Characteristics and prognostic value of “Ring-Like” late gadolinium Enhancement - A systematic review of literature

Abstract

Ring-like late gadolinium enhancement (RLE) on cardiac magnetic resonance imaging (CMR) is being increasingly recognized as a marker for arrhythmic events in patients with non-ischemic cardiomyopathy (NICM). We aimed to systematically and critically appraise the published literature on the RLE and its associations with clinical outcomes.We searched Ovid MEDLINE for English-language studies published through Apr 07, 2025, that reported on patients with RLE on CMR and ventricular arrhythmias (VA). Data on imaging characteristics, genetics, and clinical outcomes were abstracted and analysed. 9 retrospective studies with a total of n = 499 patients with RLE were identified. Patients were predominantly male and relatively young. RLE was consistently associated with higher risk of arrhythmic events- including sustained VA, appropriate implantable cardioverter-defibrillator therapy, and sudden cardiac death. In studies with genetic testing, 61–73% of patients had pathogenic or likely pathogenic genetic variants. RLE is frequently associated with positive genetic testing and is an independent prognostic factor for arrhythmic as well as heart failure outcomes.