The Incidence, Pattern, and Prognostic Value of Left Ventricular Myocardial Scar by Late Gadolinium Enhancement in Patients With Atrial Fibrillation

doi:10.1016/j.jacc.2013.07.067

Journal of the American College of Cardiology

Volume 62, Issue 23, 10 December 2013, Pages 2205-2214

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Objectives

This study sought to identify the frequency, pattern, and prognostic significance of left ventricular (LV) late gadolinium enhancement (LGE) in patients with atrial fibrillation (AF).

Background

There are limited data on the presence, pattern, and prognostic significance of LV myocardial fibrosis in patients with AF. LGE during cardiac magnetic resonance imaging is a marker for myocardial fibrosis.

Methods

A group of 664 consecutive patients without known prior myocardial infarction who were referred for radiofrequency ablation of AF were studied. Cardiac magnetic resonance imaging was requested to assess pulmonary venous anatomy.

Results

Overall, 73% were men, with a mean age of 56 years and a mean LV ejection fraction of 56 ± 10%. LV LGE was found in 88 patients (13%). The endpoint was all-cause mortality, and in this cohort, 68 deaths were observed over a median follow-up period of 42 months. On univariate analysis, age (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 1.03 to 1.08; chi-square likelihood ratio [LRχ²]: 15.2; p = 0.0001), diabetes (HR: 2.39; 95% CI: 1.41 to 4.09; LRχ²: 10.3; p = 0.001), a history of heart failure (HR: 1.78; 95% CI: 1.09 to 2.91; LRχ²: 5.37; p = 0.02), left atrial dimension (HR: 1.04; 95% CI: 1.01 to 1.08; LRχ²: 6.47; p = 0.01), presence of LGE (HR: 5.08; 95% CI: 3.08 to 8.36; LRχ²: 28.8; p < 0.0001), and LGE extent (HR: 1.15; 95% CI: 1.10 to 1.21; LRχ²: 35.6; p < 0.0001) provided the strongest associations with mortality. The mortality rate was 8.1% per patient-year in patients with LGE compared with 2.3% patients without LGE. In the best overall multivariate model for mortality, age and the extent of LGE were independent predictors of mortality. Indeed, each 1% increase in the extent of LGE was associated with a 15% increased risk for death.

Conclusions

In patients with AF, LV LGE is a frequent finding and is a powerful predictor of mortality.

Key Words

atrial fibrillation

cardiac magnetic resonance

late gadolinium enhancement

Abbreviations and Acronyms

atrial fibrillation

confidence interval

CMR

cardiac magnetic resonance

computed tomography

ECG

electrocardiography

ejection fraction

hazard ratio

LGE

late gadolinium enhancement

LRχ²

chi-square likelihood ratio

left ventricular

myocardial infarction

Cited by (0)

: Dr. Neilan is supported by an American Heart Association Fellow to Faculty Grant (12FTF12060588). Dr. Abbassi has received NIH funding. Drs. Jerosch-Herold and Kwong are supported by research grants from the National Institutes of Health (RO1HL090634 and RO1HL091157, respectively). Dr. Shah has served as a consultant for Ventripoint. Dr. John has received a speaking honorarium from St. Jude Medical. Dr. van der Geest is a consultant for Medis Medical Imaging Systems. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.