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(Circulation. 2007;115:2006-2014.)
© 2007 American Heart Association, Inc.

Imaging

Infarct Tissue Heterogeneity by Magnetic Resonance Imaging Identifies Enhanced Cardiac Arrhythmia Susceptibility in Patients With Left Ventricular Dysfunction

André Schmidt, MD^*; Clerio F. Azevedo, MD^*; Alan Cheng, MD; Sandeep N. Gupta, PhD; David A. Bluemke, MD, PhD; Thomas K. Foo, PhD; Gary Gerstenblith, MD; Robert G. Weiss, MD; Eduardo Marbán, MD, PhD; Gordon F. Tomaselli, MD; João A.C. Lima, MD; Katherine C. Wu, MD

From the Division of Cardiology, Department of Medicine (A.S., C.F.A., A.C., D.A.B., G.G., R.G.W., E.M., G.F.T., J.A.C.L., K.C.W.) and Department of Radiology (D.A.B., R.G.W., J.A.C.L.), Johns Hopkins University; and the Applied Science Laboratory, GE Healthcare Technologies (S.N.G., T.K.F.), Baltimore, Md.

Reprint requests to Katherine C. Wu, MD, Division of Cardiology, Johns Hopkins Hospital, 600 N Wolfe St, Carnegie 568, Baltimore, MD 21287. E-mail kwu{at}jhmi.edu

Received April 29, 2005; accepted February 20, 2007.

Background— The extent of the peri-infarct zone by magnetic resonance imaging (MRI) has been related to all-cause mortality in patients with coronary artery disease. This relationship may result from arrhythmogenesis in the infarct border. However, the relationship between tissue heterogeneity in the infarct periphery and arrhythmic substrate has not been investigated. In the present study, we quantify myocardial infarct heterogeneity by contrast-enhanced MRI and relate it to an electrophysiological marker of arrhythmic substrate in patients with left ventricular (LV) systolic dysfunction undergoing prophylactic implantable cardioverter defibrillator placement.

Methods and Results— Before implantable cardioverter defibrillator implantation for primary prevention of sudden cardiac death, 47 patients underwent cine and contrast-enhanced MRI to measure LV function, volumes, mass, and infarct size. A method for quantifying the heterogeneous infarct periphery and the denser infarct core is described. MRI indices were related to inducibility of sustained monomorphic ventricular tachycardia during electrophysiological or device testing. For the noninducible versus inducible patients, LV ejection fraction (30±10% versus 29±7%, P=0.79), LV end-diastolic volume (220±70 versus 228±57 mL, P=0.68), and infarct size by standard contrast-enhanced MRI definitions (P=NS) were similar. Quantification of tissue heterogeneity at the infarct periphery was strongly associated with inducibility for monomorphic ventricular tachycardia (noninducible versus inducible: 13±9 versus 19±8 g, P=0.015) and was the single significant factor in a stepwise logistic regression.

Conclusions— Tissue heterogeneity is present and quantifiable within human infarcts. More extensive tissue heterogeneity correlates with increased ventricular irritability by programmed electrical stimulation. These findings support the hypothesis that anatomic tissue heterogeneity increases susceptibility to ventricular arrhythmias in patients with prior myocardial infarction and LV dysfunction.

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