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Brief Report
June 2017

Value of Cardiovascular Magnetic Resonance Imaging in Noninvasive Risk Stratification in Tetralogy of Fallot

Author Affiliations
  • 1Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
  • 2Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
  • 3Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
  • 4Department of Cardiology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
  • 5Department of Cardiology, University of Groningen, Groningen University Medical Center, Groningen, the Netherlands
  • 6Department of Cardiology, Utrecht University Medical Center, Utrecht, the Netherlands
  • 7Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
JAMA Cardiol. 2017;2(6):678-683. doi:10.1001/jamacardio.2016.5818
Key Points

Question  What is the value of cardiovascular magnetic resonance imaging in noninvasive risk stratification of adults with tetralogy of Fallot?

Findings  In this study, the optimal cardiovascular magnetic resonance thresholds for ventricular function were right ventricular ejection fraction less than 30% and left ventricular ejection fraction less than 45%, and they were independently predictive of death and ventricular arrhythmias. These independently predictive thresholds may be implemented in noninvasive risk stratification combined with the noninvasive components of the Khairy et al risk model.

Meaning  In patients with repaired tetralogy of Fallot, right ventricular ejection fraction less than 30% and left ventricular ejection fraction less than 45% may be implemented in noninvasive risk stratification.

Abstract

Importance  Adults late after total correction of tetralogy of Fallot (TOF) are at risk for major complications. Cardiovascular magnetic resonance (CMR) imaging is recommended to quantify right ventricular (RV) and left ventricular (LV) function. However, a commonly used risk model by Khairy et al requires invasive investigations and lacks CMR imaging to identify high-risk patients.

Objective  To implement CMR imaging in noninvasive risk stratification to predict major adverse clinical outcomes.

Design, Setting, and Participants  This multicenter study included 575 adult patients with TOF (4.083 patient-years at risk) from a prospective nationwide registry in whom CMR was performed. This study involved 5 tertiary referral centers with a specialized adult congenital heart disease unit. Multivariable Cox hazards regression analysis was performed to determine factors associated with the primary end point. The CMR variables were combined with the noninvasive components of the Khairy et al risk model, and the C statistic of the final noninvasive risk model was determined using bootstrap sampling. The data analysis was conducted from January to December 2016.

Main Outcomes and Measures  The composite primary outcome was defined as all-cause mortality or ventricular arrhythmia, defined as aborted cardiac arrest or documented ventricular fibrillation and ventricular tachycardia (lasting ≥30 seconds or recurrent symptomatic).

Results  Of the 575 patients with TOF, 57% were male, and the mean (SD) age was 31 (11) years. During a mean (SD) follow-up of 7.1 (3.5) years, the primary composite end point occurred in 35 patients, including all-cause mortality in 13 patients. Mean (SD) RV ejection fraction (EF) was 44% (10%), and mean (SD) LV EF was 53% (8%). There was a correlation between RV EF and LV EF (R, 0.36; 95% CI, 0.29-0.44; P < .001). Optimal thresholds for ventricular function (RV EF <30%: hazard ratio, 3.90; 95% CI, 1.84-8.26; P < .001 and LV EF <45%: hazard ratio, 3.23; 95% CI, 1.57-6.65; P = .001) were independently predictive in multivariable analysis. Both thresholds were included in a point-based noninvasive risk model (C statistic, 0.75; 95% CI, 0.63-0.85) and combined with the noninvasive components of the Khairy et al risk model.

Conclusions and Relevance  In patients with repaired TOF, biventricular dysfunction on CMR imaging was associated with major adverse clinical outcomes. The quantified thresholds (RV EF <30% and LV EF <45%) may be implemented in noninvasive risk stratification.

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