Comparison of myocardial fibrosis quantification methods by cardiovascular magnetic resonance imaging for risk stratification of patients with suspected myocarditis

J Cardiovasc Magn Reson. 2019 Feb 28;21(1):14. doi: 10.1186/s12968-019-0520-0.

Abstract

Background: Although the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method.

Methods: Six hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods.

Results: Ninety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02-1.08, p = 0.001; HR 1.02, 95%CI:1.00-1.04; p = 0.001; HR 1.02, 95%CI: 1.00-1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04-1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values.

Conclusions: FWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients.

Trial registration number: NCT03470571 . Registered 13th March 2018. Retrospectively registered.

Keywords: CMR; Cardiovascular magnetic resonance imaging; FWHM; Full width half maximum; MACE; Myocarditis; Outcome; Quantification method; SD; Standard deviation.

Publication types

  • Comparative Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Contrast Media / administration & dosage
  • Female
  • Fibrosis
  • Gadolinium DTPA / administration & dosage
  • Humans
  • Image Interpretation, Computer-Assisted / methods*
  • Magnetic Resonance Imaging / methods*
  • Male
  • Meglumine / administration & dosage
  • Meglumine / analogs & derivatives
  • Middle Aged
  • Myocarditis / diagnostic imaging*
  • Myocarditis / pathology
  • Myocardium / pathology*
  • Organometallic Compounds / administration & dosage
  • Predictive Value of Tests
  • Prognosis
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index

Substances

  • Contrast Media
  • Organometallic Compounds
  • gadobenic acid
  • Meglumine
  • Gadolinium DTPA

Associated data

  • ClinicalTrials.gov/NCT03470571