For cardiologists and patients living with dilated cardiomyopathy, the structural appearance of the heart's inner wall has long carried diagnostic weight — sometimes triggering aggressive anticoagulation or implantable device decisions. A large multicenter analysis now challenges whether the presence of excessive trabeculation independently worsens outcomes, with implications for how this morphological trait is interpreted clinically.
Drawing on data from 1,160 DCM patients across 22 international centers — 86% of whom underwent genetic testing alongside cardiac MRI — this study tracked embolic events, advanced heart failure, and ventricular arrhythmias over a median follow-up exceeding five years. Left ventricular hypertrabeculation, identified in roughly 30% of patients by both fractal analysis and Petersen criteria, showed no statistically significant association with embolic risk (HR 1.5; 95% CI 0.75–3.00). Even in the higher-risk subgroup with reduced ejection fraction (≤40%) and sinus rhythm, the hazard ratio remained non-significant. Atrial fibrillation and depressed LV ejection fraction emerged as the true drivers of embolic events. Hypertrabeculation also failed to predict arrhythmia burden or disease progression; genetic architecture and ejection fraction were the dominant prognostic variables.
This finding matters because LV noncompaction — now reframed as hypertrabeculation — has carried an outsized diagnostic reputation, sometimes prompting anticoagulation in patients without AF and device implantation based on morphology alone. The multicenter design and near-complete genetic characterization lend this study considerable statistical credibility, though the observational nature limits causal inference. The cohort's referral-center composition may also skew toward more complex presentations. Broadly, the work aligns with a growing consensus that trabeculation is a spectrum rather than a discrete pathology, and that genotype-informed risk stratification should anchor DCM management rather than wall texture. The findings are potentially practice-reorienting for how this morphological trait influences treatment decisions.