Multiparametric Mapping
Antonella Meloni, PhD
Biomedical Engineer
Fondazione G. Monasterio CNR Regione Toscana
Pisa, Toscana, Italy
Antonella Meloni, PhD
Biomedical Engineer
Fondazione G. Monasterio CNR Regione Toscana
Pisa, Toscana, Italy
Laura Pistoia, MSc
Biologist
Fondazione G. Monasterio CNR Regione Toscana
Pisa, Toscana, Italy
Vincenzo Positano, MSc
Biomedical Engineer
Fondazione G. Monasterio CNR Regione Toscana
Pisa, Toscana, Italy
Stefania Renne, MD
Cardiologist
Presidio Ospedaliero “Giovanni Paolo II”
Lamezia Terme (CZ), Calabria, Italy
Emanuele Grassedonio, MD
Radiologist
Policlinico "Paolo Giaccone"
Palermo, Sicilia, Italy
Nicolò Schicchi, MD
Radiologist
Azienda Ospedaliero-Universitaria Ospedali Riuniti "Umberto I-Lancisi-Salesi"
Ancona, Marche, Italy
Massimiliano Missere, MD
Radiologist
Gemelli Molise SpA, Fondazione di Ricerca e Cura "Giovanni Paolo II"
Campobasso, Molise, Italy
Giuseppe Peritore, MD
Radiologist
"ARNAS" Civico, Di Cristina Benfratelli
Palermo, Sicilia, Italy
Stefano Pulini, MD
Hematologist
Ospedale Civile “Spirito Santo”
Pescara, Abruzzi, Italy
Monica Benni, MD
Hematologist
Policlinico S. Orsola "L. e A. Seragnoli"
Bologna, Italy
Saveria Campisi, MD
Hematologist
Presidio Ospedaliero “Umberto I”
Siracusa, Italy
Filippo Cademartiri, MD, PhD
Radiologist
Fondazione G. Monasterio CNR Regione Toscana
Pisa, Italy
Iron-induced heart failure (HF) remains the main cause of mortality in patients with thalassemia major (TM), although the introduction of the T2* CMR for the non-invasive assessment of myocardial iron overload (MIO) led to a significant increase in survival rate. However, the pathophysiology of HF in TM can be multifactorial. Thanks to its multiparametric potential, CMR represents a unique tool for characterization of myocardial involvement. It is the gold standard for the quantification of biventricular function by cine images and for the detection of replacement fibrosis by late gadolinium enhancement (LGE) technique.
This multicenter study evaluated the prognostic value of multiparametric CMR in predicting death for HF.
Methods:
We considered 1398 white TM patients who performed a baseline CMR exam within the Myocardial Iron Overload in Thalassemia (MIOT) network. As per inclusion criteria, no patient had a history of HF. Mean age was 30.8±8.9 years and 725 (51.9%) patients were females.
Results:
During a mean follow-up of 4.83±2.05 years, 49.1% of the patients changed at least once the chelation regimen (switched to a different type of chelator and/or underwent dose/frequency modification); these patients were more likely to have significant MIO (global heart T2* value< 20ms) than patients who maintained the same regimen (33.2% vs 19.7%; P< 0.0001)
Twelve (1.0%) patients died from HF. No association was detected between age or gender and HF mortality. Significant MIO, ventricular dysfunction, ventricular dilation, and replacement myocardial fibrosis were identified as significant univariate prognosticators (Table 1).
Due to the low number of deaths for HF, it was not possible to perform a multivariate model. However, based on the presence of the four CMR predictors of HF death, patients were divided into three subgroups: four markers (7 patients; one HF death-14.3%), one to three markers (617 patients, 9 HF deaths-1.5%), and none of the four markers (488 patients; one HF death-0.2%). Patients having all four markers had a significantly higher risk of dying for HF than patients without markers (hazard ratio-HR=89.93; 95%CI=5.62-1439.46; P=0.001) or with one to three CMR markers (HR=12.69; 95%CI=1.60-100.36; P=0.016) (Figure 1).
Conclusion:
In our homogeneous white and well-treated Italian/Mediterranean population, we detected a low incidence of deaths for HF, since the T2* report guided the patient-specific adjustment of the chelation regimen. As expected, MIO was a significant predictor of HF death but also other CMR parameters, namely ventricular dilatation, ventricular dysfunction, and replacement myocardial fibrosis emerged as unfavorable prognosis determinant. Importantly, when the four CMR indices were evaluated in combination, they fine-tuned the prognostic stratification of TM patients. Hence, the findings of the present study promote the exploitation of the full potential of CMR, including LGE, for a better risk stratification of TM patients.