Key result
Adverse remodeling and fibrosis drive MACE risk in excessive LV trabeculation over trabeculation indices.
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Why the study?
Excessive trabeculation of the left ventricle is a heterogeneous phenotype overlapping physiological remodeling and cardiomyopathy, with uncertain prognostic stratification.
Does a CMR-based multiparametric model predict major adverse cardiovascular events in patients with excessive trabeculation of the left ventricle?
Cohort (n=589)
Yes
Does a CMR-based multiparametric model predict major adverse cardiovascular events in patients with excessive trabeculation of the left ventricle?
Effect estimate: C-statistic 0.79
p-value: p=0.012
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The comparable outcomes support the concept that prognosis in ETLV is primarily determined by the underlying morphofunctional phenotype rather than the trabeculation itself. This supports a phenotype-based interpretation of ETLV, in which trabeculation burden is clinically relevant mainly when accompanied by LV dilation, systolic dysfunction, abnormal deformation or myocardial fibrosis.”
CMR-based risk stratification in excessive left ventricular trabeculation is driven primarily by adverse remodeling and fibrosis, suggesting the phenotype is benign in the absence of high-risk imaging features.
BACKGROUND: Excessive trabeculation of the left ventricle (ETLV) is a heterogeneous and controversial phenotype that overlaps with both physiological remodeling and cardiomyopathy. OBJECTIVES: This study sought to develop and validate a cardiac magnetic resonance (CMR)-based model to predict major adverse cardiovascular events (MACE) and to assess the incremental prognostic value of trabeculation metrics. METHODS: In this international retrospective study, 589 patients with ETLV across 17 centers underwent core-laboratory CMR analysis. The composite MACE endpoint included heart failure, ventricular arrhythmia, systemic embolism, or all-cause death. A prediction model was derived from morphofunctional CMR parameters and validated in an independent cohort. The incremental value of trabeculation indices was then assessed. Outcomes were further compared with a propensity-matched cohort of 197 patients with dilated cardiomyopathy. RESULTS: Mean age was 43 ± 18 years, 43% were women, mean left ventricular (LV) ejection fraction was 48% ± 14%, and 12% had late gadolinium enhancement (LGE). Over a median follow-up of 3.6 years, 121 (21%) patients experienced MACE. A model including indexed LV end-diastolic volume, LV global longitudinal strain, and LGE extent demonstrated moderate prognostic performance (C-statistic 0.77 in derivation; 0.70 in validation) and calibration. Addition of trabeculated mass percentage (TM%) modestly improved discrimination (C-statistic 0.79 in derivation, P = 0.012; 0.72 in validation); an exploratory TM% ≥28% identified higher-risk patients. However, TM% was not predictive among individuals with normal indexed LV end-diastolic volume, preserved LV global longitudinal strain, and minimal LGE, who exhibited excellent outcomes. Prognosis was comparable in propensity-matched ETLV and dilated cardiomyopathy cohorts (P = 0.557). CONCLUSIONS: CMR-based risk stratification in ETLV is primarily driven by adverse LV remodeling and fibrosis, whereas trabeculation indices provide only modest incremental prognostic value. In the absence of high-risk imaging features, ETLV likely represents a benign morphologic trait. This pragmatic multiparametric CMR score may support clinical decision-making in this debated phenotype.
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Casas et al. (2026) conducted a cohort in Excessive trabeculation of the left ventricle (ETLV) (n=589). Adverse LV remodeling, fibrosis, and trabeculation indices on CMR vs. Normal CMR parameters was evaluated on Composite MACE (heart failure, ventricular arrhythmia, systemic embolism, or all-cause death) (C-statistic 0.79, p=0.012). In patients with excessive left ventricular trabeculation, MACE prediction is primarily driven by adverse LV remodeling and fibrosis, while trabeculation indices provide modest incremental value.
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