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Two cases of dilated cardiomyopathy with right ventricular wall degeneration demonstrated by late gadolinium enhanced MRI
International Journal of Cardiology 129 (2008) e21 – e23 www.elsevier.com/locate/ijcard
Letter to the Editor
Two cases of dilated cardiomyopathy with right ventricular wall degeneration demonstrated by late gadolinium enhanced MRI Tairo Kurita a , Katsuya Onishi b,⁎, Munenobu Motoyasu a , Tetsuya Kitamura a , Takeshi Takamura a , Naoki Fujimoto a , Masaki Tanabe a , Kaoru Dohi a , Takashi Tanigawa a , Naoki Isaka a , Masaaki Ito a , Hajime Sakuma c b
a Department of Cardiology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan c Department of Radiology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
Received 22 March 2007; accepted 15 June 2007 Available online 8 August 2007
Abstract Right heart failure is prominent in some patients with dilated cardiomyopathy (DCM). In this article, we present right ventricular wall degeneration and fibrosis demonstrated by late gadolinium enhanced magnetic resonance imaging (MRI) in patients with DCM. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Late gadolinium enhanced MRI; Dilated cardiomyopathy; Right ventricular wall degenaration
1. Case report We reported two cases of dilated cardiomyopathy (DCM) involving the right ventricular (RV) degeneration and dysfunction on cardiac magnetic resonance imaging (MRI).
hospital because of right heart failure. Cine MRI showed severe bilateral ventricular cavity dilatation and decreased wall-thickening in systole with LV ejection fraction of 0.10 and RV ejection fraction of 0.12. Contrast enhanced MRI revealed late gadolinium enhancement in the free wall of the RV as well as the postero-inferior wall of the LV (Fig. 1).
1.1. Case 1 1.2. Case 2 A 75-year-old female was admitted to our hospital due to right heart failure. She was diagnosed as idiopathic DCM on cardiac biopsy and cardiac catheterization with normal coronary artery and left ventricular (LV) dysfunction 16 years ago. She had been treated with enalapril and metoprolol. Recently, she was frequently admitted to our
⁎ Corresponding author. Tel.: +81 59 231 5161; fax: +81 59 231 5250. E-mail address: [email protected] (K. Onishi). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.06.087
A 38-year-old male was referred for the evaluation of congestive heart failure. Cardiac catheterization showed normal coronary artery and LV dysfunction with LV ejection fraction 0.25. Cine MRI showed severe bilateral ventricular cavity dilatation and a decrease in systolic wall thickening with LV ejection fraction of 0.19 and RV ejection fraction of 0.28. Contrast enhanced MRI revealed late gadolinium enhancement in the RV free wall and ventricular side of septum. After cardiac evaluation, we diagnosed idiopathic DCM and he underwent medical treatment for heart
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T. Kurita et al. / International Journal of Cardiology 129 (2008) e21–e23
Fig. 1. Cardiac cine magnetic resonance imaging shows dilated left and right ventricle, systolic wall thickening, and left ventricular ejection fraction 0.10. Late gadolinium enhancement was observed in the whole right ventricle wall and posteroinferior wall of the left ventricle. (White arrow).
failure with enalapril, carvedilol, digitalis, and pimobendan (Fig. 2). 2. Discussion In the current 2 patients with dilated cardiomyopathy, late gadolinium enhanced MRI revealed marked degeneration of the right ventricular myocardium. Some patients with DCM show marked RV systolic dysfunction, resulting in marked right heart failure which has been reported as a prognostic parameter of DCM [1,2]. It is very difficult to evaluate morphological features of RV myocardial by 2D echocardiography or nuclear imaging. As we could demonstrate, marked degeneration of the RV myocardium was delineated by late gadolinium enhanced MRI in
these two cases with DCM and RV dysfunction. Cardiac MRI has high spatial resolution, and facilitates the evaluation of cardiac function, morphology and myocardial features of RV as well as LV wall. Furthermore, late gadolinium-enhanced MRI is useful in detecting myocardial degeneration including myocardial infarction and fibrosis [3]. Several studies reported that late gadolinium enhancement reflected myocardial degeneration, necrosis, and fibrosis, which has been shown to be one of prognostic factors for cardiac dysfunction in patients with DCM [4]. Right ventricular dysfunction in patients with DCM is idiopathic, associated with secondary pulmonary hypertension or tricuspid valve insufficiency after a long time-course. Secondary cardiomyopathy and chronic myocarditis may induce RV degeneration in addition to LV degeneration. Although LV
Fig. 2. Cardiac cine magnetic resonance imaging shows dilated left ventricle, decreased systolic wall thickening, and left ventricular ejection fraction 0.19. Contrast-enhanced MRI reveals late gadolinium enhancement in the RV apex and right ventricular side of the septum. (White arrow).
T. Kurita et al. / International Journal of Cardiology 129 (2008) e21–e23
dysfunction can be involved in patients with arrhythmogenic right ventricular cardiomyopathy, the concurrent development of severe LV dysfunction is rare [5]. Although LV contractility was markedly reduced in the both cases, majority of the dysfunctional LV myocardium did not exhibit late gadoliniumenhanced MRI, indicating that late gadolinium enhancement in patients with cardiomyopathy may not directly correlate with wall motion abnormalities. In the present report, late gadolinium-enhanced MRI demonstrated marked degeneration of the RV myocardium in patients with DCM and RV dysfunction. Thus, late gadolinium-enhanced MRI would be useful to detect RV degeneration and fibrosis in patients with DCM concomitant with RV dysfunction. References [1] Suzuki J, Caputo GR, Masui T, Chang JM, O'Sullivan M, Higgins CB. Assessment of right ventricular diastolic and systolic function in patients with dilated cardiomyopathy using cine magnetic resonance imaging. Am Heart J 1991;122:1035–40.
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[2] Sun JP, James KB, Yang XS, et al. Comparison of mortality rates and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus nondilated right ventricular cavities. Am J Cardiol 1997;80:1583–7. [3] Wu E, Judd RM, Vargas JD, et al. Visualization of presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction. Lancet 2001;357:21–8. [4] Aisawa M, Matsumura Y, Kitaoka H, Yamasaki N, Takata J, Doi Y. Myocardial enhancement on magnetic resonance imaging with gadolinium-diethylenetramine pentaacetic acid and improvement of left ventricular function in patients with dilated cardiomyopathy. J Cardiol 2002;40: 145–52. [5] Fontaine G, Fontaliran F, Frank R. Arrhythmogenic right ventricular cardiomyopathies. Clinical forms and main differential diagnosis. Circulation 1998;97:1532–5.
Letter to the Editor
Two cases of dilated cardiomyopathy with right ventricular wall degeneration demonstrated by late gadolinium enhanced MRI Tairo Kurita a , Katsuya Onishi b,⁎, Munenobu Motoyasu a , Tetsuya Kitamura a , Takeshi Takamura a , Naoki Fujimoto a , Masaki Tanabe a , Kaoru Dohi a , Takashi Tanigawa a , Naoki Isaka a , Masaaki Ito a , Hajime Sakuma c b
a Department of Cardiology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan c Department of Radiology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
Received 22 March 2007; accepted 15 June 2007 Available online 8 August 2007
Abstract Right heart failure is prominent in some patients with dilated cardiomyopathy (DCM). In this article, we present right ventricular wall degeneration and fibrosis demonstrated by late gadolinium enhanced magnetic resonance imaging (MRI) in patients with DCM. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Late gadolinium enhanced MRI; Dilated cardiomyopathy; Right ventricular wall degenaration
1. Case report We reported two cases of dilated cardiomyopathy (DCM) involving the right ventricular (RV) degeneration and dysfunction on cardiac magnetic resonance imaging (MRI).
hospital because of right heart failure. Cine MRI showed severe bilateral ventricular cavity dilatation and decreased wall-thickening in systole with LV ejection fraction of 0.10 and RV ejection fraction of 0.12. Contrast enhanced MRI revealed late gadolinium enhancement in the free wall of the RV as well as the postero-inferior wall of the LV (Fig. 1).
1.1. Case 1 1.2. Case 2 A 75-year-old female was admitted to our hospital due to right heart failure. She was diagnosed as idiopathic DCM on cardiac biopsy and cardiac catheterization with normal coronary artery and left ventricular (LV) dysfunction 16 years ago. She had been treated with enalapril and metoprolol. Recently, she was frequently admitted to our
⁎ Corresponding author. Tel.: +81 59 231 5161; fax: +81 59 231 5250. E-mail address: [email protected] (K. Onishi). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.06.087
A 38-year-old male was referred for the evaluation of congestive heart failure. Cardiac catheterization showed normal coronary artery and LV dysfunction with LV ejection fraction 0.25. Cine MRI showed severe bilateral ventricular cavity dilatation and a decrease in systolic wall thickening with LV ejection fraction of 0.19 and RV ejection fraction of 0.28. Contrast enhanced MRI revealed late gadolinium enhancement in the RV free wall and ventricular side of septum. After cardiac evaluation, we diagnosed idiopathic DCM and he underwent medical treatment for heart
e22
T. Kurita et al. / International Journal of Cardiology 129 (2008) e21–e23
Fig. 1. Cardiac cine magnetic resonance imaging shows dilated left and right ventricle, systolic wall thickening, and left ventricular ejection fraction 0.10. Late gadolinium enhancement was observed in the whole right ventricle wall and posteroinferior wall of the left ventricle. (White arrow).
failure with enalapril, carvedilol, digitalis, and pimobendan (Fig. 2). 2. Discussion In the current 2 patients with dilated cardiomyopathy, late gadolinium enhanced MRI revealed marked degeneration of the right ventricular myocardium. Some patients with DCM show marked RV systolic dysfunction, resulting in marked right heart failure which has been reported as a prognostic parameter of DCM [1,2]. It is very difficult to evaluate morphological features of RV myocardial by 2D echocardiography or nuclear imaging. As we could demonstrate, marked degeneration of the RV myocardium was delineated by late gadolinium enhanced MRI in
these two cases with DCM and RV dysfunction. Cardiac MRI has high spatial resolution, and facilitates the evaluation of cardiac function, morphology and myocardial features of RV as well as LV wall. Furthermore, late gadolinium-enhanced MRI is useful in detecting myocardial degeneration including myocardial infarction and fibrosis [3]. Several studies reported that late gadolinium enhancement reflected myocardial degeneration, necrosis, and fibrosis, which has been shown to be one of prognostic factors for cardiac dysfunction in patients with DCM [4]. Right ventricular dysfunction in patients with DCM is idiopathic, associated with secondary pulmonary hypertension or tricuspid valve insufficiency after a long time-course. Secondary cardiomyopathy and chronic myocarditis may induce RV degeneration in addition to LV degeneration. Although LV
Fig. 2. Cardiac cine magnetic resonance imaging shows dilated left ventricle, decreased systolic wall thickening, and left ventricular ejection fraction 0.19. Contrast-enhanced MRI reveals late gadolinium enhancement in the RV apex and right ventricular side of the septum. (White arrow).
T. Kurita et al. / International Journal of Cardiology 129 (2008) e21–e23
dysfunction can be involved in patients with arrhythmogenic right ventricular cardiomyopathy, the concurrent development of severe LV dysfunction is rare [5]. Although LV contractility was markedly reduced in the both cases, majority of the dysfunctional LV myocardium did not exhibit late gadoliniumenhanced MRI, indicating that late gadolinium enhancement in patients with cardiomyopathy may not directly correlate with wall motion abnormalities. In the present report, late gadolinium-enhanced MRI demonstrated marked degeneration of the RV myocardium in patients with DCM and RV dysfunction. Thus, late gadolinium-enhanced MRI would be useful to detect RV degeneration and fibrosis in patients with DCM concomitant with RV dysfunction. References [1] Suzuki J, Caputo GR, Masui T, Chang JM, O'Sullivan M, Higgins CB. Assessment of right ventricular diastolic and systolic function in patients with dilated cardiomyopathy using cine magnetic resonance imaging. Am Heart J 1991;122:1035–40.
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[2] Sun JP, James KB, Yang XS, et al. Comparison of mortality rates and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus nondilated right ventricular cavities. Am J Cardiol 1997;80:1583–7. [3] Wu E, Judd RM, Vargas JD, et al. Visualization of presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction. Lancet 2001;357:21–8. [4] Aisawa M, Matsumura Y, Kitaoka H, Yamasaki N, Takata J, Doi Y. Myocardial enhancement on magnetic resonance imaging with gadolinium-diethylenetramine pentaacetic acid and improvement of left ventricular function in patients with dilated cardiomyopathy. J Cardiol 2002;40: 145–52. [5] Fontaine G, Fontaliran F, Frank R. Arrhythmogenic right ventricular cardiomyopathies. Clinical forms and main differential diagnosis. Circulation 1998;97:1532–5.