Echocardiographic two-dimensional speckle tracking identifies acute regional myocardial edema and sub-acute fibrosis in pediatric focal myocarditis with normal ejection fraction: comparison with cardiac magnetic resonance

Standardization in paediatric echocardiographic reporting and critical interpretation of measurements, functional parameters, and prediction scores: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology and the Association for European Paediatric and Congenital Cardiology

This document has been developed to provide a guide for basic and advanced reporting in paediatric echocardiography. Furthermore, it aims to help clinicians in the interpretation of echocardiographic measurements and functional data for estimating the severity of disease in different paediatric age groups. The following topics will be reviewed and discussed in the present document: (i) the general principle in constructing a paediatric echocardiographic report, (ii) the basic elements to be included, and (iii) the potential and limitation of currently employed tools used for disease severity quantification during paediatric reporting. A guide for the interpretation of Z-scores will be provided. Use and interpretation of parameters employed for quantification of ventricular systolic function will be discussed. Difficulties in the adoption of adult parameters for the study of diastolic function and valve defects at different ages and pressure and loading conditions will be outlined, with pitfalls for the assessment listed. A guide for careful use of prediction scores for complex congenital heart disease will be provided. Examples of basic and advanced (disease-specific) formats for reporting in paediatric echocardiography will be provided. This document should serve as a comprehensive guide to (i) structure a comprehensive paediatric echocardiographic report; (ii) identify the basic morphological details, measures, and functional parameters to be included during echocardiographic reporting; and (iii) correctly interpret measurements and functional data for estimating disease severity.

The Role of Speckle Tracking Echocardiography in the Evaluation of Advanced-Heart-Failure Patients

Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

Clinical Predictors of Subacute Myocardial Dysfunction in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19

Multisystem Inflammatory Syndrome in Children (MIS-C) often involves a post-viral myocarditis and associated left ventricular dysfunction. We aimed to assess myocardial function by strain echocardiography after hospital discharge and to identify risk factors for subacute myocardial dysfunction. We conducted a retrospective single-center study of MIS-C patients admitted between 03/2020 and 03/2021. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-ventricular circumferential strain (CS), and left atrial strain (LAS) were measured on echocardiograms performed 3-10 weeks after discharge and compared with controls. Among 60 MIS-C patients, hypotension (65%), ICU admission (57%), and vasopressor support (45%) were common, with no mortality. LVEF was abnormal (< 55%) in 29% during hospitalization but only 4% at follow-up. Follow-up strain abnormalities were prevalent (GLS abnormal in 13%, 4C-LS in 18%, CS in 16%, LAS in 5%). Hypotension, ICU admission, ICU and hospital length of stay, and any LVEF < 55% during hospitalization were factors associated with lower strain at follow-up. Higher peak C-reactive protein (CRP) was associated with hypotension, ICU admission, total ICU days, and with lower follow-up GLS (r = - 0.55; p = 0.01) and CS (r = 0.41; p = 0.02). Peak CRP < 18 mg/dL had negative predictive values of 100% and 88% for normal follow-up GLS and CS, respectively. A subset of MIS-C patients demonstrate subclinical systolic and diastolic function abnormalities at subacute follow-up. Peak CRP during hospitalization may be a useful marker for outpatient cardiac risk stratification. MIS-C patients with hypotension, ICU admission, any LVEF < 55% during hospitalization, or a peak CRP > 18 mg/dL may warrant closer monitoring than those without these risk factors.

Mechanisms of Myocardial Edema Development in CVD Pathophysiology

Myocardial edema is the excess accumulation of fluid in the myocardial interstitium or cardiac cells that develops due to changes in capillary permeability, loss of glycocalyx charge, imbalance in lymphatic drainage, or a combination of these factors. Today it is believed that this condition is not only a complication of cardiovascular diseases, but in itself causes aggravation of the disease and increases the risks of adverse outcomes. The study of molecular, genetic, and mechanical changes in the myocardium during edema may contribute to the development of new approaches to the diagnosis and treatment of this condition. This review was conducted to describe the main mechanisms of myocardial edema development at the molecular and cellular levels and to identify promising targets for the regulation of this condition based on articles cited in Pubmed up to January 2024.

Isolated myocardial edema in cardiac magnetic resonance - in search of a management strategy

Isolated myocardial edema not accompanied by late gadolinium enhancement (LGE) may be occasionally found on cardiac magnetic resonance (CMR). This type of picture may be encountered in patients with suspected myocarditis, post some acute cardiac events, with cardiac allograft rejection or even in athletes after an extreme exercise. Currently, there is no clear management strategy for this type of incidental finding. In this narrative review we discuss the methods and pitfalls of edema detection with means of CMR, review published data on isolated myocardial edema for each of the most probable clinical scenarios and propose a structured clinical decision-making algorithm to help clinicians navigate through this type of CMR result. Finally, we highlight the most important gaps in evidence related to isolated myocardial edema without fibrosis, where further research is particularly needed.

Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

Although the frequency of myocarditis in the general population is very difficult to accurately determine due to the large number of asymptomatic cases, the incidence of this disease is increasing significantly due to better defined criteria for diagnosis and the development of modern diagnostic methods. The multitude of different etiological factors, the diversity of the clinical picture, and the variability of the diagnostic findings make this disease often demanding both for the selection of the diagnostic modality and for the proper therapeutic approach. The previously known most common viral etiology of this disease is today overshadowed by new findings based on immune-mediated processes, associated with diseases that in their natural course can lead to myocardial involvement, as well as the iatrogenic cause of myocarditis, which is due to use of immune checkpoint inhibitors in the treatment of cancer patients. Suspecting that a patient with polymorphic and non-specific clinical signs and symptoms, such as changes in ECG and echocardiography readings, has myocarditis is the starting point in the diagnostic algorithm. Cardio magnetic resonance imaging is non-invasive and is the gold standard for diagnosis and clinical follow-up of these patients. Endomyocardial biopsy as an invasive method is the diagnostic choice in life-threatening cases with suspicion of fulminant myocarditis where the diagnosis has not yet established or there is no adequate response to the applied therapeutic regimen. The treatment of myocarditis is increasingly demanding and includes conservative methods of treating heart failure, immunomodulatory and immunospressive therapy, methods of mechanical circulatory support, and heart transplantation. The goal of developing new diagnostic and therapeutic methods is to reduce mortality from this complex disease, which is still high.

Echocardiography in inflammatory heart disease: A comparison of giant cell myocarditis, cardiac sarcoidosis, and acute non-fulminant myocarditis

Background

Giant cell myocarditis (GCM) and cardiac sarcoidosis (CS) are, in contrast to acute non-fulminant myocarditis (ANFM), rare inflammatory diseases of the myocardium with poor prognosis. Although echocardiography is the first-line diagnostic tool in these patients, their echocardiographic appearance has so far not been systematically studied.

Methods

We assessed a total of 71 patients with endomyocardial biopsy-proven GCM (n = 21), and CS (n = 25), as well as magnetic resonance-verified ANFM (n = 25). All echocardiographic examinations, performed upon clinical presentation, were reanalysed according to current guidelines including a detailed assessment of right ventricular (RV) dysfunction.

Results

In comparison with ANFM, patients with either GCM or CS were older (mean age (±SD) 55 ± 12 or 53 ± 8 vs 25 ± 8 years), more often of female gender (52% or 24% vs 8%), had more severe clinical symptoms and higher natriuretic peptide levels. For both GCM and CS, echocardiography revealed more frequently signs of left ventricular (LV) dysfunction in form of a reduced ejection fraction (p < 0.001), decreased cardiac index (p < 0.001) and lower global longitudinal strain (p < 0.001) in contrast to ANFM. The most prominent increase in LV end-diastolic volume index was observed in CS. In addition, RV dysfunction was more frequently found in both GCM and CS than in ANFM (p = 0.042).

Conclusions

Both GCM and CS have an echocardiographic and clinical appearance that is distinct from ANFM. However, the method cannot further differentiate between the two rare entities. Consequently, echocardiography can strengthen the initial clinical suspicion of a more severe form of myocarditis, thus warranting a more rigorous clinical work-up.

Identification of early cardiac dysfunction and heterogeneity after pressure and volume overload in mice by high-frequency echocardiographic strain imaging

Object

Aortic stenosis and regurgitation are clinically important conditions characterized with different hypertrophic types induced by pressure or volume overload, respectively, but with comparable cardiac function in compensated stage. Speckle-tracking based strain imaging has been applied to assess subtle alterations in cardiac abnormality, but its application in differentiating these two types of ventricular hypertrophy is still sparse. Here, we performed strain imaging analysis of cardiac remodeling in these two loading conditions.

Methods

C57BL/6J mice were subjected to transverse aortic constriction (TAC)-induced pressure overload or aortic regurgitation (AR)-induced volume overload. Conventional echocardiography and strain imaging were comprehensively assessed to detect stimulus-specific alterations in TAC and AR hearts.

Results

Conventional echocardiography did not detect significant changes in left ventricular systolic (ejection fraction and fractional shortening) and diastolic (E/E') function in either TAC or AR mice. On the contrary, global strain analysis revealed global longitudinal strain and strain rate were remarkably impaired in TAC while preserved in AR mice, although global radial, and circumferential strain and strain rate were significantly reduced in both models. Regional strain analysis in the long axis demonstrated that longitudinal strain and strain rate in all or most segments were decreased in TAC but maintained or slightly dented in AR mice, while radial strain and strain rate indicated overt decline in both models. Moreover, decreased radial and circumferential strain and strain rate were observed in most segments of TAC and AR mice in the short axis.

Conclusion

Strain imaging is superior to conventional echocardiography to detect subtle changes in myocardial deformation, with longitudinal strain and strain rate indicating distinct functional changes in pressure versus volume overload myocardial hypertrophy, making it potentially an advanced approach for early detection and differential diagnosis of cardiac dysfunction.

Repeated cardiopulmonary performance measurements in young competitive handball players with and without SARS-CoV-2 infection

BACKGROUND

The SARS-CoV-2 virus and its long-term consequences in adolescents have a global impact on upcoming medical issues. The aim of this study was to investigate the effects of a SARS-CoV-2 infection on cardiorespiratory parameters in young athletes.

METHODS

In a cohort study involving repeated measurements during a six-month period, cardiorespiratory parameters were assessed in infected (SCoV) and non-infected (noSCoV) athletes. We evaluated handball players (17.2 ± 1.0 years) via performance diagnostics and a specific examination after a SARS-CoV-2 infection or without.

RESULTS

We observed no significant differences between the two groups at the first visit. But between the first and second visit, the SCoV group's maximum power output was significantly lower than the noSCoV group's (- 48.3 ± 12.5; p ≤ 0.01 vs. - 15.0 ± 26.0 W; p = 0.09). At the second visit, lung diffusion capacity (DL_CO/V_A, %predicted) did not differ between groups (111.6 ± 11.5 vs. 116.1 ± 11.8%; p = 0.45). HR during comparative stress showed no group differences. The SCoV group's mean oxygen uptake during incremental exercise was lower (Two-way-ANOVA: 1912 vs. 2106 ml; p ≤ 0.01; mean difference: - 194 ml; 95% CI - 317 to - 71); we also noted a significantly lower stroke volume course during exercise (Two-way-ANAOVA: 147.5 vs. 169.5 ml; mean difference: - 22 ml; p ≤ 0.01; 95% CI - 34.2 to - 9.9). The probability of premature ventricular complexes after a SARS-CoV-2 infection yielded an odds ratio of 1.6 (95% CI 0.24-10.81).

CONCLUSIONS

The physical performance of young athletes infected with SARS-CoV-2 was impaired. This decreased performance is probably due to cardiac and/or peripheral deconditioning. Studies with larger cohorts are needed to make more profound conclusions.

Is strain echocardiography a more sensitive indicator of myocardial involvement in patients with multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2?

OBJECTIVE

The aim of the study was to evaluate the early myocardial dysfunction detected by strain echocardiography in children with multisystem inflammatory syndrome related to SARS-CoV-2 infection.

METHODS

This cross-sectional study was conducted with 47 patients diagnosed with MIS-C and 32 healthy age- and gender-matched children. All patients underwent two-dimensional, colour, pulsed, and tissue Doppler, and 2D speckle tracking echocardiography examination at admission, 2 weeks, and 2 months after discharge. The MIS-C patient group was compared with the control group. Echocardiographic changes in MIS-C patients during follow-up were evaluated.

RESULTS

Of 47 patients, 30 (63.8%) were male and 17 (36.2%) were female. The mean age at diagnosis was 9.1 ± 4.3 (1.25-17) years. At admission, 25 patients had abnormal findings on conventional echocardiography. Among them, eight patients had left ventricular systolic dysfunction. Ejection fraction and fractional shortening were significantly lower in the patient group at admission compared to controls (p = 0.013, p = 0.010, respectively). While the ejection fraction was <55% in eight patients, and global longitudinal strain was lower than -2SD in 29 patients at admission. Global longitudinal strain z-score <-2SD persisted in 13 patients at 2-month follow-up. Ejection fraction increased above 55% in 3.42 ± 0.53 days in 7 of 8 patients with left ventricular systolic dysfunction, ejection fraction was 51% at discharge in one patient, and left ventricular systolic dysfunction persisted at the 6-month of follow-up.

CONCLUSION

These results confirmed that speckle tracking echocardiography is more likely to detect subclinical myocardial damage compared to conventional echocardiography. In addition, it is a valuable method for follow-up in this patient group.

Parametric Mapping Cardiac Magnetic Resonance Imaging for the Diagnosis of Myocarditis in Children in the Era of COVID-19 and MIS-C

Myocarditis comprises many clinical presentations ranging from asymptomatic to sudden cardiac death. The history, physical examination, cardiac biomarkers, inflammatory markers, and electrocardiogram are usually helpful in the initial assessment of suspected acute myocarditis. Echocardiography is the primary tool to detect ventricular wall motion abnormalities, pericardial effusion, valvular regurgitation, and impaired function. The advancement of cardiac magnetic resonance (CMR) imaging has been helpful in clinical practice for diagnosing myocarditis. A recent Scientific Statement by the American Heart Association suggested CMR as a confirmatory test to diagnose acute myocarditis in children. However, standard CMR parametric mapping parameters for diagnosing myocarditis are unavailable in pediatric patients for consistency and reliability in the interpretation. The present review highlights the unmet clinical needs for standard CMR parametric criteria for diagnosing acute and chronic myocarditis in children and differentiating dilated chronic myocarditis phenotype from idiopathic dilated cardiomyopathy. Of particular relevance to today’s practice, we also assess the potential and limitations of CMR to diagnose acute myocarditis in children exposed to severe acute respiratory syndrome coronavirus-2 infections. The latter section will discuss the multi-inflammatory syndrome in children (MIS-C) and mRNA coronavirus disease 19 vaccine-associated myocarditis.

Role of CT and MRI in Cardiac Emergencies

Current strategies for the evaluation of patients with chest pain have significantly changed thanks to the implemented potentiality of CT and MRI. The possible fatal consequences and high malpractice costs of missed acute coronary syndromes lead to unnecessary hospital admissions every year. CT provides consistent diagnostic support, mainly in suspected coronary disease in patients with a low or intermediate pre-test risk. Moreover, it can gain information in the case of cardiac involvement in pulmonary vascular obstructive disease. MRI, on the other hand, has a leading role in the condition of myocardial damage irrespective of the underlying inflammatory or stress related etiology. This article discusses how radiology techniques (CT and MRI) can impact the diagnostic workflow of the most common cardiac and vascular pathologies that are responsible for non-traumatic chest pain admissions to the Emergency Department.

COVID-19 Myocarditis: Prognostic Role of Bedside Speckle-Tracking Echocardiography and Association with Total Scar Burden

SARS-CoV2 infection, responsible for the COVID-19 disease, can determine cardiac as well as respiratory injury. In COVID patients, viral myocarditis can represent an important cause of myocardial damage. Clinical presentation of myocarditis is heterogeneous. Furthermore, the full diagnostic algorithm can be hindered by logistical difficulties related to the transportation of COVID-19 patients in a critical condition to the radiology department. Our aim was to study longitudinal systolic cardiac function in patients with COVID-19-related myocarditis with echocardiography and to compare these findings with cardiac magnetic resonance (CMR) results. Patients with confirmed acute myocarditis and age- and gender-matched healthy controls were enrolled. Both patients with COVID-19-related myocarditis and healthy controls underwent standard transthoracic echocardiography and speckle-tracking analysis at the moment of admission and after 6 months of follow-up. The data of 55 patients with myocarditis (mean age 46.4 ± 15.3, 70% males) and 55 healthy subjects were analyzed. The myocarditis group showed a significantly reduced global longitudinal strain (GLS) and sub-epicardial strain, compared to the control (p < 0.001). We found a positive correlation (r = 0.65, p < 0.0001) between total scar burden (TSB) on CMR and LV GLS. After 6 months of follow-up, GLS showed marked improvements in myocarditis patients on optimal medical therapy (p < 0.01). Furthermore, we showed a strong association between baseline GLS, left ventricular ejection fraction (LVEF) and TSB with LVEF at 6 months of follow-up. After a multivariable linear regression analysis, baseline GLS, LVEF and TSB were independent predictors of a functional outcome at follow-up (p < 0.0001). Cardiac function and myocardial longitudinal deformation, assessed by echocardiography, are associated with TSB at CMR and have a predictive value of functional recovery in the follow-up.

What Is New on Paediatric Echocardiography for the Diagnosis, Management and Follow-Up of the Multisystem Inflammatory Syndrome Associated with COVID-19?

Conventional echocardiography is an essential tool for the diagnosis, bedside management and follow-up evaluations of children with multisystem inflammatory syndrome associated with COVID-19. However, a more comprehensive echocardiographic exam, including myocardial deformation parameters, may allow early identification of subtle changes in ventricular function, provide risk stratification and, identify sub-clinical cardiac dysfunction at follow-up. Thus, myocardial deformation analysis should be routinely integrated to conventional echocardiography assessment in these patients.

Longitudinal Assessment of Global and Regional Left Ventricular Strain in Patients with Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem inflammatory syndrome in children (MIS-C) is one of the most significant sequela of coronavirus disease 2019 (COVID-19) in children. Emerging literature has described myocardial dysfunction in MIS-C patients using traditional and two-dimensional speckle tracking echocardiography in the acute phase. However, data regarding persistence of subclinical myocardial injury after recovery is limited. We aimed to detect these changes with deformation imaging, hypothesizing that left ventricular global longitudinal (GLS) and circumferential strain (GCS) would remain impaired in the chronic phase despite normalization of ventricular function parameters assessed by two-dimensional echocardiography. A retrospective, single-institution review of 22 patients with MIS-C was performed. Fractional shortening, GLS, and GCS, along with regional longitudinal (RLS) and circumferential strain (RCS) were compared across the acute, subacute, and chronic timepoints (presentation, 14-42, and > 42 days, respectively). Mean GLS improved from - 18.4% in the acute phase to - 20.1% in the chronic phase (p = 0.4). Mean GCS improved from - 19.4% in the acute phase to - 23.5% in the chronic phase (p = 0.03). RCS and RLS were impaired in the acute phase and showed a trend towards recovery by the chronic phase, with the exception of the basal anterolateral segment. In our longitudinal study of MIS-C patients, GLS and GCS were lower in the acute phase, corroborating with left ventricular dysfunction by traditional measures. Additionally, as function globally recovers, GLS and GCS also normalize. However, some regional segments continue to have decreased strain values which may be an important subclinical marker for future adverse events.

Cardiac MRI Assessment of Nonischemic Myocardial Inflammation: State of the Art Review and Update on Myocarditis Associated with COVID-19 Vaccination

Myocarditis is a nonischemic inflammatory disease of the myocardium that can be triggered by a multitude of events, including viral infection and toxins. Recently, there has been heightened interest in myocarditis given its association with COVID-19 vaccination. Timely identification of myocarditis can affect patient management and prognosis. Therefore, it is crucial for radiologists and cardiac imagers to understand the role of cardiac imaging to establish a diagnosis and inform treatment decisions. Cardiac MRI is the most important noninvasive imaging modality for evaluation of myocarditis, with typical findings of focal or diffuse myocardial edema and myocardial damage, including presence of late gadolinium enhancement. There are currently limited data available to indicate that the pattern of myocardial injury following COVID-19 vaccination is similar to other causes of myocarditis, although the severity of disease may be relatively mild. A description of the role of imaging and typical imaging features will be reviewed here, with a focus on emerging data in the setting of myocarditis after COVID-19 vaccination. Keywords: MRI, Heart, Inflammation © RSNA, 2021.

Application Effect and Evaluation of Two-Dimensional Speckle Tracking Imaging on Myocardial Damage in Patients with Malignant Lymphoma Treated with Anthracyclines

Objective

The purpose was to study the monitoring effect and application value of two-dimensional speckle tracking imaging (2D-STI) on myocardial function in patients with malignant lymphoma after treatment with anthracyclines.

Methods

50 patients with malignant lymphoma treated in our hospital from June 2017 to December 2019 were randomly selected and were treated with anthracyclines to compare the cardiac global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS), left ventricular twist (LVtw), GLS × LVtw, and changes of atrioventricular inner diameters before and after 3 cycles of treatment. According to the pathological examination results, the accuracy of 2D-STI in the detection of changes in myocardial function of patients was also clarified.

Results

The absolute values of GLS, GRS and GCS after treatment were significantly lower than those before treatment, with statistical significance (P < 0.05). The LVtw and GLS × LVtw after 3 cycles of treatment were significantly lower than those before treatment, with statistical significance (P < 0.05). There was no significant difference in the atrioventricular inner diameters of patients before and after treatment, with no statistical significance (P > 0.05). There was no significant difference between the monitoring results of 2D-STI and the pathological examination results, with no statistical significance (P > 0.05).

Conclusion

Anthracyclines can cause some myocardial damage in patients with malignant lymphoma. The application of 2D-STI to monitor the changes in myocardial function of patients can give more accurate monitoring results, facilitating the early implementation of appropriate treatment.

Long COVID: Distinction between Organ Damage and Deconditioning

(1) Background: Long COVID syndrome refers to long-term sequelae of the novel viral disease, which occur even in patients with initially mild disease courses. However, there is still little evidence of the actual organic consequences and their frequency, and there is no standardized workup to diagnose long COVID syndrome yet. In this study, we aim to determine the efficiency of a stepwise diagnostic approach for reconvalescent COVID-19 patients with cardiopulmonary symptoms. (2) Methods: The diagnostic workup for long COVID syndrome included three steps. In the first step, the focus was on broad applicability (e.g., blood tests and body plethysmography). In the second step, cardiopulmonary exercise testing (CPET) and cardiac MRI (CMR) were used. The third step was tailored to the individual needs of each patient. The observation period lasted from 22 February to 14 May 2021. (3) Results: We examined 231 patients in our long COVID unit (mean [SD] age, 47.8 [14.9], 132 [57.1%] women). Acute illness occurred a mean (SD) of 121 (77) days previously. Suspicious findings in the first visit were seen in 80 (34.6%) patients, prompting further diagnostics. Thirty-six patients were further examined with CPET and CMR. Of those, 16 (44.4%) had pathological findings. The rest had functional complaints without organ damage (“functional long COVID”). Cardiopulmonary sequelae were found in asymptomatic as well as severe courses of the initial COVID-19 disease. (4) Conclusions: A structured diagnostic pathway for the diagnosis of long COVID syndrome is practicable and rational in terms of resource allocation. With this approach, manifest organ damage can be accurately and comprehensively diagnosed and distinguished from functional complaints.

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.

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.