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Background. Cardiac magnetic resonance imaging (CMR) is an excellent non-invasive imaging tool in the assessment of patients with
dilated cardiomyopathy (DCM). Few studies have analysed the ndings in primary (idiopathic) DCM.
Objectives. To study the CMR features in primary DCM.
Methods. We conducted a descriptive observational study on 20 adult patients with suspected or conrmed primary DCM. Each patient
underwent a dedicated 3-Tesla CMR scan, and the ndings were evaluated.
Results. Seventeen patients had systolic dysfunction with a reduced ejection fraction and elevated end-diastolic volume, 19 patients had
contractile dysfunction in the form of global le ventricular hypokinesia, 13 patients showed no abnormal delayed contrast enhancement
with gadolinium administration, and 7 patients showed abnormal late gadolinium enhancement patterns.
Conclusion. In patients with primary DCM, CMR is a powerful diagnostic tool that can denitively establish the diagnosis, assess the
severity of the disease, predict the risk of future adverse cardiovascular outcomes, check for complications, and assist in future follow-ups.
Keywords. Cardiac magnetic resonance imaging, CMR, dilated cardiomyopathy, primary dilated cardiomyopathy.
Afr J Thoracic Crit Care Med 2024;30(1):e844. https://doi.org/10.7196/AJTCCM.2024.v30i1.844
Primary dilated cardiomyopathy (DCM) is a myocardial disease
characterised by left ventricular (LV) dilation and systolic
dysfunction in the absence of coronary artery disease or other causes
of LV overload.[1] Patients present clinically with symptoms of heart
failure. Complications include thromboembolism, conduction
disturbances, arrhythmias, or even sudden death.[2] Identifying
potential complications and diagnosing DCM early is crucial, as it
can lead to better clinical results and decrease medical expenses.
Cardiac magnetic resonance imaging (CMR) is a valuable imaging
technique for the diagnosis and follow-up of DCM, as it can provide
comprehensive information on myocardial morphology, function,
perfusion and brosis.
e aim of this study was to examine the CMR features in 20 adult
patients with primary DCM.
Methods
We conducted a descriptive observational study on 20 adult patients
with suspected or conrmed primary DCM at Dr. D. Y. Patil Medical
College, Hospital and Research Centre in Pune, India, from
September 2020 to June 2022. Adult patients referred from the
cardiology department with either clinical suspicion or a diagnosis
of primary DCM (based on clinical data and two-dimensional
transthoracic echocardiography) were included in the study. Patients
with known risk factors for secondary DCM, including alcohol abuse,
ischaemic heart disease, myocardial infarction, hypertension and
myocarditis, were excluded from the study. Patients with metabolic,
endocrine or haematological disorders, collagen vascular diseases,
or exposure to drugs such as anthracycline or cyclophosphamide
were also excluded.
A detailed medical history was taken beforehand, and patients with
magnetic resonance imaging-incompatible metallic implants were not
included in the study. Haemodynamically unstable, claustrophobic or
unco-operative patients, and patients with chronic kidney disease
with a severely decreased estimated glomerular ltration rate, were
also excluded. Before the CMR scan, the patients provided written
informed consent. Each patient received a brief explanation of the
3-Tesla cardiac magnetic resonance imaging in primary dilated
cardiomyopathy
T Kalekar, MBBS, MD (Radiodiagnosis); A Gupta, MBBS, MD (Radiodiagnosis); M Kumar, MBBS, MD (Radiodiagnosis)
Department of Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
Corresponding author: A Gupta (arunimag462@gmail.com)
Study synopsis
What the study adds. Cardiac magnetic resonance imaging (CMR) is an excellent non-invasive imaging tool in the assessment of patients with
primary dilated cardiomyopathy (DCM). Findings include global ventricular enlargement, systolic dysfunction (ejection fraction <40%), and
elevated end-diastolic (≥140 mL) and end-systolic volumes. Global abnormal wall contractility is oen seen. In DCM there is either no abnormal
gadolinium enhancement or curvilinear mid-myocardial or subepicardial late gadolinium enhancement, unrelated to a coronary artery distribution.
Implications of the ndings. In patients with primary DCM, CMR provides powerful diagnostic and prognostic information. Enhanced
awareness and understanding of this relatively uncommon condition among clinicians and radiologists would be of benet in patient
management and treatment.
AJTCCM VOL. 30 NO. 1 2024 3
ORIGINAL RESEARCH: ARTICLES
scan method before it was performed. Each patient was also coached
on proper breath-holding technique.
The CMR scan was conducted using a MAGNETOM Vida
MRI 3-Tesla scanner (Siemens, Germany) with retrospective
electrocardiogram (ECG) gating.
e patients were placed in a head-rst supine position. e ECG
leads were connected accordingly. A standard body coil was placed
over the chest and secured using straps to prevent artefacts. Cushions
were provided for extra comfort. Light music was played to soothe
the patients.
Table 1 summarises the sequences used for 3-Tesla CMR in the
study.
Results
Twenty patients were evaluated. Thirteen (65%) were male and
7 (35%) were female, and the mean age was 41.5 (range 25 - 60)
years. Nineteen of the 20 patients were symptomatic, and 1 patient
was asymptomatic. Six patients had mild cardiomegaly, and 14 had
moderate cardiomegaly (Figs 1 and 2). Seventeen patients had dilation
of the le ventricle only, and 3 patients had dilation of both the le
and right ventricles.
Only 3 patients had a preserved LV ejection fraction (LVEF) (>50%).
e other 17 patients had reduced systolic function with a reduced
LVEF (<40%); 15 of them had a severely reduced LVEF (<30%). ese
17 patients also had elevated end-diastolic volumes (EDVs) (≥140 mL).
Only 3 patients had a normal EDV (<140 mL). e mean (standard
deviation (SD)) LVEF was 30.5 (15.3) mL (range 16.5 - 57.50 mL). e
mean LV EDV was 210 (70.8) mL (range 110 - 343 mL).
Sixteen patients also had elevated LV end-systolic volumes (ESVs)
(normal range 15 - 64 mL for women and 19 - 88 mL for men). Four
patients had normal ESVs. The mean (SD) LV ESV was 149.13
(66.8) mL (range 47.8 - 295 mL).
All but 1 of the patients had contractile dysfunction in the form of
global LV hypokinesia. Valvular dysfunction in the form of mitral or
tricuspid regurgitation was seen in 17 patients.
Thirteen patients showed no abnormal delayed contrast
enhancement with gadolinium administration. Three patients
showed a mid-myocardial pattern of late gadolinium enhancement
(LGE) (Fig. 1C and D). One patient had both mid-myocardial and
subepicardial LGE (Fig. 3). Two patients had patchy subendocardial
LGE in a non-territorial distribution. Only 1 patient showed contrast
enhancement in the subendocardial location in the diseased coronary
artery territory distribution. Fig. 4 summarises the distribution of
patterns of LV LGE in the study participants.
Two patients showed mild myocardial oedema on short inversion
time inversion recovery. None of the patients had an intracardiac
thrombus or clot.
Discussion
Cardiomyopathies are myocardial diseases causing impaired heart
function. DCM is characterised by enlargement and dilation of one or
both of the ventricles, with associated systolic dysfunction.[3,4] It is the
most common form of cardiomyopathy. DCM usually aects adults
between 20 and 60 years of age, but it can also occur in the paediatric
population and in the elderly. Patients present clinically with
symptoms of heart failure. Complications include thromboembolism,
conduction disturbances, arrhythmias, or even sudden death.
In primary or idiopathic DCM, a definite cause cannot be
identified. It is likely that a number of factors, including genetic
alterations[5] and environmental exposures that cause myocardial
Table 1. A summary of sequences used for 3-Tesla cardiac magnetic resonance imaging in the study
1. For morphology
T2 TRUFI single shot
T2 HASTE dark blood
T1 TSE dark blood
T2 TSE dark blood
T2 STIR dark blood long axis
2. For LV function
2-chamber cine TRUFI retro long axis
4-chamber cine TRUFI retro long axis
Cine TRUFI retro long axis
Cine LVOT
Cine RVOT
3. For perfusion
Images are taken in 2-chamber, 4-chamber, and short-axis views for le side and 2-chamber view for right side
DYNAMIC TRUFI SR EPAT
4. For late enhancement imaging
TI SCOUT
Delayed TRUFI high- resolution PSIR
TRUFI = true fast imaging with steady-state free precession; HASTE = half-Fourier single-shot turbo spin-echo; TSE = turbo spin echo; STIR = short inversion time inversion recovery; LVOT = le
ventricular outow tract; RVOT = right ventricular outow tract; TI SCOUT = inversion time mapping sequence; PSIR = phase-sensitive inversion recovery.
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injury, contribute to these conditions.
Secondary DCM occurs as a result of any
myocardial insult that causes LV failure
and subsequent ventricular enlargement.
Secondary causes include alcohol abuse,
ischaemic heart disease, hypertension,
infectious myocarditis (e.g. viral, parasitic
or bacterial), drug-induced myocarditis
(e.g. anthracyclines, cyclophosphamide,
heavy metals), peripartum cardiomyopathy,
metabolic, endocrine or haematological
disorders, infiltrative diseases such as
sarcoidosis, and collagen vascular diseases.[4,6]
A diagnosis of primary or idiopathic DCM is
established only aer the exclusion of known
secondary causes. We included patients
with suspected or conrmed DCM in our
study only aer comprehensive exclusion of
secondary causes.
e primary investigations used for DCM
evaluation are echocardiography and CMR.
Transthoracic echocardiography is generally
the initial diagnostic modality employed.
It is able to detect chamber dynamics,
valvular motion, and gross morphological
and functional anomalies. However,
several factors, such as the experience of
the operator, a smaller field of view and
unfavourable patient body characteristics,
limit its imaging capability. Transoesophageal
echocardiography is not limited by a
restricted field of view, but is an invasive
technique.[7] Also, neither echocardiographic
technique enables tissue characterisation of
the myocardium.
CMR is a valuable technique for the
diagnosis and prognosis of patients with
DCM. It provides high spatial and temporal
resolution, enhanced so-tissue contrast, and
improved cardiac tissue characterisation.
CMR has therefore been established as
an essential non-invasive tool for the
comprehensive evaluation of patients with
DCM.[8]
Findings at CMR include global
enlargement of the LV or both ventricles
and systolic dysfunction (decreased ejection
fraction <40%). e ventricular enlargement
is usually uniform with normal wall
thickness. e EDV (≥140 mL) and ESV are
elevated.[9,10] In our study, all the patients had
variable degrees of cardiomegaly; 85% had
systolic dysfunction with a reduced LVEF
and elevated LV EDV.
Wall motion abnormalities are also
seen in DCM, generally in the form of
global hypokinesis. Valvular dysfunction
is frequently evident as a result of chamber
expansion and annular strain. Ventricular
thrombus may be a problem in patients with
DCM because of diminished wall mobility.
[10] In our study, 95% of the patients had
contractile dysfunction. Valvular dysfunction
was seen in 85% of the patients. None of the
patients had an intracardiac thrombus or clot.
CMR makes it possible to differentiate
between ischaemic cardiomyopathy and
idiopathic DCM. DCM shows either no
abnormal enhancement[11] or curvilinear mid-
myocardial or subepicardial LGE, unrelated to
A B
C D
Fig. 1. A 55-year-old woman with primary dilated cardiomyopathy. (A) Two-chamber cine two-
dimensional steady-state free precession and (B) morphological T2-weighted black blood four-
chamber long-axis images acquired at 3-Tesla show a markedly dilated le ventricle. e calculated
le ventricular end-diastolic volume was 256 mL. e patient had severely decreased le ventricular
systolic function (le ventricular ejection fraction 19%). (A) also shows mild pericardial eusion.
Late-enhancement short-axis (C) and four-chamber long-axis (D) images show abnormal mid-
myocardial late gadolinium enhancement in the interventricular septum (arrows).
A B
Fig. 2. A 40-year-old man with primary dilated cardiomyopathy. (A) Le ventricular outow tract
steady-state free precession and (B) four-chamber long-axis steady-state free precession images
acquired at 3-Tesla show a markedly dilated le ventricle (le ventricular end-diastolic volume
339 mL). e patient was clinically symptomatic and had severely decreased le ventricular
systolic function (le ventricular ejection fraction 26.5%). No abnormal delayed enhancement
was seen with gadolinium administration.
AJTCCM VOL. 30 NO. 1 2024 5
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a coronary artery distribution.[12,13] In our study,
13 patients showed no abnormal LGE. ree
patients showed a mid-myocardial LGE
pattern, indicative of mid-wall brosis, and
1 patient showed both mid-myocardial and
subepicardial LGE.
In our study, one 35-year-old patient, with
no prior history of myocardial infarction,
showed contrast enhancement in the
subendocardial location in the diseased
coronary artery territory distribution.
This may be explained by the findings of
McCrohon et al.,[14] who showed that some
patients with DCM may have subendocardial
fibrosis characteristic of infarction. These
may either represent cases of coronary
emboli-induced ischaemic cardiomyopathy,
or recanalisation aer an occlusive coronary
event.[12,14]
One possible application of CMR is to
assess the prognosis of patients with DCM.
LGE, particularly mid-myocardial, in
patients with DCM is linked to an increased
likelihood of serious cardiovascular events,
including ventricular tachycardia and
sudden cardiac death.[11,15] In our study, 7
patients showed abnormal LGE, with 4 of the
7 showing mid-myocardial LGE. e latter
nding was indicative of a poorer prognosis.
In summary, CMR has many uses as
a diagnostic tool that can significantly
benefit patient management. It can
help differentiate primary DCM from
other causes of LV dysfunction, such as
ischaemic cardiomyopathy or restrictive
cardiomyopathy. It can also detect areas of
brosis within the myocardium, which may
have prognostic value and guide therapeutic
decisions. Furthermore, CMR can assess the
degree of ventricular dilation and systolic
dysfunction, which are important parameters
for monitoring disease progression and
response to treatment.
Conclusion
Primary DCM is relatively uncommon, but
contributes significantly to cardiovascular
morbidity and mortality. An accurate
diagnosis is therefore of the utmost
importance. At present, the primary
diagnosis is based on clinical suspicion
and echocardiographic ndings. CMR has
emerged as a powerful diagnostic tool that,
by providing accurate, high-resolution
reproducible images, can denitively establish
the diagnosis, assess the severity of the disease
both qualitatively and quantitatively, predict
the risk of future adverse cardiovascular
outcomes, check for complications, and assist
in future follow-ups.
Declaration. e research for this study was
done in partial fullment of the requirements
for AG’s MD (Radiodiagnosis) degree at Dr. D.
Y. Patil Medical College, Hospital and Research
Centre, Pune.
Acknowledgements. We extend our heartfelt
gratitude to the Department of Radiodiagnosis
at Dr. D. Y. Patil Medical College, Hospital and
Research Centre for their valuable support.
Author contributions. TK conceived and
supervised the findings of this work. AG
prepared the first draft of the manuscript,
interpreted the results, and reviewed the
literature. MK helped with statistical analysis
and revision of the manuscript. All authors
discussed the results and contributed to the nal
version of the manuscript.
Funding.None.
Conicts of interest.None.
A B
Fig. 3. A 46-year-old man with primary dilated cardiomyopathy. Short-axis delayed contrast
images show (A) patchy mid-myocardial late gadolinium enhancement in the interventricular
septum (arrows), and (B) patchy subepicardial enhancement of the anteroseptal segment of the
basal cavity (arrows).
Pattern of LGE
Study participants, n
14
12
10
8
6
4
2
0
13
34
1
Patchy subepicardial
No LGE
Patchy subendocardial
Patchy mid-myocardial
Fig. 4. Distribution of patterns of le ventricular LGE in the study participants (N=20). One
patient had both mid-myocardial and subepicardial patterns of LGE. (LGE = late gadolinium
enhancement.)
6 AJTCCM VOL. 30 NO. 1 2024
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Submitted 27 March 2023. Accepted 8 January 2024. Published 4 April 2024.
