Assessment of Right-Sided Heart Failure in Patients with Dilated Cardiomyopathy using Magnetic Resonance Relaxometry of the Liver

doi:10.1016/j.amjcard.2021.03.012

The American Journal of Cardiology

Volume 149, 15 June 2021, Pages 103-111

https://doi.org/10.1016/j.amjcard.2021.03.012 Get rights and content

In non-ischemic dilated cardiomyopathy (DC) patients at risk of developing right heart failure (RHF), early depiction of congestive heart failure (CHF) is pivotal to inform about the hemodynamic status and tailor medical therapy. We hypothesized increased liver relaxation times measured at routine cardiovascular magnetic resonance (CMR), reflecting passive hepatic congestion, may be a valuable imaging biomarker to depict congestive heart failure. The study cohort consisted of DC patients with LV dysfunction (i.e., ejection fraction <35%) with (n = 48) and without (n = 46) right ventricular dysfunction (RVD), defined as a right ventricular ejection fraction <35%, and >45%, respectively, and a control group (n = 40). Native T1, T2, and extracellular volume (ECV) liver values were measured on routinely acquired cardiac maps. DC+RVD patients had higher C-reactive protein, troponin I and NT-pro BNP values, and worse LV functional parameters than DC-RVD patients (all p <0.001). T1, T2 and ECV Liver values were significantly higher in DC+RVD compared to DC-RVD patients and controls, that is, T1: 675 ± 88 ms verses 538 ± 39 ms and 540 ± 34 ms; T2: 54± 8 ms versus 45 ± 5 ms and 46 ± 4 ms; ECV: 36 ± 7% versus 29 ± 4% and 30 ± 3% (all p <0.001). Gamma-glutamyltranspeptidase (GGT) correlated moderately but significantly with native T1 (r² = 0.34), T2 (r² = 0.27), and ECV liver (r² = 0.23) (all p <0.001). Using right atrial (RA) pressure, as surrogate measure of RHF (i.e., RA pressure >5 mm Hg), native T1 liver yielded at ROC analysis the highest area under the curve (0.906), significantly higher than ECV liver (0.813), GGT (0.806), T2 liver (0.797), total bilirubin (0.737) and alkaline phosphatase (0.561)(p = 0.04). A T1 value of 617 ms yielded a sensitivity of 79.5% and specificity of 91.0% to depict RHF. Excellent intra-/inter-observer agreement was found for assessment of native T1/T2/ECV liver values. In conclusion, in DC patients, assessment of liver relaxation times acquired on a cardiovascular magnetic resonance exam, may provide valuable information with regard to the presence of RHF.

Section snippets

Methods

First, we identified all DC patients who underwent CMR between, January 2017 and March 2020, in the context of their clinical work-up (Figure 1). The diagnosis of DC was based on the current standard criteria.¹⁵ Next, we selected DC patients having at CMR an LV ejection fraction < 35%. In a further step, we defined 2 groups, that is, patients presenting at CMR at least moderate RV dysfunction (i.e., RV ejection-fraction<35% [DC+RVD]) and those with preserved RV function (RV ejection-fraction

Results

DC patients were older than controls (Table 1). Recent CHF episodes were more often diagnosed in DC+RVD than DC-RVD patients. However, no differences in traditional risk factors, New York Heart Association (NYHA) class or atrial flutter/fibrillation found between groups. Pedal edema or jugular venous distension were more common in DC+RVD than DC-RVD patients. CRP, troponin-I and NT-proBNP circulating levels were higher in DC+RVD than in DC-RVD patients (all p <0.001) (Table 1).

Discussion

To the best of our knowledge, this is the first study informing about the use of liver relaxometry to estimate CVP in DC patients based on standard parametric images routinely acquired for myocardial characterization. Remarkably, DC+RVD patients showed increased native T1, T2 and ECV liver values as compared to DC-RVD patients and controls, reflecting liver congestion due to increased CVP. Liver relaxation times were positively correlated with cholestatic or cytolytic liver biomarkers (i.e.,

Authors' Contribution

Jan Bogaert: Conceptualization, Methodology, Data Curation, Validation, Original draft preparation, Writing, Reviewing and Editing

Rolf Symons: Data curation, Statistics, Validation

Pinelopi Rafouli-Stergio: Data curation, Reviewing

Walter Droogné: Data curation, Reviewing

Tom Dresselaers: Data curation, Software, Reviewing

Pier Giorgio Masci: Writing, Reviewing and Editing

Disclosures

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Citation Excerpt :
Limitations. The limitations in the current manuscript are to a large extent similar as the ones we mentioned before.18,30 The most important limitation is that we do not have histologic evidence of liver congestion as none of the patients received a liver biopsy.
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Assessment of liver relaxation times as part of a comprehensive CMR exam in PH patients may provide valuable information with regard to the presence of passive liver congestion.
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Assessment of Right-Sided Heart Failure in Patients with Dilated Cardiomyopathy using Magnetic Resonance Relaxometry of the Liver

Section snippets

Methods

Results

Discussion

Authors' Contribution

Disclosures

J Am Coll Cardiol

J Cardiac Failure

J Hepatol

J Am Coll Cardiol Img

J Am Coll Cardiol

J Cardiovasc Magn Reson

J Am Coll Cardiol Imag

Eur J Radiol

J Cardiovasc Magn Reson

J Hepatol

Evaluation and management of right-sided heart failure. A scientific statement from the American Heart Association

Circulation

Impact of systemic venous congestion in heart failure

Curr Heart Fail Rep

Abnormal liver function in relation to hemodynamic profile in heart failure patients

J Cardiac Failure

Right ventricle in heart failure with preserved ejection fraction

Heart