Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Feasibility of the Threshold-Based Quantification of Myocardial Fibrosis on Cardiac CT as a Prognostic Marker in Nonischemic Dilated Cardiomyopathy

  • Na Young Kim (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine) ;
  • Dong Jin Im (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine) ;
  • Yoo Jin Hong (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine) ;
  • Byoung Wook Choi (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine) ;
  • Seok-Min Kang (Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine) ;
  • Jong-Chan Youn (Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea) ;
  • Hye-Jeong Lee (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine)
  • Received : 2023.12.21
  • Accepted : 2024.03.22
  • Published : 2024.06.01
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Abstract

Objective: This study investigated the feasibility and prognostic relevance of threshold-based quantification of myocardial delayed enhancement (MDE) on CT in patients with nonischemic dilated cardiomyopathy (NIDCM). Materials and Methods: Forty-three patients with NIDCM (59.3 ± 17.1 years; 21 male) were included in the study and underwent cardiac CT and MRI. MDE was quantified manually and with a threshold-based quantification method using cutoffs of 2, 3, and 4 standard deviations (SDs) on three sets of CT images (100 kVp, 120 kVp, and 70 keV). Interobserver agreement in MDE quantification was assessed using the intraclass correlation coefficient (ICC). Agreement between CT and MRI was evaluated using the Bland-Altman method and the concordance correlation coefficient (CCC). Patients were followed up for the subsequent occurrence of the primary composite outcome, including cardiac death, heart transplantation, heart failure hospitalization, or appropriate use of an implantable cardioverter-defibrillator. The Kaplan-Meier method was used to estimate event-free survival according to MDE levels. Results: Late gadolinium enhancement (LGE) was observed in 29 patients (67%, 29/43), and the mean LGE found with the 5-SD threshold was 4.1% ± 3.6%. The 4-SD threshold on 70-keV CT showed excellent interobserver agreement (ICC = 0.810) and the highest concordance with MRI (CCC = 0.803). This method also yielded the smallest bias with the narrowest range of 95% limits of agreement compared to MRI (bias, -0.119%; 95% limits of agreement, -4.216% to 3.978%). During a median follow-up of 1625 days (interquartile range, 712-1430 days), 10 patients (23%, 10/43) experienced the primary composite outcome. Event-free survival significantly differed between risk subgroups divided by the optimal MDE cutoff of 4.3% (log-rank P = 0.005). Conclusion: The 4-SD threshold on 70-keV monochromatic CT yielded results comparable to those of MRI for quantifying MDE as a marker of myocardial fibrosis, which showed prognostic value in patients with NIDCM.

Keywords

Acknowledgement

We express our sincere appreciation to Kyunghwa Han, PhD, from the Research Institute of Radiological Science at Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, for consulting on the statistical analysis of our data.

References

  1. Ambale-Venkatesh B, Lima JA. Cardiac MRI: a central prognostic tool in myocardial fibrosis. Nat Rev Cardiol 2015;12:18-29 https://doi.org/10.1038/nrcardio.2014.159
  2. Liu T, Song D, Dong J, Zhu P, Liu J, Liu W, et al. Current understanding of the pathophysiology of myocardial fibrosis and its quantitative assessment in heart failure. Front Physiol 2017;8:238
  3. Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, Simonetti O, et al. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation 1999;100:1992-2002 https://doi.org/10.1161/01.CIR.100.19.1992
  4. Moon JC, Sheppard M, Reed E, Lee P, Elliott PM, Pennell DJ. The histological basis of late gadolinium enhancement cardiovascular magnetic resonance in a patient with Anderson-Fabry disease. J Cardiovasc Magn Reson 2006;8:479-482 https://doi.org/10.1080/10976640600605002
  5. Azevedo CF, Nigri M, Higuchi ML, Pomerantzeff PM, Spina GS, Sampaio RO, et al. Prognostic significance of myocardial fibrosis quantification by histopathology and magnetic resonance imaging in patients with severe aortic valve disease. J Am Coll Cardiol 2010;56:278-287 https://doi.org/10.1016/j.jacc.2009.12.074
  6. Eijgenraam TR, Sillje HHW, de Boer RA. Current understanding of fibrosis in genetic cardiomyopathies. Trends Cardiovasc Med 2020;30:353-361 https://doi.org/10.1016/j.tcm.2019.09.003
  7. Flett AS, Hasleton J, Cook C, Hausenloy D, Quarta G, Ariti C, et al. Evaluation of techniques for the quantification of myocardial scar of differing etiology using cardiac magnetic resonance. JACC Cardiovasc Imaging 2011;4:150-156 https://doi.org/10.1016/j.jcmg.2010.11.015
  8. Gerber BL, Belge B, Legros GJ, Lim P, Poncelet A, Pasquet A, et al. Characterization of acute and chronic myocardial infarcts by multidetector computed tomography: comparison with contrast-enhanced magnetic resonance. Circulation 2006;113:823-833 https://doi.org/10.1161/CIRCULATIONAHA.104.529511
  9. Zhao L, Ma X, Feuchtner GM, Zhang C, Fan Z. Quantification of myocardial delayed enhancement and wall thickness in hypertrophic cardiomyopathy: multidetector computed tomography versus magnetic resonance imaging. Eur J Radiol 2014;83:1778-1785 https://doi.org/10.1016/j.ejrad.2014.05.035
  10. Lee HJ, Im DJ, Youn JC, Chang S, Suh YJ, Hong YJ, et al. Assessment of myocardial delayed enhancement with cardiac computed tomography in cardiomyopathies: a prospective comparison with delayed enhancement cardiac magnetic resonance imaging. Int J Cardiovasc Imaging 2017;33:577-584 https://doi.org/10.1007/s10554-016-1024-8
  11. Chang S, Han K, Youn JC, Im DJ, Kim JY, Suh YJ, et al. Utility of dual-energy CT-based monochromatic imaging in the assessment of myocardial delayed enhancement in patients with cardiomyopathy. Radiology 2018;287:442-451 https://doi.org/10.1148/radiol.2017162945
  12. Ohta Y, Kitao S, Yunaga H, Fujii S, Mukai N, Yamamoto K, et al. Myocardial delayed enhancement CT for the evaluation of heart failure: comparison to MRI. Radiology 2018;288:682-691 https://doi.org/10.1148/radiol.2018172523
  13. Oda S, Emoto T, Nakaura T, Kidoh M, Utsunomiya D, Funama Y, et al. Myocardial late iodine enhancement and extracellular volume quantification with dual-layer spectral detector dual-energy cardiac CT. Radiol Cardiothorac Imaging 2019;1:e180003
  14. Wichmann JL, Bauer RW, Doss M, Stock W, Lehnert T, Bodelle B, et al. Diagnostic accuracy of late iodine-enhancement dual-energy computed tomography for the detection of chronic myocardial infarction compared with late gadolinium-enhancement 3-T magnetic resonance imaging. Invest Radiol 2013;48:851-856 https://doi.org/10.1097/RLI.0b013e31829d91a8
  15. Wichmann JL, Arbaciauskaite R, Kerl JM, Frellesen C, Bodelle B, Lehnert T, et al. Evaluation of monoenergetic late iodine enhancement dual-energy computed tomography for imaging of chronic myocardial infarction. Eur Radiol 2014;24:1211-1218 https://doi.org/10.1007/s00330-014-3126-9
  16. Lee HJ, Im DJ, Youn JC, Chang S, Suh YJ, Hong YJ, et al. Myocardial extracellular volume fraction with dual-energy equilibrium contrast-enhanced cardiac CT in nonischemic cardiomyopathy: a prospective comparison with cardiac MR imaging. Radiology 2016;280:49-57 https://doi.org/10.1148/radiol.2016151289
  17. Im DJ, Youn JC, Lee HJ, Nam K, Suh YJ, Hong YJ, et al. Role of cardiac computed tomography for etiology evaluation of newly diagnosed heart failure with reduced ejection fraction. J Clin Med 2020;9:2270
  18. Kim NY, Im DJ, Youn JC, Hong YJ, Choi BW, Kang SM, et al. Synthetic extracellular volume fraction derived using virtual unenhanced attenuation of blood on contrast-enhanced cardiac dual-energy CT in nonischemic cardiomyopathy. AJR Am J Roentgenol 2022;218:454-461 https://doi.org/10.2214/AJR.21.26654
  19. Cho JY, Cho DH, Youn JC, Kim D, Park SM, Jung MH, et al. Korean Society of Heart Failure guidelines for the management of heart failure: definition and diagnosis. Korean Circ J 2023;53:195-216 https://doi.org/10.4070/kcj.2023.0046
  20. Youn JC, Kim D, Cho JY, Cho DH, Park SM, Jung MH, et al. Korean Society of Heart Failure guidelines for the management of heart failure: treatment. Int J Heart Fail 2023;5:66-81 https://doi.org/10.36628/ijhf.2023.0011
  21. Carrasco JL, Phillips BR, Puig-Martinez J, King TS, Chinchilli VM. Estimation of the concordance correlation coefficient for repeated measures using SAS and R. Comput Methods Programs Biomed 2013;109:293-304 https://doi.org/10.1016/j.cmpb.2012.09.002
  22. Becker MAJ, Cornel JH, van de Ven PM, van Rossum AC, Allaart CP, Germans T. The prognostic value of late gadolinium-enhanced cardiac magnetic resonance imaging in nonischemic dilated cardiomyopathy: a review and meta-analysis. JACC Cardiovasc Imaging 2018;11:1274-1284
  23. Di Marco A, Anguera I, Schmitt M, Klem I, Neilan TG, White JA, et al. Late gadolinium enhancement and the risk for ventricular arrhythmias or sudden death in dilated cardiomyopathy: systematic review and meta-analysis. JACC Heart Fail 2017;5:28-38 https://doi.org/10.1016/j.jchf.2016.09.017
  24. Lehrke S, Lossnitzer D, Schob M, Steen H, Merten C, Kemmling H, et al. Use of cardiovascular magnetic resonance for risk stratification in chronic heart failure: prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated cardiomyopathy. Heart 2011;97:727-732 https://doi.org/10.1136/hrt.2010.205542
  25. Poyhonen P, Kivisto S, Holmstrom M, Hanninen H. Quantifying late gadolinium enhancement on CMR provides additional prognostic information in early risk-stratification of nonischemic cardiomyopathy: a cohort study. BMC Cardiovasc Disord 2014;14:110
  26. Neilan TG, Farhad H, Mayrhofer T, Shah RV, Dodson JA, Abbasi SA, et al. Late gadolinium enhancement among survivors of sudden cardiac arrest. JACC Cardiovasc Imaging 2015;8:414-423 https://doi.org/10.1016/j.jcmg.2014.11.017
  27. Kim EK, Lee GY, Jang SY, Chang SA, Kim SM, Park SJ, et al. 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. Korean J Radiol 2021;22:324-333 https://doi.org/10.3348/kjr.2020.0082
  28. Moravsky G, Ofek E, Rakowski H, Butany J, Williams L, Ralph-Edwards A, et al. Myocardial fibrosis in hypertrophic cardiomyopathy: accurate reflection of histopathological findings by CMR. JACC Cardiovasc Imaging 2013;6:587-596 https://doi.org/10.1016/j.jcmg.2012.09.018
  29. Mikami Y, Cornhill A, Heydari B, Joncas SX, Almehmadi F, Zahrani M, et al. Objective criteria for septal fibrosis in non-ischemic dilated cardiomyopathy: validation for the prediction of future cardiovascular events. J Cardiovasc Magn Reson 2016;18:82
  30. Yu L, Christner JA, Leng S, Wang J, Fletcher JG, McCollough CH. Virtual monochromatic imaging in dual-source dual-energy CT: radiation dose and image quality. Med Phys 2011;38:6371-6379 https://doi.org/10.1118/1.3658568
  31. Rodriguez-Granillo GA, Carrascosa P, Cipriano S, de Zan M, Deviggiano A, Capunay C, et al. Myocardial signal density levels and beam-hardening artifact attenuation using dual-energy computed tomography. Clin Imaging 2015;39:809-814 https://doi.org/10.1016/j.clinimag.2015.04.007
  32. Kwong RY, Farzaneh-Far A. Measuring myocardial scar by CMR. JACC Cardiovasc Imaging 2011;4:157-160 https://doi.org/10.1016/j.jcmg.2010.12.004