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Mid-Wall LGE Prognostic Significance — RACP Adult Medicine MCQ

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HardCardiologyMid-Wall LGE Prognostic SignificanceRACP Adult Medicine

A 55-year-old man with known HFrEF (LVEF 22%) presents with worsening dyspnoea. His NT-proBNP is 8,500 pg/mL. He is on optimal quadruple therapy. Cardiac MRI shows extensive late gadolinium enhancement in the mid-wall (non-ischaemic pattern). What does mid-wall LGE indicate in dilated cardiomyopathy?

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Correct answer: E — Normal finding in HFrEF

Mid-wall late gadolinium enhancement (LGE) on cardiac MRI in non-ischaemic dilated cardiomyopathy (DCM) represents myocardial fibrosis and is a powerful prognostic marker. It is associated with: (1) higher risk of sudden cardiac death and ventricular arrhythmias, (2) worse LV remodelling and functional decline, and (3) reduced response to medical therapy and CRT. The presence and extent of mid-wall LGE influences ICD decision-making – it may support ICD implantation even in patients with LVEF 35–50% who would not otherwise meet conventional criteria. The CMR-GUIDE RCT is evaluating LGE-guided ICD implantation.

Reference: NHF/CSANZ – 2022 – Heart Failure Consensus; ESC – 2023 – Cardiomyopathies