10 MVPs underwent ambulatory EKG monitoring. CMR images were acquired using a GE 3.0T Discovery MR750w scanner. Global ECV fraction was calculated using pre- and 10 minutes post-contrast T1 times after administration of 0.1 mmol/kg of gadobutrol (Gadavist). Late gadolinium enhancement (LGE) was also obtained. MR fraction was quantified by velocity encoded CMR. Mild MR was defined as MR fraction < 16%. Results: MVP patients had significantly higher ECV fraction compared to controls (mean ECV (%) 32 ± 4 vs 20 ± 6, p = 0.0002), with 5/10 demonstrating non-sustained VT on ambulatory EKG monitoring. The majority (9/10 or 90%) of MVPs had mild or no MR (MR fraction < 16%), and 1/10 or 10% had moderate MR (MR fraction 18%). Only one individual in the MVP group had late gadolinium enhancement (LGE) in the papillary muscles. Conclusion: MVP with ventricular arrhythmias is associated with increased global ECV reflective of diffuse myocardial fibrosis, even in the absence of significant MR or LGE. Our preliminary findings highlight for the first time a primary interstitial derangement in MVP. Larger studies are needed to understand the mechanisms and prognostic significance of primary diffuse fibrosis in MVP.

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2070 Mitral valve prolapse is associated with abnormal CMR late gadolinium enhancement of the mitral valve leaflets and the papillary muscles

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-10-s1-a339 ◽

2008 ◽

Vol 10 (S1) ◽

Author(s):

Yuchi Han ◽

Dana C Peters ◽

Reza Nezafat ◽

Beth Goddu ◽

Kraig V Kissinger ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Mitral Valve ◽

Mitral Valve Prolapse ◽

Papillary Muscles ◽

Gadolinium Enhancement

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Cardiac magnetic resonance predictors of mitral regurgitation and papillary muscle fibrosis in mitral valve prolapse

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-12-s1-p281 ◽

2010 ◽

Vol 12 (S1) ◽

Author(s):

Francesca N Delling ◽

Dana C Peters ◽

Susan B Yeon ◽

Kraig V Kissinger ◽

Beth Goddu ◽

...

Keyword(s):

Cardiac Magnetic Resonance ◽

Magnetic Resonance ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Papillary Muscle ◽

Mitral Valve Prolapse ◽

Muscle Fibrosis

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Novel dark-blood versus conventional bright-blood late gadolinium enhancement CMR: A pilot study comparing impact on myocardial ischaemic burden

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.303 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

R Franks ◽

R Holtackers ◽

M Nazir ◽

S Plein ◽

A Chiribiri

Keyword(s):

Late Gadolinium Enhancement ◽

Perfusion Imaging ◽

Stress Perfusion ◽

Strong Positive Correlation ◽

Gadolinium Enhancement ◽

Dark Blood ◽

Scar Burden ◽

Perfusion Defects ◽

Bright Blood ◽

Ischaemic Burden

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background In patients with coronary artery disease (CAD), increasing myocardial ischaemic burden (MIB) is a strong predictor of adverse events. When measured by cardiovascular magnetic resonance (CMR), a MIB ≥12.5% is considered significant and often used as a threshold to guide revascularisation. Ischaemic scar can cause stress perfusion defects which do not represent ischaemia and should be excluded from the MIB calculation. Conventional bright-blood late gadolinium enhancement (LGE) is able to identify ischaemic scar but can suffer from poor scar-to-blood contrast, making accurate assessment of scar volume difficult. Dark-blood LGE methods increase scar-to-blood contrast and improve scar conspicuity which may impact the calculated scar burden and consequently the estimation of MIB when read in conjunction with perfusion images. Purpose To evaluate the impact of dark-blood LGE versus conventional bright-blood LGE on the estimation of MIB in patients with CAD. Methods 37 patients with suspected or known CAD who had evidence of CMR stress perfusion defects and ischaemic scar on LGE imaging were recruited. Patients underwent adenosine stress perfusion imaging followed by dark-blood LGE then conventional bright-blood LGE imaging at 3T. For dark-blood LGE, phase sensitive inversion recovery imaging with a shorter inversion time to null the LV blood-pool was used without any additional magnetization preparation. For each patient, three short-axis LGE slices were selected to match the three perfusion slice locations. Images were anonymised and analysed in random order. Ischaemic scar burden (ISB) was quantified for both LGE methods using a threshold >5 standard deviations above remote myocardium. Perfusion defect burden (PDB) was quantified by manual contouring of perfusion defects. MIB was calculated by subtracting the ISB from the PDB. Results MIB calculated using dark-blood LGE was 19% less compared to bright-blood LGE (15.7 ± 15.2% vs 19.4 ± 15.2%, p < 0.001). There was a strong positive correlation between the two LGE methods (rs = 0.960, p < 0.001, Figure 1A). Bland-Altman analysis revealed a significant fixed bias (mean bias = -3.6%, bias 95% CI: -2.6 to -4.7%, 95% limits of agreement: -9.8 to 2.5%) with no proportional bias (Figure 1B). MIB was calculated ≥12.5% and <12.5% by both LGE methods in 19 (51%) and 12 (32%) patients respectively. In 6 patients (16%), MIB was ≥12.5% using bright-blood LGE and <12.5% using dark-blood LGE (Figure 1A – orange data points). Overall, when used to classify MIB as <12.5% or ≥12.5%, there was only substantial agreement between the two LGE methods (κ=0.67, 95% CI: 0.45 to 0.90). Conclusions The use of dark-blood LGE in conjunction with perfusion imaging results in a lower estimate of MIB compared to conventional bright-blood LGE. This can cause disagreement around the threshold of clinically significant ischaemia which could impact clinical management in patients being considered for coronary revascularisation. Abstract Figure. Linear regression with corresponding B&A

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