Prognostic value of cardiovascular magnetic resonance midwall late gadolinium enhancement granularity in ischaemic cardiomyopathy

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Late gadolinium enhancement (LGE) extent on cardiovascular magnetic resonance (CMR) is a strong predictor of adverse outcomes in ischaemic cardiomyopathy (ICM).1 Beyond ischaemic scarring, midwall LGE, classically described as a marker of non-specific fibrosis in non-ischaemic cardiomyopathy, has also been reported in patients with ICM and is associated with worse prognosis, particularly when located in the left ventricular septum.2 However, the prevalence and prognostic value of midwall LGE in large ICM populations remain insufficiently characterized, and its significance at the population level, independently of ischaemic scar burden, is still unclear. The multicentre study population, CMR acquisition protocol, LGE analysis, and outcome adjudication were identical to those previously reported.3 Briefly, 6082 consecutive patients with ischaemic cardiomyopathy (LVEF <50% with prior myocardial infarction and/or coronary revascularization) underwent standardized 1.5-T CMR (Aera, Siemens Healthcare, Erlangen, Germany). Cine images were acquired using balanced steady-state free-precession sequences, and LGE imaging was performed 10 min after administration of a gadolinium-based contrast agent (Dotarem®, 0.1 mmol/kg). Ischaemic LGE was defined as subendocardial or transmural enhancement consistent with prior myocardial infarction, whereas midwall LGE was defined as non-subendocardial mid-myocardial fibrosis, excluding junctional enhancement and artefacts, with interpretation by three experienced cardiologists (EACVI level 3). A high ischaemic LGE burden was defined as involvement of >2 left ventricular segments. The primary endpoint was all-cause mortality, obtained from the French National Registry of Death (INSEE) through January 2023. Prognostic associations were assessed using Cox proportional hazards models before and after adjustment for established clinical and imaging risk factors, including age, sex, body mass index, diabetes mellitus, hypertension, smoking status, dyslipidaemia, prior heart failure hospitalization, atrial fibrillation, renal failure, history of myocardial infarction, LVEF, and ischaemic LGE extent (number of involved segments).

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