Radiomics of Late Gadolinium Enhancement Reveals Prognostic Value of Myocardial Scar Heterogeneity in Hypertrophic Cardiomyopathy

Late gadolinium enhancement (LGE) scar burden by cardiac magnetic resonance is a major risk factor for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). However, there is currently limited data on the incremental prognostic value of integrating myocardial LGE radiomics (ie, shape and texture features) into SCD risk stratification models. The purpose of this study was to investigate the incremental prognostic value of myocardial LGE radiomics beyond current European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) models for SCD risk prediction in HCM. A total of 1,229 HCM patients (62% men; age 52 ± 16 years) from 3 medical centers were included. Left ventricular myocardial radiomic features were calculated from LGE images. Principal component analysis was used to reduce the radiomic features and calculate 3 principal radiomics (PrinRads). Cox and logistic regression analyses were then used to evaluate the significance of the extracted PrinRads of LGE images, alone or in combination with ESC or ACC/AHA models, to predict SCD risk. The ACC/AHA risk markers include LGE burden using a dichotomized 15% threshold of LV scar. SCD events occurred in 30 (2.4%) patients over a follow-up period of 49 ± 28 months. Risk prediction using PrinRads resulted in higher c-statistics than the ESC (0.69 vs 0.57; P = 0.02) and the ACC/AHA (0.69 vs 0.67; P = 0.75) models. Risk predictions were improved by combining the 3 PrinRads with ESC (0.73 vs 0.57; P < 0.01) or ACC/AHA (0.76 vs 0.67; P < 0.01) risk scores. The net reclassification index was improved by combining the PrinRads with ESC (0.25 [95% CI: 0.08-0.43]; P = 0.005) or ACC/AHA (0.05 [95% CI: −0.07 to 0.16]; P = 0.42) models. One PrinRad was a significant predictor of SCD risk (HR: 0.57 [95% CI: 0.39-0.84]; P = 0.01). LGE heterogeneity was a major component of PrinRads and a significant predictor of SCD risk (HR: 0.07 [95% CI: 0.01-0.75]; P = 0.03). Myocardial LGE radiomics are strongly associated with SCD risk in HCM and provide incremental risk stratification beyond current ESC or AHA/ACC risk models. Our proof-of-concept study warrants further validation.