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Radunski UK, Bohnen S, Lund GK, Lindner D, Westermann D, Adam G, Blankenberg S, Muellerleile K. Advances in Quantitative Tissue Characterization in Myocarditis. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9398-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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52
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Lagan J, Schmitt M, Miller CA. Clinical applications of multi-parametric CMR in myocarditis and systemic inflammatory diseases. Int J Cardiovasc Imaging 2017; 34:35-54. [PMID: 28130644 PMCID: PMC5797564 DOI: 10.1007/s10554-017-1063-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 01/03/2017] [Indexed: 12/22/2022]
Abstract
Cardiac magnetic resonance (CMR) has changed the management of suspected viral myocarditis by providing a ‘positive’ diagnostic test and has lead to new insights into myocardial involvement in systemic inflammatory conditions. In this review we analyse the use of CMR tissue characterisation techniques across the available studies including T2 weighted imaging, early gadolinium enhancement, late gadolinium enhancement, Lake Louise Criteria, T2 mapping, T1 mapping and extracellular volume assessment. We also discuss the use of multiparametric CMR in acute cardiac transplant rejection and a variety of inflammatory conditions such as sarcoidosis, systemic lupus erythrematous, rheumatoid arthritis and systemic sclerosis.
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Affiliation(s)
- Jakub Lagan
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
- Institute of Cardiovascular Sciences, Faculty of Medical & Human Sciences, University of Manchester, Manchester, M13 9NT, UK
| | - Matthias Schmitt
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
| | - Christopher A Miller
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK.
- Institute of Cardiovascular Sciences, Faculty of Medical & Human Sciences, University of Manchester, Manchester, M13 9NT, UK.
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53
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Jeserich M, Merkely B, Schlosser P, Kimmel S, Pavlik G, Achenbach S. Assessment of edema using STIR+ via 3D cardiovascular magnetic resonance imaging in patients with suspected myocarditis. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2017; 30:309-316. [DOI: 10.1007/s10334-016-0603-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/04/2016] [Accepted: 12/07/2016] [Indexed: 11/29/2022]
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Lalude OO, Lerakis S. Cardiovascular Magnetic Resonance Imaging. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Stamatios Lerakis
- Emory University School of Medicine and Georgia Institute of Technology; Atlanta GA USA
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55
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Mills KI, Vincent JA, Zuckerman WA, Hoffman TM, Canter CE, Marshall AC, Blume ED, Bergersen L, Daly KP. Is Endomyocardial Biopsy a Safe and Useful Procedure in Children with Suspected Cardiomyopathy? Pediatr Cardiol 2016; 37:1200-10. [PMID: 27272694 DOI: 10.1007/s00246-016-1416-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
Endomyocardial biopsy (EMB) is a common procedure used to aid in the diagnosis, prognosis and treatment of suspected pediatric cardiomyopathy. In suspected cardiomyopathy, no multicenter experience has previously reported on the safety and utility of EMBs. Retrospectively, adverse event (AE) and patient and procedural characteristics were obtained at seven institutions participating in the Congenital Cardiac Catheterization Outcomes Project for both a cardiomyopathy (n = 158) and a post-transplant surveillance (n = 2665) cohort. Descriptive information regarding biopsy indication, pathology and clinical management based on EMB findings were retrospectively obtained. High-severity AEs were more common in the cardiomyopathy cohort when compared to the post-transplant surveillance cohort. The cardiomyopathy cohort was younger, more hemodynamically vulnerable and required more cardiorespiratory support during the procedure. The eight high-severity AEs in the cardiomyopathy group included one myocardial perforation, two ECMO cannulations and three deaths following the EMB. Factors associated with high-severity AEs included performing another catheter-based intervention during the EMB and longer fluoroscopy time. Notably, an increased number of biopsy attempts did not increase the risk of an AE. Suspected myocarditis was the most common indication. Diagnostic EMB pathology and thus alteration to clinical management based on pathology occurred more frequently in patients with suspected myocarditis. In conclusion, there is an increased incidence of high-severity AEs in patients undergoing EMB for suspected cardiomyopathy. EMB may be more clinically useful in the management of suspected myocarditis. The increased risk of high-severity AEs when additional interventions are performed highlights the hemodynamic vulnerability in patients with suspected cardiomyopathy.
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Affiliation(s)
- Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Julie A Vincent
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York Presbyterian - Columbia University Medical Center, New York, NY, USA
| | - Warren A Zuckerman
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York Presbyterian - Columbia University Medical Center, New York, NY, USA
| | - Timothy M Hoffman
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Charles E Canter
- Department of Pediatrics, St. Louis Children's Hospital and Washington University in St. Louis, St. Louis, MO, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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56
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Gil KE, Pawlak A, Gil RJ, Frontczak-Baniewicz M, Bil J. The role of invasive diagnostics and its impact on the treatment of dilated cardiomyopathy: A systematic review. Adv Med Sci 2016; 61:331-343. [PMID: 27589574 DOI: 10.1016/j.advms.2016.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 06/29/2016] [Accepted: 07/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dilated cardiomyopathy is one of the most frequent causes of non-ischemic heart failure. Many factors including genetic disorders, infectious agents, toxins, drugs and autoimmune disorders might take part in the development of dilated cardiomyopathy. Diagnosis of left ventricular dilatation is most often limited to performing echocardiography and excluding ischemic etiology (coronary angiography). Since many pathologies take place at the cellular and subcellular level the only way to clarify the etiology of the disease is to examine the myocardium itself (endomyocardial biopsy). METHODS A systematic literature search was conducted for studies published between September 2000 and September 2015 using the PubMed database. RESULTS Of 7104 studies identified, 73 studies were included in this review. Controversies raised by opponents of the endomyocardial biopsy collide with the low percentage of serious complications confirmed in several single-center registries. Based on the available data the overall complication rate varies from 1% to about 3%, with 0.5% risk of serious complications. According to the current recommendations of the European and American scientific societies endomyocardial biopsy should be performed in most cases of left ventricular dilatation and heart failure of non-ischemic etiology. Endomyocardial biopsy allows for making the diagnosis and providing prognostic information especially in patients with familial dilated cardiomyopathy, diabetic cardiomyopathy with dilated phenotype, alcoholic cardiomyopathy, peripartum cardiomyopathy, iron overload cardiomyopathy, as well as inflammatory and viral cardiomyopathy. Iron overload cardiomyopathy, peripartum cardiomyopathy, inflammatory and viral cardiomyopathy are potentially treatable and reversible. CONCLUSIONS Targeted therapies are more effective when started early before myocardial injury becomes irreversible. Unfortunately, non-invasive techniques are not precise enough to decide if and which targeted therapy is required. Therefore endomyocardial biopsy should be mainly recognized as the essential diagnostic tool and should not be postponed.
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Affiliation(s)
- Katarzyna E Gil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland.
| | - Agnieszka Pawlak
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland; Mossakowski Medical Research Centre, Academy of Science, Warsaw, Poland
| | - Robert J Gil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland; Mossakowski Medical Research Centre, Academy of Science, Warsaw, Poland
| | | | - Jacek Bil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland
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57
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Sinagra G, Anzini M, Pereira NL, Bussani R, Finocchiaro G, Bartunek J, Merlo M. Myocarditis in Clinical Practice. Mayo Clin Proc 2016; 91:1256-66. [PMID: 27489051 DOI: 10.1016/j.mayocp.2016.05.013] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 05/24/2016] [Accepted: 05/25/2016] [Indexed: 12/21/2022]
Abstract
Myocarditis is a polymorphic disease characterized by great variability in clinical presentation and evolution. Patients presenting with severe left ventricular dysfunction and life-threatening arrhythmias represent a demanding challenge for the clinician. Modern techniques of cardiovascular imaging and the exhaustive molecular evaluation of the myocardium with endomyocardial biopsy have provided valuable insight into the pathophysiology of this disease, and several clinical registries have unraveled the disease's long-term evolution and prognosis. However, uncertainties persist in crucial practical issues in the management of patients. This article critically reviews current information for evidence-based management, offering a rational and practical approach to patients with myocarditis. For this review, we searched the PubMed and MEDLINE databases for articles published from January 1, 1980, through December 31, 2015, using the following terms: myocarditis, inflammatory cardiomyopathy, and endomyocardial biopsy. Articles were selected for inclusion if they represented primary data or were review articles published in high-impact journals. In particular, a risk-oriented approach is proposed. The different patterns of presentation of myocarditis are classified as low-, intermediate-, and high-risk syndromes according to the most recent evidence on prognosis, clinical findings, and both invasive and noninvasive testing, and appropriate management strategies are proposed for each risk class.
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Affiliation(s)
- Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy.
| | - Marco Anzini
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | | | - Rossana Bussani
- Institute of Pathological Anatomy and Histology, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Gherardo Finocchiaro
- Cardiovascular Sciences Research Centre, St George's University of London, London, UK
| | | | - Marco Merlo
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy
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58
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Lurz P, Luecke C, Eitel I, Föhrenbach F, Frank C, Grothoff M, de Waha S, Rommel KP, Lurz JA, Klingel K, Kandolf R, Schuler G, Thiele H, Gutberlet M. Comprehensive Cardiac Magnetic Resonance Imaging in Patients With Suspected Myocarditis: The MyoRacer-Trial. J Am Coll Cardiol 2016; 67:1800-1811. [PMID: 27081020 DOI: 10.1016/j.jacc.2016.02.013] [Citation(s) in RCA: 277] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data suggest that T1 and T2 mapping have excellent diagnostic accuracy in patients with suspected myocarditis. However, the true diagnostic performance of comprehensive cardiac magnetic resonance (CMR) mapping versus endomyocardial biopsy (EMB) has not been determined. OBJECTIVES This study assessed the performance of CMR imaging, including T1 and T2 mapping, compared with EMB in an unselected, consecutive patient cohort with suspected myocarditis. It also examined the potential role of CMR field strength by comparing 1.5-T versus 3.0-T imaging. METHODS Patients underwent biventricular EMB, cardiac catheterization (for exclusion of coronary artery disease), and CMR imaging on 1.5- and 3-T scanners. The CMR protocol included current standard Lake Louise criteria (LLC) for myocarditis as well as native T1, calculation of extracellular volume fraction (ECV), and T2 mapping (only on 1.5-T). Patients were divided into 2 groups according to symptom duration (acute: ≤14 days vs. chronic: >14 days). RESULTS A total of 129 patients underwent 1.5-T imaging. In patients with acute symptoms, native T1 yielded the best diagnostic performance as defined by the area under the curve (AUC) of receiver-operating curves (0.82) followed by T2 (0.81), ECV (0.75), and LLC (0.56). In patients with chronic symptoms, only T2 mapping yielded an acceptable AUC (0.77). On 3.0-T, AUCs of native T1, ECV, and LLC were comparable to 1.5-T with no significant differences. CONCLUSIONS In patients with acute symptoms, mapping techniques provide a useful tool for confirming or rejecting the diagnosis of myocarditis and are superior to the LLC. However, only T2 mapping has acceptable diagnostic performance in patients with chronic symptoms. (Magnetic Resonance Imaging in Myocarditis [MyoRacer]; NCT02177630).
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Affiliation(s)
- Philipp Lurz
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany.
| | - Christian Luecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Ingo Eitel
- University Heart Center Luebeck, University of Schleswig-Holstein, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), Luebeck, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Luebeck, Germany
| | - Felix Föhrenbach
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Clara Frank
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Matthias Grothoff
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Suzanne de Waha
- University Heart Center Luebeck, University of Schleswig-Holstein, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), Luebeck, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Luebeck, Germany
| | - Karl-Philipp Rommel
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Julia Anna Lurz
- Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Karin Klingel
- Department of Molecular Pathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Reinhard Kandolf
- Department of Molecular Pathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Gerhard Schuler
- Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Holger Thiele
- University Heart Center Luebeck, University of Schleswig-Holstein, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), Luebeck, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Luebeck, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
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59
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Hinojar R, Nagel E, Puntmann VO. Advances in Cardiovascular MRI using Quantitative Tissue Characterisation Techniques: Focus on Myocarditis. Eur Cardiol 2016; 11:20-24. [PMID: 30310443 DOI: 10.15420/ecr.2016:18:2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Tissue characterisation capabilities are continuing to evolve and proving to be valuable in the non-invasive diagnosis of clinically-heterogeneous manifestations of myocarditis. The authors investigate how cardiovascular magnetic resonance imaging offers an increasingly reliable alternative to invasive biopsy for clinically-stable patients, and how this tool - with further longitudinal study - will improve the overall understanding of the natural course of myocarditis.
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Affiliation(s)
- Rocio Hinojar
- Institute for experimental and translational cardiovascular Imaging, Goethe University Hospital Frankfurt, Frankfurt, Germany.,Department of Cardiology, University Hospital Ramón y Cajal, Alcala University, Madrid, Spain
| | - Eike Nagel
- Institute for experimental and translational cardiovascular Imaging, Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Valentina O Puntmann
- Institute for experimental and translational cardiovascular Imaging, Goethe University Hospital Frankfurt, Frankfurt, Germany.,Department of Cardiology, Division of Internal Medicine III, Goethe University Hospital Frankfurt, Frankfurt, Germany
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60
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Abstract
Viral myocarditis remains a prominent infectious-inflammatory disease for patients throughout the lifespan. The condition presents several challenges including varied modes of clinical presentation, a range of timepoints when patients come to attention, a diversity of approaches to diagnosis, a spectrum of clinical courses, and unsettled perspectives on therapeutics in different patient settings and in the face of different viral pathogens. In this review, we examine current knowledge about viral heart disease and especially provide information on evolving understanding of mechanisms of disease and efforts by investigators to identify and evaluate potential therapeutic avenues for intervention.
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Affiliation(s)
- Gabriel Fung
- From the Department of Pathology and Laboratory Medicine (G.F., H.L., Y.Q., D.Y., B.M.), Centre for Heart Lung Innovation (G.F., H.L., Y.Q., D.Y., B.M.), Centre of Excellence for Prevention of Organ Failure (PROOF Centre), and Institute for Heart + Lung Health, St. Paul's Hospital (B.M.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Honglin Luo
- From the Department of Pathology and Laboratory Medicine (G.F., H.L., Y.Q., D.Y., B.M.), Centre for Heart Lung Innovation (G.F., H.L., Y.Q., D.Y., B.M.), Centre of Excellence for Prevention of Organ Failure (PROOF Centre), and Institute for Heart + Lung Health, St. Paul's Hospital (B.M.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Ye Qiu
- From the Department of Pathology and Laboratory Medicine (G.F., H.L., Y.Q., D.Y., B.M.), Centre for Heart Lung Innovation (G.F., H.L., Y.Q., D.Y., B.M.), Centre of Excellence for Prevention of Organ Failure (PROOF Centre), and Institute for Heart + Lung Health, St. Paul's Hospital (B.M.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Decheng Yang
- From the Department of Pathology and Laboratory Medicine (G.F., H.L., Y.Q., D.Y., B.M.), Centre for Heart Lung Innovation (G.F., H.L., Y.Q., D.Y., B.M.), Centre of Excellence for Prevention of Organ Failure (PROOF Centre), and Institute for Heart + Lung Health, St. Paul's Hospital (B.M.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce McManus
- From the Department of Pathology and Laboratory Medicine (G.F., H.L., Y.Q., D.Y., B.M.), Centre for Heart Lung Innovation (G.F., H.L., Y.Q., D.Y., B.M.), Centre of Excellence for Prevention of Organ Failure (PROOF Centre), and Institute for Heart + Lung Health, St. Paul's Hospital (B.M.), University of British Columbia, Vancouver, British Columbia, Canada.
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61
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Besler C, Schuler G, Lurz P. [Myocarditis in the differential diagnosis of cardiomyopathies. Endomyocardial biopsy or MRI?]. Herz 2016; 40:607-15. [PMID: 25963031 DOI: 10.1007/s00059-015-4229-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Myocarditis is an inflammatory disease of the heart muscle commonly caused by viral pathogens. Dilated cardiomyopathy is a major long-term sequela of myocarditis and at least in part related to post-viral immune-mediated responses. Establishing a diagnosis of myocarditis represents a major challenge because of the variable clinical picture and the lack of readily available, non-invasive diagnostic tests. In recent years, cardiac magnetic resonance imaging (cMRI) has emerged as a promising additional diagnostic tool in patients with suspected myocarditis: cMRI not only provides important insights into structural and functional abnormalities of the heart but relevant tissue pathologies can also be visualized. The diagnostic accuracy of three tissue criteria, i.e. the edema ratio, early gadolinium enhancement ratio and late gadolinium enhancement, has been characterized in several studies. Endomyocardial biopsy (EMB) is widely considered to be the reference standard for diagnosis of myocarditis. Although limited by sampling error, EMB is the only diagnostic procedure that can be used to confirm myocarditis. Laboratory analyses of EMB may provide information about specific causes of myocarditis and are, at least in part, of prognostic relevance. In a subset of patients the results of EMB may guide therapeutic decision-making. Additional efforts are needed in cardiac imaging, molecular characterization of EMB and evaluation of serum biomarkers to improve the diagnostic work-up in patients with suspected myocarditis and to identify potential novel targets for a cause-specific therapy of myocarditis.
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Affiliation(s)
- C Besler
- Abteilung Innere Medizin/Kardiologie, Universität Leipzig - Herzzentrum, Strümpellstr. 39, 04289, Leipzig, Deutschland
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63
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Kalisz K, Rajiah P. Impact of cardiac magnetic resonance imaging in non-ischemic cardiomyopathies. World J Cardiol 2016; 8:132-145. [PMID: 26981210 PMCID: PMC4766265 DOI: 10.4330/wjc.v8.i2.132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/23/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
Non-ischemic cardiomyopathies include a wide spectrum of disease states afflicting the heart, whether a primary process or secondary to a systemic condition. Cardiac magnetic resonance imaging (CMR) has established itself as an important imaging modality in the evaluation of non-ischemic cardiomyopathies. CMR is useful in the diagnosis of cardiomyopathy, quantification of ventricular function, establishing etiology, determining prognosis and risk stratification. Technical advances and extensive research over the last decade have resulted in the accumulation of a tremendous amount of data with regards to the utility of CMR in these cardiomyopathies. In this article, we review CMR findings of various non-ischemic cardiomyopathies and focus on current literature investigating the clinical impact of CMR on risk stratification, treatment, and prognosis.
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Shiba M, Sugano Y, Ikeda Y, Ishibashi-Ueda H, Ohara T, Hasegawa T, Kanzaki H, Anzai T. Pathohistological Evidence of Smoldering Inflammation in Rheumatic Heart Disease with Massive Left Atrial Calcification. Intern Med 2016; 55:751-4. [PMID: 27041159 DOI: 10.2169/internalmedicine.55.6125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 74-year-old man, who had a history of a mitral valve replacement for rheumatic heart disease (RHD) 30 years previously, was admitted with progressive heart failure. Massive calcification was observed around the left atrium on multidetector CT, in addition to a late gadolinium enhancement (LGE)-positive layer adjacently outside of the calcification on MRI. He underwent a second mitral valve replacement for the prosthetic valve failure. Pathohistological analyses of a tissue section of the left atrial wall from a surgical specimen revealed lymphocyte and macrophage infiltration that coincided with the LGE-positive layer on MRI, suggesting the existence of sustained active inflammation even after the long period of RHD.
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Affiliation(s)
- Mikio Shiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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65
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Abstract
The novel Middle east respiratory syndrome coronavirus (MeRS-CoV) has been identified as a cause of pneumonia; however, it has not been reported as a cause of acute myocarditis. A 60-year-old man presented with pneumonia and congestive heart failure. On the first day of admission, he was found to have an elevated troponin-l level and severe global left ventricular systolic dysfunction on echo-cardiography. The serum creatinine level was found mildly elevated. Chest radiography revealed in the lower lung fields accentuated bronchovascular lung markings and multiple small patchy opacities. Laboratory tests were negative for viruses known to cause myocarditis. Sputum sample was positive for MeRS-CoV. Cardiovascular magnetic resonance revealed evidence of acute myocarditis. the patient had all criteria specified by the international Consensus Group on CMR in Myocarditis that make a clinical suspicion for acute myocarditis. this was the first case that demonstrated that MeRS-CoV may cause acute myocarditis and acute-onset heart failure.
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Affiliation(s)
- Tariq Alhogbani
- Dr. Tariq Alhogbani, Department of Cardiology,, King Khalid University Hospital,, King Saud University,, Riyadh 11352 Saudi Arabia,, T: (+966) 505-245494,
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66
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Krumm P, Martirosian P, Rath D, Zitzelsberger T, Ruff CA, Klumpp BD, Nikolaou K, Gawaz M, Geisler T, Schick F, Kramer U. Signal decay mapping of myocardial edema using dual-contrast fast spin-echo MRI. J Magn Reson Imaging 2015; 44:186-93. [PMID: 26717865 DOI: 10.1002/jmri.25142] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/10/2015] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To introduce a dual-contrast fast spin-echo (dcFSE) sequence for signal decay mapping of myocardial edema. MATERIALS AND METHODS After consultation with the Institutional Review Board, 22 acute myocardial infarction (MI) patients were examined with magnetic resonance imaging (MRI) at 1.5T 2 days after revascularization. Edema was evaluated in 16 myocardial segments with an exponential fit for signal decay time (SDT) in dcFSE mapping and T2 signal intensity ratio for single-contrast FSE. Myocardial viability was evaluated in late gadolinium enhancement (LGE). A control group of 10 volunteers was examined for edema imaging. SDT was compared in segment groups: 1) with LGE in MI, 2) penumbra, 3) remote from LGE, 4) controls. Groups 1/3 and 3/4 were tested on difference. Three phantoms providing similar T2 but different T1 relaxation times (low, intermediate, high) were examined with dcFSE and multicontrast spin echo sequence as a reference. RESULTS The SDT/T2 ratio for segment groups was 1) 82msec/1.7 in segments with LGE; 2) 65msec/1.6 for penumbra, 3) 62msec/1.7 for remote segments, and 4) 50msec/1.6 in controls. In dcFSE group 1/3 (P < 0.0001) and in group 3/4 (P = 0.0002) SDT was significantly different. In single-contrast FSE the T2 ratio was not significantly different for both tests: 1/3 P = 0.1889; 3/4 P = 0.8879. T2 -overestimation of dcFSE was 23% in low, 29% in intermediate, and 35% in highly T1 contaminated phantoms. CONCLUSION dcFSE signal decay edema mapping is feasible in volunteers and patients. DcFSE SDT is superior to T2 ratio for detection of high-grade and diffuse myocardial edema. J. Magn. Reson. Imaging 2016;44:186-193.
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Affiliation(s)
- Patrick Krumm
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Petros Martirosian
- Department of Diagnostic and Interventional Radiology, Section on Experimental Radiology, Eberhard Karls University, Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University, Tübingen, Germany
| | - Tanja Zitzelsberger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Christer Andreas Ruff
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Bernhard Daniel Klumpp
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University, Tübingen, Germany
| | - Fritz Schick
- Department of Diagnostic and Interventional Radiology, Section on Experimental Radiology, Eberhard Karls University, Tübingen, Germany
| | - Ulrich Kramer
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
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Jeserich M, Merkely B, Olschewski M, Kimmel S, Pavlik G, Bode C. Patients with exercise-associated ventricular ectopy present evidence of myocarditis. J Cardiovasc Magn Reson 2015; 17:100. [PMID: 26590904 PMCID: PMC4655086 DOI: 10.1186/s12968-015-0204-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/09/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The origin and clinical relevance of exercise-induced premature ventricular beats (PVBs) in patients without coronary heart disease or cardiomyopathies is unknown. Cardiovascular magnetic resonance enables us to non-invasively assess myocardial scarring and oedema. The purpose of our study was to discover any evidence of myocardial anomalies in patients with exercise-induced ventricular premature beats. METHODS We examined 162 consecutive patients presenting palpitations and documented exercise-induced premature ventricular beats (PVBs) but no history or evidence of structural heart disease. Results were compared with 70 controls matched for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained as well as LV function and dimensions. RESULTS Structural anomalies in the myocardium and/or pericardium were present in 85 % of patients with exercise-induced PVBs. We observed a significant difference between patients with PVBs and controls in late gadolinium enhancement, that is 68 % presented subepicardial or midmyocardial lesions upon enhancement, whereas only 9 % of the controls did so (p < 0.0001). More patients presented pericardial enhancement (35 %) or pericardial thickening (27 %) compared to controls (21 % and 13 %, p < 0.0001). Myocardial oedema was present in 37 % of the patients and in only one control, p < 0.0001. Left ventricular ejection fraction did not differ between patients and controls (63.1 ± 7.9 vs. 64.7 ± 7.0, p = 0.13). CONCLUSIONS The majority of patients with exercise-associated premature ventricular beats present evidence of myocardial disease consistent with acute or previous myocarditis or myopericarditis.
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Affiliation(s)
- Michael Jeserich
- Department for Cardiology and Angiology, Heart Center University of Freiburg, Albert-Ludwigs University Freiburg, Freiburg, Germany.
- , Koenigstr. 39, 90402, Nuernberg, Germany.
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor str, 68, 1122, Budapest, Hungary.
| | - Manfred Olschewski
- Department of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany.
| | - Simone Kimmel
- Medical Practice, Cardiology and Angiology, Koenigstr. 39, 90402, Nuernberg, Germany.
| | - Gabor Pavlik
- Department of Health Sciences and Sports Medicine, Universitiy of Physical Education, H-1123 Alkotás str. 44, Budapest, Hungary.
| | - Christoph Bode
- Department for Cardiology and Angiology, Heart Center University of Freiburg, Albert-Ludwigs University Freiburg, Freiburg, Germany.
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Løgstrup BB, Nielsen JM, Kim WY, Poulsen SH. Myocardial oedema in acute myocarditis detected by echocardiographic 2D myocardial deformation analysis. Eur Heart J Cardiovasc Imaging 2015; 17:1018-26. [PMID: 26588987 DOI: 10.1093/ehjci/jev302] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/17/2015] [Indexed: 12/31/2022] Open
Abstract
AIMS The clinical diagnosis of acute myocarditis is based on symptoms, electrocardiography, elevated myocardial necrosis biomarkers, and echocardiography. Often, conventional echocardiography reveals no obvious changes in global cardiac function and therefore has limited diagnostic value. Myocardial deformation imaging by echocardiography is an evolving method used to characterize quantitatively longitudinal systolic function, which may be affected in acute myocarditis. The aim of our study was to assess the utility of echocardiographic deformation imaging of the left ventricle in patients with diagnosed acute myocarditis in whom cardiovascular magnetic resonance (CMR) evaluation was performed. METHODS AND RESULTS We included 28 consecutive patients (mean age 32 ± 13 years) with CMR-verified diagnosis of acute myocarditis according to the Lake Louise criteria. Cardiac function was evaluated by a comprehensive assessment of left ventricular (LV) function, including 2D speckle-tracking echocardiography. We found no significant correlation between the peak values of cardiac enzymes and the amount of myocardial oedema assessed by CMR (troponin: r= 0.3; P = 0.05 and CK-MB: r = 0.1; P = 0.3). We found a larger amount of myocardial oedema in the basal part of the left ventricle [American Heart Association (AHA) segments 1-6] in inferolateral and inferior segments, compared with the anterior, anterolateral, anteroseptal, and inferoseptal segments. In the mid LV segments (AHA segments 7-12), this was more pronounced in the anterior, anterolateral, and inferolateral segments. Among conventional echocardiographic parameters, LV function was not found to correlate with the amount of myocardial oedema of the left ventricle. In contrast, we found the wall motion score index to be significantly correlated with the amount of myocardial oedema, but this correlation was only present in patients with an extensive amount of oedema (>11% of the total left ventricle). Global longitudinal systolic myocardial strain correlated significantly with the amount of oedema (r = 0.65; P < 0.001). We found that both the epicardial longitudinal and the endocardial longitudinal systolic strains were significantly correlated with oedema (r = 0.55; P = 0.003 and r = 0.54; P < 0.001). CONCLUSION In patients with acute myocarditis, 2D speckle-tracking echocardiography was a useful tool in the diagnostic process of acute myocarditis. Global longitudinal strain adds important information that can support clinical and conventional echocardiographic evaluation, especially in patients with preserved LV ejection fraction in relation to the diagnosis and degree of myocardial dysfunction.
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Affiliation(s)
- B B Løgstrup
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - J M Nielsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - W Y Kim
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - S H Poulsen
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
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Torreão JA, Ianni BM, Mady C, Naia E, Rassi CH, Nomura C, Parga JR, Avila LF, Ramires JAF, Kalil-Filho R, Rochitte CE. Myocardial tissue characterization in Chagas' heart disease by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2015; 17:97. [PMID: 26581396 PMCID: PMC4652401 DOI: 10.1186/s12968-015-0200-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chagas' heart disease is an important public health problem in South America. Several aspects of the pathogenesis are not fully understood, especially in its subclinical phases. On pathology Chagas' heart disease is characterized by chronic myocardial inflammation and extensive myocardial fibrosis. The latter has also been demonstrated by late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR). In three clinical phases of this disease, we sought to investigate the presence of LGE, myocardial increase in signal intensity in T2-weighted images (T2W) and in T1-weighted myocardial early gadolinium enhancement (MEGE), previously described CMR surrogates for myocardial fibrosis, myocardial edema and hyperemia, respectively. METHODS Fifty-four patients were analyzed. Sixteen patients with the indeterminate phase (IND), seventeen patients with the cardiac phase with no left ventricular systolic dysfunction (CPND), and twenty-one patients with the cardiac phase with left ventricular systolic dysfunction (CPD). All patients underwent 1.5 T CMR scan including LGE, T2W and MEGE image sequences to evaluate myocardial abnormalities. RESULTS Late gadolinium enhancement was present in 72.2 % of all patients, in 12.5 % of IND, 94.1 % of the CPND and 100 % of the CPD patients (p < 0.0001). Myocardial increase in signal intensity in T2-weighted images (T2W) was present in 77.8 % of all patients, in 31.3 % of the IND, 94.1 % of the CPND and 100 % of the CPD patients (p < 0.0001). T1-weighted myocardial early gadolinium enhancement (MEGE) was present in 73.8 % of all patients, in 25.0 % of the IND, 92.3 % of the CPND and 94.1 % of the CPD (p < 0.0001). A good correlation between LGE and T2W was observed (r = 0.72, and p < 0.001). CONCLUSIONS Increase in T2-weighted (T2W) myocardial signal intensity and T1-weighted myocardial early gadolinium enhancement (MEGE) can be detected by CMR in patients throughout all phases of Chagas' heart disease, including its subclinical presentation (IND). Moreover, those findings were parallel to myocardial fibrosis (LGE) in extent and location and also correlated with the degree of Chagas' heart disease clinical severity. These findings contribute to further the knowledge on pathophysiology of Chagas' heart disease, and might have therapeutic and prognostic usefulness in the future.
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Affiliation(s)
- Jorge A Torreão
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
- Santa Izabel Hospital, Santa Casa de Misericórdia da Bahia, Bahia, Brazil.
| | - Barbara M Ianni
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Charles Mady
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Evandro Naia
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Carlos H Rassi
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Cesar Nomura
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - José R Parga
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Luis F Avila
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - José A F Ramires
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Roberto Kalil-Filho
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Carlos E Rochitte
- Heart Institute, InCor, University of Sao Paulo Medical School,Cardiovascular Magnetic Resonance andComputed Tomography Sector, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. How to approach the great mimic? Improving techniques for the diagnosis of myocarditis. Expert Rev Cardiovasc Ther 2015; 14:105-15. [PMID: 26559548 DOI: 10.1586/14779072.2016.1110486] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Myocarditis is characterized by inflammation of the myocardium, assessed by histological, immunological and immunohistochemical criteria, due to exogenous or endogenous causes. Abnormal QRS, increased troponin T and left ventricular regional or global dysfunction may be detected. Strain Doppler echocardiography can detect longitudinal segmental dysfunction of the myocardium, due to edema, which is in agreement with cardiac magnetic resonance imaging. Nuclear imaging shows a good sensitivity, but carries serious limitations. Somatostatin receptor positron emission tomography/computed tomography seems promising. Cardiac magnetic resonance imaging, using T2-weighted, early T1-weighted, delayed enhanced images and recently T2 and T1 mapping, has the best diagnostic capability. Endomyocardial biopsy has further contributed to the etiologic diagnosis of myocarditis. To conclude, cardiac magnetic resonance and endomyocardial biopsy have both significantly increased our diagnostic performance. However, further assessment by multicenter studies is needed to establish a clinically useful algorithm.
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Affiliation(s)
- Sophie Mavrogeni
- a Department of Cardiology , Onassis Cardiac Surgery Center , Athens , Greece
| | | | - Genovefa Kolovou
- a Department of Cardiology , Onassis Cardiac Surgery Center , Athens , Greece
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Luetkens JA, Homsi R, Sprinkart AM, Doerner J, Dabir D, Kuetting DL, Block W, Andrié R, Stehning C, Fimmers R, Gieseke J, Thomas DK, Schild HH, Naehle CP. Incremental value of quantitative CMR including parametric mapping for the diagnosis of acute myocarditis. Eur Heart J Cardiovasc Imaging 2015; 17:154-61. [PMID: 26476398 DOI: 10.1093/ehjci/jev246] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/14/2015] [Indexed: 12/27/2022] Open
Abstract
AIM Cardiac magnetic resonance (CMR) can visualize inflammatory tissue changes in acute myocarditis. Several quantitative image-derived parameters have been described to enhance the diagnostic value of CMR, but no direct comparison of these techniques is available. METHODS AND RESULTS A total of 34 patients with suspected acute myocarditis and 50 control subjects underwent CMR. CMR protocol included quantitative assessment of T1 relaxation times using modified Look-Locker inversion recovery (MOLLI) and shortened MOLLI (ShMOLLI) acquisition schemes, extracellular volume fraction (ECV), T2 relaxation times, and longitudinal strain. Established Lake-Louise criteria (LLC) consisting of T2-weighted signal intensity ratio (T2-ratio), early gadolinium enhancement ratio (EGEr), and late gadolinium enhancement (LGE) were assessed. Receiver operating characteristics analysis was performed to compare diagnostic performance. Areas under the curve of native T1 (MOLLI: 0.95; ShMOLLI: 0.92) and T2 relaxation times (0.92) were higher compared with those of the other CMR parameters (T2-ratio: 0.71, EGEr: 0.71, LGE: 0.87, LLC: 0.90, ECV MOLLI: 0.77, ECV ShMOLLI: 0.80, longitudinal strain: 0.83). Combined with LGE, each native mapping technique outperformed the diagnostic performance of LLC (P < 0.01, respectively). A combination of native parameters (T1, T2, and longitudinal strain) significantly increased the diagnostic performance of CMR compared with LLC without need of contrast media application (0.99 vs. 0.90; P = 0.008). CONCLUSION In patients suspected of having acute myocarditis, diagnostic performance of CMR can be improved by implementation of quantitative CMR parameters. Especially, native mapping techniques have the potential to replace current LLC. CLINICALTRIALS. GOV NUMBER NCT02299856.
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Affiliation(s)
- Julian A Luetkens
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Rami Homsi
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Alois M Sprinkart
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Jonas Doerner
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany Department of Radiology, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Darius Dabir
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Daniel L Kuetting
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Wolfgang Block
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - René Andrié
- Department of Cardiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | | | - Rolf Fimmers
- Department of Medical Biometry, Informatics, and Epidemiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Juergen Gieseke
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany Philips Research, Hamburg, Germany
| | - Daniel K Thomas
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Hans H Schild
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Claas P Naehle
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
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Isolated Right Ventricular Myocarditis: Rarely Reported Pathology. Case Rep Cardiol 2015; 2015:790246. [PMID: 26421195 PMCID: PMC4572472 DOI: 10.1155/2015/790246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/19/2015] [Accepted: 08/27/2015] [Indexed: 11/17/2022] Open
Abstract
Objective. Preventing the morbidity and mortality from isolated right ventricular myocarditis by its early recognition and treatment. Background. The clinical presentation of myocarditis ranges from nonspecific systemic symptoms (fever, myalgia, palpitations, or exertional dyspnea) to fulminant cardiac failure and sudden death. In our case, echocardiography raised the possibility of myocarditis at an early stage, although the signs and symptoms did not indicate right ventricular disease. Review of the literature showed only 4 previous reports, all diagnosed at autopsy, in which diagnosis was not suspected in vivo. Design/Methods. We are reporting case of a 23-year-old male with no past medical history who presented to emergency room with a nonexertional sharp left sided chest pain. Diagnostic tests were conducted, which revealed elevated troponins, decreased right ventricular ejection function but preserved left ventricular function, and no evidence of coronary artery disease. Results. A diagnosis of isolated right ventricular myocarditis was made on the basis of clinical, echocardiographic, and cardiac MRI findings. Conclusions. Isolated right ventricular myocarditis should be suspected in a patient with depressed right ventricular function without left ventricular involvement on echocardiography and cardiac MRI, elevated cardiac enzymes, and no evidence of coronary artery disease.
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The relationship between late gadolinium enhancement imaging and myocardial biopsy in the evaluation of chronic heart failure patients with suspected myocarditis. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 11:404-8. [PMID: 26336457 PMCID: PMC4349041 DOI: 10.5114/kitp.2014.47340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 07/25/2014] [Accepted: 08/25/2014] [Indexed: 11/17/2022]
Abstract
Aim The aim of this study was to assess the relationship between late gadolinium-enhanced (LGE) cardiovascular magnetic resonance (CMR) and immunohistochemical markers of inflammation in patients with heart failure and a reduced ejection fraction (HFrEF). Material and methods Endomyocardial biopsy and CMR were performed in 38 consecutive patients (24 males, average age 43.2 ± 6.9 years, New York Heart Association [NYHA] class II) with HFrEF and suspected myocarditis. The immunohistochemical evaluation was done by the En-Vision system using DAKO monoclonal antibodies. The presence of > 14 infiltrating cells together with myocardial damage and ≥ 2 + up-regulation of HLA class II was considered diagnostic for myocarditis. The results of LGE were compared with the immunohistochemical markers of inflammation. All patients underwent coronary angiography. Results Twelve out of 38 (31.6%) patients met the immunohistological criteria for the diagnosis of myocarditis. Late gadolinium enhancement was present in 23 of 38 (60.5%) patients, mostly at the interventricular septum. No correlation was found between LGE and immunohistochemistry results (Kendall's tau; r = 0.21, p = 0.09). Conclusions Our study revealed no significant relationship between LGE cardiovascular magnetic resonance imaging and immunohistochemical markers of inflammation in patients with HFrEF.
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Venero JV, Doyle M, Shah M, Rathi VK, Yamrozik JA, Williams RB, Vido DA, Rayarao G, Benza R, Murali S, Glass J, Olson P, Sokos G, Biederman RWW. Mid wall fibrosis on CMR with late gadolinium enhancement may predict prognosis for LVAD and transplantation risk in patients with newly diagnosed dilated cardiomyopathy-preliminary observations from a high-volume transplant centre. ESC Heart Fail 2015; 2:150-159. [PMID: 27708858 PMCID: PMC5034795 DOI: 10.1002/ehf2.12041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/02/2015] [Accepted: 05/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high‐risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration. Methods Over 49 consecutive months, 61 consecutives DCM patients were referred for standard CMR(1.5T, GE) to interrogate the LV pattern, distribution, and extent of LGE (MultiHance, Princeton, NJ). Inclusion criteria for a primary non‐ischaemic DCM and EF <45% were met in 31 patients. DCM patients were categorized into: (i) presence of midwall LV stripe (+Stripe) and (ii) absence of midwall stripe (−Stripe) groups. Primary outcome was defined by the composite of death, need for LV assist device (LVAD), and urgent orthotopic cardiac transplantation (Tx) during a 12‐month follow‐up period. Kaplan–Meier survival analysis was conducted grouping patients by +Stripe and −Stripe. Results There were no differences between groups for demographics, blood pressure, labs, baseline LVEF, NYHA class, or invasive haemodynamics. There were 18 patients (58%) with +Stripe. Nine events occurred: seven patients required urgent Tx and/or LVAD implantation and two patients died. The +Stripe categorization strongly predicted the need for LVAD, urgent Tx surgery, and death (log‐rank = 9, P = 0.002). All the events occurred in the +Stripe patients with no MACE experienced in the −Stripe group. The −Stripe group experienced marked signs of improvement in LVEF (P = 0.01) at follow‐up. LVEDD was predictive of need for LVAD/Tx and death by univariate analysis. Otherwise, no common clinical metric such as LVEF, LVEDV, RVEF, RVEDV, or any invasive haemodynamic parameter predicted MACE. Conclusions The presence of +Stripe on CMR is strongly predictive of LVAD, transplant need, and death during a 12‐month follow‐up period in DCM patients in this proof of concept study. All −Stripe patients survived without experiencing any events. Incorporating CMR imaging into routine clinical practice may have prognostic value in DCM patients; indicating conservative management in low‐risk patients while expectantly managing high‐risk patients.
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Affiliation(s)
- Jose V Venero
- Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA
| | - Mark Doyle
- Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA
| | - Moneal Shah
- Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA
| | - Vikas K Rathi
- Bon Secours Richmond Health System Sherwood Drive Colonial Heights VA 23834 USA
| | - June A Yamrozik
- Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA
| | - Ronald B Williams
- Gerald McGinnis Cardiovascular Institute East North Ave Pittsburgh PA USA
| | - Diane A Vido
- Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA
| | - Geetha Rayarao
- Division of Cardiology Allegheny General Hospital East North Ave Pittsburgh PA USA
| | - Raymond Benza
- Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA
| | - Srinivas Murali
- Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA
| | - Jerry Glass
- Division of Pathology Allegheny General Hospital East North Ave Pittsburgh PA USA
| | - Peter Olson
- Division of Pathology Allegheny General Hospital East North Ave Pittsburgh PA USA
| | - George Sokos
- Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA
| | - Robert W W Biederman
- Division of CardiologyAllegheny General HospitalEast North AvePittsburghPAUSA; Gerald McGinnis Cardiovascular InstituteEast North AvePittsburghPAUSA
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Pollack A, Kontorovich AR, Fuster V, Dec GW. Viral myocarditis--diagnosis, treatment options, and current controversies. Nat Rev Cardiol 2015; 12:670-80. [PMID: 26194549 DOI: 10.1038/nrcardio.2015.108] [Citation(s) in RCA: 353] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Myocarditis--a frequent cause of dilated cardiomyopathy and sudden cardiac death--typically results from cardiotropic viral infection followed by active inflammatory destruction of the myocardium. Characterization of this disease has been hampered by its heterogeneous clinical presentations and diverse aetiologies. Advances in cardiac MRI and molecular detection of viruses by endomyocardial biopsy have improved our ability to diagnose and understand the pathophysiological mechanisms of this elusive disease. However, therapeutic options are currently limited for both the acute and chronic phases of myocarditis. Several randomized, controlled trials have demonstrated potential benefit with immunosuppressive and immunomodulatory therapies, but further investigations are warranted. In this Review, we explore the pathophysiology, natural history, and modes of diagnosis of myocarditis, as well as evidence-based treatment strategies. As novel imaging techniques and human in vitro models of the disease emerge, the landscape of therapies for myocarditis is poised to improve.
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Affiliation(s)
- Ari Pollack
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Amy R Kontorovich
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - G William Dec
- Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Dastidar AG, Rodrigues JCL, Ahmed N, Baritussio A, Bucciarelli-Ducci C. The Role of Cardiac MRI in Patients with Troponin-Positive Chest Pain and Unobstructed Coronary Arteries. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8:28. [PMID: 26146527 PMCID: PMC4483181 DOI: 10.1007/s12410-015-9345-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Acute coronary syndrome (ACS) still remains one of the leading causes of mortality and morbidity worldwide. Seven to fifteen percent of patients presenting with ACS have unobstructed coronary artery disease (CAD) on urgent angiography. Patients with ACS and unobstructed coronary arteries represent a clinical dilemma and their diagnosis and management is quite variable in current practice. Cardiovascular magnetic resonance imaging with its unique non-invasive myocardial tissue characterization property has the potential to identify underlying etiologies and reach a final diagnosis. These include acute and chronic myocarditis, embolic/spontaneous recanalization myocardial infarction, and Tako-Tsubo cardiomyopathy, and other conditions. Establishing a final diagnosis has a direct implication on patient's management and prognosis. In this article, we have reviewed the current evidence on the diagnostic role of cardiac magnetic resonance (CMR) in patients with ACS and unobstructed coronary arteries. We have also highlighted the potential role of CMR as a risk stratification or prognostication tool for this patient population.
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Affiliation(s)
- Amardeep Ghosh Dastidar
- NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Malborough St, Bristol, BS2 8HW UK
| | - Jonathan C. L. Rodrigues
- NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Malborough St, Bristol, BS2 8HW UK
| | - Nauman Ahmed
- NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Malborough St, Bristol, BS2 8HW UK
| | - Anna Baritussio
- NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Malborough St, Bristol, BS2 8HW UK
| | - Chiara Bucciarelli-Ducci
- NIHR Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Malborough St, Bristol, BS2 8HW UK
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77
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Structural and functional cardiac analyses using modern and sensitive myocardial techniques in adult Pompe disease. Int J Cardiovasc Imaging 2015; 31:947-56. [PMID: 25744427 DOI: 10.1007/s10554-015-0629-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 02/17/2015] [Indexed: 01/22/2023]
Abstract
The purpose of this study was to analyze comprehensively the heart using modern and sensitive myocardial techniques in order to determine if structural or functional cardiac alterations are present in adult Pompe disease. Twelve patients with adult Pompe disease and a control group of 187 healthy subjects of similar age and gender were included. Structural and functional cardiac characteristics were analyzed by conventional and 2D speckle-tracking echocardiography. In addition, in a subgroup of adult Pompe patients, we analyzed the myocardial and musculoskeletal features by means of cardiac and whole-body muscle magnetic resonance imaging. Patients with Pompe disease had significant structural and functional musculoskeletal alterations such as atrophy with fatty replacement and weakness in trunk and extremities. In contrast, Pompe patients had similar structural and functional myocardial features to healthy subjects (LV strain -20.7 ± 1.9 vs. -21.3 ± 2.1%; RV strain -24.2 ± 5.3 vs. -24.8 ± 3.8%; LA strain 41.5 ± 10.3 vs. 44.8 ± 11.0%; P > 0.05; and no evidence of LV and RV hypertrophy or LA enlargement). In addition, there was no evidence of valvular cardiac alterations, electrocardiographic abnormalities, or myocardial fibrosis in Pompe patients. In the current study analyzing the heart with modern and sensitive myocardial techniques, we evidenced that functional and structural cardiac alterations are not present when Pompe disease begins in adulthood. Therefore, these findings suggest that adult Pompe disease should not be taken into consideration in the differential diagnostic of structural or functional cardiac disorders.
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Sachdeva S, Song X, Dham N, Heath DM, DeBiasi RL. Analysis of clinical parameters and cardiac magnetic resonance imaging as predictors of outcome in pediatric myocarditis. Am J Cardiol 2015; 115:499-504. [PMID: 25554534 DOI: 10.1016/j.amjcard.2014.11.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022]
Abstract
Myocarditis causes significant morbidity and mortality in pediatric patients, with potential adverse outcomes including heart failure, transplantation requirement, and/or death. The objective of this study was to determine predictors of early and late poor outcomes, defined as requirement for extracorporeal membrane oxygenation, ventricular assist device, transplantation, or death in pediatric myocarditis patients. A retrospective cohort study was conducted to evaluate pediatric myocarditis presenting over a 5-year period at a pediatric institution. Patients were identified using an institutional heart failure database and International Classification of Diseases, Ninth Revision, discharge diagnosis codes for myocarditis and confirmed by review of medical records. Data extraction included epidemiologic factors, the presenting ejection fraction (EF), initial and peak troponin levels, brain natriuretic peptide (BNP) level, pathogen identification, cardiac magnetic resonance imaging (MRI), and outcomes. Univariate and multivariate regression was performed to identify variables predictive of outcomes. Because published pediatric cardiac MRI data are sparse, whether late enhancement was associated with specific clinical variables or predictive of outcomes was also evaluated. Fifty-eight patients were identified. The mean age was 10.5 years, 64% were male, 62% were Caucasian, 15% were African-American, and 23% were Hispanic or Asian. Eighty-one percent presented at the institution <1 week after symptom onset. Presenting EFs were normal (>50%) or mildly decreased (40% to 50%) in 48%, moderately decreased (30% to 40%) in 9%, and severely decreased (<30%) in 42%. Thirty patients (52%) underwent viral studies; 17 of these (56%) had acute viral origins of myocarditis identified, including 8 with parvovirus (2 with influenza coinfection), 7 with enterovirus, 1 with Epstein-Barr virus, and 1 with cytomegalovirus. Twenty-eight percent had poor outcomes. Univariate analysis identified Hispanic or Asian race (odds ratio [OR] 4.5, p = 0.05), a severely decreased EF (OR 13, p = 0.002), initial BNP >10,000 pg/ml (OR 5.6, p = 0.01), and peak BNP >10,000 pg/ml (OR 13.65, p = 0.001) as risk factors for poor outcomes; initial and peak troponin >1 ng/ml were correlated significantly with good outcomes (OR 0.22, p = 0.04, and OR 0.26, p = 0.05, respectively). Multivariate analysis adjusting for severe EF, troponin, BNP, and cardiac MRI revealed peak BNP >10,000 ng/L (OR 27.71, p = 0.04), a severely decreased EF (OR 12.8, p = 0.03), and late enhancement on cardiac MRI (OR 24.51, p = 0.04) as risk factors for poor outcomes. Thirty-four patients underwent cardiac MRI (50% with abnormal and 50% with normal results). No significant differences were found between these groups with respect to gender, race, symptom duration, the EF, BNP, troponin, inflammation on cardiac biopsy, or pathogen identification. In conclusion, this study provides data from a large cohort of pediatric myocarditis patients. A presenting EF <30%, peak BNP >10,000 ng/L, and cardiac MRI late enhancement were identified as predictors of poor outcomes.
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Abstract
During the past century, cardiac imaging technologies have revolutionized the diagnosis and treatment of acquired and congenital heart disease. Many important contributions to the field of cardiac imaging were initially reported in Radiology. The field developed from the early stages of cardiac imaging, including the use of coronary x-ray angiography and roentgen kymography, to nowadays the widely used echocardiographic, nuclear medicine, cardiac computed tomographic (CT), and magnetic resonance (MR) applications. It is surprising how many of these techniques were not recognized for their potential during their early inception. Some techniques were described in the literature but required many years to enter the clinical arena and presently continue to expand in terms of clinical application. The application of various CT and MR contrast agents for the diagnosis of myocardial ischemia is a case in point, as the utility of contrast agents continues to expand the noninvasive characterization of myocardium. The history of cardiac imaging has included a continuous process of advances in our understanding of the anatomy and physiology of the cardiovascular system, along with advances in imaging technology that continue to the present day.
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Affiliation(s)
- Albert de Roos
- From the Department of Radiology, Leiden University Medical Center, C2-S, Albinusdreef 2, Leiden, South-Holland 2333 ZA, the Netherlands (A.d.R); and Department of Radiology, University of California-San Francisco, San Francisco, Calif (C.B.H.)
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Hinojar R, Foote L, Arroyo Ucar E, Jackson T, Jabbour A, Yu CY, McCrohon J, Higgins DM, Carr-White G, Mayr M, Nagel E, Puntmann VO. Native T1 in discrimination of acute and convalescent stages in patients with clinical diagnosis of myocarditis: a proposed diagnostic algorithm using CMR. JACC Cardiovasc Imaging 2014; 8:37-46. [PMID: 25499131 DOI: 10.1016/j.jcmg.2014.07.016] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/15/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study investigated whether T1 mapping by cardiac magnetic resonance (CMR) reflects the clinical evolution of disease in myocarditis and supports its diagnosis independently of the disease stages. BACKGROUND Acute viral myocarditis is characterized by a range of intracellular changes due to viral replication and extracellular spill of debris within days of viral infection. Convalescence may be characterized by a chronic low-grade inflammation leading to ventricular remodelling, but also a complete resolution of myocardial changes. METHODS Patients with clinical diagnosis of viral myocarditis (N = 165) underwent routine clinical CMR protocol (1.5- and 3.0-T) for assessment of cardiac function and structure, and tissue characterization with T2-weighted imaging and late gadolinium enhancement. T1 mapping was obtained in a mid-ventricular short-axis slice before and >20 min after administration of 0.2 mmol/kg of gadobutrol. RESULTS Compared with control subjects (n = 40), T1 indexes were increased in patients with myocarditis. Patients with acute symptoms (n = 61) had higher values of T1 indexes compared with patients in clinical convalescence (n = 67). Native T1 is an independent discriminator between health and disease, as well as a discriminator between acute and convalescent stage of the disease. Native T1- was superior to T2-weighted imaging and late gadolinium enhancement with high diagnostic accuracy and positive and negative predictive values. Using pre-defined cutoff values for normal ranges, we demonstrated that acute myocarditis can be independently identified by native T1 of >5 SD above the mean of normal range, whereas convalescence is best defined by either abnormal native T1 (>2 SD) or presence of late gadolinium enhancement. We prospectively tested a new diagnostic algorithm in an independent dataset of patients with clinical diagnosis of myocarditis and achieved similar diagnostic performance. CONCLUSIONS The new diagnostic algorithm using native T1 can reliably discriminate between health and disease and determine the clinical disease stage in patients with a clinical diagnosis of myocarditis.
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Affiliation(s)
- Rocio Hinojar
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom
| | - Lucy Foote
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom
| | - Eduardo Arroyo Ucar
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom
| | - Thomas Jackson
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom
| | - Andrew Jabbour
- St. Vincent's Hospital and the Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Chung-Yao Yu
- St. Vincent's Hospital and the Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Jane McCrohon
- St. Vincent's Hospital and the Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | | | | | - Manuel Mayr
- Cardiovascular Division, King's College London, London, United Kingdom
| | - Eike Nagel
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom
| | - Valentina O Puntmann
- Cardiovascular Imaging Department, Division of Imaging Sciences, King's College London, London, United Kingdom.
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Péter A, Balogh Á, Szilágyi S, Faludi R, Nagy-Vincze M, Édes I, Dankó K. Echocardiographic abnormalities in new-onset polymyositis/dermatomyositis. J Rheumatol 2014; 42:272-81. [PMID: 25433528 DOI: 10.3899/jrheum.140626] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify early echocardiographic abnormalities at the time of diagnosis of polymyositis (PM) and dermatomyositis (DM) and follow the echocardiographic findings during the first 3 months of therapy. METHODS We included 30 PM/DM patients (23/7) with a mean age of 42.3 ± 1.6 years and without cardiovascular symptoms. Age-matched healthy patients served as controls. Clinical characteristics were recorded. Traditional echocardiography and tissue Doppler imaging (TDI) were performed to measure systolic [ejection fraction, right ventricular fractional area change (RV FAC), lateral and tricuspid annulus s velocities] and diastolic echocardiographic variables (mitral inflow velocities: E, A; deceleration time: DT; lateral and tricuspid annulus e', a' velocities, lateral E/e'). RESULTS The left and right ventricular systolic dysfunction detected by TDI at the time of the PM/DM diagnosis improved, and characteristic values at the end of the followup period were comparable to those of the controls (lateral s: 10.6 ± 0.2, 8.7 ± 0.4, 9.6 ± 0.3, 11.3 ± 0.2 cm/s; RV FAC: 45.2 ± 2.3, 36.9 ± 1.5, 42.2 ± 1.3, 46.9 ± 1.2%; tricuspid s: 13.3 ± 0.2, 9.5 ± 0.4, 10.3 ± 0.3, 11.6 ± 0.5 cm/s; control, 0, 1, and 3 mos, respectively). Measurements indicated the development of diastolic dysfunction at 3 mos (E/A: 1.4 ± 0.1, 1.29 ± 0.05, 1.03 ± 0.05, 0.92 ± 0.05; DT: 148.6 ± 3.6, 157.3 ± 5.7, 168.3 ± 6.0, 184.3 ± 6.2 ms; lateral e': 12.8 ± 0.3, 12.1 ± 0.5, 10.2 ± 0.6, 10.8 ± 0.8 cm/s; E/e': 5.6 ± 0.1, 5.0 ± 0.22, 6.92 ± 0.46, 7.64 ± 0.47; control, 0, 1, and 3 mos, respectively). CONCLUSION TDI is a useful method to detect early cardiac abnormalities complementing the conventional echocardiographic measurements. LV and RV systolic dysfunction found in the acute phase significantly improved during the first 3 months of therapy; however, deterioration of diastolic dysfunction was also observed.
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Affiliation(s)
- Andrea Péter
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen.
| | - Ágnes Balogh
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
| | - Szabolcs Szilágyi
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
| | - Réka Faludi
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
| | - Melinda Nagy-Vincze
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
| | - István Édes
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
| | - Katalin Dankó
- From the Institute of Cardiology, and the Institute of Internal Medicine, University of Debrecen, Debrecen; Heart Institute, University of Pécs, Pécs, Hungary; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK.A. Péter, MD; Á. Balogh, MD, PhD, Institute of Cardiology, University of Debrecen; S. Szilágyi, MD, PhD, Cardiothoracic Centre, Freeman Hospital; R. Faludi, MD, PhD, Heart Institute, University of Pécs; M. Nagy-Vincze, MD, Institute of Internal Medicine, University of Debrecen; I. Édes, MD, PhD, DSc, Institute of Cardiology, University of Debrecen; K. Dankó, MD, PhD, DSc, Institute of Internal Medicine, University of Debrecen
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Abstract
Cardiovascular magnetic resonance using late gadolinium enhancement (LGE) provides a unique opportunity to assess myocardial tissue in vivo. LGE enables tissue characterization in ischemic and nonischemic cardiomyopathies and other cardiac diseases. LGE is associated with adverse clinical outcomes across a range of different cardiac conditions and may improve risk stratification for death, sudden cardiac death, or serious adverse events beyond traditional prognostic markers. Generally, matching data for the prognostic impact of LGE are frequently reached in cardiac disorders. In other diseases, only a limited number of trials are available, but it is anticipated that the prognostic impact of delayed enhancement will become evident. The development and validation of new cardiovascular magnetic resonance methods for diffuse myocardial fibrosis measurements would even improve the prognostic impact of LGE. The evaluation of diffuse myocardial fibrosis has a great potential in large-scale diseases, including their initial phases, with the possibility to identify patients at risk for subsequent development of clinical heart failure, to assess repeatedly the stage and progression of cardiac diseases, and to monitor the effect of treatment.
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83
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Morris DA, Blaschke D, Canaan-Kühl S, Krebs A, Knobloch G, Walter TC, Haverkamp W. Global cardiac alterations detected by speckle-tracking echocardiography in Fabry disease: left ventricular, right ventricular, and left atrial dysfunction are common and linked to worse symptomatic status. Int J Cardiovasc Imaging 2014; 31:301-13. [PMID: 25315709 DOI: 10.1007/s10554-014-0551-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/07/2014] [Indexed: 01/29/2023]
Abstract
The aim of this study was to test the hypothesis that in patients with Fabry disease, 2D speckle-tracking echocardiography (2DSTE) could detect functional myocardial alterations such as left ventricular (LV), right ventricular (RV), and left atrial (LA) dysfunction, even when conventional cardiac measurements are normal. In addition, we hypothesized that these global cardiac alterations could be linked to worse symptomatic status in these patients. Fifty patients with Fabry disease and a control group of 118 healthy subjects of similar age and gender were included. The myocardial function and structural changes of the LV, RV, and LA were analyzed by 2DSTE and cardiac magnetic resonance imaging. Patients with Fabry disease had significantly lower functional myocardial values of the LV, RV, and LA than healthy subjects (LV, RV, and LA strain -18.1 ± 4.0, -21.4 ± 4.9, and 29.7 ± 9.9 % vs. -21.6 ± 2.2, -25.2 ± 4.0, and 44.8 ± 11.1 %, respectively, P < 0.001) and elevated rates of LV, RV, and LA myocardial dysfunction (24, 20, and 26 %, respectively), even when conventional cardiac measurements such as LVEF, TAPSE, and LAVI were normal. LV septal wall thickness ≥15 mm, RV free wall thickness ≥7 mm, and LV longitudinal dysfunction were the principal factors linked to reduced LV, RV, and LA strain, respectively. In addition, but to a lesser extent, LV and RV fibrosis were linked to reduced LV and RV strain. Patients with reduced LV, RV, and LA strain had worse functional class (dyspnea-NYHA classification) than those with normal cardiac function. In conclusion, in patients with Fabry disease, 2DSTE analyses detect LV, RV, and LA functional myocardial alterations, even when conventional cardiac measurements are normal. These functional myocardial alterations are common and significantly associated with worse symptomatic status in Fabry patients. Therefore, these findings provide important evidence to introduce global myocardial analyses using 2DSTE in the early detection of functional cardiac alterations in Fabry disease.
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Affiliation(s)
- Daniel A Morris
- Department of Cardiology, Charité University Hospital, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany,
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84
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Natalia S, Lilyasari O, Wicaksono SH, Kasim M. Clinical presentation of myocarditis in pediatric: the role of cardiac magnetic resonance in diagnosis. MEDICAL JOURNAL OF INDONESIA 2014. [DOI: 10.13181/mji.v23i3.654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Myocarditis is an inflammatory disease of myocard with varied onset and clinical presentation which lead to diagnosis difficulties. These difficulties often cause incoming patients with acute condition are not diagnosed as acute myocarditis that subsequently may lead to improper therapy. This circumstance will probably cause more severe myocardial injury and even sudden death. On another circumstance, patients may also come late in conditions of dilated cardiomyopathy (DCM) or aritmogenik cardiomyopathy (ARVD) due to complexities of myocarditis early detection. Therefore, myocarditis diagnosis is extremely important. This case shows how CMR is important and highly accurate in diagnosing myocarditis through a case whereby a boy had complaints of chest pain and his CMR examination showed normal cardiac morphology with normal function of right and left ventricular, but with myocardial edema and tissue fibrosis, which confirmed the diagnosis of myocarditis according to the Lake Louise Consensus criteria. CMR is an important and high accuracy non-invasive diagnostic tool in myocarditis diagnosis.
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85
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Kanaganayagam GS, Ngo AT, Alsafi A, Kamanahalli R, Sutaria N, Mittal T, Ariff B. CT coronary angiography in the investigation of chest pain — Beyond coronary artery atherosclerosis; A pictorial review. Int J Cardiol 2014; 176:618-29. [DOI: 10.1016/j.ijcard.2014.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 07/13/2014] [Accepted: 08/05/2014] [Indexed: 12/26/2022]
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Hsing J, Peters DC, Knowles BR, Manning WJ, Josephson ME. Cardiovascular magnetic resonance imaging of scar development following pulmonary vein isolation: a prospective study. PLoS One 2014; 9:e104844. [PMID: 25251403 PMCID: PMC4174508 DOI: 10.1371/journal.pone.0104844] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/17/2014] [Indexed: 11/30/2022] Open
Abstract
Aims Cardiovascular magnetic resonance (MR) provides non-invasive assessment of early (24-hour) edema and injury following pulmonary vein isolation (by ablation) and subsequent scar formation. We hypothesize that 24-hours after ablation, cardiovascular MR would demonstrate a pattern of edema and injury due to ablation and the severity would correlate with subsequent scar. Methods Fifteen atrial fibrillation patients underwent cardiovascular MR prior to pulmonary vein isolation, 24-hours post (N = 11) and 30-days post (N = 7) ablation, with T2-weighted (T2W) and late gadolinium enhancement (LGE) imaging. Left atrial wall thickness, edema enhancement ratio and LGE enhancement were assessed at each time point. Volumes of LGE and edema enhancement were measured, and the circumferential presence of injury was assessed at 24-hours, including comparison with LGE enhancement at 30 days. Results Left atrial wall thickness was increased 24-hours post-ablation (10.7±4.1 mm vs. 7.0±1.8 mm pre-PVI, p<0.05). T2W enhancement at 24-hours showed increased edema enhancement ratio (1.5±0.4 for post-ablation, vs. 0.9±0.2 pre-ablation, p<0.001). Edema and LGE volumes at 24-hours were correlated with 30-day LGE volume (R = 0.76, p = 0.04, and R = 0.74, p = 0.09, respectively). Using a 16 segment model for assessment, 24-hour T2W had sensitivity, specificity, and accuracy of 82%, 63%, and 79% respectively, for predicting 30-day LGE. 24-hour LGE had sensitivity, specificity, and accuracy of 91%, 47%, and 84%. Conclusions Increased left atrial wall thickening and edema were characterized on cardiovascular MR early post-ablation, and found to correlate with 30-day LGE scar.
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Affiliation(s)
- Jeff Hsing
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dana C. Peters
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Radiology, Yale Medical School, New Haven, Connecticut, United States of America
- * E-mail:
| | - Benjamin R. Knowles
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Warren J. Manning
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Mark E. Josephson
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
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Weisser-Thomas J, Ferrari VA, Lakghomi A, Lickfett LM, Nickenig G, Schild HH, Thomas D. Prevalence and clinical relevance of the morphological substrate of ventricular arrhythmias in patients without known cardiac conditions detected by cardiovascular MR. BJR Case Rep 2014. [DOI: 10.1259/bjrcr.20140059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Yilmaz A, Ferreira V, Klingel K, Kandolf R, Neubauer S, Sechtem U. Role of cardiovascular magnetic resonance imaging (CMR) in the diagnosis of acute and chronic myocarditis. Heart Fail Rev 2014; 18:747-60. [PMID: 23076423 DOI: 10.1007/s10741-012-9356-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The aetiopathogenesis of acute and chronic myocarditis is rather complex as a great variety of infectious agents can induce cardiac inflammation. Moreover, many systemic and autoimmune diseases such as sarcoidosis, giant cell myocarditis and systemic lupus erythematodes, drugs and toxins have been described as non-infectious causes of inflammatory heart disorders. Myocarditis may cause sudden death and lead to dilated cardiomyopathy. The correct and timely diagnosis of myocarditis is still a difficult clinical challenge, since the clinical spectrum of myocarditis is broad and comprises (amongst others) even those patients with no symptoms or those presenting with acute cardiogenic shock. Although endomyocardial biopsy still represents the gold standard for the diagnosis of myocarditis, new non-invasive imaging techniques such as cardiovascular magnetic resonance (CMR) imaging promise the non-invasive diagnosis of myocarditis. Considering the hallmarks of acute and chronic myocarditis (accumulation of inflammatory cells; swelling, necrosis and/or apoptosis of cardiomyocytes; increase in extracellular space and water content; myocardial remodelling with fibrotic tissue replacement), an imaging modality such as CMR that enables non-invasive detection of changes in myocardial tissue composition is highly valuable and welcome. This review will focus on the 'clinical role' of CMR in the diagnosis of acute and chronic myocarditis.
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Affiliation(s)
- Ali Yilmaz
- Division of Cardiology, Robert-Bosch-Krankenhaus, Auerbachstrasse 110, 70376, Stuttgart, Germany,
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Stojanovska J, Garg A, Patel S, Melville DM, Kazerooni EA, Mueller GC. Congenital and hereditary causes of sudden cardiac death in young adults: diagnosis, differential diagnosis, and risk stratification. Radiographics 2014; 33:1977-2001. [PMID: 24224591 DOI: 10.1148/rg.337125073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sudden cardiac death is defined as death from unexpected circulatory arrest-usually a result of cardiac arrhythmia-that occurs within 1 hour of the onset of symptoms. Proper and timely identification of individuals at risk for sudden cardiac death and the diagnosis of its predisposing conditions are vital. A careful history and physical examination, in addition to electrocardiography and cardiac imaging, are essential to identify conditions associated with sudden cardiac death. Among young adults (18-35 years), sudden cardiac death most commonly results from a previously undiagnosed congenital or hereditary condition, such as coronary artery anomalies and inherited cardiomyopathies (eg, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy [ARVC], dilated cardiomyopathy, and noncompaction cardiomyopathy). Overall, the most common causes of sudden cardiac death in young adults are, in descending order of frequency, hypertrophic cardiomyopathy, coronary artery anomalies with an interarterial or intramural course, and ARVC. Often, sudden cardiac death is precipitated by ventricular tachycardia or fibrillation and may be prevented with an implantable cardioverter defibrillator (ICD). Risk stratification to determine the need for an ICD is challenging and involves imaging, particularly echocardiography and cardiac magnetic resonance (MR) imaging. Coronary artery anomalies, a diverse group of congenital disorders with a variable manifestation, may be depicted at coronary computed tomographic angiography or MR angiography. A thorough understanding of clinical risk stratification, imaging features, and complementary diagnostic tools for the evaluation of cardiac disorders that may lead to sudden cardiac death is essential to effectively use imaging to guide diagnosis and therapy.
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Affiliation(s)
- Jadranka Stojanovska
- From the Department of Radiology, Division of Cardiothoracic Radiology (J.S., S.P., D.M.M., E.A.K., G.C.M.), and Department of Internal Medicine, Division of Cardiovascular Medicine (A.G.), University of Michigan Health System, 1500 E Medical Center Dr, UH B1-132 Taubman, Box 0302, Ann Arbor, MI 48109-0302
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Vermes E, Childs H, Faris P, Friedrich MG. Predictive value of CMR criteria for LV functional improvement in patients with acute myocarditis. Eur Heart J Cardiovasc Imaging 2014; 15:1140-4. [DOI: 10.1093/ehjci/jeu099] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Luetkens JA, Doerner J, Thomas DK, Dabir D, Gieseke J, Sprinkart AM, Fimmers R, Stehning C, Homsi R, Schwab JO, Schild H, Naehle CP. Acute myocarditis: multiparametric cardiac MR imaging. Radiology 2014; 273:383-92. [PMID: 24910904 DOI: 10.1148/radiol.14132540] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the diagnostic value of cardiac magnetic resonance (MR) imaging at 3 T in patients suspected of having acute myocarditis by using a multiparametric cardiac MR imaging approach including T1 relaxation time as an additional tool for tissue characterization. MATERIALS AND METHODS Ethics commission approval was obtained for this prospective study, and written informed consent was obtained from all subjects. Twenty four patients with acute myocarditis (mean age ± standard deviation, 34.7 years ± 15.1; 75% men) and 42 control subjects (mean age, 38.7 years ± 10.2; 64% men) were included. Cardiac MR imaging approaches included relative T2 short tau inversion-recovery signal intensity ratio (T2 ratio), early gadolinium enhancement ratio, late gadolinium enhancement, native T1 relaxation times, and extracellular volume fraction. Receiver operating characteristic analysis was performed to compare diagnostic performance. The reference standard was the clinical evidence for acute myocarditis. RESULTS Native T1 relaxation times were significantly longer in patients with acute myocarditis than in control subjects (1185.3 msec ± 49.3 vs 1089.1 msec ± 44.9, respectively; P < .001). Areas under the curve of native T1 relaxation times (0.94) were higher compared with those of other cardiac MR parameters (late gadolinium enhancement, 0.90; T2 ratio, 0.79; extracellular volume fraction, 0.71; early gadolinium enhancement ratio, 0.63; P = .390, .018, .002, and < .001, respectively). Sensitivity (92%), specificity (91%), and diagnostic accuracy (91%) for native T1 relaxation times (cutoff, 1140 msec) were equivalent compared with those of the established combined Lake Louise criteria (sensitivity, 92%; specificity, 80%; diagnostic accuracy, 85%). CONCLUSION Diagnostic performance with native T1 mapping was superior to that with T2 ratio and early gadolinium enhancement ratio, and specificity was higher with native T1 mapping than that with Lake Louise criteria. This study underlines the potential of native T1 relaxation times to complement current cardiac MR approaches in patients suspected of having acute myocarditis.
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Affiliation(s)
- Julian A Luetkens
- From the Departments of Radiology (J.A.L., J.D., D.K.T., D.D., J.G., A.M.S., R.H., H.S., C.P.N.), Medical Biometry (R.F.), and Cardiology (J.O.S.), University of Bonn, Sigmund-Freud-Str 25, 53127 Bonn, Germany; and Philips Research, Hamburg, Germany (J.G., C.S.)
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Krieghoff C, Barten MJ, Hildebrand L, Grothoff M, Lehmkuhl L, Lücke C, Andres C, Nitzsche S, Riese F, Strüber M, Mohr FW, Gutberlet M. Assessment of sub-clinical acute cellular rejection after heart transplantation: comparison of cardiac magnetic resonance imaging and endomyocardial biopsy. Eur Radiol 2014; 24:2360-71. [PMID: 24895035 PMCID: PMC4155184 DOI: 10.1007/s00330-014-3246-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 03/31/2014] [Accepted: 05/15/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Comparing the diagnostic value of multi-sequential cardiac magnetic resonance imaging (CMR) with endomyocardial biopsy (EMB) for sub-clinical cardiac allograft rejection. METHODS One hundred and forty-six examinations in 73 patients (mean age 53 ± 12 years, 58 men) were performed using a 1.5 Tesla system and compared to EMB. Examinations included a STIR (short tau inversion recovery) sequence for calculation of edema ratio (ER), a T1-weighted spin-echo sequence for assessment of global relative enhancement (gRE), and inversion-recovery sequences to visualize late gadolinium enhancement (LGE). Histological grade ≥1B was considered relevant rejection. RESULTS One hundred and twenty-seven (127/146 = 87 %) EMBs demonstrated no or mild signs of rejection (grades ≤1A) and 19/146 (13 %) a relevant rejection (grade ≥1B). Sensitivity, specificity, positive predictive, and negative predictive values were as follows: ER: 63 %, 78 %, 30 %, and 93 %; gRE: 63 %, 70 %, 24 %, and 93 %; LGE: 68 %, 36 %, 13 %, and 87 %; with the combination of ER and gRE with at least one out of two positive: 84 %, 57 %, 23 %, and 96 %. ROC analysis revealed an area under the curve of 0.724 for ER and 0.659 for gRE. CONCLUSION CMR parameters for myocarditis are useful to detect sub-clinical acute cellular rejection after heart transplantation. Comparable results to myocarditis can be achieved with a combination of parameters. KEY POINTS • Magnetic resonance imaging is useful for the assessment of cardiac allograft rejection. • CMR has a high negative predictive value for exclusion of allograft rejection. • Diagnostic performance is not yet good enough to replace endomyocardial biopsy.
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Affiliation(s)
- Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, University Leipzig - Heart Centre, Leipzig, Germany,
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Acute results and long-term follow-up of patients with accompanying myocarditis after viral respiratory or gastrointestinal tract infection. Int J Cardiol 2014; 174:853-5. [PMID: 24836685 DOI: 10.1016/j.ijcard.2014.04.196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 04/17/2014] [Indexed: 11/20/2022]
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Weisser-Thomas J, Ferrari VA, Lakghomi A, Lickfett LM, Nickenig G, Schild HH, Thomas D. Prevalence and clinical relevance of the morphological substrate of ventricular arrhythmias in patients without known cardiac conditions detected by cardiovascular MR. Br J Radiol 2014; 87:20140059. [PMID: 24712323 DOI: 10.1259/bjr.20140059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Cardiac MR (CMR) identifies the substrate of ventricular arrhythmia (VA) in cardiomyopathies and coronary heart disease. However, little is known about the value of CMR in patients with VA without previously known cardiac disorders. METHODS 76 patients with VA (Lown ≥2) without known cardiac disease after regular diagnostic work-up were studied with CMR, and findings were correlated with electrocardiogram (ECG) and electrophysiological stimulation (EPS). Structural abnormalities matching the VA origin as defined by ECG and/or EPS, or a CMR-detected cardiac condition known to cause arrhythmia were defined as VA substrate. CMR findings were defined as clinically relevant, if resulting in a new diagnosis, change of treatment or additional diagnostic procedure. RESULTS 44/76 patients demonstrated pathological CMR findings. In 24/76 patients, the pathology was detected by CMR and not by echocardiography. CMR-based diagnoses of cardiac disease were established in 20/76 patients, and all were morphological substrates for VA. In seven patients, the location of the CMR finding (scar) directly matched the VA origin. CMR findings resulted in a change of treatment in 21 patients and/or additional diagnostics in 8 patients. CONCLUSION Undetected cardiac conditions are frequent causes of VA. This is the first study demonstrating the value of CMR for detection of morphological substrate and/or underlying cardiac disorders in VA patients without known cardiac disease. ADVANCES IN KNOWLEDGE The high incidence of clinically relevant CMR findings which were not detected during initial diagnostic work-up strongly supports the use of CMR to screen VA patients for underlying heart disease.
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Bitar ZI, Swede M, Almerri K. ST elevation without myocardial infarction. BMJ Case Rep 2014; 2014:bcr-2013-201160. [PMID: 24711464 DOI: 10.1136/bcr-2013-201160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute myocarditis may mimic myocardial infarction because the affected patients report 'classical' chest pain; the ECG changes and echocardiography are identical to those observed in acute coronary syndromes, and serum markers are increased. We describe a case with ST segment elevation on admission ECG, and coronary angiography was normal. Cardiac magnetic resonance with myocardial delayed enhancement sequences is a non-invasive alternative for diagnosing myocarditis.
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Zhang J, He S, Qi X, Li Y. Combined electrocardiography, coronary angiography and magnetic resonance imaging for the diagnosis of viral myocarditis: A case report. Exp Ther Med 2014; 7:1643-1646. [PMID: 24926359 PMCID: PMC4043629 DOI: 10.3892/etm.2014.1671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 03/14/2014] [Indexed: 12/30/2022] Open
Abstract
Endomyocardial biopsy is the gold standard for diagnosing viral myocarditis. However, this method is rarely used as it is more invasive, less sensitive and has a higher incidence of complications than other methods. With recent developments in myocarditis research, cardiovascular nuclear magnetic resonance imaging has been demonstrated to have a marked advantage over endomyocardial biopsy, specifically regarding the differential diagnosis of acute coronary syndrome, as it is noninvasive, repeatable, highly sensitive and highly specific for diagnosing myocarditis. Myocardial edema is characteristic of myocardial inflammation, myocardial necrosis and myocardial fibrosis. T2-weighted nuclear magnetic resonance imaging sensitively detects myocardial tissue edema and additional imaging parameters contribute to the diagnosis of myocarditis. Therefore, combining these methods with the current sophisticated electrocardiogram and coronary angiography examination methods may facilitate the rapid and accurate assessment of viral myocarditis. A 44-year-old male patient with symptoms of dyspnea and shortness of breath accompanied by dizziness, through electrocardiography, coronary angiography and magnetic resonance imaging, was diagnosed viral myocarditis.
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Affiliation(s)
- Jing Zhang
- Department of Cardiology, Northern Jiangsu People's Hospital, Medical College of Yangzhou University, Yangzhou, Jiangsu 225001, P.R. China
| | - Shenghu He
- Department of Cardiology, Northern Jiangsu People's Hospital, Medical College of Yangzhou University, Yangzhou, Jiangsu 225001, P.R. China
| | - Xiang Qi
- Department of Cardiology, Northern Jiangsu People's Hospital, Medical College of Yangzhou University, Yangzhou, Jiangsu 225001, P.R. China
| | - Yimin Li
- Department of Cardiology, Nanjing Chest Hospital, Nanjing, Jiangsu 210000, P.R. China
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Francone M, Chimenti C, Galea N, Scopelliti F, Verardo R, Galea R, Carbone I, Catalano C, Fedele F, Frustaci A. CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis. JACC Cardiovasc Imaging 2014; 7:254-63. [PMID: 24560214 DOI: 10.1016/j.jcmg.2013.10.011] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/08/2013] [Accepted: 10/10/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether clinical presentation and type of cell death in acute myocarditis might contribute to cardiac magnetic resonance (CMR) sensitivity. BACKGROUND Growing evidence indicates CMR is the reference noninvasive tool for the diagnosis of acute myocarditis. However, factors affecting CMR sensitivity are still unclear. METHODS We retrospectively evaluated 57 consecutive patients with a diagnosis of acute myocarditis made on the basis of clinical history (≤3 months) and endomyocardial biopsy evidence of lymphocytic infiltrates (≥14 infiltrating leukocytes/mm(2) at immunohistochemistry) in association with damage of the adjacent myocytes and absence or minimal evidence of myocardial fibrosis. CMR acquisition protocol included T2-weighted (edema), early (hyperemia), and late (fibrosis/necrosis) gadolinium enhancement sequences. Presence of ≥2 CMR criteria denoted myocarditis. Type of cell death was evaluated by using in situ ligation with hairpin probes. RESULTS Three clinical myocarditis patterns were recognized: infarct-like (pattern 1, n = 21), cardiomyopathic (pattern 2, n = 21), and arrhythmic (pattern 3, n = 15). Tissue edema was observed in 81% of pattern 1, 28% of pattern 2, and 27% of pattern 3. Early enhancement was evident in 71% of pattern 1, 67% of pattern 2, and 40% of pattern 3. Late gadolinium enhancement was documented in 71% of pattern 1, 57% of pattern 2, and 47% of pattern 3. CMR sensitivity was significantly higher in pattern 1 (80%) compared with pattern 2 (57%) and pattern 3 (40%) (p < 0.05). Cell necrosis was the prevalent mechanism of death in pattern 1 compared with pattern 2 (p < 0.001) and pattern 3 (p < 0.05), whereas apoptosis prevailed in pattern 2 (p < 0.001 vs. pattern 1 and p < 0.05 vs. pattern 3). CONCLUSIONS In acute myocarditis, CMR sensitivity is high for infarct-like, low for cardiomyopathic, and very low for arrhythmic clinical presentation; it correlates with the extent of cell necrosis-promoting expansion of interstitial space.
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Affiliation(s)
- Marco Francone
- Department of Radiology, Oncology and Pathology, La Sapienza University, Rome, Italy
| | - Cristina Chimenti
- Department of Cardiovascular, Respiratory, Nefrologic, Anestesiologic and Geriatric Sciences, La Sapienza University, Rome, Italy; IRCCS San Raffaele La Pisana, Rome, Italy
| | - Nicola Galea
- Department of Radiology, Oncology and Pathology, La Sapienza University, Rome, Italy
| | | | | | - Roberto Galea
- Fondazione IRCSS Ospedale Maggiore Policlinico Università degli Studi di Milano, Rome, Italy
| | - Iacopo Carbone
- Department of Radiology, Oncology and Pathology, La Sapienza University, Rome, Italy
| | - Carlo Catalano
- Department of Radiology, Oncology and Pathology, La Sapienza University, Rome, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nefrologic, Anestesiologic and Geriatric Sciences, La Sapienza University, Rome, Italy
| | - Andrea Frustaci
- Department of Cardiovascular, Respiratory, Nefrologic, Anestesiologic and Geriatric Sciences, La Sapienza University, Rome, Italy; IRCCS L. Spallanzani, Rome, Italy.
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Edema and fibrosis imaging by cardiovascular magnetic resonance: how can the experience of Cardiology be best utilized in rheumatological practice? Semin Arthritis Rheum 2014; 44:76-85. [PMID: 24582213 DOI: 10.1016/j.semarthrit.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/19/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis. METHOD CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies. RESULTS Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs. CONCLUSION The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.
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A fast and effective method to assess myocardial hyperemia in acute myocarditis by magnetic resonance. Int J Cardiovasc Imaging 2014; 30:629-37. [PMID: 24449336 DOI: 10.1007/s10554-014-0371-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/15/2014] [Indexed: 12/23/2022]
Abstract
Current cardiac magnetic resonance (CMR) quantitative signs for the diagnosis of myocarditis include myocardial edema, fibrosis and myocardial hyperemia (Hyp). Methods for the assessment of Hyp are actually complex and time-consuming. To test a simple and fast method to assess Hyp, using contrast enhancement steady state free precession (ceSSFP) technique. CMR imaging at 1.5T was performed on 39 patients with diagnosis of acute myocarditis and in 20 healthy controls. Hyp was evaluated in systolic and diastolic frames (Hyp-SYS and Hyp-DIA) as areas of myocardial hyperintensity in ceSSFP images early after gadolinium injection. Myocardial edema was evaluated using T2-STIR images. Myocardial fibrosis was assessed in conventional late gadolinium enhancement (LGE) images. A value of ≤12.1 g of Hyp-DIA was obtained as cut-off of normality in healthy controls. Using this threshold, Hyp was detected in 30 patients (77 %) with myocarditis. LGE was detected in 36 patients (92 %), and myocardial edema in 38 (97 %) patients with myocarditis A linear relation was found between Hyp-DIA and the extent of myocardial edema (R(2) 0.48, 95 % CI 0.47-0.85, p < 0.001) and the extent of LGE (R(2) 0.41, 95 % CI 0.31-0.61, p < 0.001). Patients with hyperemia had higher levels of C-reactive protein (p < 0.001), a higher extent of LGE (p < 0.05) and a larger left atrial area (p < 0.05). ceSSFP sequence at CMR is a novel and fast method to assess myocardial hyperemia in patient with acute myocarditis. Compared with non-Hyp subjects, patients with Hyp had more signs of inflammation and myocardial damage.
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