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Subendocardial Involvement as an Underrecognized LGE Subtype Related to Adverse Outcomes in Hypertrophic
Shujuan Yang1, Kankan Zhao2, Kai Yang1
1MR Center, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
Insights
In hypertrophic cardiomyopathy (HCM), subendocardium-involved late gadolinium enhancement (LGE) predicts adverse outcomes in patients with nonextensive LGE. This finding helps refine risk stratification beyond LGE extent alone.
Area of Science:
- Cardiology
- Medical Imaging
- Cardiovascular Research
Background:
- Late gadolinium enhancement (LGE) is a known predictor of adverse events in hypertrophic cardiomyopathy (HCM).
- The prognostic significance of specific LGE patterns, such as subendocardial involvement, requires further elucidation.
- Right ventricle insertion points (RVIPs) LGE is common, but its clinical impact is less understood.
Purpose of the Study:
- To evaluate the prognostic value of subendocardium-involved LGE patterns in HCM patients.
- To assess the association between RVIPs LGE and adverse outcomes in HCM.
- To determine if LGE patterns improve risk stratification in HCM, particularly in patients with nonextensive LGE.
Main Methods:
- Retrospective analysis of 497 HCM patients with LGE confirmed by cardiac magnetic resonance (CMR).
- Defined subendocardium-involved LGE and excluded subjects with ischemic heart disease.
- Assessed composite endpoints including heart failure, arrhythmias, and stroke, with a median follow-up of 57.9 months.
Main Results:
- Subendocardium-involved LGE was present in 37.0% and RVIP LGE in 83.3% of patients.
- Extensive LGE (≥15% LV mass) was associated with higher adverse event rates (5.1% vs 1.9% annually).
- In nonextensive LGE (<15%), subendocardium-involved LGE independently predicted adverse outcomes (HR: 2.12; P=0.03), unlike LGE extent. RVIP LGE showed no significant association.
Conclusions:
- Subendocardium-involved LGE is a significant predictor of adverse outcomes in HCM patients with nonextensive LGE.
- This LGE pattern offers potential for improved risk stratification beyond LGE extent in specific HCM patient groups.
- RVIP LGE did not demonstrate prognostic value in this cohort.
Background:
Late gadolinium enhancement (LGE) has been established as an independent predictor for adverse outcomes in hypertrophic cardiomyopathy (HCM). However, the prevalence and clinical significance of some LGE subtypes have not been well demonstrated.
Objectives:
In this study, the authors sought to investigate the prognostic value of subendocardium-involved LGE pattern and location of right ventricle insertion points (RVIPs) with LGE in HCM patients.
Methods:
In this single-center retrospective study, 497 consecutive HCM patients with LGE confirmed by cardiac magnetic resonance (CMR) were included. Subendocardium-involved LGE was defined as LGE involving subendocardium not corresponding to a coronary vascular distribution. Subjects with ischemic heart disease that would contribute to subendocardial LGE were excluded. Endpoints included a composite of heart failure-related events, arrhythmic events, and stroke.
Results:
Of the 497 patients, subendocardium-involved LGE and RVIP LGE were observed in 184 (37.0%) and 414 (83.3%), respectively. Extensive LGE (≥15% of left ventricular mass) was detected in 135 patients. During a median follow-up of 57.9 months, 66 patients (13.3%) experienced composite endpoints. Patients with extensive LGE had a significantly higher annual incidence of adverse events (5.1% vs 1.9% per year; P < 0.001). However, spline analysis showed that the association between LGE extent and HRs for adverse outcomes tended to be nonlinear. The risk of composite endpoint increased with percentage increase in LGE extent in patients with extensive LGE, whereas a similar trend was not observed in patients with nonextensive LGE (<15%). In patients with extensive LGE, LGE extent significantly correlated with composite endpoints (HR: 1.05; P = 0.03) after adjusting for left ventricular ejection fraction <50%, atrial fibrillation, and nonsustained ventricular tachycardia, whereas in patients with nonextensive LGE, subendocardium-involved LGE rather than LGE extent was independently associated with adverse outcomes (HR: 2.12; P = 0.03). RVIP LGE was not significantly associated with poor outcomes.
Conclusions:
In HCM patients with nonextensive LGE, the presence of subendocardium-involved LGE rather than LGE extent is associated with unfavorable outcomes. Given that the prognostic value of extensive LGE has been broadly recognized, subendocardial involvement as an underrecognized LGE pattern shows the potential to improve risk stratification in HCM patients with nonextensive LGE.
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