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基于心脏 MRI 的特发性扩张型心肌病危险分层。

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy.

机构信息

Cardiac MRI Department, North West Heart Centre, Manchester University Foundation Trust-Wythenshawe Site, Manchester, UK.

Arrhythmia Unit, Heart Disease Institute, Bellvitge University Hospital, Barcelona, Spain.

出版信息

Heart. 2019 Feb;105(4):270-275. doi: 10.1136/heartjnl-2018-313767. Epub 2018 Oct 30.

Abstract

Sudden cardiac death (SCD) secondary to arrhythmia remains a risk in those with dilated cardiomyopathy (DCM), an implantable cardiac defibrillator (ICD) is an effective strategy to prevent SCD. Current guidelines recommend selection for ICD based on ejection fraction (EF) less than 35%, however, most SCD occurs in those with EF>35%. Although meta-analysis has demonstrated a survival benefit for primary prevention ICD in DCM, no randomised trial has shown a significant reduction in overall mortality including the most recent 'Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heat Failure on Mortality' study. Clearly, a more sophisticated selection strategy is required. Cardiac MRI (CMR) is an ideal non-invasive imaging technique which allows calculation of EF as well as tissue characterisation with gadolinium contrast, parametric mapping and feature tracking. Late gadolinium enhancement detects mid-wall fibrosis in approximately 30% of those with DCM, three meta-analyses have demonstrated an association between fibrosis in DCM and SCD, and those without fibrosis are at low risk of SCD. T1 mapping and extracellular volume (ECV) calculation are methods of demonstrating diffuse fibrosis in the myocardium. Raised ECV and native T1 have been associated with worse outcomes but the relationship to SCD has not been well studied. Undoubtedly, more research is required but CMR has several tools which offer incremental value above EF to improve risk stratification and consequent outcomes and resource utilisation in those with DCM.

摘要

心律失常导致的心脏性猝死 (SCD) 仍然是扩张型心肌病 (DCM) 患者的风险因素,植入式心脏除颤器 (ICD) 是预防 SCD 的有效策略。目前的指南建议根据射血分数 (EF) 小于 35% 选择 ICD,但大多数 SCD 发生在 EF>35%的患者中。尽管荟萃分析表明原发性预防 ICD 对 DCM 具有生存获益,但没有随机试验显示总体死亡率显著降低,包括最近的“丹麦评估 ICD 在非缺血性收缩性心力衰竭患者中的疗效研究”。显然,需要更复杂的选择策略。心脏磁共振 (CMR) 是一种理想的非侵入性成像技术,可计算 EF,并用钆对比剂进行组织特征分析、参数映射和特征跟踪。大约 30%的 DCM 患者存在中壁纤维化的延迟钆增强检测,三项荟萃分析表明 DCM 中的纤维化与 SCD 之间存在关联,而没有纤维化的患者发生 SCD 的风险较低。T1 映射和细胞外容积 (ECV) 计算是显示心肌弥漫性纤维化的方法。升高的 ECV 和原发性 T1 与预后较差相关,但与 SCD 的关系尚未得到很好的研究。毫无疑问,需要进行更多的研究,但 CMR 有几种工具,除了 EF 外,还可以提供额外的价值,以改善 DCM 患者的风险分层和随后的结果以及资源利用。

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