Subclinical left ventricular dysfunction and correlation with regional strain analysis in myocarditis with normal ejection fraction. A new diagnostic criterion

The role of echocardiography in sports cardiology: An expert opinion statement of the Italian Society of Sports Cardiology (SIC sport)

Transthoracic echocardiography (TTE) is routinely required during pre-participation screening in the presence of symptoms, family history of sudden cardiac death or cardiomyopathies <40-year-old, murmurs, abnormal ECG findings or in the follow-up of athletes with a history of cardiovascular disease (CVD). TTE is a cost-effective first-line imaging modality to evaluate the cardiac remodeling due to long-term, intense training, previously known as the athlete's heart, and to rule out the presence of conditions at risk of sudden cardiac death, including cardiomyopathies, coronary artery anomalies, congenital, aortic and heart valve diseases. Moreover, TTE is useful for distinguishing physiological cardiac adaptations during intense exercise from pathological behavior due to an underlying CVD. In this expert opinion statement endorsed by the Italian Society of Sports Cardiology, we discussed common clinical scenarios where a TTE is required and conditions falling in the grey zone between the athlete's heart and underlying cardiomyopathies or other CVD. In addition, we propose a minimum dataset that should be included in the report for the most common indications of TTE in sports cardiology clinical practice.

Prevalence of abnormal left ventricular global longitudinal strain by speckle tracking echocardiography and its prognostic value in patients with COVID-19

IMPORTANCE

Although cardiac injury is a known complication of COVID-19 infection, there is no established tool to predict cardiac involvement and in-hospital mortality in this patient population.

OBJECTIVE

To assess if left ventricular global longitudinal strain (LV-GLS) can detect cardiac involvement and be used as a risk-stratifying parameter for hospitalised patients with COVID-19.

MAIN OUTCOMES AND MEASURES

In-hospital mortality.

RESULTS

We found a statistically significant association between LV-GLS and in-hospital mortality (adjusted OR (aOR)=1.09; 95% CI 1.0 to 1.19, p=0.050). Furthermore, right ventricular fractional area change was significantly associated with in-hospital mortality (aOR=1.04; 95% CI 1.0 to 1.08, p=0.043). Troponin level had no statistically significant association with in-hospital mortality (aOR=3.43; 95% CI 0.78 to 15.03, p=0.101).

CONCLUSION AND RELEVANCE

LV-GLS can be a useful parameter for cardiovascular risk assessment in hospitalised patients with COVID-19 infection.

Echocardiographic parameters of cardiac structure and function in the diagnosis of acute myocarditis in adult patients: A systematic review and meta-analysis

BACKGROUND

Transthoracic echocardiography (TTE) plays a key role in the initial work-up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of myocarditis in adult populations.

METHODS

A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta-analyzed using a random-effects model for effect size, and assessed through standardized mean difference (SMD).

RESULTS

Available data from six studies (with a pooled total of 269 myocarditis patients and 240 controls) revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end-diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) (p ≤ .01 for all). LV-GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46-1.98|). Two studies also demonstrated that impairment in LV-GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF.

CONCLUSIONS

LV-GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population.

HIGHTLIGHTS

What is already known on this subject? Myocarditis is a disease process that is often a diagnosis of exclusion, as it frequently mimics other acute cardiac pathologies. Transthoracic echocardiography is traditionally the initial imaging modality used for noninvasive structural assessment in populations with myocarditis. What might this study add? This study demonstrates that left ventricular (LV) global longitudinal strain, LV ejection fraction and LV end-diastolic diameter can differentiate between myocarditis patients and healthy controls. LV-GLS demonstrated the greatest overall effect size when comparing these two populations, in comparison to the other measures. How might this impact on clinical practice? This study demonstrates that assessment of myocardial deformation indices allows for sensitive discrimination between myocarditis patients from healthy controls. Routine assessment of LV-GLS may serve as an important diagnostic tool in the acute care setting.

Cardiogenic shock presenting in myocardial infarction with myocarditis case report: The role of advanced echocardiography parameter

Myocarditis is distinguished by a wide array of nonspecific symptoms, including chest pain, dyspnea, and palpitations. These symptoms are accompanied by electrocardiographic abnormalities that exhibit similarities to those observed in myocardial infarction. However, the results of coronary angiography frequently, though not consistently, show normal findings. Therefore, the clinical diagnostic procedure often encounters difficulties and is susceptible to the misdiagnosis of myocardial infarction with nonobstructive coronary arteries. The signs of poor cardiac contractility are a common manifestation of myocarditis and can be evaluate with bedside echocardiography. Two-dimensional speckle tracking echocardiography bestows a precise left ventricle (LV) global and regional dysfunction . We present a case of a 40-year-old man with typical chest pain for 8 hours, and dyspnea. He had no significant medical history. This patient was first diagnosed with high lateral ST-elevation myocardial infarction (STEMI) with cardiogenic shock. Angiography examination revealed no significant obstruction of coronary vessels. However, serial left ventricle global longitudinal strain supports the diagnosis of myocarditis. After receiving the treatment for myocarditis, the patient makes a full recovery within 7 days.

Cardiac Magnetic Resonance Relaxometry Parameters, Late Gadolinium Enhancement, and Feature-Tracking Myocardial Longitudinal Strain in Patients Recovered from COVID-19

COVID-19 infection is associated with myocarditis, and cardiovascular magnetic resonance (CMR) is the reference non-invasive imaging modality for myocardial tissue characterization. Quantitative CMR techniques, such as feature tracking (FT) and left ventricular global longitudinal strain (GLS) analysis, have been introduced as promising diagnostic tools to improve the diagnostic accuracy of suspected myocarditis. The aim of this study was to analyze the left ventricular global longitudinal strain (GLS) and the influence of T1 and T2 relaxation times, ECV, and LGE appearance on GLS parameters in a multiparametric imaging protocol in patients who recovered from COVID-19. The 86 consecutive patients enrolled in the study had all recovered from mild or moderate COVID-19 infections; none required hospitalization. Their persistent symptoms and suspected myocarditis led to cardiac magnetic resonance imaging within 3 months of the diagnosis of the SARS-CoV-2 infection. Results: Patients with GLS less negative than -15% had significantly lower LVEF (53.6% ± 8.9 vs. 61.6% ± 4.8; <0.001) and were significantly more likely to have prolonged T1 (28.6% vs. 7.5%; p = 0.019). Left ventricular GLS correlated significantly with T1 (r = 0.303; p = 0.006) and LVEF (r = -0.732; p < 0.001). Left ventricular GLS less negative than -15% was 7.5 times more likely in patients with prolonged T1 (HR 7.62; 95% CI 1.25-46.64). The reduced basal inferolateral longitudinal strain had a significant impact on the global left ventricular longitudinal strain. ROC results suggested that a GLS of 14.5% predicted prolonged T1 relaxation time with the best sensitivity and specificity. Conclusions: CMR abnormalities, including a myocarditis pattern, are common in patients who have recovered from COVID-19. The CMR feature-tracking left ventricular GLS is related to T1 relaxation time and may serve as a novel parameter to detect global and regional myocardial injury and dysfunction in patients with suspected myocardial involvement after recovery from COVID-19.

The effect of hyperbaric oxygen therapy on myocardial function in post-COVID-19 syndrome patients: a randomized controlled trial

Post-COVID-19 condition refers to a range of persisting physical, neurocognitive, and neuropsychological symptoms following SARS-CoV-2 infection. Recent evidence revealed that post-COVID-19 syndrome patients may suffer from cardiac dysfunction and are at increased risk for a broad range of cardiovascular disorders. This randomized, sham-control, double-blind trial evaluated the effect of hyperbaric oxygen therapy (HBOT) on the cardiac function of post-COVID-19 patients with ongoing symptoms for at least three months after confirmed infection. Sixty patients were randomized to receive 40 daily HBOT or sham sessions. They underwent echocardiography at baseline and 1-3 weeks after the last protocol session. Twenty-nine (48.3%) patients had reduced global longitudinal strain (GLS) at baseline. Of them, 13 (43.3%) and 16 (53.3%) were allocated to the sham and HBOT groups, respectively. Compared to the sham group, GLS significantly increased following HBOT (- 17.8 ± 1.1 to - 20.2 ± 1.0, p = 0.0001), with a significant group-by-time interaction (p = 0.041). In conclusion, post-COVID-19 syndrome patients despite normal EF often have subclinical left ventricular dysfunction that is characterized by mildly reduced GLS. HBOT promotes left ventricular systolic function recovery in patients suffering from post COVID-19 condition. Further studies are needed to optimize patient selection and evaluate long-term outcomes.This study was registered with ClinicalTrials.gov, number NCT04647656 on 01/12/2020.

The prevalence of abnormal right ventricle speckle strain in the setting of acute myocarditis and preserved left ventricle function

BACKGROUND

Acute myocarditis has a wide spectrum of clinical presentation, from subclinical disease to acute heart failure, and sudden cardiac death. Two-dimensional speckle tracking echocardiography (2D-STE) has been proven effective in early diagnosis of subclinical cardiac injury, however, there is a limited data regarding the right ventricle (RV) involvement among patients with acute myocarditis.

PURPOSE

We evaluated the prevalence of early subclinical RV injury assessed by 2D-STE, among patients with acute myocarditis and preserved left ventricle (LV) function.

METHODS

We performed a retrospective single-center study at Tel-Aviv Sourasky Medical Center, including all adult patients hospitalized with acute myocarditis, who presented with preserved LV function. 2D-STE analysis of the RV was performed offline, assessing both the RV four-chamber longitudinal strain peak systolic (RV4CLS PK) and the free wall longitudinal strain peak systolic (RVFWLS PK). The myocarditis group was compared to a healthy control group.

RESULTS

From 2011 to 2020, a total of 90 patients included in the study and were compared to 70 healthy subjects. RV 2D-STE emerged as significantly lower for both the RV4CLS PK (-21.8 ± 4.2 vs. -24.9 ± 4.8, P < 0.001) and RVFWLS PK (-24.7 ± 4.9 vs. -28.4 ± 5, P < 0.001), and remained significant in a multivariate analysis.

CONCLUSION

We presented for the first time the presence of subclinical RV dysfunction, assessed by 2D-STE, in patients diagnosed with acute myocarditis, in the presence of preserved LV function. Further studies are needed to evaluate its' role in the development of LV dysfunction, heart failure and mortality.

2D Strain Analysis in Myocarditis-Can We Be Any Closer to Diagnose the Acute Phase of the Disease?

BACKGROUND

The aim of present study was to assess left ventricular myocardial deformation detected by 2D STE in patients with suspected acute myocarditis (AM) early on admission in whom later cardiac magnetic resonance (CMR) evaluation was performed.

METHODS

A total of 47 patients with suspected AM based on clinical practice were prospectively enrolled. Coronary angiography was performed on all patients to rule out significant coronary artery disease. CMR confirmed myocardial inflammation, oedema, and regional necrosis meeting the Lake Louise criteria in 25 patients (53%, oedema (+) subgroup). In the remaining patients, only LGE was confirmed in the sub-epicardial or intramuscular localization (22 patients, 47%, oedema (-) subgroup). Early on admission, echocardiography with measurements of global and segmental longitudinal strains (GLS), circumferential strains (GCS) at the endocardial (endocardial GCS) and epicardial (epicardial GCS) layers, transmural GCS, and radial strains (RS) were performed.

RESULTS

Mild reduction of GLS, GRS, and transmural GCS values were found in patients with oedema (+) subgroup. The epicardial GCS turned out to be the diagnostic factor for oedema with a cut-off point of 13,0% (AUC 0.747, p = 0.0005). Twenty-two patients (all but three) with an acute phase of myocarditis and epicardial GCS -13.0% or less had oedema confirmed by CMR.

CONCLUSIONS

2D STE can help to set the diagnosis of AM in patients with acute chest pain with a normal coronary angiogram. The epicardial GCS can serve as a diagnostic factor for oedema in patients with early stage of AM. In patients presenting with signs of AM (oedema in CMR), the epicardial GCS is modified in comparison with a subgroup without oedema; therefore, this parameter could be used to improve the performance of ultrasound.

Longitudinal Assessment of Cardiac Function Following Multisystem Inflammatory Syndrome in Children Associated with COVID-19

Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2-4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (N = 18), 44% were abnormal (GLS < |- 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.

Immune myocarditis related to sintilimab treatment in a patient with advanced lung adenocarcinoma: A case report

Immune checkpoint inhibitors (ICI) have improved clinical outcomes of patients with advanced lung cancer, but may lead to fatal cardiac injury. We describe a 66-year-old man with advanced lung adenocarcinoma who presented with chest pain and dyspnea 3 weeks after the first dose of sintilimab. The initial electrocardiogram (ECG) demonstrated ST-elevation in leads V5-V9, and a high-sensitivity troponin level was significantly elevated. However, coronary angiography did not reveal any significant stenosis. The patient was successfully treated with methylprednisolone and immunoglobulin. Cardiac MRI was carried out before discharge and late gadolinium enhancement (LGE) was found to be in the mid layer of the septal segment and the subepicardial layer of the inferolateral wall. Due to the high fatality, ICI-related myocarditis requires close surveillance, prompt management and long-term follow-up.

Multimodality imaging in acute myocarditis

The diagnosis of acute myocarditis often involves several noninvasive techniques that can provide information regarding volumes, ejection fraction, and tissue characterization. In particular, echocardiography is extremely helpful for the evaluation of biventricular volumes, strain and ejection fraction. Cardiac magnetic resonance, beyond biventricular volumes, strain, and ejection fraction allows to characterize myocardial tissue providing information regarding edema, hyperemia, and fibrosis. Contemporary cardiac computed tomography angiography (CCTA) can not only be extremely important for the assessment of coronary arteries, pulmonary arteries and aorta but also tissue characterization using CCTA can be an additional tool that can explain chest pain with a diagnosis of myocarditis.

Right ventricular peak systolic free wall longitudinal strain as a practical tool to detect right ventricular dysfunction in acute myocarditis

INTRODUCTION

Acute myocarditis is one of the etiologies of acute heart failure, chronic dilated cardiomyopathy, and cardiac mortality. The extent of right ventricular (RV) involvement and its impact on the course of the disease have been scarcely studied. This study aimed to evaluate both the prevalence of RV dysfunction in acute myocarditis and echocardiographic measures as a diagnostic tool for RV dysfunction compared with cardiac magnetic resonance imaging (CMR) findings.

METHODS

This retrospective study enrolled patients with a definite or probable acute myocarditis diagnosis based on the Lake Louise criteria in CMR and evaluated the diagnostic accuracy of echocardiographic measures in predicting RV dysfunction in CMR.

RESULTS

The study population consisted of 71 patients, including 54 men (76%), at a median (Q1-Q3) age of 33 (26-46) years. CMR detected RV dysfunction in 53.5% of the patients. The RV free wall peak systolic longitudinal strain showed the highest correlation (r = -.786, p < .001) and area under the curve (.919) with the RV ejection fraction in CMR, followed by the RV global peak systolic longitudinal strain and the RV fractional area change. The RV-free wall peak systolic longitudinal strain had a sensitivity of 92% and a specificity of 73% for the diagnosis of RV dysfunction in myocarditis. A cutoff value of -17.9% was 100% specific for RV systolic dysfunction.

CONCLUSIONS

Echocardiography, as a readily available tool, was predictive of and had acceptable accuracy for RV dysfunction in acute myocarditis compared with CMR.

Feasibility of one breath-hold cardiovascular magnetic resonance compressed sensing cine for left ventricular strain analysis

Objective

To investigate the feasibility of 3D left ventricular global and regional strain by using one breath-hold (BH) compressed sensing cine (CSC) protocol and determine the agreement between CSC and conventional cine (CC) protocols.

Methods

A total of 30 volunteers were enrolled in this study. Cardiovascular magnetic resonance (CMR) images were acquired using a 1.436 T magnetic resonance imaging (MRI) system. The CSC protocols included one BH CSC and the shortest BH CSC protocols with different parameters and were only performed in short-axis (SA) view following CC protocols. Left ventricular (LV) end-diastole volume (EDV), end-systole volume (ESV), stroke volume (SV), and ejection fraction (EF) global and regional strain were calculated by CC, one BH CSC, and shortest BH CSC protocols. The intraclass correlation coefficient (ICC) and coefficient of variance (CV) of these parameters were used to determine the agreement between different acquisitions.

Results

The agreement of all volumetric variables and EF between the CC protocol and one BH CSC protocol was excellent (ICC &gt; 0.9). EDV, ESV, and SV between CC and shortest BH CSC protocols also had a remarkable coherence (ICC &gt; 0.9). The agreement of 3D LV global strain assessment between CC protocol and one BH CSC protocol was good (ICC &gt; 0.8). Most CVs of variables were also good (CV &lt; 15%). ICCs of all variables were lower than 0.8. CVs of all parameters were higher than 15% except global longitudinal strain (GLS) between CC and shortest BH CSC protocols. The agreement of regional strain between CC and BH CSC protocols was heterogeneous (-0.2 &lt; ICC &lt; 0.7). Many variables of CVs were poor.

Conclusion

Notably, one BH CSC protocol can be used for 3D global strain analysis, along with a good correlation with the CC protocol. The regional strain should continue to be computed by the CC protocol due to poor agreement and a remarkable variation between the protocols. The shortest BH CSC protocol was insufficient to replace the CC protocol for 3D global and regional strain.

3D-speckle-tracking echocardiography correlates with cardiovascular magnetic resonance imaging diagnosis of acute myocarditis – An observational study

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Regional changes in myocardial texture (as diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain.

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3D and 2D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF and LVEDV in our patient collective.

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3D-speckle-tracking echocardiography offers a promising diagnostic tool in the diagnosis of myocarditis.

Background

The diagnostic importance of three-dimensional (3D) speckle-tracking strain-imaging echocardiography in patients with acute myocarditis remains unclear. The aim of this study was to test the diagnostic performance of 3D-speckle-tracking echocardiography compared to CMR (cardiovascular magnetic resonance imaging) for the diagnosis of acute myocarditis.

Methods and results

45 patients with clinically suspected myocarditis were enrolled in our study (29% female, mean age: 43.9 ± 16.3 years, peak troponin I level: 1.38 ± 3.51 ng/ml). 3D full-volume echocardiographic images were obtained and offline 2D as well as 3D speckle-tracking analysis of regional and global LV deformation was performed. All patients received CMR scans and myocarditis was diagnosed in 29 subjects based on original Lake-Louise criteria. The 16 patients, in whom myocarditis was excluded by CMR, served as controls. Regional changes in myocardial texture (diagnosed by CMR) were significantly associated with regional impairment of circumferential, longitudinal, and radial strain, as well as regional 3D displacement and total 3D strain. Interestingly, the 2D and 3D global longitudinal strain (GLS) showed higher diagnostic performance than well-known parameters associated with myocarditis, such as LVEF (as obtained by echocardiography and CMR) and LVEDV (as obtained by CMR).

Conclusions

In this study, we examined the use of 3D-speckle-tracking echocardiography in patients with acute myocarditis. Global longitudinal strain was significantly impaired in patients with acute myocarditis and correlated with CMR findings. Therefore, 3D echocardiography could become a useful diagnostic tool in the primary diagnosis of myocarditis.

Biventricular myocardial function in Covid-19 recovered patients assessed by speckle tracking echocardiography: a prospective cohort echocardiography study

Although severe acute respiratory syndrome coronavirus 2 causes respiratory disease, it may also lead to cardiovascular involvement with unknown long-term consequences. The aim of our study was to evaluate prospectively cardiac involvement in patients after the recovery from Covid-19, using two-dimensional speckle tracking echocardiography. 100 Covid-19 recovered patients with preserved left ventricular ejection fraction, were included, divided based upon clinical manifestation into two groups, those who were treated ambulant and those who were hospitalized. All patients underwent echocardiographic evaluation after their recovery. Although overall LV systolic function expressed by EF was normal, left ventricular global longitudinal strain (LVGLS) was significantly lower in Covid-19 recovered patients (33.28 ± 9.4 days after diagnosis) compared to controls (- 18.47 ± - 2.4 vs. - 21.07 ± - 1.76% respectively, p < 0.0001). Εspecially the lateral wall longitudinal strain (LATLS) and posterior wall longitudinal strain (POSTLS) were significantly reduced in all patients compared to controls (- 17.77 ± - 3.48 vs. - 20.97 ± - 2.86%, p < 0.0001 and - 19.52 ± - 5.3 vs. - 22.23 ± - 2.65%, p = 0.01). right ventricular global longitudinal strain (RVGLS) was significantly diminished only in the hospitalized group of Covid-19 recovered patients, compared to controls (- 18.17 ± - 3.32 vs. - 26.03 ± - 4.55% respectively, p < 0.0001). LVGLS is affected in almost all individuals after Covid-19 infection independently of the infection severity, with LATLS being the most sensitive marker of LV impairment and with POSTLS to follow. RV shows impaired GLS in severely ill patients highlighting RVGLS as a helpful tool of prognosis. Recovered patients from Covid-19 infection have to be monitored for a long time, since the term "long Covid disease" might also include the cardiac function.

Emerging Role of Cardiac Magnetic Resonance Imaging in Diagnosing Myocarditis: A Blunder or The Way To Get the Problem Sorted?

Acute myocarditis is a disease affecting the myocardial tissue, which is caused by infections, rheumatic diseases, especially sarcoidosis, or certain therapies. Its diagnosis may be difficult, owing to its variable clinical presentation. In this setting, cardiac magnetic resonance plays a pivotal role in detecting myocardial inflammation through qualitative, semiquantitative, and quantitative parameters, in particular with the new quantitative techniques such as T1 and T2 mapping, combined or not with late gadolinium enhancement evaluation. This is in accordance with the revised Lake Louise criteria. In this review, the emerging role of the new cutting-edge cardiac magnetic resonance imaging techniques in diagnosing myocarditis is extensively presented.

Longitudinal Assessment of Cardiac Outcomes of Multisystem Inflammatory Syndrome in Children Associated With COVID-19 Infections

Background

In multisystem inflammatory syndrome in children, there is paucity of longitudinal data on cardiac outcomes. We analyzed cardiac outcomes 3 to 4 months after initial presentation using echocardiography and cardiac magnetic resonance imaging.

Methods and Results

We included 60 controls and 60 cases of multisystem inflammatory syndrome in children. Conventional echocardiograms and deformation parameters were analyzed at 4 time points: (1) acute phase (n=60), (2) subacute phase (n=50; median, 3 days after initial echocardiography), (3) 1‐month follow‐up (n=39; median, 22 days), and (4) 3‐ to 4‐month follow‐up (n=25; median, 91 days). Fourteen consecutive cardiac magnetic resonance imaging studies were reviewed for myocardial edema or fibrosis during subacute (n=5) and follow‐up (n=9) stages. In acute phase, myocardial injury was defined as troponin‐I level ≥0.09 ng/mL (>3 times normal) or brain‐type natriuretic peptide >800 pg/mL. All deformation parameters, including left ventricular global longitudinal strain, peak left atrial strain, longitudinal early diastolic strain rate, and right ventricular free wall strain, recovered quickly within the first week, followed by continued improvement and complete normalization by 3 months. Median time to normalization of both global longitudinal strain and left atrial strain was 6 days (95% CI, 3–9 days). Myocardial injury at presentation (70% of multisystem inflammatory syndrome in children cases) did not affect short‐term outcomes. Four patients (7%) had small coronary aneurysms at presentation, all of which resolved. Only 1 of 9 patients had residual edema but no fibrosis by cardiac magnetic resonance imaging.

Conclusions

Our short‐term study suggests that functional recovery and coronary outcomes are good in multisystem inflammatory syndrome in children. Use of sensitive deformation parameters provides further reassurance that there is no persistent subclinical dysfunction after 3 months.

Protective effect of a chronic hypobaric hypoxic environment at high altitude on cardiotoxicity induced by doxorubicin in rats: a 7 T magnetic resonance study

Background

Doxorubicin (DOX)-induced cardiotoxicity (DIC), a major clinical problem, has no effective preventive therapies. We hypothesized that left ventricular (LV) systolic function would be improved in a chronic hypobaric hypoxia environment at high altitude. The purpose of this study was to investigate whether cardiovascular magnetic resonance could reveal the cardioprotective effect of chronic hypobaric hypoxia on DIC.

Methods

In total, 60 rats were randomly assigned to 1 of 6 groups (n=10 per group): the P group (plain), PD group (plain + DOX), HH group (high altitude), HHD4 group (high altitude + DOX for 4 weeks), HHD8 group (high altitude + DOX for 8 weeks), and HHD12 group (high altitude + DOX for 12 weeks). The rats were transported to either Yushu (altitude: 4,250 m) or Chengdu (altitude: 500 m) where they underwent intraperitoneal injection of DOX (5 mg/kg/week for 3 weeks) or saline. Preclinical 7 T cardiovascular magnetic resonance was performed at weeks 4, 8, and 12. Tissue tracking was used to measure LV cardiac function and to analyze global and segmental strains. Subsequently, histological and oxidative stress tests were performed to evaluate the protective effect of a high-altitude environment on DIC.

Results

The left ventricular ejection fraction (LVEF) and global and regional strains in the middle, apical, anterior, septal, inferior, and lateral segments (all P<0.05) were improved in the HHD4 group compared with the PD group. The global strain was significantly greater in absolute value in the HHD8 and HHD12 groups than in the HHD4 group (all P<0.05). Additionally, histological and enzyme-linked immunosorbent assay evaluations supported the in vivo results.

Conclusions

A chronic hypobaric and hypoxic environment at high altitude partially prevented cardiac dysfunction and increased global and regional strain in DIC rat models, thereby minimizing myocardial injury and fibrosis. In addition, by increasing the total duration of chronic hypobaric hypoxia, the global strain was further increased, which was likely due to reduced oxidative stress.

Multiparametric Cardiovascular Magnetic Resonance Approach in Diagnosing, Monitoring, and Prognostication of Myocarditis

Myocarditis represents the entity of an inflamed myocardium and is a diagnostic challenge caused by its heterogeneous presentation. Contemporary noninvasive evaluation of patients with clinically suspected myocarditis using cardiac magnetic resonance (CMR) includes dimensions and function of the heart chambers, conventional T2-weighted imaging, late gadolinium enhancement, novel T1 and T2 mapping, and extracellular volume fraction calculation. CMR feature-tracking, texture analysis, and artificial intelligence emerge as potential modern techniques to further improve diagnosis and prognostication in this clinical setting. This review will describe the evidence surrounding different CMR methods and image postprocessing methods and highlight their values for clinical decision making, monitoring, and risk stratification across stages of this condition.

Left ventricular global longitudinal strain imaging in identifying subclinical myocardial dysfunction among covid-19 survivors

BACKGROUND

Covid-19 is multi-system viral infection caused by SARS-CoV-2 virus. Apart from having acute severe respiratory illness causing high mortality, the disease also has a variety of cardiovascular manifestations contributing to morbidity as well as mortality. Cardiac dysfunction and myocarditis are well established complications of Covid-19 as evident in multiple studies after the Covid-19 pandemic. However it is not sufficiently studied in Indian patients either by Echocardiography or by any other imaging modalities like cardiac magnetic resonance imaging (MRI).

METHODOLOGY

In this study, we analysed the severity of Left ventricular(LV) dysfunction in Covid-19 survivors. A total of 100 consecutive patients of Covid-19 after one month of discharge who had no underlying cardiovascular diseases underwent echocardiography and global longitudinal strain (GLS) imaging. This study cohort included patients with mild 42 (42%),moderate 46(46%) and severe 12(12%) Covid-19 disease as defined by computerised tomography (CT) severity score.

RESULT

We observed that total 36(36%) patients had reduced ejection fraction(EF) which included 11 patients having EF <40% and remaining 25(25%) having EF 40-50% (p<0.002). Also 22 (22%) patients had abnormal global longitudinal strain (GLS) values with normal ejection fraction which is suggestive of subclinical myocarditis. We observed LV dysfunction in 7(19.5%) patients who had severe Covid-19 while mild to moderate LV dysfunction observed in 29(80.5%) non critical patients.

CONCLUSION

In conclusion our study demonstrates that myocardial dysfunction is common in covid-19 regardless of disease severity. 2D-echocardiography with GLS is likely to detect early LV dysfunction among these patients.

Subclinical myocardial dysfunction in patients recovered from COVID-19

Background

Myocardial injury (MI) can be detected during the acute phase of Coronavirus disease 19 (COVID‐19) and is associated with a dismal prognosis. Recent imaging studies described the persistence of cardiac abnormalities after the recovery. The aim of the study was to investigate the spectrum of cardiac abnormalities at mid‐term follow‐up in patients recovered from COVID‐19 using clinical assessment, laboratory tests, and imaging evaluation with comprehensive echocardiography.

Methods

This is an observational, cross‐sectional study assessing an unselected cohort of consecutive patients recovered from COVID‐19. MI was defined by elevated plasma levels of high sensitive troponin T (hsTnT). At the follow‐up, a complete examination including echocardiography was performed.

Results

The 123 patients included were divided into two groups according to the presence of MI during hospitalization: group A (without MI) and group B (with MI). After a median of 85 days, group B patients were more frequently symptomatic for dyspnea and had significantly higher values of hsTnT and N‐Terminal prohormone of Brain Natriuretic Peptide (NT‐proBNP), compared to Group A. No differences between the two groups in left nor right ventricle dimension and ejection fraction were found. However, in group B a significant reduction of mean left ventricle global longitudinal strain was observed (‐15.7±.7 vs ‐18.1± .3 in group A, p < 0.001), together with higher frequency of impaired diastolic function and higher values of pulmonary pressure.

Conclusions

In patients recovered from COVID‐19, echocardiography with speckle‐tracking analysis may be an useful imaging tool to identify subclinical myocardial dysfunction and potentially guide management strategies.

[Comparative analysis of myocardial deformation in patients recovered from mild SARS-CoV-2 infection]

Objectives

During acute infection by the SARS-CoV-2 virus, myocardial involvement has been demonstrated; it is unknown if cardiovascular sequelae in patients recovered from this infection and if these are associated with global morbidity and mortality. The objective of this study was to compare myocardial deformation in patients recovered from mild SARS-CoV-2 virus infection with healthy controls.

Materials and methods

This was a cross-sectional observational study that included 33 subjects recovered from mild SARS-CoV-2 infection, who were diagnosed in the previous three to six months, and 31 healthy volunteers, both groups free of cardiovascular risk factors. The study of myocardial deformation was performed using echocardiography with the speckle tracking modality. Clinical and anthropometric variables were compared.

Results

The 2D global longitudinal strain of the left ventricle was lower in the subjects recovered from mild SARS-CoV-2 infection than the controls (-20.2% ± 2.6 v -21.6% ± 2.4; p: 0.036). Both groups presented differences in the three ventricular levels, significant at the apical level (-21.2 ± 4.0 vs -23.4% ± 4.2; p: 0.044). The effect by levels shows an inverse Takotsubo pattern. The left ventricular ejection fraction was preserved in both groups (p: 0.153).

Conclusions

Left ventricular myocardial deformation is affected in subjects recovered from mild SARS-CoV-2 infection, while the ejection fraction was found in normal ranges. Our study shows a potential role of global longitudinal strain in the detection of subclinical myocardial alterations in patients who had SARS-CoV-2.

Left ventricular global longitudinal strain in COVID-19 recovered patients

Objectives

Myocardial injury during active coronavirus disease‐2019 (COVID‐19) infection is well described; however, its persistence during recovery is unclear. We assessed left ventricle (LV) global longitudinal strain (GLS) using speckle tracking echocardiography (STE) in COVID‐19 recovered patients and its correlation with various parameters.

Methods

A total of 134 subjects within 30–45 days post recovery from COVID‐19 infection and normal LV ejection fraction were enrolled. Routine blood investigations, inflammatory markers (on admission) and comprehensive echocardiography including STE were done for all.

Results

Of the 134 subjects, 121 (90.3%) were symptomatic during COVID‐19 illness and were categorized as mild: 61 (45.5%), moderate: 50 (37.3%) and severe: 10 (7.5%) COVID‐19 illness. Asymptomatic COVID‐19 infection was reported in 13 (9.7%) patients. Subclinical LV and right ventricle (RV) dysfunction were seen in 40 (29.9%) and 14 (10.5%) patients, respectively. Impaired LVGLS was reported in 1 (7.7%), 8 (13.1%), 22 (44%) and 9 (90%) subjects with asymptomatic, mild, moderate and severe disease, respectively. LVGLS was significantly lower in patients recovered from severe illness(mild: ‐21 ± 3.4%; moderate: ‐18.1 ± 6.9%; severe: ‐15.5 ± 3.1%; p < 0.0001). Subjects with reduced LVGLS had significantly higher interleukin‐6 (p < 0.0001), C‐reactive protein (p = 0.001), lactate dehydrogenase (p = 0.009), serum ferritin (p = 0.03), and troponin (p = 0.01) levels during index admission.

Conclusions

Subclinical LV dysfunction was seen in nearly a third of recovered COVID‐19 patients while 10.5% had RV dysfunction. Our study suggests a need for closer follow‐up among COVID‐19 recovered subjects to elucidate long‐term cardiovascular outcomes.

Diagnostic and Prognostic Value of Cardiac Magnetic Resonance Strain in Suspected Myocarditis With Preserved LV-EF: A Comparison Between Patients With Negative and Positive Late Gadolinium Enhancement Findings

BACKGROUND

Late gadolinium enhancement (LGE) is absent in many patients with suspected myocarditis and preserved left ventricular ejection fraction (LV-EF), which poses difficulties in diagnosis and risk stratification.

PURPOSE

To investigate the diagnostic and prognostic value of ventricular myocardial strain in patients with suspected myocarditis, preserved LV-EF, and negative Lake Louis Criteria (LLC) by comparing the findings in LGE negative and LGE positive patients.

STUDY TYPE

Retrospective.

POPULATION

A total of 108 patients with clinically suspected myocarditis who did not satisfy LLC were divided into LGE negative (N = 65) and LGE positive (N = 43) groups. A control group consisted of 50 healthy volunteers.

FIELD STRENGTH/SEQUENCE

Steady-state free precession cine and phase-sensitive inversion recovery segmented gradient echo LGE sequences at 3.0 T.

ASSESSMENT

Myocardial strain of the ventricles was evaluated by feature tracking, major adverse cardiovascular events (MACE) were assessed during follow-up since the date of magnetic resonance examination.

STATISTICAL TESTS

Independent-samples t test, Mann-Whitney U test, receiver operating characteristic curve analysis, and Cox proportional hazard regression were performed. A P-value <0.05 was considered statistically significant.

RESULTS

Cardiac function and myocardial deformability were impaired in all patients relative to controls. Left ventricular-global radial (LV-GRS), circumferential (LV-GCS), and longitudinal (LV-GLS) strain had diagnostic value, even in LGE negative patients (sensitivity = 0.446, 0.523, and 0.662; specificity = 0.92, 0.80, and 0.64; AUC = 0.685, 0.675, and 0.648, respectively). After a median follow-up of 530.5 (interquartile range: 168.5-969.25) days, MACE occurred in 18 (16.67%) patients. Right ventricular GLS showed prognostic value in all patients and in LGE negative patients, both in univariable analysis (hazard ratio [HR] 1.049, 95% confidence interval [CI] 1.001-1.099 and HR 1.068, 95% CI 1.011-1.127, respectively) and in multivariable Cox survival analysis. LV-GLS was associated with MACE in LGE positive patients in multivariable Cox survival analysis.

DATA CONCLUSION

Myocardial strain provides diagnostic and prognostic value in suspected myocarditis with preserved LV-EF, even in the absence of LGE.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: 2.

Usefulness of Left Ventricular Myocardial Deformation in Children Hospitalized for Acute Myocarditis who Develop Arrhythmias

Cardiac arrhythmias occur in 3-40% of patients with acute myocarditis and cause significant morbidity and mortality. Myocardial injury also results in abnormal myocardial deformation. The relationship between left ventricular (LV) deformation, measured by two-dimensional speckle tracking echocardiography (2D-STE), and arrhythmia in pediatric myocarditis is unknown. We evaluated the association between 2D-STE and arrhythmias in children hospitalized with acute myocarditis. We reviewed patients ≤ 18 years hospitalized for acute myocarditis from 2008 to 2018. Arrhythmias were defined as 1) non-sustained or sustained ventricular tachycardia or ventricular fibrillation, 2) sustained supraventricular tachycardia (SVT), 3) high-grade or complete heart block, and 4) any arrhythmia treated with an antiarrhythmic medication. Systolic LV strain values (including LV global longitudinal strain (GLS), global circumferential strain (GCS), and six segments of LV regional long axis strain) were obtained from initial echocardiograms during hospitalization. Of 66 patients hospitalized, 23 (35%) had arrhythmias. SVT was the predominant arrhythmia (74%). Global and regional strain indices were reduced in the arrhythmia group: LV GLS [-8.9 (IQR -13.6, -6.1) vs. -13.7 (IQR -16.9, -9.7), p = 0.038]; basal inferior/septal [-10.7 (IQR -15.5, -7.8) vs. -16.4 (IQR -18, -11.8), p = 0.009]; basal anterior/lateral [-7.1 (IQR -12.8, -4.7) vs. -9.4 (IQR -16.7, -7.4), p = 0.025]; and mid inferior/septal segments [-9 (IQR -13, -7.7) vs. -14.1 (IQR -22.5, -10.7), p = 0.007]. After controlling for age, reductions in GLS and segmental strain in the two basal and two mid-segments were associated with increased arrhythmia occurrence (p <0.05). Our findings suggest that echocardiographic LV deformation by 2D-STE may be useful in identifying pediatric patients with acute myocarditis at risk for arrhythmias.

Review of COVID-19 Myocarditis in Competitive Athletes: Legitimate Concern or Fake News?

Since the first reported case of COVID-19 in December 2019, the global landscape has shifted toward an unrecognizable paradigm. The sports world has not been immune to these ramifications; all major sports leagues have had abbreviated seasons, fan attendance has been eradicated, and athletes have opted out of entire seasons. For these athletes, cardiovascular complications of COVID-19 are particularly concerning, as myocarditis has been implicated in a significant portion of sudden cardiac death (SCD) in athletes (up to 22%). Multiple studies have attempted to evaluate post-COVID myocarditis and develop consensus return-to-play (RTP) guidelines, which has led to conflicting information for internists and primary care doctors advising these athletes. We aim to review the pathophysiology and diagnosis of viral myocarditis, discuss the heterogeneity regarding incidence of COVID myocarditis among athletes, and summarize the current expert recommendations for RTP. The goal is to provide guidance for practitioners who will be managing and advising athletes in the COVID era.

Myocardial Work Efficiency, A Novel Measure of Myocardial Dysfunction, Is Reduced in COVID-19 Patients and Associated With In-Hospital Mortality

Background: Although troponin elevation is common in COVID-19, the extent of myocardial dysfunction and its contributors to dysfunction are less well-characterized. We aimed to determine the prevalence of subclinical myocardial dysfunction and its association with mortality using speckle tracking echocardiography (STE), specifically global longitudinal strain (GLS) and myocardial work efficiency (MWE). We also tested the hypothesis that reduced myocardial function was associated with increased systemic inflammation in COVID-19. Methods and Results: We conducted a retrospective study of hospitalized COVID-19 patients undergoing echocardiography (n = 136), of whom 83 and 75 had GLS (abnormal >-16%) and MWE (abnormal <95%) assessed, respectively. We performed adjusted logistic regression to examine associations of GLS and MWE with in-hospital mortality. Patients were mean 62 ± 14 years old (58% men). While 81% had normal left ventricular ejection fraction (LVEF), prevalence of myocardial dysfunction was high by STE; [39/83 (47%) had abnormal GLS; 59/75 (79%) had abnormal MWE]. Higher MWE was associated with lower in-hospital mortality in unadjusted [OR 0.92 (95% CI 0.85-0.99); p = 0.048] and adjusted models [aOR 0.87 (95% CI 0.78-0.97); p = 0.009]. In addition, increased systemic inflammation measured by interleukin-6 level was associated with reduced MWE. Conclusions: Subclinical myocardial dysfunction is common in COVID-19 patients with clinical echocardiograms, even in those with normal LVEF. Reduced MWE is associated with higher interleukin-6 levels and increased in-hospital mortality. Non-invasive STE represents a readily available method to rapidly evaluate myocardial dysfunction in COVID-19 patients and can play an important role in risk stratification.

Segmentally impaired left ventricular longitudinal strain: a new predictive diagnostic parameter for asymptomatic patients with severe aortic stenosis and preserved ejection fraction

INTRODUCTION

This study aims to investigate the correlation between severe aortic stenosis (sAS) and impairment of left ventricular global longitudinal strain (LVGLS) in particular segments, using two-dimensional speckle tracking echocardiography in patients with sAS and normal ejection fraction of left ventricle (LVEF).

METHODS

The study included 53 consecutive patients with asymptomatic sAS and preserved LVEF. The regional longitudinal systolic LV wall strain was evaluated at the area opposite of the aorta as the median strain value of the basal, middle, and apical segments of the lateral and posterior walls and was compared to the average strain value of the interventricular septum (IVS) at the same views.

RESULTS

LVGLS was decreased and was not statistically different between three- and four-chamber views (-12.5 ± 3.6 vs -11.4 ± 5.5%, p = 0.2). The average strain values of the lateral and posterior walls were statistically reduced compared to the average value of the IVS (lateral vs IVS: -7.8 ± 3.7 vs -10 ± 5.3%, p = 0.005, posterior vs IVS: -7.7 ± 4.2 vs -10.3 ± 3.8%, p < 0.0001). There was no significant difference between lateral and posterior walls (-7.8 ± 3.7 vs -7.7 ± 4.2%, p = 0.9).

CONCLUSIONS

The strain of lateral and posterior walls of left ventricle, which lay just opposite to the aortic valve seem to be more reduced compared to other walls in patients with sAS and preserved LVEF possibly due to their anatomical position. This impairment seems to be the reason of the overall LVGLS reduction. Regional strain could be used as an extra tool for the estimation of the severity of AS as well as for prognostic information in asymptomatic patients.

Peripheral Blood MicroRNAs as Potential Biomarkers of Myocardial Damage in Acute Viral Myocarditis

Background: microRNAs (miRs) have emerged as important modulators of cardiovascular development and disease. Our aim was to determine whether cardiac-related miRs such as miR-21-5p and miR-1-3p were differentially expressed in acute viral myocarditis and whether any of them was related with the extent of myocardial damage and left ventricular dysfunction. Methods: We enrolled 40 patients with acute viral myocarditis. Blood samples were taken on admission and miRs expression levels in peripheral blood mononuclear cells were quantified by real-time reverse transcription polymerase chain reaction. Results: miR-21-5p, miR-1-3p were significantly elevated in acute myocarditis. miR-21-5p levels showed a strong correlation with global longitudinal strain (r = 0.71, p < 0.01), while miR-1-3p had significant correlations with troponin I (r = 0.79, p < 0.01). Conclusions: The expression of miR-21-5p and miR-1-3p in peripheral blood is increased in acute viral myocarditis, and this increase is correlated with myocardial damage and indicative of left ventricular systolic dysfunction in these patients.

Clozapine-Associated Myocarditis: A Protocol for Monitoring Upon Clozapine Initiation and Recommendations for How to Conduct a Clozapine Rechallenge

BACKGROUND

Clozapine is the only medication with Food and Drug Administration approval for treatment-resistant schizophrenia. However, it is underutilized in the United States because of several life-threatening adverse effects, including clozapine-associated myocarditis (CAM), and a limited understanding of how to manage these complications. To date, recommendations for rechallenging patients with CAM that incorporate the cardiac literature or cardioprotective medications have not been developed.

FINDINGS

In this article, we outline a protocol developed with cardiologists and guided by the cardiac literature that provides direction on how to monitor for the initial development of CAM and how to rechallenge patients with CAM. Furthermore, we present 2 successful cases of clozapine rechallenge that were managed using this protocol.

CONCLUSIONS

In both cases, the patients showed marked improvement in their psychiatric symptoms and functioning, demonstrating the importance of considering rechallenge in patients after CAM.

Detailed Assessment of Left Ventricular Function in Multisystem Inflammatory Syndrome in Children, Using Strain Analysis

Background

Cardiac manifestations in multisystem inflammatory syndrome in children (MIS-C) occur in ∼80% of patients. Left ventricular (LV) systolic dysfunction is the most frequent cardiac finding.

Methods

In this single-centre, retrospective cohort study, we report on detailed assessment of LV function in MIS-C patients using strain and strain rate analysis. We compare those with normal peak systolic strain z-scores (both longitudinal and circumferential strain) to those with abnormal peak systolic strain z-scores (decreased circumferential and/or longitudinal strain).

Results

Among 25 patients, 14 (56%) were male, 20 (80%) were Black or Hispanic, 13 (52%) were overweight/obese, and the median age was 11.4 years (interquartile range: 7.5 to 16). Median ejection fraction (EF) was 55.2% (interquartile range: 48.3% to 58%), with the abnormal strain patients having a lower EF (P < 0.01). Demographics were similar between groups. The abnormal strain patients had more organ systems involved and were more likely to require inotropic support. In a comparison of MIS-C patients with normal EF (n = 15) to controls, MIS-C patients had lower peak systolic strain as well as lower early diastolic strain rates. In patients with initially depressed function, EF normalized in 8 of 10 (80%), but 4 of 11 (36%) patients had persistently abnormal systolic strain after discharge.

Conclusions

LV systolic dysfunction is common in the acute phase of MIS-C, and detection may be improved with strain imaging. Longitudinal cardiac follow-up is imperative, as some patients may be at risk for persistent LV dysfunction.

Left ventricular global longitudinal strain in identifying subclinical myocardial dysfunction among patients hospitalized with COVID-19

Background

The incidence of acute cardiac injury in COVID-19 patients is very often subclinical and can be detected by cardiac magnetic resonance imaging. The aim of this study was to assess if subclinical myocardial dysfunction could be identified using left ventricular global longitudinal strain (LV-GLS) in patients hospitalized with COVID-19.

Methods

We performed a search of COVID-19 patients admitted to our institution from January 1st, 2020 to June 8th, 2020, which revealed 589 patients (mean age = 66 ± 18, male = 56%). All available 60 transthoracic echocardiograms (TTE) were reviewed and off-line assessment of LV-GLS was performed in 40 studies that had sufficient quality images and the views required to calculate LV-GLS. We also analyzed electrocardiograms and laboratory findings including inflammatory markers, Troponin-I, and B-type natriuretic peptide (BNP).

Results

Of 589 patients admitted with COVID-19 during our study period, 60 (10.1%) underwent TTE during hospitalization. Findings consistent with overt myocardial involvement included reduced ejection fraction (23%), wall motion abnormalities (22%), low stroke volume (82%) and increased LV wall thickness (45%). LV-GLS analysis was available for 40 patients and was abnormal in 32 patients (80%). All patients with LV dysfunction had elevated cardiac enzymes and positive inflammatory biomarkers.

Conclusions

Subclinical myocardial dysfunction as measured via reduced LV-GLS is frequent, occurring in 80% of patients hospitalized with COVID-19, while prevalent LV function parameters such as reduced EF and wall motion abnormalities were less frequent findings. The mechanism of cardiac injury in COVID-19 infection is the subject of ongoing research.

Acute Myocarditis After Black Widow Spider Bite: A Case Report

The black widow spider (BWS) is a venomous spider whose bite can cause various clinical conditions that range from local damage to serious systemic complications, including death. Cases of myocarditis following a BWS bite are rare but they can be fatal on occasion. However, the prognostic significance of the bite and presentation of myocarditis is unknown. Our case involved a 50-year-old man who presented with myocarditis after being bitten by a BWS and subsequently admitted to the intensive care unit for cardiac monitoring. During the hospital stay, he showed worsening signs on both the electrocardiographic and echocardiographic evaluations despite therapeutic success. Subsequent cardiac magnetic resonance and coronary angiography investigations showed no significant alterations; blood and instrumental test results slowly improved, and the patient was discharged home after 12 days of hospitalization without complications. This case illustrates that acute myocarditis, although an infrequent complication of BWS bite, has the potential to be lethal. The correct diagnosis, which is not always easy to formulate, is important to identify those patients who can benefit from careful monitoring and specific therapies aimed at reducing the risk of life.

Non-invasive assessment of early and acute myocarditis in a rat model using cardiac magnetic resonance tissue tracking analysis of myocardial strain

Background

Myocardial strain analysis can provide diagnostic and prognostic information for myocarditis. The aim of the present study was to assess early and acute myocarditis in a rat model using cardiac magnetic resonance tissue tracking (CMR-TT) for myocardial strain analysis. We compared the strain's findings with the histological and immunohistochemical results.

Methods

Experimental autoimmune myocarditis (EAM) was induced by footpad injections of porcine cardiac myosin. The rats were examined by 7.0T preclinical CMR at day 14 (n=15) and day 21 (n=16) after EAM induction and the two control groups (each n=15) were also examined at day 14 and day 21, respectively. Using CMR-TT, we found a global peak systolic radial strain (Err_SAX) and a circumferential strain (Ecc_SAX) from the short-axis cine views and a radial strain (Err_LAX) and a longitudinal strain (Ell_LAX) from the long-axis cine views, which were calculated by dedicated TT software. Subsequently, histological and immunohistochemical evaluations were performed.

Results

Ell_LAX significantly decreased in early myocarditis compared with the control (-23.40%±1.48% vs. -22.02%±0.81%, P<0.05). Err_SAX, Ecc_SAX, Err_LAX, and Ell_LAX values significantly reduced in acute myocarditis compared with the controls (Err_SAX: 34.27%±9.80% vs. 49.76%±4.97%, Ecc_SAX: -18.98%±3.69% vs. -24.13±1.23, Err_LAX: 33.21%±10.24% vs. 49.59%±5.69%, and Ell_LAX: -17.75%±3.58% vs. -23.39%±1.48%; P<0.001, respectively). The receiver operating characteristic curve showed that myocardial strain analysis had a good diagnostic performance in early and acute myocarditis. The pathological evaluation revealed that inflammatory lesions began to appear in early myocarditis and peaked in acute myocarditis.

Conclusions

The CMR-TT strain analysis allowed accurate and reliable evaluation of early and acute myocarditis in a rat model, and has the potential to serve as a diagnostic indicator for the assessment of myocardial dysfunction in myocarditis.

Performance of cardiovascular magnetic resonance strain in patients with acute myocarditis

Background

To explore the value of myocardial strain derived from cardiac magnetic resonance (CMR) feature tracking in evaluating left ventricular function in acute myocarditis and its relationship with the left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE).

Methods

A total of 115 cases of clinically suspected acute myocarditis, confirmed by CMR, were collected from two centers and divided into groups with reduced and preserved ejection fraction (EF). Fifty normal volunteers were enrolled as the control group. The myocardial strain analysis was based on feature tracking imaging (FTI).

Results

Compared with the control group, the group with myocarditis and preserved EF showed an increased peak ejecting rate (PER), end diastolic volume (EDV), end systolic volume (ESV), stroke volume (SV), EDV index (EDVi), ESV index (ESVi), SV index (SVi) and decreased strain indices. In patient with myocarditis, the group with reduced EF showed increased EDV, ESV, LGE, LGE% and decreased strain indices compared to the group with preserved EF. EF showed good correlation with LGE, PSC, PSSRC (r>0.6). Peak strain circumferential (PSC) showed good correlation with LGE (r=0.62). The AUC of PSC was optimal to detect early left ventricular dysfunction in myocarditis patient with preserved EF using a cutoff of -19.72% (sensitivity of 68% and specificity of 88%).

Conclusions

Myocardial strain analysis using CMR FTI can provide information about early ventricular dysfunction in myocarditis patient with preserved EF. PSC showed best diagnostic performance, and correlated with LGE.

Myocarditis successfully diagnosed and controlled with speckle tracking echocardiography

Background

Speckle tracking echocardiography (STE) is an objective, well-validated and reproducible technique of assessing left ventricular longitudinal deformation; it also offers a more sensitive assessment of myocardial contractility than widely used visual estimation. Evaluating global longitudinal strain may help identify patients with subclinical left ventricular systolic dysfunction.

Case presentation

We report the case of a 28-year-old man with myocarditis, which successfully diagnosed and followed-up with the novel echocardiography method using speckle tracking imaging. The patient was referred to our hospital with an initial diagnosis of ST-segment elevation myocardial infarction. Transthoracic echocardiography did not show any contractility abnormalities. Hence, in the course of further diagnostics, left ventricular function was assessed by STE. Depressed global longitudinal strain was noted within several segments of the left ventricle. Then, cardiac magnetic resonance imaging was performed to confirm the diagnosis of myocarditis.

Conclusions

STE seems to be competitive in relation to cardiac magnetic resonance imaging in the diagnosis of some diseases, such as myocarditis.

Strain analysis reveals subtle systolic dysfunction in confirmed and suspected myocarditis with normal LVEF. A cardiac magnetic resonance study

AIMS

Lake Louise Criteria (LLC) are time-dependent and some acute myocarditis (AM) with preserved left ventricular ejection fraction (LVEF) could be missed, due to the limited accessibility of Cardiac Magnetic Resonance (CMR). We aimed to assess the potential value of cardiac strain measured by feature tracking (FT) imaging in this population.

METHODS AND RESULTS

Eighty-three patients with clinically suspected AM and normal LVEF were divided into 39 "confirmed AM" (positive LLC) and 44 "suspected AM" (negative LLC). An age and gender-matched sample of 42 normal subjects underwent CMR. In all groups, FT-derived biventricular strains and STE- global longitudinal strain (GLS) were assessed, being regularly measurable. Strain values < 5th percentile of the control group were considered abnormal. "Suspected" and "confirmed" AM were similar, except for medium time of CMR evaluation (5.2 vs 1 months from presentation, respectively; p = 0.004). Compared to healthy controls, both "suspected" and "confirmed" AM showed significantly impaired strain values. LV-global circumferential strain (GCS), right ventricular GCS and LV-GLS were abnormal in 15.4% and 15.9%, 20.5% and 15.9%, 7.7% and 9.1% in "confirmed" and "suspected" AM, respectively. STE analysis confirmed the results on LV-GLS, however a weak correlation emerged between STE and CMR-FT LV-GLS (p = 0.08).

CONCLUSIONS

Compared to STE, CMR-FT analysis provided a more comprehensive and complementary biventricular strain evaluation that resulted similar in "confirmed" and "suspected" AM with normal LVEF. Conversely, mostly biventricular GCS was significantly reduced in up to 20% of patients, compared to healthy controls.

Natural History of Cardiomyopathy in Adult Dogs With Golden Retriever Muscular Dystrophy

Background

Duchenne muscular dystrophy (DMD) is an X‐linked disease that causes progressive muscle weakness. Affected boys typically die from respiratory or cardiac failure. Golden retriever muscular dystrophy (GRMD) is genetically homologous with DMD and causes analogous skeletal and cardiac muscle disease. Previous studies have detailed features of GRMD cardiomyopathy in mostly young dogs. Cardiac disease is not well characterized in adult GRMD dogs, and cardiac magnetic resonance (CMR) imaging studies have not been completed.

Methods and Results

We evaluated echocardiography and CMR in 24 adult GRMD dogs at different ages. Left ventricular systolic and diastolic functions, wall thickness, and myocardial strain were assessed with echocardiography. Features evaluated with CMR included left ventricular function, chamber size, myocardial mass, and late gadolinium enhancement. Our results largely paralleled those of DMD cardiomyopathy. Ejection fraction and fractional shortening correlated well with age, with systolic dysfunction occurring at ≈30 to 45 months. Circumferential strain was more sensitive than ejection fraction in early disease detection. Evidence of left ventricular chamber dilatation provided proof of dilated cardiomyopathy. Late gadolinium enhancement imaging showed DMD‐like left ventricular lateral wall lesions and earlier involvement of the anterior septum. Multiple functional indexes were graded objectively and added, with and without late gadolinium enhancement, to give cardiac and cardiomyopathy scores of disease severity. Consistent with DMD, there was parallel skeletal muscle involvement, as tibiotarsal joint flexion torque declined in tandem with cardiac function.

Conclusions

This study established parallels of progressive cardiomyopathy between dystrophic dogs and boys, further validating GRMD as a model of DMD cardiac disease.

Speckle Tracking Echocardiography in Non-ST-Segment Elevation Acute Coronary Syndromes

Non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) are a group of clinical conditions characterized by acute myocardial ischemia. Conventional echocardiography is generally used to evaluate cardiac function using wall motion analysis and left ventricular ejection fraction but may be insufficient to explore all the complex features of NSTE-ACSs, which may vary substantially from patient to patient in terms of severity of ischemia and extent of involved myocardium. In the last years, speckle tracking echocardiography (STE) has become a widely available technique for the non-invasive assessment of cardiac function and has been repeatedly applied in the setting of NSTE-ACSs. In this review we summarize current evidence about the use of STE in patients with NSTE-ACSs, trying to underline advantages and limitations in comparison with conventional echocardiography for: diagnosis of NSTE-ACS, differential diagnosis, identification of high-risk patients, and prediction of outcome.