Abstract
BackgroundThe left ventricular ejection fraction (LVEF) is the key selection criterion for an implanted cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. LVEF is usually assessed by two-dimensional echocardiography, but cardiovascular magnetic resonance (CMR) imaging is increasingly used. The aim of our study was to evaluate whether LVEF assessment using CMR imaging (CMR-LVEF) or two-dimensional echocardiography (2D echo-LVEF) may predict differently the occurrence of clinical outcomes.MethodsIn this retrospective study, we reviewed patients referred for primary prevention ICD implantation to Caen University Hospital from 2005 to 2014. We included 173 patients with either ischemic (n = 120) or dilated cardiomyopathy (n = 53) and who had undergone pre-ICD CMR imaging. The primary composite end point was the time to death from any cause or first appropriate device therapy.ResultsThe mean CMR-LVEF was significantly lower than the mean 2D echo-LVEF (24% ± 6 vs 28% ± 6, respectively; p < 0.001). CMR-LVEF was a better independent predictive factor for the occurrence of the primary composite endpoint with a cut-off value of 22% (Hazard Ratio [HR] = 2.22; 95% CI [1.34–3.69]; p = 0.002) than 2D echo-LVEF with a cut-off value of 26% (HR = 1.61; 95% CI [0.99–2.61]; p = 0.056). Combination of the presence of scar with CMR-LVEF< 22% improved the predictive value for the occurrence of the primary outcome (HR = 2.58; 95% CI [1.54–4.30]; p < 0.001). The overall survival was higher among patients with CMR-LVEF≥22% than among patients with CMR-LVEF< 22% (p = 0.026), whereas 2D echo-LVEF was not associated with death.ConclusionsCMR-LVEF is better associated with clinical outcomes than 2D echo-LVEF in primary prevention using an ICD. Scar identification further improved the outcome prediction. The combination of CMR imaging and echocardiography should be encouraged in addition to other risk markers to better select patients.
Highlights
The left ventricular ejection fraction (LVEF) is the key selection criterion for an implanted cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death
cardiovascular magnetic resonance (CMR)-LVEF is better associated with clinical outcomes than Two dimensional (2D) echo-LVEF in primary prevention using an ICD
During the study period, 1181 patients were successfully implanted with an ICD at Caen University Hospital, including 534 with ischemic cardiomyopathy (ICM) or nonischemic cardiomyopathy (NICM) referred for primary prevention of sudden cardiac death
Summary
The left ventricular ejection fraction (LVEF) is the key selection criterion for an implanted cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. LVEF is usually assessed by two-dimensional echocardiography, but cardiovascular magnetic resonance (CMR) imaging is increasingly used. Randomized controlled trials have proven the benefit of implanted cardioverter defibrillator (ICD) therapy in patients with altered left ventricular ejection fraction (LVEF) in both secondary and primary prevention of sudden cardiac death [1,2,3,4,5,6,7]. Simpson’s biplane method is based on geometric assumptions inconsistent with wall deformations occurring in dilated failing ventricles; cardiovascular magnetic resonance (CMR) imaging is more accurate [8] and is considered the non-invasive gold standard for LVEF assessment [9]. Late gadolinium enhancement (LGE) CMR imaging allows scar identification known as the malignant arrhythmia substrate [12]
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