Raj Pulin Shah MD, MBA, Presenter: Nothing to Disclose

Electra Veson Kaloudis MD, MPH, Abstract Co-Author: Nothing to Disclose

Christopher Pickett MD, Abstract Co-Author: Nothing to Disclose

In the setting of discordant LVEF data, a growing use of Cardiac MRI (CMR) , and a lack of randomized control trial data using MRI to assess LVEF prior to ICD implants, we wish to assess patterns of clinical use of CMR and risk assessment before ICD placement.  

This study contained a survey, which addressed clinical guidelines and standard of care practices; American board-certified cardiologists our geographic area participated in the voluntary study, which took approximately 10 minutes to complete. 

    33 cardiologists participated in the survey; when given a clinical scenario of a hypertensive patient with ischemic cardiomyopathy, NYHA class II symptoms and disparate LVEF readings: 30% on echocardiogram, 35% on myocardial perfusion, and 45% on cardiac MRI, in other words, meeting criteria for ICD by echocardiogram and myocardial perfusion but not CMR, there was no consensus on appropriateness of ICD implant amongst our surveyed cardiologists. 42% stated that they would recommend ICD placement, and equal number said that they would not recommend an ICD. 15% would refer the patient to an electrophysiologist for further evaluation.     When given the same scenario, but a non-ischemic cardiomyopathy, and disparate LVEF readings, our surveyed cardiologists became less likely to refer for ICD. 30% of cardiologists stated that they would recommend ICD placement, whereas 46% said that they would not. 15% would refer the patient to an electrophysiologist for evaluation, and 9% would further stratify risk.      

In this group of surveyed cardiologists, although 97% most frequently used echocardiogram in their practices to assess LVEF (in patients with ischemic and non-ischemic cardiomyopathy), less than half chose to give weightage to its result when discrepant nuclear stress test and CMR results were available. Although there is no randomized control trial to support the use of MRI in assessing LVEF prior to the placement of ICD implants, clinicians are sometimes relying on its results. With a lack of consensus amongst practitioners on how to manage discrepant LVEF data, there is a potential for variable implementation of guideline-supported treatment with primary prevention ICDs.  

Baring consensus statement from governing societies on how to extrapolate CMR derived LVEF to vulnerable populations, we expect that this will continue to be an area of clinical uncertainty.  

Shah, R, Kaloudis, E, Pickett, C, The Role of Various Imaging Modalities in the Placement of AICDs in Patients with Low LVEF.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14045504.html