3D Fractal Dimension Analysis: Prognostic Value of Right Ventricular Trabecular Complexity in Participants with Arrhythmogenic Cardiomyopathy

Background Arrhythmogenic cardiomyopathy (ACM) is characterized by progressive myocardial fibro‐fatty infiltration accompanied by trabecular disarray. Traditionally, two‐dimensional (2D) instead of 3D fractal dimension (FD) analysis has been used to evaluate trabecular disarray. However, the prognostic value of trabecular disorder assessed by 3D FD measurement remains unclear. Purpose To investigate the prognostic value of right ventricular trabecular complexity in ACM patients using 3D FD analysis based on cardiac MR cine images. Study Type Retrospective. Population 85 ACM patients (mean age: 45 ± 17 years, 52 male). Field Strength/Sequence 3.0T/cine imaging, T2‐short tau inversion recovery (T2‐STIR), and late gadolinium enhancement (LGE). Assessment Using cine images, RV (right ventricular) volumetric and functional parameters were obtained. RV trabecular complexity was measured with 3D fractal analysis by box‐counting method to calculate 3D‐FD. Cox and logistic regression models were established to evaluate the prognostic value of 3D‐FD for major adverse cardiac events (MACE). Statistical Tests Cox regression and logistic regression to explore the prognostic value of 3D‐FD. C‐index, time‐dependent receiver operating characteristic (ROC) curves and area under the ROC curve (AUC) to evaluate the incremental value of 3D‐FD. Intraclass correlation coefficient for interobserver variability. P < 0.05 indicated statistical significance. Results 26 MACE were recorded during the 60 month follow‐up (interquartile range: 48–67 months). RV 3D‐FD significantly differed between ACM patients with MACE (2.67, interquartile range: 2.51 ~ 2.81) and without (2.52, interquartile range: 2.40 ~ 2.67) and was a significant independent risk factor for MACE (hazard ratio, 1.02; 95% confidence interval: 1.01, 1.04). In addition, prognostic model fitness was significantly improved after adding 3D‐FD to RV global longitudinal strain, LV involvement, and 5‐year risk score separately. Data Conclusion The myocardial trabecular complexity assessed through 3D FD analysis was found associated with MACE and provided incremental prognostic value beyond conventional ACM risk factors. Evidence Level 4 Technical Efficacy Stage 1