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LGE Transmurality and Viability — EECC MCQ

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ModerateCardiac ImagingLGE Transmurality and ViabilityEECC

A 55-year-old man with suspected myocardial viability in a region of prior MI undergoes late gadolinium enhancement CMR. The anterior wall shows 40% transmural LGE (subendocardial, not full-thickness). What is the likelihood of functional recovery after revascularisation?

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Correct answer: D — Segments with ≤50% transmural LGE (subendocardial scar with preserved outer myocardium) have a ~75-80% probability of functional recovery after revascularisation; segments with >75% transmural LGE have <5% probability of recovery — LGE extent is the strongest predictor of viability

LGE transmurality on CMR is the gold-standard non-invasive assessment of myocardial viability. The landmark Kim et al. (NEJM 2000) study established the relationship: (1) 0% LGE (no scar): ~80% probability of functional recovery; (2) 1-25% transmural LGE: ~60-70% recovery; (3) 26-50% transmural LGE: ~40-50% recovery; (4) 51-75% transmural LGE: ~10-15% recovery; (5) >75% transmural LGE: <5% recovery. The 50% transmurality threshold is the commonly used clinical cut-off: segments with ≤50% LGE are considered viable (likely to recover with revascularisation); >50% are non-viable. This patient's anterior wall with 40% transmural LGE has a reasonable probability of recovery. The 2024 ESC CCS Guidelines recommend viability assessment before revascularisation of chronically dysfunctional myocardium.

Reference: ESC (2024): CCS Guidelines; Kim et al. NEJM 2000