Septal Midwall Late Gadolinium Enhancement in Ischemic Cardiomyopathy and Nonischemic Dilated Cardiomyopathy—Characteristics and Prognosis

Septal midwall late gadolinium enhancement (LGE) is a characteristic finding on cardiac magnetic resonance imaging (CMR) in nonischemic dilated cardiomyopathy (DCM) and is associated with adverse events. Its significance in ischemic cardiomyopathy (ICM) is unknown. With this multicenter observational study, we aimed to study the characteristics of septal midwall LGE and evaluate its prognostic value in ICM. A total of 1,084 patients with an impaired left ventricular (LV) ejection fraction (<50%) on LGE-CMR, either because of ICM (53%) or DCM, were included retrospectively. Septal midwall LGE was defined as midmyocardial stripe-like or patchy LGE in septal segments and was present in 10% of patients with ICM compared with 34% of patients with DCM (p <0.001). It was significantly associated with larger LV volumes and lower LV ejection fraction, irrespective of etiology. The primary endpoint was all-cause mortality and secondary endpoint was ventricular arrhythmias (VAs), including resuscitated cardiac arrest, sustained VA, and appropriate implantable cardioverter-defibrillator (ICD) therapy. During a median follow-up of 2.7 years, we found a significant association between septal midwall LGE and mortality in patients with DCM (hazard ratio HR 1.92, p = 0.03), but not in patients with ICM (HR 1.35, p = 0.39). Risk of VAs was significantly higher in patients with septal midwall LGE on CMR, both in DCM (HR 2.80, p <0.01) and in ICM (HR 2.70, p <0.01). In conclusion, septal midwall LGE, typically seen in DCM, was also present in 10% of patients with ICM and was associated with increased LV dilation and worse function, irrespective of etiology. When present, septal midwall LGE was associated with adverse outcome. Septal midwall late gadolinium enhancement (LGE) is a characteristic finding on cardiac magnetic resonance imaging (CMR) in nonischemic dilated cardiomyopathy (DCM) and is associated with adverse events. Its significance in ischemic cardiomyopathy (ICM) is unknown. With this multicenter observational study, we aimed to study the characteristics of septal midwall LGE and evaluate its prognostic value in ICM. A total of 1,084 patients with an impaired left ventricular (LV) ejection fraction (<50%) on LGE-CMR, either because of ICM (53%) or DCM, were included retrospectively. Septal midwall LGE was defined as midmyocardial stripe-like or patchy LGE in septal segments and was present in 10% of patients with ICM compared with 34% of patients with DCM (p <0.001). It was significantly associated with larger LV volumes and lower LV ejection fraction, irrespective of etiology. The primary endpoint was all-cause mortality and secondary endpoint was ventricular arrhythmias (VAs), including resuscitated cardiac arrest, sustained VA, and appropriate implantable cardioverter-defibrillator (ICD) therapy. During a median follow-up of 2.7 years, we found a significant association between septal midwall LGE and mortality in patients with DCM (hazard ratio HR 1.92, p = 0.03), but not in patients with ICM (HR 1.35, p = 0.39). Risk of VAs was significantly higher in patients with septal midwall LGE on CMR, both in DCM (HR 2.80, p <0.01) and in ICM (HR 2.70, p <0.01). In conclusion, septal midwall LGE, typically seen in DCM, was also present in 10% of patients with ICM and was associated with increased LV dilation and worse function, irrespective of etiology. When present, septal midwall LGE was associated with adverse outcome. In patients with heart failure, cardiac magnetic resonance (CMR) imaging is the imaging modality of choice to differentiate between ischemic and nonischemic etiology,1Ponikowski P Voors AA Anker SD Bueno H Cleland JGF Coats AJS Falk V González-Juanatey JR Harjola VP Jankowska EA Jessup M Linde C Nihoyannopoulos P Parissis JT Pieske B Riley JP Rosano GMC Ruilope LM Ruschitzka F Rutten FH van der Meer P ESC Scientific Document Group2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J. 2016; 37: 2129-2200Crossref PubMed Google Scholar using late gadolinium enhancement (LGE).2Gonzalez JA Kramer CM Role of imaging techniques for diagnosis, prognosis and management of heart failure patients: cardiac magnetic resonance.Curr Heart Fail Rep. 2015; 12: 276-283Crossref PubMed Scopus (34) Google Scholar,3Mahrholdt H Wagner A Judd RM Sechtem U Kim RJ Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies.Eur Heart J. 2005; 26: 1461-1474Crossref PubMed Scopus (668) Google Scholar Typically, subendocardial or transmural contrast enhancement in a coronary artery territory identifies the presence of ischemic heart disease, whereas septal midwall LGE is deemed a characteristic finding in patients with nonischemic dilated cardiomyopathy (DCM).3Mahrholdt H Wagner A Judd RM Sechtem U Kim RJ Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies.Eur Heart J. 2005; 26: 1461-1474Crossref PubMed Scopus (668) Google Scholar,4McCrohon JA Moon JC Prasad SK McKenna WJ Lorenz CH Coats AJ Pennell DJ Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance.Circulation. 2003; 108: 54-59Crossref PubMed Scopus (911) Google Scholar In addition to its diagnostic value, the presence of LGE, and in particular septal midwall LGE, in patients with DCM is associated with adverse events, including mortality and ventricular arrhythmias (VAs).5Assomull RG Prasad SK Lyne J Smith G Burman ED Khan M Sheppard MN Poole-Wilson PA Pennell DJ Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy.J Am Coll Cardiol. 2006; 48: 1977-1985Crossref PubMed Scopus (912) Google Scholar, 6Becker 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: 1274-1284Crossref PubMed Scopus (152) Google Scholar, 7Halliday BP Gulati A Ali A Guha K Newsome S Arzanauskaite M Vassiliou VS Lota A Izgi C Tayal U Khalique Z Stirrat C Auger D Pareek N Ismail TF Rosen SD Vazir A Alpendurada F Gregson J Frenneaux MP Cowie MR Cleland JGF Cook SA Pennell DJ Prasad SK Association between midwall late gadolinium enhancement and sudden cardiac death in patients with dilated cardiomyopathy and mild and moderate left ventricular systolic dysfunction.Circulation. 2017; 135: 2106-2115Crossref PubMed Scopus (223) Google Scholar In contrast, the absence of septal midwall LGE in patients with DCM is a predictor of left ventricular (LV) reverse remodeling with functional recovery of LV function.6Becker 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: 1274-1284Crossref PubMed Scopus (152) Google Scholar,8Kubanek M Sramko M Maluskova J Kautznerova D Weichet J Lupinek P Vrbska J Malek I Kautzner J Novel predictors of left ventricular reverse remodeling in individuals with recent-onset dilated cardiomyopathy.J Am Coll Cardiol. 2013; 61: 54-63Crossref PubMed Scopus (102) Google Scholar,9Masci PG Schuurman R Andrea B Ripoli A Coceani M Chiappino S Todiere G Srebot V Passino C Aquaro GD Emdin M Lombardi M Myocardial fibrosis as a key determinant of left ventricular remodeling in idiopathic dilated cardiomyopathy: a contrast-enhanced cardiovascular magnetic study.Circ Cardiovasc Imaging. 2013; 6: 790-799Crossref PubMed Scopus (116) Google Scholar Interestingly, evaluation of LGE-CMR in patients with heart failure with reduced ejection fraction demonstrated that septal midwall enhancement can also occur in patients with systolic heart failure because of ischemic cardiomyopathy (ICM).10Kim J Kochav JD Gurevich S Afroz A Petashnick M Volo S Diaz B Okin PM Horn E Devereux RB Weinsaft JW Left ventricular geometric remodeling in relation to non-ischemic scar pattern on cardiac magnetic resonance imaging.Int J Cardiovasc Imaging. 2014; 30: 1559-1567Crossref PubMed Scopus (12) Google Scholar However, little is known about the incidence, characteristics, and predictive value of septal midwall LGE in patients with ICM. This study aimed to describe the characteristics of septal midwall LGE in patients with myocardial dysfunction because of ICM compared with patients with DCM. In addition, we studied the prognostic value of the presence of septal midwall LGE on the occurrence of VA and all-cause mortality during follow-up. Data from consecutive patients who underwent CMR imaging including LGE between 2014 and 2018 were retrospectively collected from 2 centers. CMR was performed either in hospitalized patients with decompensated heart failure for diagnosis of underlying etiology, or in patients referred from the outpatient clinics for viability assessment before elective revascularization or for prognostic evaluation before implantable cardioverter-defibrillator (ICD) implantation for prevention of sudden cardiac death. Patients with impaired LV systolic function, defined as LV ejection fraction (LVEF) <50%, either because of DCM or ICM were included (Figure 1). Patients with a history of significant obstructive coronary artery disease (coronary stenosis ≥70% or fractional flow reserve <0.80), a history of myocardial infarction or revascularization, or an ischemic LGE-pattern of sufficient severity to the degree of LV dysfunction, were classified as ICM. DCM was defined as LV dysfunction in the absence of obstructive coronary artery disease, primary valvular heart disease, or severe arterial hypertension, according to current guidelines.1Ponikowski P Voors AA Anker SD Bueno H Cleland JGF Coats AJS Falk V González-Juanatey JR Harjola VP Jankowska EA Jessup M Linde C Nihoyannopoulos P Parissis JT Pieske B Riley JP Rosano GMC Ruilope LM Ruschitzka F Rutten FH van der Meer P ESC Scientific Document Group2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J. 2016; 37: 2129-2200Crossref PubMed Google Scholar,11Elliott P Andersson B Arbustini E Bilinska Z Cecchi F Charron P Dubourg O Kühl U Maisch B McKenna WJ Monserrat L Pankuweit S Rapezzi C Seferovic P Tavazzi L Keren A Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.Eur Heart J. 2008; 29: 270-276Crossref PubMed Scopus (2038) Google Scholar Exclusion criteria were acute myocarditis, hypertrophic or infiltrative cardiomyopathy, arrhythmogenic cardiomyopathy, or congenital heart disease. Incomplete CMR scans or scans in which quantitative analysis was impossible because of poor quality were also excluded. The primary endpoint was all-cause mortality. Secondary endpoint was a composite of sudden cardiac arrest, sustained VAs, or appropriate ICD therapy, including anti-tachycardia pacing and shock. Clinical and demographic data regarding baseline characteristics were obtained from electronic medical records. Informed consent was not required by the local ethics committee. For follow-up, medical records of all patients were evaluated for occurrence of endpoints until October 2019. Additionally, the National Health and Social Care Information Service was independently consulted for survival status for patients lost to follow-up. The study was conducted in accordance with the Declaration of Helsinki Ethical and the local ethics review the data and management of this CMR scans were performed on and with cardiac imaging was performed using imaging with in and a the were to gadolinium using a with The presence and pattern of gadolinium were by and LGE was present the was seen in 2 or 2 LGE-pattern was ischemic was subendocardial or transmural in the territory of a coronary was classified as a nonischemic H Wagner A Judd RM Sechtem U Kim RJ Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies.Eur Heart J. 2005; 26: 1461-1474Crossref PubMed Scopus (668) Google Scholar Septal midwall LGE was defined as stripe-like or patchy midmyocardial in the or ventricular LV volumes and were by of the and from using The and Cardiovascular were from the and included in the as SD data were or as median and data as and The or U was for between for on was or was for and data were compared using U or data were from were using and were using and were obtained using were performed including data and CMR data associated with to mortality. Patients of follow-up were were performed for to Patients that during follow-up a ventricular were for the secondary of death. Patients lost during follow-up were excluded. with p in analysis were in a analysis using a A significance of was for all were performed in A total of 1,084 consecutive patients with LGE-CMR were patients (53%) with ICM and patients with DCM. characteristics by etiology. Patients with ICM were compared with patients with DCM and years, p were and p and Heart Association functional compared with patients with DCM (p <0.01). ICD was in patients including cardiac in a median of functional were from = = = = coronary artery = cardiac DCM = dilated ICD = implantable ICM = = = Heart Association functional history of dysfunction defined as were from = = = = coronary artery = cardiac DCM = dilated ICD = implantable ICM = = = Heart Association functional in a dysfunction defined as LGE was present in of patients with ICM compared with of patients with DCM (p <0.001). Septal midwall LGE was seen in patients with ICM and in patients with DCM. LV volumes were significantly larger and was significantly lower in the presence of septal midwall LGE, irrespective of underlying p functional to higher in patients with septal midwall LGE present (p in DCM, p = in cardiac magnetic resonance imaging in patients with ischemic cardiomyopathy and nonischemic dilated septal midwall LGE = midwall LGE = septal midwall LGE = midwall LGE = = cardiac magnetic resonance DCM = dilated ICM = ischemic LGE = late gadolinium = left ventricular = left ventricular ejection = left ventricular = left ventricular in a CMR = cardiac magnetic resonance DCM = dilated ICM = ischemic LGE = late gadolinium = left ventricular = left ventricular ejection = left ventricular = left ventricular Data of patients were lost to follow-up of the primary During a median follow-up of 2.7 to years, patients was higher in patients with ICM patients with DCM and to p associated with all-cause mortality in ICM included LV and to p and 10% to p was significant association between all-cause mortality and the presence of septal midwall LGE in patients with ICM (HR 1.35, to p = (Figure 1). functional and dysfunction were associated with the primary and dysfunction predictors of all-cause mortality in patients with ICM 1). In patients with DCM, septal midwall LGE was significantly associated with to all-cause mortality analysis (HR 1.92, to p = (Figure and functional and the functional and independently associated with all-cause mortality in patients with DCM. For the composite secondary patients were lost and from the patients with ICM and with a total of ventricular in patients with ICM compared with in patients with DCM (p = In both the presence of septal midwall LGE was significantly associated with to VAs analysis (HR 2.70, to p in patients with ICM (Figure and to p in patients with DCM (Figure and were in both associated with the secondary endpoint analysis ICM to p and 10% to p In DCM to p and 10% to p <0.001). In patients with secondary prevention ICD was an predictor of VA (HR to p whereas in patients with DCM, an predictor (HR to p and This multicenter CMR study in patients with myocardial dysfunction and reduced demonstrated that septal midwall LGE, a characteristic finding in patients with DCM, was also present in 10% of patients with ICM. of septal midwall LGE was associated with myocardial including increased LV dilation and lower irrespective of underlying etiology. During follow-up, was a significant association between septal midwall LGE presence and increased all-cause mortality in patients with DCM but not in patients with ICM. Interestingly, the composite secondary ventricular endpoint was significantly associated with the presence of septal midwall LGE, irrespective of underlying etiology. This that analysis of septal midwall LGE to of heart failure patients who from ICD The gadolinium in the midwall of the which with myocardial A A Ismail TF Guha K J S K Ismail MR E M R R Sheppard MN Alpendurada F Cook SA Cowie MR RG Pennell DJ Prasad SK Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy in 2013; PubMed Scopus Google M M JA RB G R S J P G fibrosis on CMR with late gadolinium enhancement prognosis for and in patients with dilated from a Heart 2015; PubMed Scopus Google Scholar was by JA Moon JC Prasad SK McKenna WJ Lorenz CH Coats AJ Pennell DJ Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance.Circulation. 2003; 108: 54-59Crossref PubMed Scopus (911) Google Scholar as a characteristic finding seen in patients with DCM. the diagnostic value of LGE-CMR for of ischemic or nonischemic in patients with heart failure, on the LGE H Wagner A Judd RM Sechtem U Kim RJ Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies.Eur Heart J. 2005; 26: 1461-1474Crossref PubMed Scopus (668) Google Scholar,4McCrohon JA Moon JC Prasad SK McKenna WJ Lorenz CH Coats AJ Pennell DJ Differentiation of heart failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced cardiovascular magnetic resonance.Circulation. 2003; 108: 54-59Crossref PubMed Scopus (911) Google Scholar Myocardial fibrosis of 2 local fibrosis, of which the is of and to and and or fibrosis, by a of the because of A C Todiere G Aquaro GD Myocardial in non-ischaemic dilated cardiomyopathy: from cardiovascular magnetic Fail 2015; PubMed Google L remodeling and cardiac 2018; PubMed Scopus Google Scholar This fibrosis is found in myocardial A C Todiere G Aquaro GD Myocardial in non-ischaemic dilated cardiomyopathy: from cardiovascular magnetic Fail 2015; PubMed Google Scholar, L remodeling and cardiac 2018; PubMed Scopus Google Scholar, the PubMed Scopus Google Scholar, A J J Myocardial fibrosis in heart failure: and Am Coll Cardiol. 2018; PubMed Scopus Google Scholar and is an to increased and cardiac in cardiac A C Todiere G Aquaro GD Myocardial in non-ischaemic dilated cardiomyopathy: from cardiovascular magnetic Fail 2015; PubMed Google Scholar fibrosis can seen in of DCM on myocardial F D F D S M PA E G H in dilated cardiomyopathy with cardiac magnetic of myocardial fibrosis and with Heart J Cardiovasc Imaging. 2015; PubMed Scopus Google Scholar was also demonstrated in in patients with heart failure because of N M C E F G P of failure in ischemic cardiomyopathy in PubMed Google Scholar myocardial remodeling the Myocardial remodeling is with and cardiovascular and J Cardiol. PubMed Scopus Google Scholar However, can also A C Todiere G Aquaro GD Myocardial in non-ischaemic dilated cardiomyopathy: from cardiovascular magnetic Fail 2015; PubMed Google the PubMed Scopus Google Scholar to dysfunction, or in increased of fibrosis, and including increased ventricular dilation and severe J Kochav JD Gurevich S Afroz A Petashnick M Volo S Diaz B Okin PM Horn E Devereux RB Weinsaft JW Left ventricular geometric remodeling in relation to non-ischemic scar pattern on cardiac magnetic resonance imaging.Int J Cardiovasc Imaging. 2014; 30: 1559-1567Crossref PubMed Scopus (12) Google Scholar The relation between septal midwall LGE and LV demonstrated in patients with A A Ismail TF Guha K J S K Ismail MR E M R R Sheppard MN Alpendurada F Cook SA Cowie MR RG Pennell DJ Prasad SK Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy in 2013; PubMed Scopus Google S D M H C H R P C G E of cardiovascular magnetic resonance for in chronic heart failure: prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated PubMed Scopus Google Scholar a relation in patients with ICM as in with a J Kochav JD Gurevich S Afroz A Petashnick M Volo S Diaz B Okin PM Horn E Devereux RB Weinsaft JW Left ventricular geometric remodeling in relation to non-ischemic scar pattern on cardiac magnetic resonance imaging.Int J Cardiovasc Imaging. 2014; 30: 1559-1567Crossref PubMed Scopus (12) Google Scholar The and the in functional that septal midwall LGE an of heart failure with a for between an ischemic and nonischemic etiology. However, the of septal midwall LGE in patients with ICM is 10% in the present This an of the septal segments in myocardial infarction in subendocardial or transmural on CMR, of septal midwall The prognostic value of septal midwall LGE presence was demonstrated in RG Prasad SK Lyne J Smith G Burman ED Khan M Sheppard MN Poole-Wilson PA Pennell DJ Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy.J Am Coll Cardiol. 2006; 48: 1977-1985Crossref PubMed Scopus (912) Google BP Gulati A Ali A Guha K Newsome S Arzanauskaite M Vassiliou VS Lota A Izgi C Tayal U Khalique Z Stirrat C Auger D Pareek N Ismail TF Rosen SD Vazir A Alpendurada F Gregson J Frenneaux MP Cowie MR Cleland JGF Cook SA Pennell DJ Prasad SK Association between midwall late gadolinium enhancement and sudden cardiac death in patients with dilated cardiomyopathy and mild and moderate left ventricular systolic dysfunction.Circulation. 2017; 135: 2106-2115Crossref PubMed Scopus (223) Google L H L PM AJ Myocardial fibrosis appropriate in patients with implantable for primary prevention of sudden cardiac Am Coll Cardiol. PubMed Scopus Google Scholar the of the present study is the to a prognostic of septal midwall LGE presence on VA in patients with ICM as poor in patients with ICM was associated with G V Aquaro GD S Lombardi M S P D A left ventricular and patients with myocardial a for prognostic Heart J. 2013; PubMed Scopus Google Scholar which is to the of ischemic R A VA JW van Rossum AC recovery acute myocardial between and cardiovascular magnetic resonance of Am Coll Cardiol. 2008; PubMed Scopus Google Scholar However, the between myocardial remodeling and septal midwall LGE an disease which worse The of VA Septal midwall fibrosis as arrhythmogenic for a van van van der RJ K scar and associated ventricular in nonischemic cardiomyopathy: for the 2013; 6: PubMed Scopus Google Scholar In contrast, the increased because of LV dilation and myocardial J Kochav JD Gurevich S Afroz A Petashnick M Volo S Diaz B Okin PM Horn E Devereux RB Weinsaft JW Left ventricular geometric remodeling in relation to non-ischemic scar pattern on cardiac magnetic resonance imaging.Int J Cardiovasc Imaging. 2014; 30: 1559-1567Crossref PubMed Scopus (12) Google Scholar LM arrhythmias in the for the of PubMed Google Scholar Additionally, of for is the assessment of the value of septal midwall LGE in patients with ICM for the of LV functional R Myocardial viability and of revascularization on prognosis in patients with coronary artery disease and left ventricular a Am Coll Cardiol. PubMed Scopus Google Scholar in DCM the absence of midwall LGE was associated with reverse M Sramko M Maluskova J Kautznerova D Weichet J Lupinek P Vrbska J Malek I Kautzner J Novel predictors of left ventricular reverse remodeling in individuals with recent-onset dilated cardiomyopathy.J Am Coll Cardiol. 2013; 61: 54-63Crossref PubMed Scopus (102) Google Scholar in This is a observational study and from the to this of ischemic or DCM as of myocardial dysfunction was on is not a of cardiomyopathy including both an ischemic and underlying DCM in this the current the of this study the analysis of cardiovascular death in all-cause mortality. Septal midwall LGE was as a of the However, the value of the in with patients with DCM A A Ismail TF Guha K J S K Ismail MR E M R R Sheppard MN Alpendurada F Cook SA Cowie MR RG Pennell DJ Prasad SK Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy in 2013; PubMed Scopus Google M M A F F C G F G L F B D G C S D of the presence and of myocardial fibrosis by cardiac magnetic resonance on and sudden cardiac death in nonischemic dilated 2014; 11: PubMed Scopus Google BP AJ Gulati A Ali A Newsome S Izgi C Arzanauskaite M Lota A Tayal U Vassiliou VS Gregson J Alpendurada F Frenneaux MP Cook SA Cleland JGF Pennell DJ Prasad SK in dilated cardiomyopathy related to the and pattern of late gadolinium Cardiovasc Imaging. 12: PubMed Scopus Google Scholar In addition, we that midwall LGE is a of LV including increased LGE-CMR is to fibrosis because on an appropriate for the of fibrosis, this is and in this CMR study Additionally, the present study data on remodeling in this was demonstrated in on the remodeling in on in both patients with ICM and DCM In septal midwall LGE, a and characteristic finding of CMR in patients with DCM, was also present in 10% of patients with systolic heart failure by ischemic heart disease. The presence of septal midwall LGE was related to myocardial including severe LV dilation and worse LV systolic function, irrespective of underlying the presence of septal midwall LGE was significantly associated with the occurrence of ventricular events, both in ICM and DCM. In patients with DCM, septal midwall LGE was also associated with increased all-cause whereas was seen in patients with ICM. of septal midwall LGE presence the of patients for ICD The of to with analysis for the primary of all-cause mortality in patients with analysis for the primary of all-cause mortality in patients with for the secondary of ventricular in patients with for the secondary of ventricular in patients with DCM