Cardiac Magnetic Resonance Monitors Reversible and Irreversible Myocardial Injury in Myocarditis

Electrocardiographic predictors of left ventricular scar in athletes with right bundle branch block premature ventricular beats

AIMS

Right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs) have been associated with the presence of non-ischaemic left ventricular scar (NLVS) in athletes. The aim of this cross-sectional study was to identify clinical and electrocardiogram (ECG) predictors of the presence of NLVS in athletes with RBBB VAs.

METHODS AND RESULTS

Sixty-four athletes [median age 39 (24-53) years, 79% males] with non-sustained RBBB VAs underwent cardiac magnetic resonance (CMR) with late gadolinium enhancement in order to exclude the presence of a concealed structural heart disease. Thirty-six athletes (56%) showed NLVS at CMR and were assigned to the NLVS positive group, whereas 28 athletes (44%) to the NLVS negative group. Family history of cardiomyopathy and seven different ECG variables were statistically more prevalent in the NLVS positive group. At univariate analysis, seven ECG variables (low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads I-aVL, negative T waves in precordial leads V4-V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads) proved to be statistically associated with the finding of NLVS; these were grouped together in a score. A score ≥2 was proved to be the optimal cut-off point, identifying NLVS athletes in 92% of cases and showing the best accuracy (86% sensitivity and 100% specificity, respectively). However, a cut-off ≥1 correctly identified all patients with NLVS (absence of false negatives).

CONCLUSION

In athletes with RBBB morphology non-sustained VAs, specific ECG abnormalities at 12-lead ECG can help in detecting subjects with NLVS at CMR.

Cardiac MRI six months after the onset of multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19: A retrospective follow-up study

BACKGROUND

In 2020, reports revealed cases called multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19 or multisystem inflammatory syndrome in children. A small proportion of patients suffer from persistent left ventricular dysfunction at discharge. The primary aim was to investigate if myocardial impairment persists during follow-up in these patients.

METHODS

Children fulfilling the criteria for multisystem inflammatory syndrome in children with cardiac involvement hospitalized between December 2020 and February 2022 were included in this retrospective single centre study. Cardiac MRI was performed six months after the onset of symptoms to evaluate possible persistent myocardial damage.

RESULTS

Fifteen patients (80% male) with a median age of 8 years (interquartile range 4.5 - 13.5 years) were included. Upon admission, eight patients (53%) presented with reduced left ventricular function, with a median left ventricular ejection fraction of 54% (interquartile range 49.5%-61.5%) on transthoracic echocardiography. Elevated levels of cardiac-specific markers were found in 14 patients (93%). Cardiac MRI was performed in 12 patients at a median of 190.5 days after the onset of symptoms. Nine patients (75%) had normal left ventricular function, with a median left ventricular ejection fraction of 59.45%, while the remaining patients showed mildly to moderately reduced values. None of the patients showed signs of late gadolinium enhancement, indicating the absence of persistent myocardial scarring.

CONCLUSION

During a follow-up of 6.2 months, mild to moderate cardiac impairment was revealed in 25% of patients evaluated by cardiac MRI. Although a majority of patients do not show signs of cardiac impairment, close follow-ups should be performed in a proportion of patients.

The Clinical Evolution of Diffuse Myocardial Fibrosis in Patients With Arterial Hypertension and Heart Failure With Mildly Reduced Ejection Fraction Treated by Olmesartan or Sacubitril / Valsartan

Aim      A 12-month evaluation of the potentialities of the angiotensin II receptor inhibitor olmesartan (Olme) and the angiotensin receptor and neprilysin inhibitor (ARNI) sacubitril/valsartan in patients with arterial hypertension (AH) and dyslipidemia in the dynamics of the following indicators of chronic heart failure (CHF): N-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), LV global longitudinal strain (LV GLS) in diffuse myocardial fibrosis (MF) previously diagnosed by magnetic resonance imaging (MRI).Material and methods  Olmesartan medoxomil (n=56) and sacubitril/valsartan (n=63) were used for 12 months in patients with hypertension, dyslipidemia and NYHA functional class II-III CHF with mid-range LVEF (CHFmrEF). MF was diagnosed by the following MRI criteria: late gadolinium enhancement and an increased proportion of extracellular matrix (33% or more). The frequency of persisting late gadolinium enhancement and the increased proportion of extracellular matrix (33% or more) was evaluated at 12 months; changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), NT-proBNP, and LV GLS were evaluated after 3, 6, and 12 months of follow-up.Results Baseline parameters did not differ between groups. The late gadolinium enhancement and increased proportion of extracellular matrix were present at baseline in all patients of both groups (100%; p=1.0). Already at 3 months, statistically significant decreases in SBP and DBP were observed in both groups. In addition, the LV GLS monitoring showed LV GLS significantly increased in both groups after 3 months and continued changing after 6 and 12 months. The NT-proBNP concentration significantly decreased in both groups already after 3 months and continued to decrease after 6 and 12 months. At 6 and 12 months, sacubitril/valsartan was superior to olmesartan in reducing SBP and NT-proBNP and in restoring LV GLS. At 12 months, the incidence of persisting, abnormal late gadolinium enhancement and increased proportion of extracellular matrix was significantly less in the ARNI group.Conclusion      Olmesartan was demonstrated effective in the multi-modality therapy of CHFmrEF and MF in patients with AH and dyslipidemia. ARNI was superior to olmesartan in this regard, but further research of this issue is required.

Cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) imaging in the diagnosis and follow-up of patients with acute myocarditis and chronic inflammatory cardiomyopathy : A review paper with practical recommendations on behalf of the European Society of Cardiovascular Radiology (ESCR)

Advanced cardiac imaging techniques such as cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) are widely used in clinical practice in patients with acute myocarditis and chronic inflammatory cardiomyopathies (I-CMP). We aimed to provide a review article with practical recommendations from the European Society of Cardiovascular Radiology (ESCR), in order to guide physicians in the use and interpretation of CMR and PET in clinical practice both for acute myocarditis and follow-up in chronic forms of I-CMP.

The pattern of late gadolinium enhancement by cardiac MRI in fulminant myocarditis and its prognostic implication: a two-year follow-up study

Background

Myocardial fibrosis, as quantified by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR), provides valuable prognostic information for patients with myocarditis. However, due to the low incidence rate of fulminant myocarditis (FM) and accordingly small sample size, the knowledge about the role of LGE to patients with FM is limited.

Methods and results

A total of 44 adults with viral-FM receiving the Chinese treating regimen were included in this retrospective study. They were divided into the low LGE group and the high LGE group according to the ratio of LGE to left ventricular mass (LGE mass%). CMR exams and LGE were performed after hemodynamic assistance at discharge in all patients with FM. Routine echocardiography parameters and global longitudinal strain (GLS) at discharge and at 2-year follow-up were obtained and then compared. Both left ventricular ejection fraction (LVEF) and GLS showed no significant difference in both groups at discharge, whereas significant differences were observed at 2-year follow-up between two groups. Moreover, there were significant improvements of LVEF and GLS in the low LGE group, but not in the high LGE group during the 2-year period. Furthermore, LGE mass% was negatively correlated with GLS and LVEF.

Conclusions

There were two distinct forms of LGE presentation in patients with FM. Moreover, the cardiac function of patients with low LGE was significantly better than those with high LGE at 2-year follow-up. LGE mass% at discharge provided significant prognosis information about cardiac function of patients with FM.

Ultra Short Heart Rate Variability Predicts Clinical Outcomes in Patients with a Clinical Presentation Consistent with Myocarditis: A Derivation Cohort Analysis

Myocarditis prognosis varies substantially, hence identification of novel prognostic factors is crucial. The prognostic role of ultra-short heart-rate variability (HRV) in myocarditis remains unknown. In a retrospective study, adult patients admitted to a tertiary hospital due to clinically suspected myocarditis were included. Clinical, laboratory and HRV parameters were assessed as predictors of severe short term complications (heart failure (HF), dilated cardiomyopathy—DCM, ventricular arrhythmia—VA and death), utilizing logistic regression (LR). Accuracy was evaluated with receiver operating characteristic (ROC) curve area under the curve (AUC). HRV indices included standard deviation of normal beat intervals (SDNN) and root mean square of successive differences (RMSSD). 115 patients, aged 34 (±13) years old, were examined. Six patients (5%) developed severe HFrEF. RMSSD was included in a multivariate LR model (RMSSD < 10.72 ms adjusted odds ratio (AOR) 14.056, p-value 0.024). Model classification accuracy was very good, with an AUC of 86%. Eight patients (7%) developed DCM. RMSSD < 10.72 ms was included in a multivariate classification model (AOR 8.826, p-value 0.013); model classification AUC of 82%. HRV did not predict development of VA or death. SDNN and especially RMSSD may be prognostic indicators in myocarditis.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Cardiac Involvement in Human Immunodeficiency Virus Infected Patients: An Observational Cardiac Magnetic Resonance Study

Objectives: To investigate the subclinical imaging changes in terms of myocardial inflammation and fibrosis and to explore the risk factors associated with myocardial fibrosis by cardiac magnetic resonance (CMR) approach in a Chinese HIV/AIDS cohort.

Methods: We evaluated myocardial function (cine), myocardial inflammation (T1, T2), and myocardial fibrosis (through extracellular volume fraction [ECV] and late gadolinium enhancement [LGE]) by a multiparametric CMR scan protocol in a total of 68 participants, including 47 HIV-infected individuals, who were divided into two groups: asymptomatic HIV (HIV+) (n = 30), and acquired immunodeficiency syndrome (AIDS) (n = 17), and 21 healthy controls.

Results: HIV-infected patients had lower left (55.3 ± 6.5 vs. 63.0 ± 7.9%, P < 0.001) and right ventricular systolic function (35.9 ± 15.7 vs. 50.8 ± 9.3%, P < 0.001). Radial systolic strain (30.7 ± 9.3 vs. 39.3 ± 9.4%, P = 0.001), circumferential systolic strain (−17.5 ± 2.6 vs. −19.4 ± 2.7%, P = 0.008), and longitudinal systolic strain (−9.4 ± 5.7 vs. −12.8 ± 3.1%, P = 0.012) were also decreased in HIV. Native T1 relaxation time (1,337.2 ± 70.2 vs. 1,249.5 ± 47.0 ms, P < 0.001), ECV value (33.5 ± 6.2 vs. 28.5 ± 2.9 ms, P = 0.026), and T2 relaxation time (45.2 ± 3.5 vs. 42.0 ± 2.6 ms, P = 0.001) were higher in HIV-infected patients compared with controls. Myocardial fibrosis, predominantly in the mid-inferior wall, was detected in 24.4% of the HIV-infected patients. HIV+ had a significantly lower value of ECV [29.1 (26.1, 31.8) vs. 35.2 (31.8, 41.9) %, P < 0.001] and frequency of LGE [3/25 (8%) vs. 7/16 (43.8%), P = 0.014)] compared with AIDS. AIDS was associated with myocardial fibrosis.

Conclusions: HIV-infected patients were associated with changes in myocardial function and higher rates of subclinical myocardial inflammation and fibrosis, which were more abnormal with greater severity of the disease. AIDS was associated with myocardial fibrosis, where the observations supported earlier initiation of antiretroviral therapy in the Chinese HIV/AIDS cohort.

Cardiac Magnetic Resonance Follow-Up of Children After Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 With Initial Cardiac Involvement

Background

Pediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2 (PIMS‐TS) is an inflammatory disease occurring in a small minority of children a few weeks after acute infection. Cardiac manifestations are common, but little is known about the potentially persistent heart changes after PIMS‐TS.

Purpose

To analyze the frequency and type of myocardial complications of PIMS‐TS with initial cardiac involvement assessed with cardiac magnetic resonance imaging (MRI), including parametric imaging, performed 3 months after hospitalization.

Study Type

Retrospective.

Population

Nineteen consecutive children (median age 10 years, interquartile range (IQR) 10–15 years, 74% male).

Field Strength/Sequence

Balanced steady state free precession (bSSFP, cine imaging), modified Look‐Locker (T1 mapping), T2‐prepared bSSFP (T2‐mapping), dark‐blood T2‐weighted turbo spin echo with fat suppression and phase sensitive inversion recovery (late gadolinium enhancement (LGE)) sequences at 1.5 T.

Assessment

Patients were scanned after a median of 99 days (IQR 89–104 days) from the diagnosis. MR data were reviewed by three independent observers, with 13, 2, and 5 years' experience in cardiac MRI. Pre‐ and post‐contrast T1, T2, extra‐cellular volume, and T2 signal intensity (T2 SI) ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Cardiac MRI parameters were compared, where possible, to previously published pediatric normal values.

Statistical Tests

Interclass correlation coefficient and Bland–Altman repeatability analysis. A P‐value <0.05 was considered statistically significant.

Results

Despite cardiac involvement including decreased left ventricular ejection fraction (LVEF) (median LVEF = 47%, IQR 43%–53%) and increased troponin I (median 101 ng/mL, IQR 50–661 ng/mL) during hospitalization, there were no persistent cardiac changes observed in cardiac MR at follow‐up. All patients had normal size and function of the left ventricle and normal precontrast T1 and T2 relaxation times. There were no signs of LGE. Persistent, mild pericardial effusion (8–9 mm) was found in three (16%) patients.

Data Conclusion

There were no persistent changes on cardiac MRI in a group of children approximately 3 months post hospitalization due to PIMS‐TS with cardiac involvement. This supports the hypothesis that cardiac involvement during PIMS‐TS is a form of transient inflammatory response rather than direct and potentially persistent injury from the virus.

Level of Evidence

4

Technical Efficacy

Stage 3

Usefulness of a multiparametric evaluation including global longitudinal strain for an early diagnosis of acute myocarditis

Cardiac magnetic resonance imaging (CMRI) represents the main imaging modality for diagnosing acute myocarditis. However, its limited availability could entail missing or delayed diagnosis. A reduction of left ventricular global longitudinal strain (LV GLS) by speckle tracking echocardiography (STE) correlates with amount of oedema in acute myocarditis and here may be early detected. Aim was to evaluate the diagnostic and prognostic role of 3-layers LV GLS in patients with acute myocarditis. Out of 122 patients with suspected acute myocarditis, a total of 86 consecutive patients with CMRI-confirmed acute myocarditis admitted in two Italian institutions were retrospectively screened. Exclusion criteria were met in 29 patients because of poor acoustic window or missing data. A total of 57 patients were then included. Clinical characteristics, laboratory examinations, transthoracic echocardiography data and STE parameters were collected early after hospitalization. In the study population, mean age was 38.8 ± 15.6 years, the prevalence of male gender was 90%. On admission, 22 patients (39%) had fever (body temperature > 37.5 °), mean white blood cell (WBC) count was 10.9 ± 1.7/10^3 and overall LV ejection fraction was 50.1% ± 11.2. An epicardial LV GLS < 18% was present in 74% of patients, and a model including at least one of LV GLS < 18% (absolute value), fever and WBC > 10.0/10^3 was able to identify all patients with CMRI-diagnosed acute myocarditis. An epicardial LV GLS < 15.3% (absolute value) at baseline significantly predicted the lack of myocarditis resolution during follow-up (AUC 0.76, 95% CI 0.58-0.93, p = 0.02). A multiparametric model including epicardial LV GLS, fever and elevated WBC count on admission could be useful for early diagnosing an acute myocarditis, especially when CMRI is not promptly available. Baseline epicardial LV GLS may also identify patients with less-likely myocarditis resolution.

Cardiac involvement in COVID-19 patients: mid-term follow up by cardiovascular magnetic resonance

BACKGROUND

Coronavirus disease 2019 (COVID-19) induces myocardial injury, either direct myocarditis or indirect injury due to systemic inflammatory response. Myocardial involvement has been proved to be one of the primary manifestations of COVID-19 infection, according to laboratory test, autopsy, and cardiovascular magnetic resonance (CMR). However, the middle-term outcome of cardiac involvement after the patients were discharged from the hospital is yet unknown. The present study aimed to evaluate mid-term cardiac sequelae in recovered COVID-19 patients by CMR METHODS: A total of 47 recovered COVID-19 patients were prospectively recruited and underwent CMR examination. The CMR protocol consisted of black blood fat-suppressed T2 weighted imaging, T2 star mapping, left ventricle (LV) cine imaging, pre- and post-contrast T1 mapping, and late gadolinium enhancement (LGE). LGE were assessed in mixed both recovered COVID-19 patients and healthy controls. The LV and right ventricle (RV) function and LV mass were assessed and compared with healthy controls.

RESULTS

A total of 44 recovered COVID-19 patients and 31 healthy controls were studied. LGE was found in 13 (30%) of COVID-19 patients. All LGE lesions were located in the mid myocardium and/or sub-epicardium with a scattered distribution. Further analysis showed that LGE-positive patients had significantly decreased LV peak global circumferential strain (GCS), RV peak GCS, RV peak global longitudinal strain (GLS) as compared to non-LGE patients (p < 0.05), while no difference was found between the non-LGE patients and healthy controls.

CONCLUSION

Myocardium injury existed in 30% of COVID-19 patients. These patients have depressed LV GCS and peak RV strains at the 3-month follow-up. CMR can monitor the COVID-19-induced myocarditis progression, and CMR strain analysis is a sensitive tool to evaluate the recovery of LV and RV dysfunction.

Application of Multiparametric Quantitative Cardiac Magnetic Resonance for Detection and Monitoring of Myocardial Injury in Patients with Fulminant Myocarditis

RATIONALE AND OBJECTIVES

To investigate whether multiparametric cardiac magnetic resonance (CMR) could detect and monitor inflammatory myocardial alterations in fulminant myocarditis.

MATERIALS AND METHODS

Nineteen patients (35 ± 14 years, 37% male) with clinical diagnosis of fulminant myocarditis underwent CMR examinations at 3.0T in the acute phase and at 3-months follow up. The control group consisted of 19 healthy volunteers. The CMR protocol included cine, black blood T2-weighted imaging, T1 mapping, T2 mapping and late gadolinium enhancement (LGE). Cardiac parameters, such as edema ratio, LGE mass, native T1, T2 and extracellular volume were measured.

RESULTS

The left ventricular mass index (67 ± 15 versus 55 ± 12 g/m², p < 0.05) and interventricular septum thickness (10.4 ± 1.5 versus 8.3 ± 1.8 mm, p < 0.001) in acute stage was significantly higher compared to controls, and normalized at the chronic stage. All quantitative inflammation metrics, including edema ratio, LGE mass, native T1, T2 and extracellular volume were significantly (all p < 0.001) decreased in the follow-up scan, but still higher compared to controls. Compared to the controls, all global strain indices including circumferential, longitudinal and radial strain values were significantly impaired in acute stage (all p < 0.001). Native T1 and T2 values led to excellent diagnostic accuracy for discriminating fulminant myocarditis from healed myocarditis, with AUC of 0.947 and 0.931.

CONCLUSION

Multiparametric CMR could detect and monitor inflammation myocardial injuries in patients with fulminant myocarditis. Native T1 and T2 values achieved excellent diagnostic performance in distinguishing acute from healed myocarditis.

Identifying myocardial injuries in "normal-appearing" myocardium in pediatric patients with clinically suspected myocarditis using mapping techniques

Background

Mapping techniques using cardiac magnetic resonance imaging have significantly improved the diagnostic accuracy for myocarditis with focal myocardial injuries. The aim of our study was to determine whether T1 and T2 mapping techniques could identify diffuse myocardial injuries in "normal-appearing" myocardium in pediatric patients with clinically suspected myocarditis and to evaluate the associations between diffuse myocardial injuries and cardiac function parameters.

Methods

Forty-six subjects were included in this study: 20 acute myocarditis patients, 11 subacute/chronic myocarditis patients and 15 control children. T2 values, native T1 values and the extracellular volume (ECV) of "normal-appearing" myocardium were compared among the three groups of patients. Associations between diffuse myocardial injuries and cardiac function parameters were also evaluated.

Results

The ECV of "normal-appearing" myocardium was significantly higher in the subacute/chronic myocarditis group than in the control group (30.1 ± 0.9 vs 27.0 ± 0.6, P =0.004). No significant differences in T1 and T2 values between the acute myocarditis and control groups were found. In the subacute/chronic myocarditis group, a significant association between ECV and left ventricle ejection fraction was found (P=0.03).

Conclusions

Diffuse myocardial injuries are likely to occur in subacute/chronic myocarditis patients with prolonged inflammatory responses. Mapping techniques have great value for the diagnosis and monitoring of myocarditis.

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.

Diagnostic value of 3.0 T cardiac MRI in children with suspected myocarditis: multi-parameter analysis for the evaluation of acute and chronic myocarditis

BACKGROUND

Cardiac magnetic resonance (CMR) is an established tool for detection of myocarditis. However, no comprehensive data for CMR based on the "Lake Louise" criteria in pediatric myocarditis exists to date.

PURPOSE

To evaluate the value of multi-parameter CMR in children with suspected acute (AMC) and chronic myocarditis (CMC).

MATERIAL AND METHODS

We examined 73 pediatric patients with clinically suspected AMC (n = 25) and CMC (n = 48). We compared them to 17 controls. All individuals underwent CMR, including function analyses, T2 ratio, early gadolinium enhancement ratio (EGEr), and late gadolinium enhancement (LGE).

RESULTS

In AMC, 19 (76%) patients were abnormal in any two of three parameters (T2 ratio, EGEr, and LGE). There was a significant difference between AMC and controls in LVEF (51.2% vs. 61.3%), mass (130.2 ± 14.0 vs. 120.5 ± 13.9 g), T2 ratio (1.96 ± 0.2 vs. 1.69 ± 0.13), and EGEr (4.1 ± 0.27 vs. 3.4 ± 0.39) (P < 0.05). In CMC, 26 (54.1%) patients were abnormal in any two of three parameters. There was no significant difference between CMC and controls in LVEF and mass, but there was a statistical difference in T2 ratio (1.88 ± 0.18 vs. 1.69 ± 0.13) and in EGEr (3.93 ± 0.22 vs. 3.4 ± 0.39) (P < 0.05). There was an increase in LVEF while both T2 ratio and EGEr significantly decreased (P < 0.05) during follow-up of acute fulminant myocarditis.

CONCLUSION

Comprehensive CMR may serve as a powerful tool in children with suspected AMC. CMR in assessment of CMC may be valuable, but it is not satisfactory.

Clinical Importance of Myocardial T2 Mapping and Texture Analysis

Late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) is valuable for diagnosis and assessment of the severity of various myocardial diseases owing to its potential to visualize myocardial scars. T₁ mapping is complementary to LGE because it can quantify the degree of myocardial fibrosis or edema. As such, T₁-weighted imaging techniques, including LGE using an inversion recovery sequence, contribute to cardiac MRI. T₂-weighted imaging is widely used to characterize the tissue of many organs. T₂-weighted imaging is used in cardiac MRI to identify myocardial edema related to chest pain, acute myocardial diseases, or severe myocardial injuries. However, it is difficult to determine the presence and extent of myocardial edema because of the low contrast between normal and diseased myocardium and image artifacts of T₂-weighted images and the lack of an established method to quantify the images. T₂ mapping quantifies myocardial T₂ values and help identify myocardial edema. The T₂ values are significantly related to the clinical symptoms or severity of nonischemic cardiomyopathy. Texture analysis is a postprocessing method to quantify tissue alterations that are reflected in the T₂-weighted images. Texture analysis provides a variety of parameters, such as skewness, entropy, and grey-scale non-uniformity, without the need for additional sequences. The abnormal signal intensity on T₂-weighted images or T₂ values may correspond to not only myocardial edema but also other tissue alterations. In this review, the techniques of cardiac T₂ mapping and texture analysis and their clinical relevance are described.

Diagnostic and prognostic role of cardiac magnetic resonance in acute myocarditis

Acute myocarditis (AM) is commonly found in everyday clinical practice. Differential diagnosis between various causes of myocardial damage with non-obstructive coronary arteries can be cumbersome for clinician. Moreover, AM may be provoked by a number of different causes and clinical presentation can be heterogeneous with potential overlap going from asymptomatic or subclinical to severe heart failure, arrhythmias, and death. Cardiac magnetic resonance (CMR) over the last decades has proven to be the diagnostic technique of choice since it allows identifying AM with excellent diagnostic accuracy. Latest technological advancement with parametric imaging such as T1 and T2 mapping further increases sensitivity and provides additional help towards a correct diagnosis. CMR however is no longer to be considered as a mere diagnostic tool but also as a powerful source of prognostic information. Scientific evidence has corroborated CMR's role beyond diagnosis demonstrating how late gadolinium enhancement (LGE) presence is a powerful predictor of cardiac events and how the presence of septal LGE is to be considered of worst prognosis regardless of LGE extension even in patients with preserved global systolic function. CMR should be routinely performed in all patients with AM suspicion since its diagnostic and prognostic role is of paramount important and could modify therapeutic strategy and subsequent clinical decisions.

The best way to assess oedema using T1, T2 mapping or three-dimensional T2-weighted fast-spin-echo triple inversion recovery sequences via cardiovascular MRI in outpatients with suspected myocarditis

AIM

To evaluated T1-, T2 mapping, and a three-dimensional (3D) T2-weighted fast-spin-echo triple inversion recovery sequences (3D STIR) for diagnosing myocardial oedema in patients with suspected early myocarditis and at follow-up.

MATERIALS AND METHODS

Sixteen patients with suspected myocarditis and 15 controls matched for gender and age were examined prospectively. To evaluate oedema, an electrocardiogram-triggered T1 and T2 mapping with a gradient spin echo technique and 3D STIR sequences were used to cover the entire left ventricle. The signal intensity ratio (heart muscle in relation to skeletal muscle) was calculated (3D STIR ratio). All patients underwent repeat examinations at follow-up.

RESULTS

The mean 3D-STIR ratio was 2.14±0.45 at the patients' initial examination as compared to the control patients' 1.54±0.18 in (p=0.0001) and 1.75±0.16 in patients at follow-up (p=0.002 versus first visit). The 3D STIR ratio of the septum, anterior, lateral, and inferior wall also differed significantly between patients and controls. No significant difference was observed in T1 and T2 mapping between patients and controls at baseline and patients at follow-up.

CONCLUSIONS

A significantly higher global signal intensity ratio with 3D-STIR was identified in patients with suspected myocarditis compared to controls, and a significant change during follow-up. No significant difference was detected in T1-, T2 mapping between patients and controls, or between the initial examination and follow-up of patients. The global 3D-STIR ratio may therefore be useful for the diagnosis of myocarditis and should be explored further.

Diagnostic and prognostic value of cardiac magnetic resonance in acute myocarditis: a systematic review and meta-analysis

While diagnostic criteria were elaborated for acute myocarditis using cardiac magnetic resonance (CMR) in 2009, studies have since examined the yield of traditional and novel CMR parameters to achieve greater accuracy and to predict clinical outcomes. The purpose of this systematic review and meta-analysis was to determine the diagnostic and prognostic value of CMR parameters for acute myocarditis. MEDLINE and EMBASE were systematically searched for original studies that reported CMR parameters in adult patients suspected of acute myocarditis. Each CMR parameter's binary prevalence, mean value and standard deviation were extracted. Parameters were meta-analyzed using a random-effects model to generate standardized mean differences. After screening 1492 abstracts, 53 studies were included encompassing 2823 myocarditis patients and 803 controls. Pooled standardized mean differences between myocarditis patients and controls were: T2 mapping time 2.26 (95% CI 1.50-3.02), extracellular volume 1.64 (95% CI 0.87-2.42), LGE percentage 1.30 (95% CI 0.95-1.64), T1 mapping time 1.18 (95% CI 0.35-2.01), T2 ratio 1.17 (95% CI 0.80-1.54), and EGE ratio 0.93 (95% CI 0.66-1.19). Prolonged T1 mapping time had the highest sensitivity (82%), pericardial effusion had the highest specificity (99%). Baseline LV dysfunction and the presence of LGE were predictive of major adverse cardiac events. The results support integration of parametric mapping criteria in the diagnostic criteria for myocarditis. The presence of baseline LV dysfunction and LGE predict patients at higher risk of adverse events.

Assessment of Cardiotoxicity of Cancer Chemotherapy: The Value of Cardiac MR Imaging

Chemotherapy is associated with cardiovascular injury, including the development of a cardiomyopathy and vascular remodeling. Cardiac magnetic resonance (CMR) is sensitive to detect not only established morphologic and functional abnormalities but also early, potentially reversible, signs of myocardial injury. It robustly detects and quantifies myocardial edema, inflammation, and focal fibrosis, as well as interstitial fibrosis and vascular remodeling. These capabilities support the role of CMR as an excellent tool for evaluating cardiotoxicity. Novel CMR markers may even enhance patient management by facilitating the early detection of reversible myocardial tissue remodeling before classic morphologic and functional changes appear.

Natural History of Myocardial Injury and Chamber Remodeling in Acute Myocarditis

Background:

Cardiovascular magnetic resonance (CMR) imaging is commonly used to diagnose acute myocarditis. However, the natural history of CMR-based tissue markers and their association with left ventricular recovery is poorly explored. We prospectively investigated the natural history of CMR-based myocardial injury and chamber remodeling over 12 months in patients with suspected acute myocarditis.

Methods:

One hundred patients with suspected acute myocarditis were enrolled. All underwent CMR evaluations at baseline and 12 months, inclusive of T2 and late gadolinium enhancement. Blinded quantitative analyses compared left ventricular chamber volumes, function, myocardial edema, and necrosis at each time point using predefined criteria. The predefined primary outcomes were improvement in left ventricular ejection fraction ≥10% and improvement in the indexed left ventricular end diastolic volume ≥10% at 12 months.

Results:

The mean age was 39.9±14.5 years (82 male) with baseline left ventricular ejection fraction of 57.1±11.2%. A total of 72 patients (72%) showed late gadolinium enhancement at baseline with 57 (57%) having any T2 signal elevation. Left ventricular volumes and EF improved significantly at 12 months. Global late gadolinium enhancement extent dropped from 8.5±9.2% of left ventricular mass to 3.0±5.2% ( P =0.0001) with prevalence of any late gadolinium enhancement dropping to 48%. Reductions in global T2 signal ratio occurred at 12 months (1.85±0.3 to 1.56±0.2; P =0.0001) with prevalence of T2 ratio ≥2.0 dropping to 7%. Neither marker provided associations with the primary outcomes.

Conclusions:

In clinically suspected acute myocarditis, significant reductions in tissue injury markers occur during the first 12 months of convalescence. Neither the presence nor extent of the investigated CMR-based tissue injury markers were predictive of our pre-defined function or remodeling outcomes at 12 months in this referral population.

Early Cardiac Involvement Affects Left Ventricular Longitudinal Function in Females Carrying α-Galactosidase A Mutation: Role of Hybrid Positron Emission Tomography and Magnetic Resonance Imaging and Speckle-Tracking Echocardiography

BACKGROUND

Hybrid ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography and magnetic resonance imaging may differentiate mature fibrosis or scar from fibrosis associated to active inflammation in patients with Anderson-Fabry disease, even in nonhypertrophic stage. This study was designed to compare the results of positron emission tomography and magnetic resonance cardiac imaging with those of speckle-tracking echocardiography in heterozygous Anderson-Fabry disease females.

METHODS AND RESULTS

Twenty-four heterozygous females carrying α-galactosidase A mutation and without left ventricular hypertrophy underwent cardiac positron emission tomography and magnetic resonance using ¹⁸F-FDG for glucose uptake and 2-dimensional strain echocardiography. ¹⁸F-FDG myocardial uptake was quantified by measuring the coefficient of variation (COV) of the standardized uptake value using a 17-segment model. Focal ¹⁸F-FDG uptake with COV >0.17 was detected in 13 patients, including 2 patients with late gadolinium enhancement at magnetic resonance. COV was 0.30±0.14 in patients with focal ¹⁸F-FDG uptake and 0.12±0.03 in those without (P<0.001). Strain echocardiography revealed worse global longitudinal systolic strain in patients with COV >0.17 compared with those with COV ≤0.17 (-18.5±2.7% versus -22.2±1.8%; P=0.024). For predicting COV >0.17, a global longitudinal strain >-19.8% had 77% sensitivity and 91% specificity and a value >2 dysfunctional segments 92% sensitivity and 100% specificity.

CONCLUSIONS

In females carrying α-galactosidase A mutation, focal ¹⁸F-FDG uptake represents an early sign of disease-related myocardial damage and is associated with impaired left ventricular longitudinal function. These findings support the hypothesis that inflammation plays an important role in glycosphingolipids storage disorders.

Doxorubicin-Induced Cardiomyopathy in Children

Doxorubicin-induced cardiotoxicity in childhood cancer survivors is a growing problem. The population of patients at risk for cardiovascular disease is steadily increasing, as five-year survival rates for all types of childhood cancers continue to improve. Doxorubicin affects the developing heart differently from the adult heart and in a subset of exposed patients, childhood exposure leads to late, irreversible cardiomyopathy. Notably, the prevalence of late-onset toxicity is increasing in parallel with improved survival. By the year 2020, it is estimated that there will be 500,000 childhood cancer survivors and over 50,000 of them will suffer from doxorubicin-induced cardiotoxicity. The majority of the research to-date, concentrated on childhood cancer survivors, has focused mostly on clinical outcomes through well-designed epidemiological and retrospective cohort studies. Preclinical studies have elucidated many of the cellular mechanisms that elicit acute toxicity in cardiomyocytes. However, more research is needed in the areas of early- and late-onset cardiotoxicity and more importantly improving the scientific understanding of how other cells present in the cardiac milieu are impacted by doxorubicin exposure. The overall goal of this review is to succinctly summarize the major clinical and preclinical studies focused on doxorubicin-induced cardiotoxicity. As the prevalence of patients affected by doxorubicin exposure continues to increase, it is imperative that the major gaps in existing research are identified and subsequently utilized to develop appropriate research priorities for the coming years. Well-designed preclinical research models will enhance our understanding of the pathophysiology of doxorubicin-induced cardiotoxicity and directly lead to better diagnosis, treatment, and prevention. © 2019 American Physiological Society. Compr Physiol 9:905-931, 2019.

Usefulness of Cardiac Magnetic Resonance in the Diagnosis of Löffler Endocarditis Secondary to Eosinophilic Granulomatosis with Polyangiitis

A 40-year-old man who was diagnosed with bronchial asthma and eosinophilia was transferred to our hospital due to a worsening respiratory status. He was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA), and eosinophilic pneumoniae. Cardiac magnetic resonance (CMR) imaging indicated Löffler endocarditis. Treatment was initiated using intravenous methylprednisolone, cyclophosphamide, and heparin as anticoagulation therapy. Three months later, CMR showed the improvement of the LV myocardium. In this case, the early diagnosis of Löffler endocarditis by CMR could prevent systemic embolism and CMR was useful for assessing the curative effects of steroid and immunosuppressant therapy.

Advanced imaging modalities to detect cardiotoxicity

Recent advances in cancer treatments have significantly improved survival rates, reemphasizing the focus on reducing the potential complications associated with some therapies. Cardiovascular disease associated with chemotherapies is a major cause of morbidity and mortality in cancer survivors. Early detection of cardiotoxicity improves cardiac outcomes among cancer patients. The review will focus on imaging modalities used to assess cardiotoxicity - the cardiovascular consequences of chemotherapies. The review will discuss the benefits and limitations associated with each technique, as well as the guidelines available to help identify at risk patients. We will discuss novel techniques that may help detect earlier signs of cardiotoxicity, directing management that may improve clinical outcomes.

Tissue characterization by T1 and T2 mapping cardiovascular magnetic resonance imaging to monitor myocardial inflammation in healing myocarditis

Aims

Monitoring disease activity in myocarditis is important for tailored therapeutic strategies. This study evaluated the ability of T1 and T2 mapping cardiovascular magnetic resonance (CMR) to monitor the course of myocardial inflammation in healing myocarditis.

Methods and Results

Forty-eight patients with strictly defined acute myocarditis underwent CMR at 1.5 T in the acute stage, at 3-months (n = 39), and at 12-months follow-up (FU) (n = 21). Normal values were obtained in a control group of 27 healthy subjects. The CMR protocol included standard ('Lake-Louise') sequences as well as T1 (modified Look-Locker inversion recovery sequence, MOLLI) and T2 (gradient- and spin-echo sequence, GraSE) mapping. T1, T2, and extracellular volume (ECV) maps were generated using an OsiriX plug-in. Native myocardial T1, T2, and ECV values were increased in the acute stage, but declined with healing of myocarditis. The performances of global native T1 and T2 to differentiate acute from healed myocarditis stages were significantly better compared with all other global CMR parameters with AUCs of 0.85 (95% CI, 0.76-0.94) and 0.83 (95% CI, 0.73-0.93). Furthermore, regional native T1 and T2 in myocarditis lesions provided AUCs of 0.97 (95% CI, 0.93-1.02) and 0.93 (95% CI, 0.85-1.01), which were significantly superior to any other global or regional CMR parameter.

Conclusion

Healing of myocarditis can be monitored by native myocardial T1 and T2 measurements without the need for contrast media. Both native myocardial T1 and T2 provide an excellent performance for assessing the stage of myocarditis by CMR.

Early diastolic septal movement in patients with myocarditis

AIM

To evaluate early diastolic septal relaxation as a parameter in the diagnostic workup via cardiovascular magnetic resonance imaging (CMRI) in patients with myocarditis.

MATERIALS AND METHODS

Early diastolic septal movement was evaluated (EDS) prospectively via frame-by-frame analysis in 255 consecutive patients with presenting signs of myocarditis and in 64 controls matched 4:1 for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained, as well as left ventricular (LV) function and dimensions in patients and controls.

RESULTS

EDS was detected in 66.7% of the patients and 18.7% of the controls (p<0.001). Sensitivity was 69.4% and specificity 79.7%. Patients with EDS had a significant lower LV ejection fraction (LV-EF) of 61.1±0.6% and significant higher end-diastolic volume (EDV) of 158.5±2.7 ml than in patients without EDS (LV-EF 65.3±0.9%, p=0.0001; EDV 148.4±3.9 ml, p=0.04). A significant negative correlation was observed between LV-EF and EDS in patients, and a lower LV-EF correlated with a more frequent occurrence of EDS (r=-0.24, p=0.0001). Scar tissue was also more frequent in patients than controls (63.1% and 7.8%, p=0.007).

CONCLUSIONS

EDS is a parameter obtained non-invasively by CMRI and is present in a high percentage of patients with myocarditis. Cardiac functional parameters are significantly altered in patients with EDS. EDS is a feasible parameter that can play an important role in the diagnosis of myocarditis.

Taxonomy of segmental myocardial systolic dysfunction

The terms used to describe different states of myocardial health and disease are poorly defined. Imprecision and inconsistency in nomenclature can lead to difficulty in interpreting and applying trial outcomes to clinical practice. In particular, the terms ‘viable’ and ‘hibernating’ are commonly applied interchangeably and incorrectly to myocardium that exhibits chronic contractile dysfunction in patients with ischaemic heart disease. The range of inherent differences amongst imaging modalities used to define myocardial health and disease add further challenges to consistent definitions. The results of several large trials have led to renewed discussion about the classification of dysfunctional myocardial segments. This article aims to describe the diverse myocardial pathologies that may affect the myocardium in ischaemic heart disease and cardiomyopathy, and how they may be assessed with non-invasive imaging techniques in order to provide a taxonomy of myocardial dysfunction.

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure

Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.

Myocardial edema in acute myocarditis: relationship of T2 relaxometry and late enhancement burden by using dual-contrast turbo spin-echo MRI

To quantify myocardial edema by using a T2 relaxometry approach with a dual-contrast turbo spin-echo (dcTSE) sequence in patients with acute myocarditis regarding focal late gadolinium enhancement (LGE) burden. CMR T2 relaxometry was performed in 39 patients (age 41 ± 19 years; 36% women) with LGE in a typical myocarditis pattern and in ten healthy volunteers (age 46 ± 12; 60% woman). dcTSE sequence (echo time 29 and 75 ms, respectively) was used for T2 mapping, analysis were performed on the basis of region of interest (ROI). Myocardial T2 relaxation times (T2 RT) in patients-ROI with focal LGE were significantly (p < 0.001) higher than T2 RT in patients-ROI without apparent LGE pattern (65 ms (IQR 36-95) vs. 60 ms (IQR 26-88), respectively). T2 RT in healthy volunteers [55 ms (IQR 35-71)] were significantly lower than in patients ROI with or without focal LGE-pattern (p < 0.001, respectively). T2 RT assessed by dcTSE are significantly higher in patients segments with and without focal LGE compared to normal controls, supporting a global myocardial inflammatory process in acute myocarditis. Furthermore, this quantitative T2-mapping approach highlights the potential to identify patients with diffuse myocarditis.

Multimodality imaging approach in the diagnosis of chronic myocarditis with preserved left ventricular ejection fraction (MCpEF): The role of 2D speckle-tracking echocardiography

BACKGROUND

Up to one third of patients with chronic myocarditis (MC) have preserved left ventricular (LV) ejection fraction (MCpEF). The purpose of this study was to evaluate the role of adding 2D speckle-tracking echocardiography (STE) to cardiac magnetic resonance imaging (cMRI) in the diagnosis of patients with MCpEF.

METHODS AND RESULTS

We analyzed 67 patients with suspected MCpEF who underwent endomyocardial biopsy (EMB). Thirty-two patients with confirmed chronic myocardial inflammation by EMB served as study group (MCpEF) and the remaining patients (n=35) served as control group. In all patients, 2D STE and cMRI were performed within 48h before EMB. Patients with MCpEF had significantly lower LV global longitudinal systolic strain (GLS) than controls (GLS: -17.01±2.42% vs. -19.39±3.81%, p<0.001; respectively). In line, an abnormal GLS had adequate diagnostic performance to detect MCpEF (sensitivity, specificity, and accuracy of 82%, 70%, and 76%, respectively), which was superior to cMRI based on the Lake-Louise criteria (sensitivity, specificity, and accuracy 54%, 71%, and 67%, respectively). In addition, adding GLS to the Lake-Louise criteria improved significantly the diagnostic performance of cMRI to detect MCpEF (sensitivity, specificity, and accuracy 96%, 55%, and 75%, respectively).

CONCLUSION

The findings of this study suggest that GLS using 2D STE could play an important role in the diagnostic evaluation of patients with suspected chronic myocarditis with preserved LV ejection fraction (MCpEF).

Detection and Monitoring of Acute Myocarditis Applying Quantitative Cardiovascular Magnetic Resonance

BACKGROUND

Cardiovascular magnetic resonance based on the Lake Louise Criteria is used to make the diagnosis of acute myocarditis. Novel quantitative parametric mapping techniques promise to overcome some of its limitations. We aimed to evaluate quantitative cardiovascular magnetic resonance to detect and monitor acute myocarditis.

METHODS AND RESULTS

Eighteen patients with clinical diagnosis of acute myocarditis (25 years [23-38 years]; 78% males) were prospectively enrolled and repeatedly underwent cardiovascular magnetic resonance at 1.5 T seven days (5-10 days) after symptom onset (FU0), after 5 weeks (FU1), and after 6 months (FU2). Eighteen age- and sex-matched healthy subjects served as controls. Cardiovascular magnetic resonance included imaging of edema, hyperemia, necrosis, and fibrosis using semiquantitative T2-weighted spin echo, T2 mapping, and T1 mapping before and 3 and 10 minutes after gadobutrol administration. Extracellular volume for diffuse and late gadolinium enhancement for focal fibrosis were assessed. Compared with controls, patients had significantly higher global T2 times at FU0 (55.1 ms [53.3-57.2 ms] versus 50.2 ms [49.2-52.0 ms]; P<0.001) and at FU1 (52.0 ms [52.0-53.2 ms]; P=0.007), which normalized at FU2 (50.9 ms [49.6-53.3 ms]; P=0.323). Global native T1 times in patients were elevated acutely (1004 ms [988-1048 ms] versus 975 ms [957-1004 ms]; P=0.002) and remained elevated throughout the follow-up (FU1: 998 ms [990-1027 ms]; P=0.014; FU2: 1000 ms [972-1027 ms]; P=0.044). Global extracellular volume fraction was statistically not different between patients and controls (P=0.057). 77.8% (14/18) of patients had focal late gadolinium enhancement. T2 ratio was significantly elevated in patients with myocarditis at FU0 (2.2 [2.0-2.3] versus 1.6 [1.5-1.7]; P<0.001). The difference decreased during follow-up (FU1: 1.9 [1.7-1.9]; P=0.001 and FU2: 1.7 [1.7-1.8]; P=0.053). The diagnostic accuracy to discriminate between patients with acute myocarditis and healthy controls was 86% for T2>52 ms, 78% for native T1>981 ms, 74% for extracellular volume fraction >0.24, and 100% for T2 ratio >1.9.

CONCLUSIONS

Although both T2 and T1 mapping reliably detected acute myocarditis, only T2 mapping discriminated between acute and healed stages, underlining the incremental value of T2 mapping.

Magnetic resonance imaging for characterizing myocardial diseases

The National Institute of Health defined cardiomyopathy as diseases of the heart muscle. These myocardial diseases have different etiology, structure and treatment. This review highlights the key imaging features of different myocardial diseases. It provides information on myocardial structure/orientation, perfusion, function and viability in diseases related to cardiomyopathy. The standard cardiac magnetic resonance imaging (MRI) sequences can reveal insight on left ventricular (LV) mass, volumes and regional contractile function in all types of cardiomyopathy diseases. Contrast enhanced MRI sequences allow visualization of different infarct patterns and sizes. Enhancement of myocardial inflammation and infarct (location, transmurality and pattern) on contrast enhanced MRI have been used to highlight the key differences in myocardial diseases, predict recovery of function and healing. The common feature in many forms of cardiomyopathy is the presence of diffuse-fibrosis. Currently, imaging sequences generating the most interest in cardiomyopathy include myocardial strain analysis, tissue mapping (T₁, T_2, T₂*) and extracellular volume (ECV) estimation techniques. MRI sequences have the potential to decode the etiology by showing various patterns of infarct and diffuse fibrosis in myocarditis, amyloidosis, sarcoidosis, hypertrophic cardiomyopathy due to aortic stenosis, restrictive cardiomyopathy, arrythmogenic right ventricular dysplasia and hypertension. Integrated PET/MRI system may add in the future more information for the diagnosis and progression of cardiomyopathy diseases. With the promise of high spatial/temporal resolution and 3D coverage, MRI will be an indispensible tool in diagnosis and monitoring the benefits of new therapies designed to treat myocardial diseases.

Factors and values at admission that predict a fulminant course of acute myocarditis: data from Tokyo CCU network database

Prognosis of acute myocarditis is generally benign, but fulminant cases exist which require advanced life support devices, such as percutaneous cardio-pulmonary support (PCPS) and ventricular assist devices (VAD), and lead to fatal outcomes. The purpose of this study was to identify predictors and their values at admission which might foreshadow a fulminant course of myocarditis. Data from 138 patients (mean age 42.0 years, 79 males) with a diagnosis of acute myocarditis in the Tokyo CCU Network database from 2007 to 2009 were analyzed retrospectively. Patients were divided into fulminant (in-hospital death, or PCPS or VAD requirement, N = 42) and non-fulminant groups (N = 96). Clinical data at admission were compared between them. Overall in-hospital mortality was 14.5%. On multivariate analysis, low systolic blood pressure (BPsys, odds ratio (OR)/mmHg 0.97; 95% confidence interval (CI) 0.93-1.00, p = 0.032) and electrocardiographic QRS complex prolongation (OR/10 ms 1.28; 95% CI 1.10-1.59, p = 0.0034) at admission were independent factors associated with a fulminant course. By receiver operator characteristic curve analysis, the area under the curve predicting a fulminant course was 0.769 for low BPsys and 0.821 for prolongation of QRS duration. The optimal cut-off value was 101 mmHg for BPsys (sensitivity 79.5%, specificity 68.0%), and 120 ms for QRS duration (sensitivity 72.2%, specificity 88.0%). Systolic hypotension and prolonged QRS on admission are predictors of a fulminant course of myocarditis.

Clinical applications of multi-parametric CMR in myocarditis and systemic inflammatory diseases

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.

Clinical and magnetic resonance evolution of "infarct-like" myocarditis

AIMS

To analyse the clinical and magnetic resonance evolution of myocarditis in patients with an "infarct-like" presentation pattern.

METHODS

The study is a retrospective analysis of 52 patients with clinical diagnosis of "infarct-like" myocarditis confirmed by CMR as acute myocarditis according to Lake Louise criteria and 6 months follow-up. The CMR protocol included T2-weighted (oedema), early (hyperaemia) and late (fibrosis/necrosis) gadolinium enhancement sequences, according to Lake Louise criteria. Clinical and radiological follow-up by CMR was performed after a median time interval of 6 months (interquartile range 5-8). Quantitative outcomes were checked for normality and compared with the non-parametric Wilcoxon's test for matched data.

RESULTS

At the clinical follow-up all patients were free of symptoms and reported no cardiac complications. The CMR follow-up evidenced a significant increase of the ejection fraction (from 53 ± 6 to 55 ± 4%, p = 0.03), a decrease of the ventricular mass [from 67.0 (58.8-79.0) to 61.0 (54.0-67.0), p < 0.0001] without significant modification of the cardiac volume index (p = 0.26). No patient had residual oedema or capillary leakage: the T2 ratio decreased from 3.94 (3.00-4.86) to 0.98 (0.75-1.17) with p < 0.0001 and the Early gadolinium enhancement (EGE) ratio from 5.7 (4.8-6.5) to 2.9 (2.4-3.2) with p < 0.0001. Late gadolinium enhancement (LGE) persisted over the course of the follow-up in 48/52 patients, but with a significant reduction in every patient (LGE % from 34.3 ± 9.1 to 19.4 ± 6.6%; p < 0.0001).

CONCLUSION

Patients diagnosed with "infarct-like" myocarditis, according to both clinical and CMR examinations may look forward to a positive evolution with a good prognosis.

Temporal change of myocardial tissue character is associated with left ventricular reverse remodeling in patients with dilated cardiomyopathy: A cardiovascular magnetic resonance study

BACKGROUND

Prognostic significance of temporal change in myocardial tissue characterization by cardiovascular magnetic resonance (CMR) has not been elucidated in patients with non-ischemic dilated cardiomyopathy (DCM).

METHODS AND RESULTS

Sixty-eight patients with newly-diagnosed DCM who underwent CMR including late gadolinium enhancement (LGE) both at baseline and during follow-up period were enrolled. LGE score was defined by a signal intensity of ≥5 standard deviations above the remote reference myocardium mean. Left ventricular reverse remodeling (LVRR) defined as a LV ejection fraction increase of ≥10% and a decrease in indexed LV end-diastolic diameter of ≥10% compared to those at baseline was detected in 38% of the patients. There was no significant difference in LGE score between baseline and follow-up (5.8% vs. 7.3%; p=0.38). The change in LGE area (delta-LGE) was significantly lower in patients with LVRR than those without (-0.5%±3.4% vs. 3.0±7.4%; p=0.02). On the other hand, T2 ratio during the follow-up significantly reduced (1.95±0.48 vs. 1.67±0.56; p<0.01); however, there was no significant difference in the change in T2 ratio between patients with LVRR and those without (-0.29±0.73 vs. -0.27±0.66; p=0.88). Multivariate logistic analysis indicated that baseline LGE score [odds ratio; 0.78; 95% confidence interval (CI) 0.66 to 0.90; p<0.01] together with delta-LGE (odds ratio; 0.77; 95% CI 0.61 to 0.92; p=0.01) were independently associated with subsequent LVRR (p<0.01).

CONCLUSIONS

The temporal change of LGE-CMR score during the clinical course was significantly correlated with following LVRR.

Quantitative changes in late gadolinium enhancement at cardiac magnetic resonance in the early phase of acute myocarditis

BACKGROUND

The presence of late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) has diagnostic and prognostic value in patients with acute myocarditis (AM). Aim of our study was to quantify the changes in LGE extension (LGE%) early after AM and evaluate its relations with biventricular function and morphology.

METHODS

We investigated 76 consecutive patients with AM (acute onset of chest pain/heart failure/ventricular arrhythmias not explained by other causes, and raised troponin) that met CMR criteria based on myocardial oedema at T2-weighted images and LGE on post-contrast images at median time of 6days from onset of symptoms. We quantified LGE% at baseline and after 148days in 49 patients.

RESULTS

Median left ventricular (LV)-ejection fraction (EF) was 64% (interquartile range [Q1-Q3]: 56-67%), and LGE% 9.4% (Q1-Q3: 7.5-13.2%). LGE% was correlated with LV end-systolic volume index (LV-ESVi; r=+0.34; p=0.003). LGE% was inversely correlated with LV-EF (r=-0.31; p=0.009) and time to CMR scan (r=-0.25; p=0.028). In the 49 patients with a second CMR scan, despite no significant variations in LV-EF, a significant decrease of LGE% was observed (p<0.0001) with a relative reduction of 42% compared with baseline. Patients showing increased LV-ESVi at follow up had a lower decrease of LGE% (p=0.038).

CONCLUSIONS

In the acute phase of AM the LGE extension is a dynamic process that reflects impairment of LV function and is time dependent. LGE% appears one of the CMR parameters with the largest relative variations in the first months after AM.

Role of cardiovascular magnetic resonance in the evaluation of cardiomyopathy

Cardiovascular magnetic resonance imaging plays a central role in the assessment and monitoring of patients with cardiomyopathy. It offers a comprehensive assessment during a single scan setting, with information on ventricular volumes, function and mass as well as tissue characterisation, fibrosis, flow, viability and perfusion. Acute tissue injury (oedema and necrosis) can be distinguished from fibrosis, infiltration and iron overload. It provides information on the cause and prognosis of the cardiomyopathy, and its high measurement accuracy makes it ideal for monitoring disease progression and effects of therapy. The present review highlights the main features of commonly encountered cardiomyopathies in imaging practice.

The role and clinical effectiveness of multimodality imaging in the management of cardiac complications of cancer and cancer therapy

With the increasing number of individuals living with a current or prior diagnosis of cancer, it is important for the cardiovascular specialist to recognize the various complications of cancer and its therapy on the cardiovascular system. This is true not only for established cancer therapies, such as anthracyclines, that have well established cardiovascular toxicities, but also for the new targeted therapies that can have "off target" effects in the heart and vessels. The purpose of this informational statement is to provide cardiologists, cardiac imaging specialists, cardio-oncologists, and oncologists an understanding of how multimodality imaging may be used in the diagnosis and management of the cardiovascular complications of cancer therapy. In addition, this document is meant to provide useful general information concerning the cardiovascular complications of cancer and cancer therapy as well as established recommendations for the monitoring of specific cardiotoxic therapies.

Comprehensive Cardiac Magnetic Resonance for Short-Term Follow-Up in Acute Myocarditis

Background

Cardiac magnetic resonance (CMR) can detect inflammatory myocardial alterations in patients suspected of having acute myocarditis. There is limited information regarding the degree of normalization of CMR parameters during the course of the disease and the time window during which quantitative CMR should be most reasonably implemented for diagnostic work‐up.

Methods and Results

Twenty‐four patients with suspected acute myocarditis and 45 control subjects underwent CMR. Initial CMR was performed 2.6±1.9 days after admission. Myocarditis patients underwent CMR follow‐up after 2.4±0.6, 5.5±1.3, and 16.2±9.9 weeks. The CMR protocol included assessment of standard Lake Louise criteria, T1 relaxation times, extracellular volume fraction, and T2 relaxation times. Group differences between myocarditis patients and control subjects were highest in the acute stage of the disease (P<0.001 for all parameters). There was a significant and consistent decrease in all inflammatory CMR parameters over the course of the disease (P<0.01 for all parameters). Myocardial T1 and T2 relaxation times—indicative of myocardial edema—were the only single parameters showing significant differences between myocarditis patients and control subjects on 5.5±1.3‐week follow‐up (T1: 986.5±44.4 ms versus 965.1±28.1 ms, P=0.022; T2: 55.5±3.2 ms versus 52.6±2.6 ms; P=0.001).

Conclusions

In patients with acute myocarditis, CMR markers of myocardial inflammation demonstrated a rapid and continuous decrease over several follow‐up examinations. CMR diagnosis of myocarditis should therefore be attempted at an early stage of the disease. Myocardial T1 and T2 relaxation times were the only parameters of active inflammation/edema that could discriminate between myocarditis patients and control subjects even at a convalescent stage of the disease.