Myocardial Fibrosis Predicts Ventricular Arrhythmias and Sudden Death After Cardiac Electronic Device Implantation

J Am Coll Cardiol. 2022 Feb 22;79(7):665-678. doi: 10.1016/j.jacc.2021.11.050.


Background: Increasing evidence supports a link between myocardial fibrosis (MF) and ventricular arrhythmias.

Objectives: The purpose of this study was to determine whether presence of myocardial fibrosis on visual assessment (MFVA) and gray zone fibrosis (GZF) mass predicts sudden cardiac death (SCD) and ventricular fibrillation/sustained ventricular tachycardia after cardiac implantable electronic device (CIED) implantation.

Methods: In this prospective study, total fibrosis and GZF mass, quantified using cardiovascular magnetic resonance, was assessed in relation to the primary endpoint of SCD and the secondary, arrhythmic endpoint of SCD or ventricular arrhythmias after CIED implantation.

Results: Among 700 patients (age 68.0 ± 12.0 years), 27 (3.85%) experienced a SCD and 121 (17.3%) met the arrhythmic endpoint over median 6.93 years (IQR: 5.82-9.32 years). MFVA predicted SCD (HR: 26.3; 95% CI: 3.7-3,337; negative predictive value: 100%). In competing risk analyses, MFVA also predicted the arrhythmic endpoint (subdistribution HR: 19.9; 95% CI: 6.4-61.9; negative predictive value: 98.6%). Compared with no MFVA, a GZF mass measured with the 5SD method (GZF5SD) >17 g was associated with highest risk of SCD (HR: 44.6; 95% CI: 6.12-5,685) and the arrhythmic endpoint (subdistribution HR: 30.3; 95% CI: 9.6-95.8). Adding GZF5SD mass to MFVA led to reclassification of 39% for SCD and 50.2% for the arrhythmic endpoint. In contrast, LVEF did not predict either endpoint.

Conclusions: In CIED recipients, MFVA excluded patients at risk of SCD and virtually excluded ventricular arrhythmias. Quantified GZF5SD mass added predictive value in relation to SCD and the arrhythmic endpoint.

Keywords: cardiac resynchronization therapy; cardiovascular magnetic resonance; gray zone mass; implantable cardioverter-defibrillator; peri-infarct mass; primary prevention; ventricular fibrillation; ventricular tachycardia.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cardiac Resynchronization Therapy / mortality*
  • Cardiac Resynchronization Therapy / trends
  • Death, Sudden, Cardiac / epidemiology
  • Death, Sudden, Cardiac / pathology*
  • Death, Sudden, Cardiac / prevention & control
  • Defibrillators, Implantable* / trends
  • Female
  • Fibrosis
  • Follow-Up Studies
  • Humans
  • Magnetic Resonance Imaging, Cine / mortality
  • Magnetic Resonance Imaging, Cine / trends
  • Male
  • Middle Aged
  • Myocardium / pathology*
  • Predictive Value of Tests
  • Prospective Studies
  • Ventricular Fibrillation / diagnostic imaging
  • Ventricular Fibrillation / mortality*
  • Ventricular Fibrillation / therapy*