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Scar Characterization to Predict Life-Threatening Arrhythmic Events and Sudden Cardiac Death in Patients With Cardiac
Juan Acosta1, Juan Fernández-Armenta1, Roger Borràs1
1Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), University of Barcelona, Barcelona, Catalonia, Spain; CIBERCV, Instituto de Salud Carlos III, Madrid, Spain.
Insights
Cardiac scar characterization improves risk prediction for life-threatening ventricular arrhythmias and sudden cardiac death (SCD) in patients receiving cardiac resynchronization therapy (CRT). Detailed scar analysis, including border zone characteristics, enhances prognostic accuracy.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- Patients with cardiac resynchronization therapy (CRT) indications often have low rates of appropriate defibrillator therapy.
- Risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD) is crucial in this population.
Purpose of the Study:
- To determine if detailed scar characterization can enhance risk stratification for SCD and life-threatening ventricular arrhythmias.
- To investigate the predictive value of myocardial scar features in patients undergoing CRT.
Main Methods:
- Prospective enrollment of primary prevention patients with a class I CRT indication.
- Pre-procedure contrast-enhanced cardiac magnetic resonance imaging (CMR) to assess scar presence, quantify core and border zone (BZ) mass, and analyze BZ distribution.
- Follow-up for the primary endpoint of appropriate defibrillator therapy or SCD.
Main Results:
- Myocardial scar was present in 57.6% of patients; none without scar experienced the primary endpoint.
- Patients with scar who experienced ICD therapies or SCD had significantly greater scar mass, scar heterogeneity, and BZ channel mass.
- BZ mass and BZ channel mass were the strongest independent predictors of the primary endpoint.
Conclusions:
- Myocardial scar characteristics, including presence, extension, heterogeneity, and BZ tissue distribution, independently predict appropriate ICD therapies and SCD in CRT patients.
- Scar assessment via CMR offers valuable prognostic information for optimizing CRT patient management.
Objectives:
The aim of this study was to analyze whether scar characterization could improve the risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD).
Background:
Among patients with a cardiac resynchronization therapy (CRT) indication, appropriate defibrillator (CRT-D) therapy rates are low.
Methods:
Primary prevention patients with a class I indication for CRT were prospectively enrolled and assigned to CRT-D or CRT pacemaker according to physician's criteria. Pre-procedure contrast-enhanced cardiac magnetic resonance was obtained and analyzed to identify scar presence or absence, quantify the amount of core and border zone (BZ), and depict BZ distribution. The presence, mass, and characteristics of BZ channels in the scar were recorded. The primary endpoint was appropriate defibrillator therapy or SCD.
Results:
217 patients (39.6% ischemic) were included. During a median follow-up of 35.5 months (12 to 62 months), the primary endpoint occurred in 25 patients (11.5%) and did not occur in patients without myocardial scar. Among patients with scar (n = 125, 57.6%), those with implantable cardioverter-defibrillator (ICD) therapies or SCD exhibited greater scar mass (38.7 ± 34.2 g vs. 17.9 ± 17.2 g; p < 0.001), scar heterogeneity (BZ mass/scar mass ratio) (49.5 ± 13.0 vs. 40.1 ± 21.7; p = 0.044), and BZ channel mass (3.6 ± 3.0 g vs. 1.8 ± 3.4 g; p = 0.018). BZ mass (hazard ratio: 1.06 [95% confidence interval: 1.04 to 1.08]; p < 0.001) and BZ channel mass (hazard ratio: 1.21 [95% confidence interval: 1.10 to 1.32]; p < 0.001) were the strongest predictors of the primary endpoint. An algorithm based on scar mass and the absence of BZ channels identified 148 patients (68.2%) without ICD therapy/SCD during follow-up with a 100% negative predictive value.
Conclusions:
The presence, extension, heterogeneity, and qualitative distribution of BZ tissue of myocardial scar independently predict appropriate ICD therapies and SCD in CRT patients.
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