Greyzone myocardial fibrosis and ventricular arrhythmias in patients with a left ventricular ejection fraction >35%

Abbasin Zegard, Osita Okafor, Joseph de Bono, Manish Kalla, Mauro Lencioni, Howard Marshall, Lucy Hudsmith, Tian Qiu, Richard Steeds, Berthold Stegemann, Francisco Leyva-Leon*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


AIMS: To determine whether myocardial fibrosis and greyzone fibrosis (GZF) on cardiovascular magnetic resonance (CMR) is associated with ventricular arrhythmias in patients with coronary artery disease (CAD) and a left ventricular ejection fraction (LVEF) >35%.

METHODS AND RESULTS: In this retrospective study of CAD patients, GZF mass using the 3SD method (GZF3SD) and total fibrosis mass using the 2SD method (TF2SD) on CMR were assessed in relation to the primary, combined endpoint of sudden cardiac death, ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest. Among 701 patients [age: 65.8 ± 12.3 years (mean ± SD)], 28 (3.99%) patients met the primary endpoint over 5.91 years (median; interquartile range 4.42-7.64). In competing risks analysis, a GZF3SD mass ≥5.0 g was strongly associated with the primary endpoint [subdistribution hazard ratio (sHR): 17.4 (95% confidence interval, CI 6.64-45.5); area under receiver operator characteristic curve (AUC): 0.85, P < 0.001]. A weaker association was observed for TF2SD mass ≥23 g [sHR 10.4 (95% CI 4.22-25.8); AUC: 0.80, P < 0.001]. The range of sHRs for GZF3SD mass (1-527) was wider than for TF2SD mass (1-37.6).

CONCLUSIONS: In CAD patients with an LVEF >35%, GZF3SD mass was strongly associated with the arrhythmic endpoint. These findings hold promise for its use in identifying patients with CAD and an LVEF >35% at risk of arrhythmic events.

Original languageEnglish
Pages (from-to)31-39
Number of pages9
Issue number1
Early online date11 Aug 2021
Publication statusPublished - 4 Jan 2022

Bibliographical note

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
Funding: We are grateful to Medtronic Plc and Boston Scientific for their support in funding this study, in the form of unrestricted educational grants.


  • Cardiovascular magnetic resonance
  • Coronary artery disease
  • Greyzone scar
  • Myocardial fibrosis
  • Sudden cardiac death
  • Ventricular fibrillation
  • Ventricular tachycardia


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