Abstract
Ventricular Arrhythmias (VAs) may present with a wide spectrum of clinical manifestations ranging from mildly symptomatic frequent premature ventricular contractions to lifethreatening events such as sustained ventricular tachycardia, ventricular fibrillation and sudden cardiac death. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias which are commonly associated with Structural Heart Diseases (SHD) such as ischemic heart disease, healed myocarditis and non-ischemic cardiomyopathies. However, the arrhythmogenic substrate may remain unclear in up to 50% of the cases after a routine diagnostic workup, comprehensive of 12-lead surface ECG, transthoracic echocardiography and coronary angiography/ computed tomography. Whenever any abnormality cannot be identified, VAs are referred as to “idiopathic”. In the last decade, Cardiac Magnetic Resonance (CMR) imaging has acquired a growing role in the identification and characterization of myocardial arrhythmogenic substrate, not only being able to accurately and reproducibly quantify biventricular function, but, more importantly, providing information about the presence of myocardial structural abnormalities such as myocardial fatty replacement, myocardial oedema, and necrosis/ fibrosis, which may otherwise remain unrecognized. Moreover, CMR has recently demonstrated to be of great value in guiding interventional treatments, such as radiofrequency ablation, by reliably identifying VA sites of origin and improving long-term outcomes. In the present manuscript, we review the available data regarding the utility of CMR in the workup of apparently “idiopathic” VAs with a special focus on its prognostic relevance and its application in planning and guiding interventional treatments.
Keywords: Cardiac magnetic resonance, idiopathic, late gadolinium enhancement, structural heart disease, tissue characterization, ventricular arrhythmias.
Graphical Abstract
[1]
Tan AY, Ellenbogen K. Ventricular arrhythmias in apparently normal hearts. Card Electrophysiol Clin 2016; 8: 613-21.
[2]
Nucifora G, Muser D, Masci PG, et al. Prevalence and prognostic value of concealed structural abnormalities in patients with apparently idiopathic ventricular arrhythmias of left versus right ventricular origin A magnetic resonance imaging study. Circ Arrhythm Electrophysiol 2014; 7: 456-62.
[3]
Mahida S, Sacher F, Dubois R, et al. Cardiac imaging in patients with ventricular tachycardia. Circulation 2017; 136: 2491-507.
[4]
Latif S, Dixit S, Callans DJ. Ventricular arrhythmias in normal hearts. Cardiol Clin 2008; 26: 367-80.
[5]
Saksena S, Camm AJ. Electrophysiological disorders of the heart: Expert consult. Elsevier Health Sciences 2011.
[6]
Lerman BB. Mechanism, diagnosis, and treatment of outflow tract tachycardia. Nat Rev Cardiol 2015; 12: 597-608.
[7]
Stevenson WG, Khan H, Sager P, et al. Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction. Circulation 1993; 88: 1647-70.
[8]
Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Circulation 2000; 101: 1288-96.
[9]
Ruberman W, Weinblatt E, Goldberg JD, Frank CW, Shapiro S. Ventricular premature beats and mortality after myocardial infarction. N Engl J Med 1977; 297: 750-7.
[10]
Chiang BN, Perlman LV, Ostrander LD, Epstein FH. Relationship of premature systoles to coronary heart disease and sudden death in the Tecumseh epidemiologic study. Ann Intern Med 1969; 70: 1159-66.
[11]
Dukes JW, Dewland TA, Vittinghoff E, et al. Ventricular ectopy as a predictor of heart failure and death. J Am Coll Cardiol 2015; 66: 101-9.
[12]
Ataklte F, Erqou S, Laukkanen J, Kaptoge S. Meta-analysis of ventricular premature complexes and their relation to cardiac mortality in general populations. Am J Cardiol 2013; 112: 1263-70.
[13]
Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA, Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med 1985; 312: 193-7.
[14]
Gaita F, Giustetto C, Di Donna P, et al. Long-term follow-up of right ventricular monomorphic extrasystoles. J Am Coll Cardiol 2001; 38: 364-70.
[15]
Engel G, Cho S, Ghayoumi A, et al. Prognostic significance of PVCs and resting heart rate. Ann Noninvasive Electrocardiol 2007; 12: 121-9.
[16]
Ephrem G, Levine M, Friedmann P, Schweitzer P. The prognostic significance of frequency and morphology of premature ventricular complexes during ambulatory holter monitoring: Prognostic significance of multiform PVCs. Ann Noninvasive Electrocardiol 2013; 18: 118-25.
[17]
Hirose H, Ishikawa S, Gotoh T, Kabutoya T, Kayaba K, Kajii E. Cardiac mortality of premature ventricular complexes in healthy people in Japan. J Cardiol 2010; 56: 23-6.
[18]
Muser D, Piccoli G, Puppato M, Proclemer A, Nucifora G. Incremental value of cardiac magnetic resonance imaging in the diagnostic work-up of patients with apparently idiopathic ventricular arrhythmias of left ventricular origin. Int J Cardiol 2015; 180: 142-4.
[19]
Muser D, Puppato M, Proclemer A, Nucifora G. Value of cardiac magnetic resonance imaging in the setting of familiar cardiomyopathy: A step toward pre-clinical diagnosis. Int J Cardiol 2016; 203: 43-5.
[20]
Lee V, Hemingway H, Harb R, Crake T, Lambiase P. The prognostic significance of premature ventricular complexes in adults without clinically apparent heart disease: A meta-analysis and systematic review. Heart 2012; 98: 1290-8.
[21]
Dello Russo A, Pieroni M, Santangeli P, et al. Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: Role of cardiac electroanatomical mapping and biopsy. Heart Rhythm 2011; 8: 1915-22.
[22]
Nucifora G, Aquaro GD, Masci PG, et al. Lipomatous metaplasia in ischemic cardiomyopathy: Current knowledge and clinical perspective. Int J Cardiol 2011; 146: 120-2.
[23]
Cannavale G, Francone M, Galea N, et al. Fatty images of the heart: Spectrum of normal and pathological findings by computed tomography and cardiac magnetic resonance imaging. BioMed Res Int 2018; 2018: 5610347.
[24]
Tandri H, Castillo E, Ferrari VA, et al. Magnetic resonance imaging of arrhythmogenic right ventricular dysplasia: Sensitivity, specificity, and observer variability of fat detection versus functional analysis of the right ventricle. J Am Coll Cardiol 2006; 48: 2277-84.
[25]
Aquaro GD, Nucifora G, Pederzoli L, et al. Fat in left ventricular myocardium assessed by steady-state free precession pulse sequences. Int J Cardiovasc Imaging 2012; 28: 813-21.
[26]
Eitel I, Friedrich MG. T2-weighted cardiovascular magnetic resonance in acute cardiac disease. J Cardiovasc Magn Reson Off J Soc Cardiovasc Magn Reson 2011; 13: 13.
[27]
Kim RJ, Chen EL, Lima JAC, Judd RM. Myocardial Gd-DTPA kinetics determine MRI contrast enhancement and reflect the extent and severity of myocardial injury after acute reperfused infarction. Circulation 1996; 94: 3318-26.
[28]
Simonetti OP, Kim RJ, Fieno DS, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001; 218: 215-23.
[29]
Selvanayagam J, Nucifora GG. Early and late gadolinium enhancement The EACVI Textbook of Cardiovascular Magnetic Resonance. Oxford, New York: Oxford University Press 2018.
[30]
Rajiah P, Desai MY, Kwon D, Flamm SD. MR imaging of myocardial infarction. Radiogr Rev Publ Radiol Soc N Am Inc 2013; 33: 1383-412.
[31]
Santangeli P, Pieroni M, Dello Russo A, et al. Noninvasive diagnosis of electroanatomic abnormalities in arrhythmogenic right ventricular cardiomyopathy. Circ Arrhythm Electrophysiol 2010; 3: 632-8.
[32]
Casella M, Pizzamiglio F, Dello Russo A, et al. Feasibility of combined unipolar and bipolar voltage maps to improve sensitivity of endomyocardial biopsy. Circ Arrhythm Electrophysiol 2015; 8: 625-32.
[33]
White JA, Fine NM, Gula L, et al. Utility of cardiovascular magnetic resonance in identifying substrate for malignant ventricular arrhythmias. Circ Cardiovasc Imaging 2012; 5: 12-20.
[34]
Neilan TG, Farhad H, Mayrhofer T, et al. Late gadolinium enhancement among survivors of sudden cardiac arrest. JACC Cardiovasc Imaging 2015; 8: 414-23.
[35]
Baritussio A, Zorzi A, Ghosh Dastidar A, et al. Out of hospital cardiac arrest survivors with inconclusive coronary angiogram: Impact of cardiovascular magnetic resonance on clinical management and decision-making. Resuscitation 2017; 116: 91-7.
[36]
Rodrigues P, Joshi A, Williams H, et al. Diagnosis and prognosis in sudden cardiac arrest survivors without coronary artery disease CLINICAL PERSPECTIVE: Utility of a clinical approach using cardiac magnetic resonance imaging. Circ Cardiovasc Imaging 2017; 10: e006709.
[37]
Zorzi A, Susana A, De Lazzari M, et al. Diagnostic value and prognostic implications of early cardiac magnetic resonance in survivors of out of hospital cardiac arrest. Heart Rhythm 2018; 15(7): 1031-41.
[38]
Krahn AD, Healey JS, Chauhan V, et al. Systematic assessment of patients with unexplained cardiac arrest: cardiac arrest survivors with preserved ejection fraction registry (CASPER). Circulation 2009; 120: 278-85.
[39]
Hennig A, Salel M, Sacher F, et al. High-resolution three-dimensional late gadolinium-enhanced cardiac magnetic resonance imaging to identify the underlying substrate of ventricular arrhythmia. Europace 2018; 20(FI2): f179-91.
[40]
Thachil A, Christopher J, Sastry BKS, et al. Monomorphic ventricular tachycardia and mediastinal adenopathy due to granulomatous infiltration in patients with preserved ventricular function. J Am Coll Cardiol 2011; 58: 48-55.
[41]
Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017. [Epub ahead of print].
[42]
Marstrand P, Axelsson A, Thune JJ, Vejlstrup N, Bundgaard H, Theilade J. Cardiac magnetic resonance imaging after ventricular tachyarrhythmias increases diagnostic precision and reduces the need for family screening for inherited cardiac disease. Europace 2016; 18(12): 1860-5.
[43]
Mavrogeni S, Anastasakis A, Sfendouraki E, et al. Ventricular tachycardia in patients with family history of sudden cardiac death, normal coronaries and normal ventricular function. Can cardiac magnetic resonance add to diagnosis? Int J Cardiol 2013; 168: 1532-3.
[44]
Jeserich M, Friedrich MG, Olschewski M, et al. Evidence for non-ischemic scarring in patients with ventricular ectopy. Int J Cardiol 2011; 147: 482-4.
[45]
Globits S, Kreiner G, Frank H, et al. Significance of morphological abnormalities detected by MRI in patients undergoing successful ablation of right ventricular outflow tract tachycardia. Circulation 1997; 96: 2633-40.
[46]
Markowitz SM, Litvak BL, Ramirez de Arellano EA, Markisz JA, Stein KM, Lerman BB. Adenosine-sensitive ventricular tachycardia: Right ventricular abnormalities delineated by magnetic resonance imaging. Circulation 1997; 96: 1192-200.
[47]
White RD, Trohman RG, Flamm SD, et al. Right ventricular arrhythmia in the absence of arrhythmogenic dysplasia: MR imaging of myocardial abnormalities. Radiology 1998; 207: 743-51.
[48]
Carlson MD, White RD, Trohman RG, et al. Right ventricular outflow tract ventricular tachycardia: detection of previously unrecognized anatomic abnormalities using cine magnetic resonance imaging. J Am Coll Cardiol 1994; 24: 720-7.
[49]
Kayser HW, Schalij MJ, van der Wall EE, Stoel BC, de Roos A. Biventricular function in patients with nonischemic right ventricle tachyarrhythmias assessed with MR imaging. Am J Roentgenol 1997; 169: 995-9.
[50]
Grimm W, Wig EH, Hoffmann J, et al. Magnetic resonance imaging and signal-averaged electrocardiography in patients with repetitive monomorphic ventricular tachycardia and otherwise normal electrocardiogram. Pacing Clin Electrophysiol 1997; 20: 1826-33.
[51]
Tandri H, Bluemke DA, Ferrari VA, et al. Findings on magnetic resonance imaging of idiopathic right ventricular outflow tachycardia. Am J Cardiol 2004; 94: 1441-5.
[52]
Tandri H, Saranathan M, Rodriguez ER, et al. Noninvasive detection of myocardial fibrosis in arrhythmogenic right ventricular cardiomyopathy using delayed-enhancement magnetic resonance imaging. J Am Coll Cardiol 2005; 45: 98-103.
[53]
Markowitz SM, Weinsaft JW, Waldman L, et al. Reappraisal of cardiac magnetic resonance imaging in idiopathic outflow tract arrhythmias. J Cardiovasc Electrophysiol 2014; 25: 1328-35.
[54]
Oebel S, Dinov B, Arya A, et al. ECG morphology of premature ventricular contractions predicts the presence of myocardial fibrotic substrate on cardiac magnetic resonance imaging in patients undergoing ablation. J Cardiovasc Electrophysiol 2017; 28: 1316-23.
[55]
Jeserich M, Merkely B, Olschewski M, Kimmel S, Pavlik G, Bode C. Patients with exercise-associated ventricular ectopy present evidence of myocarditis. J Cardiovasc Magn Reson 2015; 17: 100.
[56]
Yokokawa M, Siontis KC, Kim HM, et al. Value of cardiac magnetic resonance imaging and programmed ventricular stimulation in patients with frequent premature ventricular complexes undergoing radiofrequency ablation. Heart Rhythm 2017; 14: 1695-701.
[57]
Aljaroudi WA, Flamm SD, Saliba W, Wilkoff BL, Kwon D. Role of CMR imaging in risk stratification for sudden cardiac death. JACC Cardiovasc Imaging 2013; 6: 392-406.
[58]
Dawson DK, Hawlisch K, Prescott G, et al. Prognostic role of CMR in patients presenting with ventricular arrhythmias. JACC Cardiovasc Imaging 2013; 6: 335-44.
[59]
Ganesan AN, Gunton J, Nucifora G, McGavigan AD, Selvanayagam JB. Impact of late gadolinium enhancement on mortality, sudden death and major adverse cardiovascular events in ischemic and nonischemic cardiomyopathy: A systematic review and meta-analysis. Int J Cardiol 2018; 254: 230-7.
[60]
Zorzi A, Marra MP, Rigato I, et al. Nonischemic left ventricular scar as a substrate of life-threatening ventricular arrhythmias and sudden cardiac death in competitive athletes. Circ Arrhythm Electrophysiol 2016; 9: e004229.
[61]
Aquaro GD, Pingitore A, Strata E, Di Bella G, Molinaro S, Lombardi M. Cardiac magnetic resonance predicts outcome in patients with premature ventricular complexes of left bundle branch block morphology. J Am Coll Cardiol 2010; 56: 1235-43.
[62]
Niwano S, Wakisaka Y, Niwano H, et al. Prognostic significance of frequent premature ventricular contractions originating from the ventricular outflow tract in patients with normal left ventricular function. Heart 2009; 95: 1230-7.
[63]
Betensky BP, Dong W, D’Souza BA, Zado ES, Han Y, Marchlinski FE. Cardiac magnetic resonance imaging and electroanatomic voltage discordance in non-ischemic left ventricle ventricular tachycardia and premature ventricular depolarizations. J Interv Card Electrophysiol 2017; 49(1): 11-9.
[64]
Muser D, Liang JJ, Witschey WR, et al. Ventricular arrhythmias associated with left ventricular noncompaction: Electrophysiologic characteristics, mapping, and ablation. Heart Rhythm 2017; 14: 166-75.
[65]
Castro SA, Pathak RK, Muser D, et al. Incremental value of electroanatomical mapping for the diagnosis of arrhythmogenic right ventricular cardiomyopathy in a patient with sustained ventricular tachycardia. Hear Case Rep 2016; 2(6): 469-72.
[66]
Perin EC, Silva GV, Sarmento-Leite R, et al. Assessing myocardial viability and infarct transmurality with left ventricular electromechanical mapping in patients with stable coronary artery disease: Validation by delayed-enhancement magnetic resonance imaging. Circulation 2002; 106: 957-61.
[67]
Gulati A, Jabbour A, Ismail TF, et al. Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy. JAMA 2013; 309: 896-908.
[68]
Haaf P, Garg P, Messroghli DR, Broadbent DA, Greenwood JP, Plein S. Cardiac T1 mapping and extracellular volume (ECV) in clinical practice: A comprehensive review. J Cardiovasc Magn Reson 2017; 18(1): 89.
[69]
Moon JC, Messroghli DR, Kellman P, et al. Myocardial T1 mapping and extracellular volume quantification: A Society for Cardiovascular Magnetic Resonance (SCMR) and CMR working group of the European Society of Cardiology consensus statement. J Cardiovasc Magn Reson Off J Soc Cardiovasc Magn Reson 2013; 15: 92.
[70]
Messroghli DR, Radjenovic A, Kozerke S, Higgins DM, Sivananthan MU, Ridgway JP. Modified Look-Locker inversion recovery (MOLLI) for high-resolution T1 mapping of the heart. Magn Reson Med 2004; 52: 141-6.
[71]
Nakamori S, Bui AH, Jang J, et al. Increased myocardial native T1 relaxation time in patients with nonischemic dilated cardiomyopathy with complex ventricular arrhythmia. J Magn Reson Imaging 2018; 47(3): 779-86.
[72]
Mekkaoui C, Reese TG, Jackowski MP, Bhat H, Sosnovik DE. Diffusion MRI in the heart: Diffusion MRI of the heart. NMR Biomed 2017; 30: e3426.
[73]
Mekkaoui C, Jackowski MP, Thiagalingam A, et al. Correlation of DTI tractography with electroanatomic mapping in normal and infarcted myocardium. J Cardiovasc Magn Reson 2014; 16: 1.
[74]
Muser D, Liang JJ, Santangeli P. Off-line analysis of electro-anatomical mapping in ventricular arrhythmias. Minerva Cardioangiol 2017; 65: 369-79.
[75]
Gepstein L, Goldin A, Lessick J, et al. Electromechanical characterization of chronic myocardial infarction in the canine coronary occlusion model. Circulation 1998; 98: 2055-64.
[76]
Hutchinson MD, Gerstenfeld EP, Desjardins B, et al. Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy. Circ Arrhythm Electrophysiol 2011; 4: 49-55.
[77]
Codreanu A, Odille F, Aliot E, et al. Electroanatomic characterization of post-infarct scars. J Am Coll Cardiol 2008; 52: 839-42.
[78]
Desjardins B, Crawford T, Good E, et al. Infarct architecture and characteristics on delayed enhanced magnetic resonance imaging and electroanatomic mapping in patients with post-infarction ventricular arrhythmia. Heart Rhythm Off J Heart Rhythm Soc 2009; 6: 644-51.
[79]
Nazarian S. Magnetic resonance assessment of the substrate for inducible ventricular tachycardia in nonischemic cardiomyopathy. Circulation 2005; 112: 2821-5.
[80]
Bogun FM, Desjardins B, Good E, et al. Delayed-enhanced magnetic resonance imaging in nonischemic cardiomyopathy: Utility for identifying the ventricular arrhythmia substrate. J Am Coll Cardiol 2009; 53: 1138-45.
[81]
Sasaki T, Miller CF, Hansford R, et al. Impact of nonischemic scar features on local ventricular electrograms and scar-related ventricular tachycardia circuits in patients with nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol 2013; 6(6): 1139-47.
[82]
Yamashita S, Sacher F, Mahida S, et al. Image integration to guide catheter ablation in scar-related ventricular tachycardia. J Cardiovasc Electrophysiol 2016; 27(6): 699-708.
[83]
Andreu D, Ortiz-Pérez JT, Boussy T, et al. Usefulness of contrast-enhanced cardiac magnetic resonance in identifying the ventricular arrhythmia substrate and the approach needed for ablation. Eur Heart J 2014; 35: 1316-26.
[84]
Ilg K, Baman TS, Gupta SK, et al. Assessment of radiofrequency ablation lesions by CMR imaging after ablation of idiopathic ventricular arrhythmias. JACC Cardiovasc Imaging 2010; 3: 278-85.
Article Metrics
52
3