Arrhythmic risk stratification in patients with left ventricular ring-like scar

Vanda Parisi, Maddalena Graziosi, Luis R. Lopes, Antonio De Luca, Ferdinando Pasquale, Giacomo Tini, Mattia Targetti, Maria R. Cueto, Ana R. Moura, Raffaello Ditaranto, Camilla Torlasco, Nevio Taglieri, Elena Nardi, Luigi Lovato, João B. Augusto, Nazzareno Galiè, Lia Crotti, Alessio Gasperetti, Mauro Biffi, Camillo AutoreMarco Merlo, Iacopo Olivotto, Gianfranco Sinagra, Perry M. Elliott, Elena Biagini*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Abstract

Aims Left ventricular (LV) ring-like scar on cardiac magnetic resonance (CMR) has been linked to malignant arrhythmias in patients with non-ischaemic cardiomyopathy. This study aimed to perform a comprehensive evaluation of this phenotype and to identify risk factors for life-threatening arrhythmic events (LAEs), a composite of sudden cardiac death (SCD), aborted SCD, and sustained ventricular tachycardia. Methods and results One hundred and fifteen patients [median age 39 (interquartile range, IQR, 28–52), 42% females] were identified at 6 referral centres. Inclusion criteria were ring-like LV scar [≥3 contiguous segments with sub-epicardial/midwall late gadolinium enhancement (LGE) in the same slice] and one among: pathogenic/likely pathogenic genetic variant, family history for cardiomyopathy, or arrhythmogenic cardiomyopathy diagnosis. During the study follow-up, survival free from LAEs was 60% (3.8 events/100 patients/year); at a median follow-up of 4.6 years (IQR 1.7–8.4) it was 84%. On multivariable analysis, anterior Q waves [hazard ratio (HR): 1.030, 95% confidence intervals (CI): 1.014–1.046, P < 0.001], QRS width (HR: 4.642, 95% CI: 1.296–16.628, P = 0.018), and LV end-diastolic volume index (LVEDVi; HR: 1.011, 95% CI: 1.001–1.021, per mL/m2 increase, P = 0.040) were independently associated with LAEs; with good discrimination power (Harrell’s C-index = 0.796). Three risk categories were identified: normal electrocardiogram (ECG), abnormal ECG and no LAEs predictive variables, abnormal ECG and ≥1 LAEs predictive variables, with a decreasing survival from 100 to 65% and 49%, respectively (Log-rank test = 0.015). Conclusion In this study, the LV ring-like scar phenotype was associated with a high rate of malignant arrhythmias in presence of anterior Q waves, QRS prolongation, and increased LVEDVi. A normal ECG identified a lower risk sub-group.
Original languageEnglish
Article numberzwae353
Number of pages11
JournalEuropean Journal of Preventive Cardiology
DOIs
Publication statusAccepted/In press - 14 Nov 2024

Keywords

  • Arrhythmias
  • Cardiac magnetic resonance
  • Cardiomyopathy
  • Electrocardiogram
  • Prognosis
  • Ring-like scar
  • Risk stratification

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