Highlights
Prospective data from 167 patients with Fabry Disease (FD) confirms that myocardial storage, hypertrophy, and fibrosis—as measured by cardiac magnetic resonance (CMR)—are independent predictors of adverse cardiovascular outcomes. A key finding is that a normal septal T1 value provides a high negative predictive value, essentially ruling out major adverse cardiovascular events (MACE) over a median follow-up of 40 months. Furthermore, a novel 3-year prognostic score incorporating age, left ventricular mass index (LVMI), late gadolinium enhancement (LGE) extent, and T1 values offers clinicians a precise tool for risk-stratifying these patients.
The Clinical Challenge of Fabry Cardiomyopathy
Fabry disease is an X-linked lysosomal storage disorder caused by a deficiency of the enzyme alpha-galactosidase A. This deficiency leads to the systemic accumulation of globotriaosylceramide (Gb3), with the heart being one of the primary organs affected. Fabry cardiomyopathy is characterized by a progressive sequence of events: initial myocardial storage of glycosphingolipids, followed by compensatory and later pathological hypertrophy, and ultimately, the development of chronic inflammation and replacement fibrosis. These structural changes are the primary drivers of morbidity and mortality, manifesting as heart failure, malignant arrhythmias, and sudden cardiac death.
While cardiac magnetic resonance (CMR) has become the gold standard for characterizing these tissue changes, its prognostic application has been inconsistent. In particular, T1 mapping—a sensitive marker for myocardial storage due to the low T1 values associated with sphingolipid accumulation—has faced challenges in clinical adoption for prognosis due to variability across different vendors and sequences. There remains a critical unmet need for a standardized, validated scoring system that integrates these multi-parametric CMR findings to guide clinical management and therapeutic timing.
Study Design and Methodology
In a rigorous prospective observational study, researchers enrolled 167 patients with genetically confirmed Fabry Disease. All participants underwent a comprehensive baseline CMR protocol that included cine imaging for volume and mass quantification, T1 mapping (utilizing both ShMOLLI and MOLLI sequences) to assess myocardial storage, and late gadolinium enhancement (LGE) imaging to detect and quantify replacement fibrosis.
The primary endpoint was a robust composite of major adverse cardiovascular events (MACE), including all-cause mortality, heart failure hospitalization, new-onset atrial fibrillation or flutter, sustained or non-sustained ventricular tachycardia, major bradyarrhythmias requiring intervention, and myocardial infarction with non-obstructive coronary arteries (MINOCA). Patients were followed for a median of 40 months, providing a longitudinal look at how baseline CMR parameters translated into clinical outcomes.
Results: The Interplay of Storage, Hypertrophy, and Fibrosis
The study cohort represented a diverse spectrum of FD progression. Over the follow-up period, 27 patients (16%) reached the primary composite endpoint. The statistical analysis revealed several critical predictors of these adverse outcomes.
The Prognostic Weight of LV Hypertrophy and Fibrosis
Left ventricular mass index (LVMI) proved to be a significant predictor, with a Hazard Ratio (HR) of 1.02 (95% CI: 1.02-1.03, p<0.001). While the increment per unit of mass appears small, the cumulative effect in patients with significant hypertrophy is substantial. Even more striking was the role of fibrosis. The presence of LGE was associated with a staggering 20-fold increase in the risk of MACE (HR 20.12, 95% CI: 6.02-67.24, p<0.001). The extent of fibrosis also mattered significantly; each additional LGE-positive segment increased the hazard by 51% (HR 1.51, 95% CI: 1.33-1.71, p<0.001).
The Power of T1 Mapping
Septal T1 values, regardless of whether they were measured via ShMOLLI or MOLLI sequences, were significantly associated with outcomes. Lower T1 values, which indicate higher sphingolipid storage, correlated with an increased risk of events (HR 0.98, p<0.001). Perhaps the most clinically actionable finding was that not a single patient with a normal T1 value at baseline experienced an adverse cardiovascular event during the follow-up period. This suggests that the absence of detectable myocardial storage via T1 mapping serves as a powerful negative predictor for short-to-medium-term cardiac complications.
Developing the 3-Year Prognostic Score
To translate these findings into a bedside tool, the researchers developed a multivariable model. The resulting prognostic score integrates four key variables: age, LVMI, the number of LGE-positive segments, and the absolute septal T1 value. This model showed high performance in predicting the 3-year risk of composite CV events. By combining markers of storage (T1), hypertrophy (LVMI), and fibrosis (LGE), the score captures the entire pathophysiological spectrum of Fabry cardiomyopathy. This multi-parametric approach is superior to relying on any single marker, as it accounts for both the early stage of the disease (storage) and the advanced stages (hypertrophy and scarring).
Expert Commentary and Clinical Implications
The introduction of a standardized prognostic score marks a significant step forward in the personalized management of Fabry disease. Historically, clinicians have often struggled with the timing of enzyme replacement therapy (ERT) or chaperone therapy, particularly in patients who are asymptomatic but show early signs of cardiac involvement. The finding that a normal T1 value carries such high negative predictive value may allow for more confident monitoring of low-risk patients, potentially avoiding over-treatment in the very early stages.
Conversely, the high hazard ratio associated with LGE presence and extent reinforces the urgency of intervention once fibrosis is detected. It is well-documented in previous literature that ERT is less effective once significant fibrosis has established; this study provides the statistical weight to justify aggressive management and closer monitoring for arrhythmias in the LGE-positive subgroup. The inclusion of T1 mapping in the score, despite historical concerns regarding reproducibility, is justified by the study’s finding that both common sequences (MOLLI and ShMOLLI) yielded consistent prognostic value. This suggests that the biological signal of storage is strong enough to overcome minor technical variations between CMR platforms.
Study Limitations
While the study is prospective and provides high-quality data, it is important to note the median follow-up of 40 months. Fabry disease is a chronic, lifelong condition, and longer-term data will be essential to see if the negative predictive value of T1 remains stable over decades. Additionally, the composite endpoint included both hard outcomes (death) and softer outcomes (non-sustained ventricular tachycardia), which requires careful interpretation when discussing individual patient risk.
Conclusion: A New Standard for Risk Stratification
The study by Camporeale et al. provides a robust framework for predicting cardiovascular outcomes in Fabry disease using CMR. By identifying the independent prognostic roles of myocardial storage, hypertrophy, and fibrosis, the researchers have moved beyond simple diagnosis into precise risk prediction. The proposed 3-year prognostic score offers a much-needed objective measure for clinicians to identify high-risk patients who require intensive intervention and low-risk patients who can be safely monitored. In the era of precision medicine, such multi-parametric imaging scores are essential for optimizing the long-term care of patients with rare genetic cardiomyopathies.
References
1. Camporeale A, Guida G, Pieroni M, et al. Prognostic role of myocardial storage, hypertrophy and inflammation/fibrosis in Fabry Cardiomyopathy: a new predictive score including T1 values. Eur Heart J Qual Care Clin Outcomes. 2025 Dec 15:qcaf154. doi: 10.1093/ehjqcco/qcaf154.
2. Nordin S, Kozor R, Baig S, et al. T1 Mapping in Fabry Disease: Myocardial Storage as a Surrogate for Early Disease Detection. JACC Cardiovasc Imaging. 2018.
3. Moon JC, Sheppard M, Reed E, et al. The histologic basis of late gadolinium enhancement in Fabry disease. J Cardiovasc Magn Reson. 2010.
