Wang Tom Kai Ming, Kocyigit Duygu, Chan Nicholas, Salam Donna, Turkmani Mustafa, Bullen Jennifer, Popović Zoran B, Nguyen Christopher, Griffin Brian P, Tang W H Wilson, Kwon Deborah H
Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Section of Cardiovascular Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA.
Eur Heart J Cardiovasc Imaging. 2024 Dec 31;26(1):80-88. doi: 10.1093/ehjci/jeae233.
Pathophysiology and prognostic implications of right ventricle (RV) dysfunction in heart failure are complex and incompletely elucidated. Cardiac magnetic resonance imaging (CMR) is the reference standard for RV quantification, but its clinical implications in non-ischaemic cardiomyopathy (NICM), in the context of myocardial fibrosis and functional mitral regurgitation are not well defined. We evaluated predictors, prognostic impact, and thresholds for defining significant RV dysfunction in NICM.
NICM patients (n = 624) undergoing CMR assessment during 2002-2017 were retrospectively studied. CMR's quantification of right ventricular ejection fraction (RVEF) was evaluated against the primary outcome of all-cause mortality, heart transplant, and/or left ventricular assist device implantation in threshold and multivariable analyses. Mean RVEF was 43 ± 13%, and factors associated with reduced RVEF were male sex, New York Heart Association (NYHA) class III-IV, right bundle branch block, lower left ventricular ejection fraction, higher mitral regurgitant fraction (MR-RF) and right ventricle size in NICM. RVEF per 5% increase was independently associated with the primary endpoint hazards ratio (95% confidence interval) 0.80 (0.73-0.88), P < 0.001. RVEF ≤40% was the optimal threshold associated with worse prognosis, regardless of late gadolinium enhancement (LGE) or MR-RF quantification. On the other hand, higher LGE was associated with primary endpoint in patients with RVEF ≤ 40% only, while risk associated with MR-RF was significant dampened after adjusting for RVEF.
RVEF provides powerful risk stratification, with RVEF ≤ 40% defining significant RV dysfunction associated with adverse outcomes in NICM. The integration of quantitative CMR measurements for RVEF, LGE, and MR-RF provides comprehensive NICM risk prognostication.
心力衰竭中右心室（RV）功能障碍的病理生理学及预后意义复杂且尚未完全阐明。心脏磁共振成像（CMR）是RV定量的参考标准，但其在非缺血性心肌病（NICM）中，在心肌纤维化和功能性二尖瓣反流背景下的临床意义尚不明确。我们评估了NICM中定义显著RV功能障碍的预测因素、预后影响及阈值。
对2002年至2017年间接受CMR评估的NICM患者（n = 624）进行回顾性研究。在阈值分析和多变量分析中，根据全因死亡率、心脏移植和/或左心室辅助装置植入的主要结局，评估CMR对右心室射血分数（RVEF）的定量。平均RVEF为43±13%，与RVEF降低相关的因素包括男性、纽约心脏协会（NYHA）III-IV级、右束支传导阻滞、较低的左心室射血分数、较高的二尖瓣反流分数（MR-RF）以及NICM中的右心室大小。RVEF每增加5%与主要终点风险比（95%置信区间）0.80（0.73 - 0.88）独立相关，P < 0.001。RVEF≤40%是与较差预后相关的最佳阈值，无论晚期钆增强（LGE）或MR-RF定量如何。另一方面，仅在RVEF≤40%的患者中，较高的LGE与主要终点相关，而在调整RVEF后，与MR-RF相关的风险显著降低。
RVEF提供了强大的风险分层，RVEF≤40%定义了NICM中与不良结局相关的显著RV功能障碍。对RVEF、LGE和MR-RF进行定量CMR测量的整合可提供全面的NICM风险预后评估。
