Magnetic Resonance Assessment of Ejection Fraction Versus Echocardiography for Cardioverter-Defibrillator Implantation Eligibility

Q: What are the key findings of this study?

Two-dimensional echocardiography showed substantial agreement with CMR for ICD eligibility at LVEF <=35% (Kappa 0.78) and <=30% (Kappa 0.65), but misclassified 10.5% and 14.6% of patients.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Nonischemic cardiomyopathy (NICM) (n=166). Intervention: Two-dimensional transthoracic echocardiography (2DE) vs. Cardiovascular magnetic resonance (CMR). Primary outcome: Agreement between CMR and 2DE in identifying subjects eligible for an ICD based on LVEF <= 35% (Cohen's Kappa 0.78, 95% CI 0.68-0.88, p=<0.001).

Q: What does this research mean for the field?

Two-dimensional echocardiography demonstrates substantial agreement with cardiovascular magnetic resonance for ICD eligibility thresholds but misclassifies 10.5% to 14.6% of patients with nonischemic cardiomyopathy. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the potential impact of using two-dimensional echocardiography compared with cardiovascular magnetic resonance to measure left ventricular ejection fraction on implantable cardioverter-defibrillator eligibility.

Călin Schiau; Daniel‐Corneliu Leucuta; Sorin Dudea; Simona Manolé

doi:10.3390/biology10111108

October 27, 2021BiologyOpen Access

Magnetic Resonance Assessment of Ejection Fraction Versus Echocardiography for Cardioverter-Defibrillator Implantation Eligibility

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Key result

2D echocardiography misclassifies ~11% of patients for ICD eligibility compared to CMR.

Cohen's Kappa 0.78
95% CI 0.68-0.88
P<0.001
n=166

Figures

Why the study?

The study investigated the potential impact of performing 2DE compared to CMR for LVEF assessment on ICD eligibility.

Does two-dimensional transthoracic echocardiography accurately agree with cardiovascular magnetic resonance in assessing LVEF for implantable cardioverter-defibrillator eligibility in patients with nonischemic cardiomyopathy?

Key Points

To evaluate the potential impact of using two-dimensional echocardiography compared with cardiovascular magnetic resonance to measure left ventricular ejection fraction on implantable cardioverter-defibrillator eligibility.
Prospective cohort of 166 consecutive patients with nonischemic cardiomyopathy undergoing transthoracic two-dimensional echocardiography (2DE) and cardiovascular magnetic resonance (CMR) imaging.
Evaluated measurement bias and limits of agreement for left ventricular end-diastolic volume, end-systolic volume, and ejection fraction (LVEF).
Calculated Cohen's kappa coefficients and disagreement rates between imaging modalities at clinical ICD eligibility cutoffs of LVEF ≤ 35% and ≤ 30%.
For the LVEF ≤ 35% threshold, agreement between CMR and 2DE yielded a Cohen's kappa of 0.78 (95% CI: 0.68–0.88, p < 0.001), with 7.9% of CMR-eligible patients misclassified as ineligible by echocardiography and 2.6% falsely classified as eligible.
For the LVEF ≤ 30% threshold, Cohen's kappa was 0.65 (95% CI: 0.52–0.78, p < 0.001), where 11.3% of patients eligible by CMR were deemed ineligible by echocardiography and 3.3% were deemed eligible only by echocardiography.
Echocardiography showed substantial differences and wide limits of agreement compared to CMR, significantly underestimating left ventricular volumes by a median of 62.2 mL for end-diastolic volume and 31.3 mL for end-systolic volume.

Study Design

Type

Cohort (n=166)

Blinding

Blind assessment (examiners did not have access to the other examination)

Multicenter

No

Structured PICO

Does two-dimensional transthoracic echocardiography accurately agree with cardiovascular magnetic resonance in assessing LVEF for implantable cardioverter-defibrillator eligibility in patients with nonischemic cardiomyopathy?

P

Population

166 hospitalized patients with nonischemic cardiomyopathy in Romania (mean age 46.35 years, 28.31% female) who underwent both transthoracic 2D echocardiography and cardiovascular magnetic resonance within 5 days.

E

Exposure

Two-dimensional transthoracic echocardiography (2DE) using Simpson's biplane method on a Vivid S70 scanner evaluated by multiple treating senior physicians blinded to CMR results

C

Comparator

Cardiovascular magnetic resonance (CMR) on a 1.5-T Avanto MRI scanner using short-axis cine steady-state free precession (SSFP) Simpson disk summation method and late gadolinium enhancement (with 0.1 mmol/kg gadobutrol), evaluated by a senior reader blinded to 2DE results

O

Outcome

Agreement between 2DE and CMR for implantable cardioverter-defibrillator (ICD) eligibility at classical LVEF thresholds of <=35% and <=30%, and agreement for left ventricular end-diastolic volume (EDV), end-systolic volume (ESV), and LVEFsurrogate

Main Result

Effect estimate: Cohen's Kappa 0.78 (95% CI 0.68-0.88)

p-value: p=<0.001

In patients with nonischemic cardiomyopathy, 2D echocardiography shows clinically relevant disagreement with cardiac MRI when evaluating LVEF thresholds for primary prevention ICD implantation, resulting in misassignment of eligibility in 10.5% to 14.6% of patients.

Limitations

Not designed to assess long-term clinical outcomes of using echocardiography vs CMR for ICD eligibility
Inherent limitations of transthoracic 2DE including image-plane positioning errors, foreshortening of the LV long axis, geometric assumptions, and cardiac translation
Time gap of up to 5 days (usually 3 days) between the two investigations
Intra- and inter-observer variability for CMR-LVEF was not assessed
Single-center non-ICD specialized regional hospital with a fair number of subjects with normal EF
Study was not designed to assess long-term clinical outcomes of using echocardiography or CMR for ICD eligibility
Inherent limitations of transthoracic 2DE (image-plane positioning errors, foreshortening of the LV long axis, geometric assumptions, and cardiac translation)
Time interval between the two investigations was about 3 days (maximum 5 days), which could explain some measurement variability
Did not assess intra- and inter-observer variability for CMR-LVEF

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Implication

2DE may misassign ICD eligibility in nonischemic cardiomyopathy; leaves open whether CMR should supplant echocardiography for LVEF thresholds.

Abstract

Background: The aim of this study was to investigate the potential impact of performing two-dimensional echocardiography (2DE) compared to cardiovascular magnetic resonance (CMR) for left ventricular ejection fraction (LVEF) on implantable cardioverter defibrillator (ICD) eligibility. Methods: A prospective cohort of 166 consecutive patients with nonischemic cardiomyopathy (NICM) was designed to compare transthoracic 2DE and CMR imaging. Results: Echocardiography measurements have important differences and large limits of agreement compared to CMR, especially when assessing ventricle volumes, and smaller but relevant differences when assessing LVEF. The agreement between CMR and 2DE regarding the identification of subjects with EF <= 35, respectively <= 30, and thus eligible for an ICD measured by Cohen’s Kappa was 0.78 (95% CI: 0.68–0.88), p < 0.001, respectively 0.65 (95% CI: 0.52–0.78), p < 0.001. The disagreement represented 7.9%/11.3% of the subjects who had EF < 35%/< 30% as observed by CMR, who would have been classified as eligible for an ICD, resulting in an additional need to use an ICD. Moreover, 2.6%/3.3% would have been deemed eligible by echocardiography for an ICD. Conclusions: These measurement problems result in incorrect assignments of eligibility that may have serious implications on the quality of life and the prevention of death events for patients assessed for eligibility of an ICD.

Discussion

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Cite This Study

Schiau et al. (2021) conducted a cohort in Nonischemic cardiomyopathy (NICM) (n=166). Two-dimensional transthoracic echocardiography (2DE) vs. Cardiovascular magnetic resonance (CMR) was evaluated on Agreement between CMR and 2DE in identifying subjects eligible for an ICD based on LVEF <= 35% (Cohen's Kappa 0.78, 95% CI 0.68-0.88, p=<0.001). Two-dimensional echocardiography showed substantial agreement with CMR for ICD eligibility at LVEF <=35% (Kappa 0.78) and <=30% (Kappa 0.65), but misclassified 10.5% and 14.6% of patients.

synapsesocial.com/papers/6a74c9115be14952a7f54705 https://doi.org/10.3390/biology10111108

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Magnetic Resonance Assessment of Ejection Fraction Versus Echocardiography for Cardioverter-Defibrillator Implantation Eligibility

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Magnetic Resonance Assessment of Ejection Fraction Versus Echocardiography for Cardioverter-Defibrillator Implantation Eligibility

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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