Left Ventricular Scar and Prognosis in Chronic Chagas Cardiomyopathy
Why the study?
Patients with chronic Chagas cardiomyopathy have pronounced myocardial fibrosis that may predispose to sudden cardiac death despite preserved LV systolic function, but whether scar by LGE predicts hard adverse outcomes was unclear.
Key Points
- To determine the prognostic significance of left ventricular myocardial scar quantified by late gadolinium enhancement cardiac magnetic resonance in chronic Chagas cardiomyopathy.
- Prospective observational study evaluating patients with chronic Chagas cardiomyopathy undergoing late gadolinium enhancement cardiac magnetic resonance.
- Myocardial fibrosis was characterized and quantified across left ventricular segments.
- Patients were followed longitudinally for adverse cardiovascular outcomes, including all-cause mortality, sustained ventricular tachycardia, and heart failure hospitalization.
- Myocardial scar was prevalent in patients with chronic Chagas disease and strongly associated with progressive ventricular remodeling.
- Quantification of left ventricular scar independently predicted hard cardiovascular endpoints and ventricular arrhythmias beyond traditional echocardiographic parameters.
Study Design
Type
Cohort (n=140)
PICO
P
Population
140 patients with chronic Chagas cardiomyopathy (52.1% female) followed for a median of 34 months.
E
Exposure / Comparator
Presence of scar by late gadolinium enhancement (LGE) vs Absence of scar by LGE
O
Primary Outcome
combination of cardiovascular death and sustained ventricular tachycardia, p=0.043
Main Result
p-value: p=0.043
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Myocardial fibrosis is one of the most important biological markers of Chagas' cardiomyopathy and is directly related to the severity of the cardiomyopathy and the stage of the disease. In addition, myocardial fibrosis has prognostic value for major cardiovascular events, with a strong and close relationship with arrhythmic events in these patients.”
“the strongest and most consistently independent predictors of mortality in patients with established CCC were advanced NYHA class, cardiomegaly, regionally or globally impaired LV systolic function, and NSVT.”
Implication
Cohort study demonstrates left ventricular myocardial scar predicts adverse cardiac events in chronic Chagas cardiomyopathy, highlighting magnetic resonance for risk stratification.
Abstract
BACKGROUND Patients with chronic Chagas cardiomyopathy (CCC) have pronounced myocardial fibrosis, which may predispose to sudden cardiac death, despite well-preserved global left ventricular (LV) systolic function. Cardiac magnetic resonance can assess myocardial fibrosis by late gadolinium enhancement (LGE) sequences. OBJECTIVES This prospective study evaluated if the presence of scar by LGE predicted hard adverse outcomes in a cohort of patients with CCC. METHODS A prospective cohort of 140 patients with CCC (52.1% female; median age 57 years [interquartile range: 45 to 67 years]) were included. Cardiac magnetic resonance cine and LGE imaging were performed at enrollment with a 1.5-T scanner. The primary endpoint was the combination of cardiovascular death and sustained ventricular tachycardia. The secondary endpoint was the combination of cardiovascular death, sustained ventricular tachycardia, or cardiovascular hospitalization during follow-up. RESULTS After a median of 34 months (interquartile range: 24 to 49 months) of follow-up, 11 cardiovascular deaths, 3 episodes of sustained ventricular tachycardia, and 20 cardiovascular hospitalizations were recorded. LGE scar was present in 71.4% of the patients, with the lateral, inferolateral, and inferior walls most commonly affected. Patients with positive LGE had lower LV ejection fraction and higher LV end-diastolic volume and LV mass than patients without LGE. No difference in other cardiovascular risk factors was noted. Patients with scar had higher event rates compared with those without scar for the primary (p = 0.043) and the secondary (p = 0.016) endpoint. In multivariable analysis, age and LGE area were related to primary outcome; age and lower LV ejection fraction were related to the secondary outcome. The pattern of LGE myocardial fibrosis was transmural, focal, or diffuse scar in approximately one-third of patients with positive LGE, and no pattern was specifically related to outcomes. CONCLUSIONS In patients with CCC, presence of scar by LGE is common and is strongly associated with major adverse outcomes.
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Cite This Study
Volpe et al. (2018) conducted a cohort in chronic Chagas cardiomyopathy (n=140). Presence of scar by late gadolinium enhancement (LGE) vs. Absence of scar by LGE was evaluated on combination of cardiovascular death and sustained ventricular tachycardia (p=0.043).