Excessive Trabeculations and Prognosis
2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 9 Linguagem: Inglês
10.1161/circimaging.117.006908
ISSN1942-0080
AutoresSteffen E. Petersen, Stefan Neubauer,
Tópico(s)Cardiovascular Function and Risk Factors
ResumoHomeCirculation: Cardiovascular ImagingVol. 10, No. 9Excessive Trabeculations and Prognosis Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBExcessive Trabeculations and PrognosisThe Plot Thickens Steffen E. Petersen, MD, DPhil, MPH and Stefan Neubauer, MD Steffen E. PetersenSteffen E. Petersen From the William Harvey Research Institute, NIHR Biomedical Research Centre at Barts, Queen Mary University of London, Charterhouse Square, United Kingdom (S.E.P.); and Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (S.N.). and Stefan NeubauerStefan Neubauer From the William Harvey Research Institute, NIHR Biomedical Research Centre at Barts, Queen Mary University of London, Charterhouse Square, United Kingdom (S.E.P.); and Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, United Kingdom (S.N.). Originally published12 Sep 2017https://doi.org/10.1161/CIRCIMAGING.117.006908Circulation: Cardiovascular Imaging. 2017;10:e006908Benign Prognosis of Excessive TrabeculationsIn this issue of Circulation: Cardiovascular Imaging, Ivanov et al1 provide further evidence that the presence of excessive trabeculations may be benign. In this prospective cohort study of 700 patients (all comers) who were clinically referred for a cardiovascular magnetic resonance (CMR) scan at a single center with a low-volume CMR service, the extent of trabeculations by 4 different imaging criteria—Petersen,2 Stacey,3 Jacquier,4 and Captur5 methods—was assessed. Over a median follow-up of ≈7 years, 209 patients (30%) had adverse events (primary combined end point of all-cause mortality, ischemic stroke, ventricular tachycardia/ventricular fibrillation, or hospitalization for heart failure). None of the 4 CMR criteria for the so-called left ventricular noncompaction (LVNC) was associated with this primary composite outcome in multivariate analysis. However, limited conclusions could be made regarding the Captur criterion because only 3% (23/700) exceeded the cutoff, and thus, too few events occurred during the follow-up for sufficient power to exclude a false-negative finding.See Article by Ivanov et alDiagnosing a heart condition is typically done taking into account the clinical context. According to Bayes principles, making a diagnosis is based on the posttest probability, which in turn is determined by the pretest probability and the result and diagnostic accuracy of a test, such as CMR.6 Here, the authors use the term left ventricular noncompaction synonymously to positive imaging criteria of excessive trabeculations without considering the pretest probability and refer to the subgroup of patients as high risk LVNC who fulfill at least 1 of the 4 CMR criteria and have a high pretest probability of having a clinical diagnosis of LVNC. High pretest probability was defined as the presence of at least 1 of the following characteristics: (1) positive family history of LVNC; (2) symptoms suggestive of a diagnosis of LVNC; (3) neuromuscular disease that is known to be associated with LVNC, or (4) evidence of potentially malignant arrhythmias, thromboembolic events, or heart failure. The lack of incremental prognostic value for the presence of excessive trabeculations in an all-comer population referred for clinical CMR scans seen in the primary analysis may not hold for patients with high pretest probability for LVNC. However, in a subanalysis of 290 (41% of 700) patients who were considered to have high pretest probability of LVNC, the authors also found no incremental prognostic value of the presence of LVNC. Taken together, accepting the limitations of a subanalysis (and we do not know whether prespecified or post hoc) and the associated smaller event rates that may impact the power of the subanalysis, the authors find no suggestion of an independent prognostic value of the presence of excessive trabeculations in all comers referred for CMR and those with a high pretest probability of LVNC.Noncompaction or Excessive TrabeculationsIn a recent narrative review, we have argued that the term noncompaction (eg, LVNC or noncompaction cardiomyopathy) should be avoided and suggested instead the term excessive trabeculations to describe the phenotype rather than imply an embryological pathology of an early arrest of the normal compaction process for which there is little evidence.7 To the contrary, there is growing evidence that there is no relevant coalescence of the trabeculations to form the solid or compact myocardial layer in mice or humans.8–10 In this editorial, we, thus, prefer to describe the phenotype as excessive trabeculations. If the phenotype is present in a patient with high pretest probability based on family history, symptoms, or imaging evidence of abnormal left ventricular size or function, we propose the term cardiomyopathy with excessive trabeculations. The rationale is to convey the message that the patient may have a heart muscle disease with a phenotype characterized by excessive trabeculations. One may wish to further classify the phenotype, for example, as dilated, nondilated, hypertrophic, or restrictive cardiomyopathy with excessive trabeculations. However, we acknowledge that this view is (not yet) widely shared—as evidenced by Oechslin and Jenni's11 editorial to our recent review.What Is the Clinical Impact of This Study in the Context of What Is Known?As the presence of excessive trabeculations is frequent and does not seem to have incremental prognostic value in this population referred for CMR scans, several questions arise that are yet unanswered.Prevalence of Excessive Trabeculations and Cardiomyopathy With Excessive Trabeculations?Ivanov et al1 found that the prevalence of excessive trabeculations by Petersen, Stacey, Jacquier, and Captur criteria were 39%, 23%, 25%, and 3%, respectively. We are not provided with the exact prevalence of cardiomyopathy with excessive trabeculations for each of the 4 analysis approaches. However, on aggregate, 41% of this all-comer population were considered to be in this category, and assuming that this proportion is the same across different imaging criteria, we would expect a prevalence of cardiomyopathy with excessive trabeculations (aka clinical diagnosis of LVNC) of ≈16%, 9%, 10%, and 1%. We need to be cautious accepting these prevalence estimates as unbiased and generalizable. Because the study cohort belongs to a single center, the referral patterns are not necessarily generalizable to all patients referred for CMR. And certainly, because these patients had been referred for CMR for a clinical reason—hence, highly selected—the prevalence described here does not represent the population prevalence.Should We, and If So How Should We, Determine Excessive Trabeculations?Partly driven by the high prevalence of positive imaging criteria for excessive trabeculations observed in population studies, there continues to be a lack of consensus for the best approach.12–14 In addition to the 4 approaches used by Ivanov et al,1 some argue that the thinness of the solid myocardium might be an important diagnostic and prognostic indicator and should be combined with the other measures of extent of trabeculations.15–18Interestingly, in this study by Ivanov et al,1 there was some concordance in classification of excessive trabeculations; all Captur criterion–positive patients (only 3% of the total) also fulfilled Petersen, Stacey, and Jacquier criteria. In contrast, 123 of 276 (45%) Petersen criterion–positive patients did not fulfill any of the other 3 criteria. An upward shift of the cutoff points for the Petersen, Stacey, and Jacquier measures would be expected to lead to lower sensitivity but higher specificity. Further studies will be required to interrogate this area further, and it is conceivable that 2 different cut points are preferable: a higher, thus less sensitive, cut point for patients with excessive trabeculations only and a lower cut point for patients with cardiomyopathy and excessive trabeculations. This would be akin to maximal wall thickness cut points in diagnosing hypertrophic cardiomyopathy in family screening (13 mm) versus diagnosing it in the absence of a family history (15 mm).There is no data to suggest that one analysis approach is undoubtedly superior to others. Part of the problem to get clarity on this is the lack of a true gold standard to diagnose cardiomyopathy with excessive trabeculations. Stacey suggested that the presence of a noncompaction to compaction ratio measured in diastolic frames of short-axis cines of >2 is predictive of adverse outcomes, but this was not confirmed in this larger study by Ivanov et al.1 A major advantage of promoting fractal dimensions is the lower observer variability compared with the other 3 approaches.5 However, conceptually, fractal dimensions do not incorporate information on the thinness of the solid myocardium. It, thus, seems inappropriate to recommend any specific approach currently.Are Excessive Trabeculations Always Benign?In a population asymptomatic for and free of known cardiovascular disease (n=2742), extent of trabeculations did not predict clinically relevant adverse cardiac remodeling over almost a decade.14 In 113 patients with an imaging phenotype of excessive trabeculations (initially on echocardiography, then confirmed by CMR based on Petersen approach), there was no independent prognostic value.19 In contrast, patients (n=122) from a retrospective study who were considered to have noncompaction or increased trabeculations based on the CMR report were found to have increased odds of adverse events (odds ratio, 8.6; 95% confidence interval, 2.5–33) after adjustment for covariates when the extent of trabeculations was measured in end-diastolic cine frames from short-axis views (Stacey criteria) but not when using other analysis approaches.3 In patients with dilated cardiomyopathy, the extent of trabeculations had no incremental prognostic value.20 In a small (n=29) CMR study of patients with incident heart failure or suspected cardiomyopathy, univariate analysis showed an inverse relationship between the extent of trabeculations measured using the Petersen criterion and a change in left ventricular ejection fraction over a 2-year follow-up period with repeat echocardiography.21 It is not known whether this finding would be robust to multivariate analysis, which was not attempted given the small sample size. Echocardiography literature supports the overall notion that the extent of trabeculations may have associations with adverse outcomes in univariate analyses, but that these became nonsignificant once adjusted for.22–32As, in particular, the Petersen, Stacey, and Jacquier criteria were found to be positive in a large proportion of all-comer patients referred for clinical CMR scans, this reminds us, as discussed earlier, that a clinical diagnosis of cardiomyopathy with excessive trabeculations (or LVNC if the reader still prefers) should be avoided unless there is a high pretest probability. This view is shared by Oechslin and Jenni.11 On balance, given the current evidence summarized earlier, we also think that there is no indication to routinely quantify the extent of trabeculations unless there is a known high pretest probability for this condition because, first, a clinical diagnosis (posttest probability) would be very unlikely and, second, there seems to be no evidence of an incremental prognostic value as also supported by Ivanov et al.1Future OutlookMost CMR studies assessing the prognosis of excessive trabeculations in various types of subjects and patients are limited by sample size or lack of generalizability given the single-center design. The study by Ivanov et al1 has contributed further important knowledge. However, even though the plot thickens, suggesting trabeculations do not indicate poor prognosis, important questions remain unanswered. Designing a large, multicenter prospective cohort study or registry of patients with likely cardiomyopathy and excessive trabeculations may allow clarification of the natural history of this condition and the incremental prognostic value of the extent of the trabeculations. Other areas of future study include improving our understanding of the genetic predisposition of trabeculae extent in the general population beyond the select group of genetic cardiomyopathies and of the role of physiological remodeling involving trabeculae and the gene–environment interactions. These research questions are likely to be explored in large-scale population studies, such as UK Biobank.33–35Sources of FundingDr Petersen acknowledges support from the NIHR Cardiovascular Biomedical Research Centre at Barts. Dr Neubauer is supported by the Oxford NIHR Biomedical Research Centre and the Oxford British Heart Foundation Centre of Research Excellence.DisclosuresDr Petersen provides consultancy to Circle Cardiovascular Imaging Inc, Calgary, Alberta, Canada. The other author reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Steffen E. Petersen, MD, DPhil, MPH, William Harvey Research Institute, NIHR Biomedical Research Centre at Barts, Charterhouse Sq, London EC1M 6BQ, United Kingdom. E-mail [email protected]References1. Ivanov A, Dabiesingh DS, Bhumireddy GP, Mohamed A, Asfour A, Briggs WM, Ho J, Khan SA, Grossman A, Klem I, Sacchi TJ, Heitner JFPrevalence and prognostic significance of left ventricular non compaction in patients referred for cardiac magnetic resonance imaging.Circ Cardiovasc Imaging. 2017; 10:e006174. doi: 10.1161/CIRCIMAGING.117.006174.LinkGoogle Scholar2. 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