Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations

Cardiac Conduction Disorders Due to Acquired or Genetic Causes in Young Adults: A Review of the Current Literature

Cardiac conduction disorders can manifest in young adults in isolated forms, associated with myocardial diseases or as part of a multiorgan disorder. Underlying causes of cardiac conduction disorders may be genetically determined or acquired. Cardiac conduction disorder in young adults is a complex and often underestimated and underrecognized disease that may need of a multidisciplinary team for the diagnosis, treatment, and long-term management of these patients. Therefore, it is crucial to raise clinicians' awareness of this condition. In this review, we provide a comprehensive update on the cause, diagnosis, and treatment of young adults with cardiac conduction disorders, also suggesting potential strategies to improve the current clinical management of these patients.

State of the Art in Imaging of Acute Coronary Syndrome with Nonobstructed Coronary Arteries

Acute chest pain is a common concern for which patients present to the emergency department. Nonetheless, many patients with acute chest pain indicative of acute coronary syndrome (ACS) show nonobstructed coronary arteries at invasive coronary angiography or coronary CT angiography (CCTA), which is a clinical conundrum in day-to-day practice. Guidelines recommend that the initial course of action for patients experiencing acute chest pain is to exclude extracardiac and cardiac conditions that could cause nonischemic myocardial damage, including aortic dissection, pulmonary embolism, or septic shock. The generic term troponin-positive with nonobstructed coronary arteries (TpNOCA) was coined to refer to patients with nonobstructed coronary arteries who present with clinical symptoms and signs of ACS and increased cardiac troponin levels, electrocardiographic changes, or both. The causes of TpNOCA may be ischemic (eg, myocardial infarction with nonobstructed coronary arteries [MINOCA] or ischemia with nonobstructed coronary arteries [INOCA]) or nonischemic (eg, extracardiac and cardiac entities). MINOCA and INOCA are working diagnostic terms used until a definitive cause is established (eg, coronary plaque rupture, coronary artery dissection, or coronary microvascular disease). Noninvasive cardiac imaging techniques, notably CCTA and cardiac MRI, and ischemia testing are pivotal in evaluating and treating these patients through accurate identification of the underlying cause, improvement in risk stratification, and guidance for clinicians in decision making for treatment and follow-up. ©RSNA, 2025.

Accuracy of photon-counting detector CT-based iodine maps for myocardial late enhancement detection

OBJECTIVES

To evaluate the diagnostic accuracy of iodine maps from photon-counting detector (PCD) CT in detecting myocardial late enhancement compared to late gadolinium enhancement (LGE)-MRI.

MATERIALS AND METHODS

In this retrospective analysis of a prospective cohort, patients underwent cardiac MRI with LGE followed by late iodine enhancement (LIE)-CT using dual-source PCD-CT. LIE-CT was performed 5 min post-intravenous administration of 100 mL iopromide (370 mg I/mL) using an ECG-triggered sequential protocol with full spectral capabilities (120 kVp, 144 × 0.4 mm collimation). Iodine maps were reconstructed with a quantitative kernel (Qr40) and iterative reconstruction. Two radiologists independently rated image quality on a four-point scale (1: "poor" to 4: "excellent"). Diagnostic performance was assessed per-patient and per-segment using LGE-MRI as reference, and inter-reader agreement was analyzed using Cohen's kappa (κ).

RESULTS

The study included 27 patients (52% female; mean age 52.9 ± 17.2 years). Twelve (44%) had positive LGE, with 87/459 (19%) myocardial segments affected. Image quality was rated as good, with no significant differences between readers (median 3 [2-4] vs 3 [3-4]; p = 0.058). Per-patient sensitivities were 100% and 91.7%, specificities 73.3% and 80.0%, and accuracies 85.2%, respectively. Per-segment sensitivities, specificities, and accuracies were 74.7%, 94.9%, and 91.1% (reader 1) and 66.7%, 96.4%, and 90.7% (reader 2). Substantial inter-reader agreement was observed (κ = 0.70 per patient, 0.63 per segment).

CONCLUSION

Iodine maps from PCD-CT demonstrate high diagnostic accuracy for assessing myocardial late enhancement, with substantial inter-reader agreement. These findings suggest that PCD-CT may serve as a valuable alternative to LGE-MRI.

KEY POINTS

Question Can PCD CT iodine maps detect myocardial late enhancement with accuracy comparable to LGE-MRI? Findings PCD-CT iodine maps achieved high accuracy (85.2% per patient, > 90% per segment) with substantial inter-reader agreement. Clinical relevance PCD-CT iodine maps offer a valuable alternative to LGE-MRI for myocardial late enhancement assessment, especially for patients with contraindications to MRI.

Multimodal Imaging of Immune Checkpoint Inhibitor Myocarditis

Immune checkpoint inhibitors (ICIs) have dramatically changed the landscape of cancer treatment and are increasingly used either as monotherapy or in combination with other ICIs, chemotherapy, and molecularly targeted agents. ICI myocarditis is a rare but potentially fatal irAE associated with the use of ICI characterized by T-cell mediated cardiomyocyte death. Diagnosing ICI myocarditis can be intricate as its atypical presentations. Multimodal imaging plays a crucial role in the diagnosis and risk stratification of ICI myocarditis. Current management strategies for ICI myocarditis include corticosteroids and immunosuppressants. Multidisciplinary collaboration is vital in these cases-combining oncology expertise with cardiology insights.

Infarct-like myocarditis in adolescents: Exploring genetic insights from diagnosis through follow-up

BACKGROUND

Myocarditis has traditionally been considered an acquired condition, but recent evidence suggests a genetic contribution, primarily in complicated cases. Data on pediatric uncomplicated or infarct-like myocarditis remain scarce. This study aimed to assess the prevalence of pathogenic or likely pathogenic (P/LP) variants in adolescents with infarct-like myocarditis and their association with clinical and imaging findings.

METHODS

This prospective, multicenter study included 30 adolescents diagnosed with infarct-like myocarditis across five hospitals in Catalunya, Spain (2016-2024). Diagnosis was confirmed using the 2018 Lake Louise Criteria on cardiac magnetic resonance imaging (CMR). Follow-up CMR was performed at 12 months, and genetic testing was conducted using a next-generation sequencing panel targeting 174 genes associated with inherited cardiac diseases.

RESULTS

P/LP variants in cardiomyopathy-associated genes were identified in 22.2 % of patients. Baseline CMR showed no significant differences in ventricular function or LGE extent, but a ring-like LGE pattern was significantly associated with genetic findings (p = 0.025), while septal involvement showed a p-value of 0.056. Over a median follow-up of 3 years (IQR 2-7), 9 patients (30 %) experienced recurrent myocarditis, more frequently in genetic-positive patients (66.7 % vs. 23.8 %). At 12 months, genetic-positive patients exhibited a greater LGE burden (p = 0.047) and persistent myocardial edema on T2-STIR (p = 0.009), suggesting ongoing myocardial remodeling.

CONCLUSIONS

The high prevalence of P/LP variants in infarct-like myocarditis highlights the need for genetic testing, particularly in patients with a ring-like LGE pattern or septal involvement. Persistent CMR abnormalities and symptomatic recurrences in genetic-positive cases support long-term monitoring, even in seemingly uncomplicated presentations.

Prognostic Value of Strain by Tissue Tracking Cardiac Magnetic Resonance in Myocardial Infarction With Nonobstructive Coronary Arteries

BACKGROUND

Strain assessed by cardiac magnetic resonance (CMR) is a key prognostic indicator in myocardial infarction. However, the strain characteristics and prognostic value in myocardial infarction with nonobstructive coronary arteries (MINOCA) with different causes are unclear. This study aims to describe left atrial (LA) and left ventricular strain in patients with MINOCA and evaluate their predictive value for major adverse cardiovascular events (MACEs) in "true MINOCA" cases.

METHODS AND RESULTS

This single-center retrospective study included patients suspected of myocardial infarction who completed CMR during hospitalization. CMR images were used to obtain LA and left ventricular strain via CMR feature tracking. True MINOCA was defined by evidence of ischemia or infarction on CMR. MACEs included all-cause death, recurrent myocardial infarction, stroke, heart failure, atrial fibrillation, and angina pectoris. This study included 386 patients, with a median time from admission to CMR of 4 days. LA and left ventricular strains varied by pathogenesis, with the lowest strain in patients with cardiomyopathy. For patients with true MINOCA, Cox regression showed that global longitudinal strain (hazard ratio [HR], 0.90 [95% CI, 0.82-0.99]; P=0.022) and LA reservoir strain (HR, 0.95 [95% CI, 0.91-0.99]; P=0.014) were independently associated with MACEs. Kaplan-Meier analysis indicated that patients with LA reservoir strain ≤21.25% or global longitudinal strain ≤16.4% had a significantly higher MACE risk (P<0.001). Integrating global longitudinal strain and LA reservoir strain improved MACE prediction.

CONCLUSIONS

LA and left ventricular strains vary among MINOCA pathogeneses. In true MINOCA patients, global longitudinal strain and LA reservoir strains independently predict MACE risk. Integrating these strains enhances MACE prediction.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06502899.

Epicardial Metastases Causing Coronary Artery Compression and Myocardial Infarction on [18F]FDG PET-CT

A 64-year-old woman with metastatic lung adenocarcinoma on immune checkpoint inhibitor (ICI) therapy suffered an acute coronary syndrome and underwent percutaneous coronary intervention (PCI). Despite PCI and anti-anginal therapy, she continued to experience angina. Cardiac magnetic resonance imaging (CMR) suggested a diagnosis of ICI myocarditis. However, refractory angina and non-resolving changes on CMR despite high-dose steroids prompted further evaluation with [18F]FDG PET-CT; this yielded a final diagnosis of epicardial metastatic coronary artery compression with myocardial infarction. This case demonstrates the incremental diagnostic value of multimodality imaging in cardio-oncology.

Multimodality Imaging of Arrhythmic Risk in Mitral Valve Prolapse

Mitral valve prolapse (MVP) affects 2% to 3% of the general population and is typically benign. However, a subset of patients may develop arrhythmic complications, including sudden cardiac arrest and sudden cardiac death. This review explores the critical role of multimodality imaging in risk stratification for arrhythmic MVP, emphasizing high-risk features such as bileaflet involvement, mitral annular disjunction, the double-peak strain pattern, mechanical dispersion, and myocardial fibrosis. Echocardiography remains the first-line imaging tool for MVP diagnosis, enabling detailed assessment of leaflet morphology, mitral annular disjunction, and mitral regurgitation quantification. Speckle tracking provides insights into abnormal valvular-myocardial mechanics as a potential arrhythmogenic mechanism in MVP. Cardiac magnetic resonance (CMR) offers detailed myocardial tissue characterization through assessment of replacement and interstitial fibrosis using late gadolinium enhancement and T1 mapping/extracellular volume fraction, respectively. Hybrid Positron Emission Tomography/CMR highlights the role of inflammation, which may coexist with fibrosis, in explaining the presence of malignant arrhythmias even with relatively limited fibrosis. The assessment of diffuse fibrosis and inflammation by CMR and Positron Emission Tomography/CMR is particularly valuable in patients without classic imaging risk factors such as mitral annular disjunction, severe mitral regurgitation, or replacement fibrosis. We propose an algorithm integrating clinical, rhythmic, echocardiographic, CMR, and Positron Emission Tomography/CMR parameters for arrhythmic risk stratification and management. Although multimodality imaging is essential for comprehensive risk assessment, most available parameters have not yet been validated in prospective studies nor linked directly to mortality. Consequently, these imaging findings should be interpreted alongside the presence of complex ventricular ectopy, which remains the most robust predictor of mortality in arrhythmic MVP.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Current Insights into Pathophysiology, Diagnosis, and Management

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an increasingly recognized clinical entity characterized by myocardial injury in the absence of a significant coronary artery obstruction. MINOCA encompasses a diverse range of pathophysiological mechanisms, including coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, thromboembolism, and spontaneous coronary artery dissection. A systematic diagnostic approach is essential to identify the underlying etiology and guide appropriate management strategies. Advanced imaging techniques, particularly cardiac magnetic resonance, play a pivotal role in distinguishing ischemic from non-ischemic myocardial injury and refining prognosis. Despite growing awareness, standardized treatment protocols remain limited, with current management largely extrapolated from strategies used in obstructive coronary artery disease. Notably, MINOCA is significantly more prevalent in women, emphasizing the need to understand sex-related differences in its pathophysiology, presentation, and clinical outcomes. This narrative review offers a comprehensive and up-to-date overview of MINOCA, including a dedicated chapter on sex-related considerations. It integrates recent advancements and highlights the importance of personalized management strategies.

CMR Findings in the Long-Term Outcomes After Multisystem Inflammatory Syndrome in Children (MUSIC) Study

BACKGROUND

Multisystem Inflammatory Syndrome in Children is characterized by high rates of acute cardiovascular involvement with rapid recovery of organ dysfunction. However, information regarding long-term sequelae is lacking. We sought to characterize the systolic function and myocardial tissue properties using cardiac magnetic resonance (CMR) imaging in a multicenter observational cohort of Multisystem Inflammatory Syndrome in Children patients.

METHODS

In this observational cohort study, comprising 32 centers in North America, CMR studies were analyzed by a core laboratory to assess ventricular volumetric data, tissue characterization, and coronary involvement.

RESULTS

A total of 263 CMRs from 255 Multisystem Inflammatory Syndrome in Children patients were analyzed. The mean patient age was 11.4±4.4 years. Most studies were performed at 3 months (33%) or 6 months (45%) after hospitalization. Left ventricular dysfunction was present in 17 (6.7%) of the first CMRs and was never worse than mild. Dysfunction was observed in 4/7 (57%) patients at admission, 5/87 (6.9%) patients at 3 months, and 6/129 (4.6%) patients imaged either at 6 months or 1 year post-hospitalization. Late gadolinium enhancement was present in 2 (0.8%) patients, 1 at 3 months and another at 6 months following hospitalization. Coronary artery dilation was present in 13 of the 174 (7.5%) patients. Nine patients met the Lake Louise criteria for myocarditis (3.5%) at the time of CMR.

CONCLUSIONS

In this largest published multiinstitutional longitudinal CMR evaluation of confirmed Multisystem Inflammatory Syndrome in Children patients, the prevalence of ventricular dysfunction and myocardial tissue characterization abnormalities on medium-term follow-up was low. However, a small number of patients had mild residual abnormalities at 6 months and 1 year following hospitalization.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05287412.

Intercalated Disc Abnormalities Are Linked to Arrhythmias in Inflammatory Cardiomyopathy

BACKGROUND

The relationship between intercalated disc abnormalities (IDAs) and arrhythmias in inflammatory cardiomyopathy (ICM) remains incompletely understood.

OBJECTIVES

This study presents a pilot research that aimed to: 1) investigate the link between IDAs and arrhythmias in humans with ICM; and 2) compare findings in humans and mice with experimental autoimmune myocarditis (EAM).

METHODS

Humans with ICM (N = 316) investigated for either genetic or autoimmune IDAs were identified at a referral center. Ultrastructural analysis on biobanked tissue was performed to determine the average intercellular cleft width (ICW) between cardiac myocytes. IDA+ cases were compared with IDA- control subjects matched 1:1 by age, sex, and race/ethnicity. The primary endpoint was the occurrence of clinically demanding supraventricular or ventricular arrhythmias, recorded either by Holter electrocardiography or implanted devices during a 24-month prospective follow-up. The relationships between ICW and arrhythmias were compared in humans and male mice with EAM (n = 12).

RESULTS

Of 316 humans with ICM (mean age 45 ± 15 years, 63% male), 70 (22%) were IDA+ and 107 (34%) had arrhythmias on admission. IDA+ patients had greater ICW than control subjects (44 ± 8 nm vs 28 ± 4 nm; P < 0.001) and higher incidence of clinically demanding arrhythmias both at presentation (31 of 70 vs 9 of 70; P < 0.001) and during follow-up (44 of 70 vs 10 of 70; P < 0.001). In a multivariable model, IDAs predicted the occurrence of major ventricular arrhythmias by 24 months (HR: 3.0; 95% CI: 1.4-6.4; P = 0.004). In mice, arrhythmias were documented in 7 of 12 EAM cases and 0 of 6 control animals (P = 0.038). Increased ICW was found in close relationship with arrhythmias in both species (humans: 32 of 44 with vs 4 of 52 without arrhythmias; P < 0.001; mice: 7 of 8 with vs 0 of 4 without arrhythmias; P = 0.010), as well as with abnormal ventricular electrograms on viable murine myocardial tissue (5 of 6 vs 0 of 6; P = 0.015).

CONCLUSIONS

As a shared trait between genetic and autoimmune ICM, IDAs are linked to arrhythmias in humans and find promising applications in the EAM mouse model.

Multimodality Imaging to Understand Mechanisms of Right Ventricular Disease

Right ventricular (RV) disease is commonly encountered in patients with cardiovascular conditions and is associated with adverse prognosis. The principal pathogenic mechanisms giving rise to RV pathology include RV pressure overload, RV volume overload, and RV myocardial diseases. Noninvasive cardiac imaging is commonly used to detect the conditions associated with RV disease and ultimately guide therapeutic decisions. Transthoracic echocardiogram is usually the first-line test in patients with suspected RV disease and it provides relevant information on biventricular size and function, valvular abnormalities, and cardiac hemodynamics including pulmonary pressures. Cardiac magnetic resonance imaging is considered the reference standard noninvasive imaging test for quantifying ventricular size and function and cardiac shunts and has a secondary role for assessing valvular disease when echocardiography is nondiagnostic. Cardiac magnetic resonance imaging also provides insight into RV myocardial diseases such as inflammation, infarction, and infiltration. Nuclear cardiology and cardiac computed tomography imaging can also be used to inform on specific RV disease mechanisms originating from lung disease and pulmonary vasculature disorders. In this review, we discuss the role and utility of cardiac imaging in characterizing RV mechanisms of disease and provide a suggested framework for clinicians to appropriately utilize imaging in these clinical scenarios.

Urgent and emergent pediatric cardiovascular imaging

The need for urgent or emergent cardiovascular imaging in children is rare when compared to adults. Patients may present from the neonatal period up to adolescence, and may require imaging for both traumatic and non-traumatic causes. In children, coronary pathology is rarely the cause of an emergency unlike in adults where it is the main cause. Radiology, including chest radiography and computed tomography in conjunction with echocardiography, often plays the most important role in the acute management of these patients. Magnetic resonance imaging can occasionally be useful and may be suitable in more subacute cases. Radiologists' knowledge of how to manage and interpret these acute conditions including knowing which imaging technique to use is fundamental to appropriate care. In this review, we will concentrate on the most common cardiovascular emergencies in the thoracic region, including thoracic traumatic and non-traumatic emergencies and pulmonary vascular emergencies, as well as acute clinical disorders as a consequence of primary and postoperative congenital heart disease. This review will cover situations where cardiovascular imaging may be acutely needed, and not strictly emergencies only. Imaging recommendations will be discussed according to the different clinical presentations and underlying pathology.

Long-term cardiovascular outcomes of immune checkpoint inhibitor-related myocarditis: A large single-centre analysis

AIMS

Immune checkpoint inhibitors (ICI) are the cornerstone of modern oncology; however, side effects such as ICI-related myocarditis (irM) can be fatal. Recently, Bonaca proposed criteria for irM; however, it is unknown if they correlate well with cardiovascular (CV) ICI-related adverse events. Additionally, whether incident irM portends worse long-term CV outcomes remains unclear. We aimed to determine the incidence of long-term CV comorbidities and CV mortality among irM patients.

PATIENTS AND METHODS

The ICI-related adverse event (irAE) registry was queried to identify irM patients by using Bonaca criteria. Random controls were selected after excluding patients with other concomitant irAEs. Patients' demographics, comorbidities and myocarditis presenting features were gathered. Outcomes included 2-year freedom from CV comorbidities (composite of atrial fibrillation, stroke, myocardial infarction and heart failure) and freedom from CV death. IrM was treated as a time-varying covariate.

RESULTS

Seventy-six patients developed irM at a median of 167 days (mean age 69, 63.2% male, 47% lung cancer). Majority of patients had new wall motion abnormalities or EKG changes on presentation. Mean LVEF was 43%, median peak TnT was 0.81, and median NTproBNP was 2057 at irM onset. Two-year freedom from CV comorbidities (67% vs 86.8%, P < 0.001) and death (93.4% vs 99.3%, P = 0.003) was lower among irM patients. Incident irM was an independent predictor of CV death (HR 8.28, P = 0.048), but not CV comorbidities (HR 2.21, P = 0.080).

CONCLUSIONS

This is the largest case-control study on irM highlighting worse long-term CV outcomes. Future studies are needed to establish appropriate therapeutic strategies and efficient screening strategies for irM survivors.

Distinctive clinical traits of lupus-related myocarditis: a multicentre retrospective study

OBJECTIVES

Cardiovascular involvement in systemic lupus erythematosus (SLE) is frequent, but little is known about possible distinctive traits of SLE-related myocarditis (myoSLE) in comparison with patients with SLE (onlySLE) or myocarditis alone (onlyMyo).

METHODS

A retrospective analysis was performed comparing patients with myoSLE (n = 25) from three centres with consecutive patients with onlySLE (n = 279) and onlyMyo (n = 88). SLE patients were dichotomized by disease duration ≤1 vs >1 year into recent onlySLE/early myoSLE vs longstanding onlySLE/late myoSLE. Further stratification into disease duration of 1-5, 5-10 and >10 years was also performed. SLE disease activity index 2000 (SLEDAI-2K) was used to estimate disease activity. Myocarditis was diagnosed through biopsy or MRI.

RESULTS

Women were significantly more frequent among myoSLE than among onlyMyo (72% vs 43%; P = 0.013). Compared with onlyMyo, myoSLE patients had a higher frequency of conduction abnormalities (22% vs 5%; P = 0.046) and presented with numerically higher frequencies of left ventricular function compromise (48% vs 30%), along with higher pro-brain natriuretic peptide levels. Inflammation markers were higher in myoSLE compared with onlyMyo and with patients with onlySLE with >10 years of disease duration. SLEDAI-2K was significantly higher in late myoSLE than in longstanding onlySLE. Antiphospholipid syndrome was more frequent in myoSLE than in onlySLE. Multivariate analysis showed an association among myoSLE, anti-β-2-glycoprotein I antibodies (aB2GPI, P = 0.014) and a higher number of involved British Isles Lupus Assessment Group domains in patient history (P = 0.003).

CONCLUSION

myoSLE has unique clinical traits compared with other forms of myocarditis and is associated with aB2GPI and a more severe SLE course.

Diagnosis and management of patients with fulminant myocarditis

Fulminant myocarditis (FM) is a progressive and severe form of acute myocarditis, complicated by cardiogenic shock. The clinical presentation and aetiologies of FM are often heterogeneous, making it difficult to diagnose. Irrespective of how FM presents, it rapidly evolves to haemodynamic deterioration and requires prompt treatment to stabilize. As such, the use of mechanical circulatory support (MCS) devices has emerged as a critical intervention to achieve haemodynamic support, early unloading, and systemic perfusion and to prevent multiorgan dysfunction in patients with FM. Although scientific societies have proposed recommendations and management pathways, due to the heterogeneity in FM, there remains a lack of clarity in the diagnostic pathway and selection of MCS device for this young patient population. This review provides an updated and integrated overview of the diagnostic flow and important clinical considerations when managing patients with FM.

Immunosuppressive therapy to treat newly diagnosed primary heart involvement in patients with systemic sclerosis: An Italian cardiac magnetic resonance based study

BACKGROUND

Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), and is associated with a poor prognosis. Therapeutic strategies to treat SSc-pHI are not yet defined.

OBJECTIVES

To evaluate the efficacy of immunosuppressive therapy on cardiac magnetic resonance (CMR) features in patients with CMR-proven SSc-pHI.

METHODS

The data from SSc patients with CMR-proven pHI who start or modify immunosuppressive therapy as indication for the newly diagnosed pHI and who had a follow-up CMR with parametric mapping after 6 to 18 months were analyzed. All patients underwent a comprehensive baseline evaluation of disease characteristics and organ involvement. In all patients, cardiac involvement was investigated at baseline and at follow up with CMR, evaluating: myocardial edema at STIR images, native-T1 and T2-mapping, extracellular volume fraction (ECV), and late gadoliunum enhancement (LGE). A p value <0.05 was considered as statistically significant.

RESULTS

Out of a cohort of 684 SSc patients, 35 (5.1 %) with SSc-pHI (females 77.1 %; median age 59 [46-64] years; anti-topoisomerase-I positivity 48.6 %; diffuse disease 34.3 %) were selected. In the majority of patients (74.3 %) at baseline CMR, signs of active myocardial inflammation (edema at STIR and/or increased T2-mapping) were found. Mycophenolate mofetil (MMF) was started in 15 (42.9 %) or increased in 7 (20.0 %) cases; 7 patients (20.0 %) received rituximab, 3 (8.6 %) azathioprine, while 3 patients were treated each one with cyclophosphamide (with pulse steroids), tocilizumab and hydroxychloroquine (with steroids). The median duration of immunosuppression was 12.0 [6.0-15.5] months. At follow-up CMR (performed after a median time 12.0 [6.5-16.0] months), increased T2-mapping suggestive for active myocardial inflammation was present in only 14 patients (40 %) (p = 0.003), and edema at STIR was present in 5 cases only (14.3 %) (p = 0.002). A significant reduction of T2-mapping (from 53.0 [49.0-55.0] to 51.0 [50.0-54.0] ms, p < 0.001), native-T1-mapping (from 1050.0 [1007.0-1084.0] to 1039.0 [1020.5-1080.5] ms, p = 0.022) and ECV (from 34.0 [31.0-36.75] to 33.0 [29.0-34.25] %, p = 0.041) was observed, especially in those with baseline increased mapping (T2-mapping from 53.0 [53.0-56.0] to 52.0 [50.0-57.0] ms; T1-mapping from 1066.0 [1050.0-1089.0] to 1057.0 [1027.5-1090.0] ms, p < 0.0001 for both]. The amelioration of the CMR features was paralleled by significant reduction of NT-proBNP (p = 0.008), high-sensitive troponin T (p = 0.003) and C-reactive protein (p = 0.010). No treatment-related adverse events were recorded.

CONCLUSIONS

Our data show that immunosuppression is a therapeutic strategy which has the potentiality to treat newly diagnosed SSc-pHI, by curbing signs of myocardial inflammation at CMR, and by significantly reducing cardiac enzymes, inflammatory markers and overall clinical burden. Larger prospective randomized studies are needed to confirm these data.

Evaluating the Effect of Heart Rate on T2 Balanced Steady-State Free Precession Cardiac MRI Mapping

Purpose To evaluate heart rate as a patient-related confounder in a commonly applied T2 balanced steady-state free precession (bSSFP) mapping sequence used for myocardial tissue characterization. Materials and Methods This retrospective analysis included prospectively (from December 2013 to November 2021) acquired cardiac MRI (1.5 T) datasets with T2 bSSFP mapping from 69 healthy volunteers. Phantom studies and Bloch simulations were performed with heart rates of 60-130 beats per minute and different resting periods (three, six, or nine R-R intervals). Sequence parameters (repetition time, echo time, flip angle, echo train length) were matched across volunteer, phantom, and simulation measurements. Reference values covered clinically relevant T1 and T2 properties found in native myocardium (short, 1041 and 44 msec; medium, 1293 and 43 msec; long, 1534 and 40 msec). A mixed linear model assessed the effect of heart rate on T2 values in volunteer measurements. Results The study included 69 healthy volunteers (median age, 34 years; 44 female and 25 male). Heart rate influenced T2 values acquired with three R-R resting periods (r = -0.38, P = .002; linear regression slope, -0.7 msec/10 beats per minute [95% CI: -1.2, -0.1]). In simulation and phantom measurements, T2 values acquired with three R-R resting periods strongly correlated with heart rate, irrespective of myocardial T1 and T2 properties (r ≤ -0.88; P < .01 for all measurements). Heart rate dependency was reduced with increased resting periods in simulations and phantom measurements. Short myocardial T1 and T2 values derived from T2 bSSFP with nine R-R resting periods were not dependent on heart rate (r = -0.41; P = .33). Conclusion T2 bSSFP with three R-R resting periods underestimates T2 values with increasing heart rates. Use of longer resting periods with T2 bSSFP mapping sequences reduced heart rate dependency. Keywords: Cardiac, Phantom Studies, Myocardium, MRI, Confounding Variables Supplemental material is available for this article. Published under a CC BY 4.0 license.

Cardiac Magnetic Resonance Imaging Findings in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitides: A Systematic Review

OBJECTIVE

Our objective was to review the available literature on cardiac magnetic resonance imaging (cMRI) findings in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), evaluate its diagnostic utility, and assess its potential as a screening tool.

METHODS

We systematically searched PubMed, Embase, Scopus, and Web of Science from inception to March 29, 2023, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. English-language studies involving adult patients diagnosed with AAV-eosinophilic granulomatosis with polyangiitis (EGPA), granulomatosis with polyangiitis (GPA), or microscopic polyangiitis (MPA)-using recognized classification criteria were included. Studies had to report specific cMRI parameters in at least three patients. Three independent reviewers conducted study selection, data extraction, and quality assessment.

RESULTS

Of 2,251 studies, 30 met the inclusion criteria, encompassing 1,149 patients with AAV (87% with EGPA, 13% with GPA, and 0.3% with MPA). The mean patient age was 52 ± 5 years, with 50.4% being female. The mean left ventricular ejection fraction (LVEF) was 55.6% ± 11.3%, and 29% of patients had an LVEF less than 50%. Myocardial fibrosis, indicated by late gadolinium enhancement (LGE), was present in 49% of patients, with predominantly subendocardial or endocardial (23%), intramyocardial (14%), and subepicardial (10%) patterns. Patients in remission (26%), when compared to those not in remission (74%), exhibited higher proportions of LGE (55% vs 47%) and glucocorticoid use (77% vs 68%), despite similar rates of abnormal electrocardiograms (44% vs 42%).

CONCLUSION

This systematic review reveals a high prevalence of myocardial fibrosis detected by cMRI in patients with AAV, even during remission. Significant subclinical cardiac involvement may be missed by conventional diagnostic methods, underscoring the utility of cMRI during routine evaluation.

Immune Checkpoint Inhibitor-Related Myocarditis With or Without Concomitant Myopathy: Clinical Findings and Cardiovascular Outcomes

BACKGROUND

Data on cardiovascular outcomes in patients with both immune checkpoint inhibitor-induced immune-related myocarditis (irMyocarditis) and immune-related myopathy (irMyopathy) are limited.

OBJECTIVES

The aim of this study was to describe clinical characteristics and cardiovascular outcomes in patients with isolated irMyocarditis vs those with concomitant irMyocarditis and irMyopathy.

METHODS

A retrospective cohort study was conducted among patients diagnosed with irMyocarditis at Massachusetts General Brigham between 2015 and 2023. Clinical, laboratory, and imaging characteristics were evaluated, and cardiovascular outcomes were compared between patients with and those without concomitant irMyopathy. The outcomes assessed included acute heart failure requiring diuresis, significant arrhythmias (ventricular arrhythmias and high-degree atrioventricular block), and cardiovascular and all-cause mortality during the index hospitalization.

RESULTS

Among 101 patients with irMyocarditis, 32 (31.7%) had concomitant irMyopathy. Patients with irMyocarditis and irMyopathy had higher high-sensitivity troponin T (median 716 ng/L vs 75 ng/L; P < 0.001) and creatine kinase levels (median 3441 U/L vs 232 U/L; P < 0.001) and were more likely to present with significant arrhythmias (HR: 2.12; 95% CI: 1.13-3.97; P = 0.019). Conversely, patients with isolated irMyocarditis had higher N-terminal prohormone of brain natriuretic peptide levels (median 2043 pg/mL vs 606 pg/mL; P = 0.007), lower left ventricular ejection fractions (median 56% vs 65%; P = 0.008), and a higher likelihood of acute decompensated heart failure (HR: 5.88; 95% CI: 1.45-25; P = 0.013). Cardiovascular and all-cause death during admission were numerically higher in patients with concomitant irMyopathy but were not significantly different between the 2 groups.

CONCLUSIONS

Patients with irMyocarditis and irMyopathy and those with isolated irMyocarditis have distinct biomarker profiles and cardiovascular complications. These differences should be confirmed in larger prospective cohorts to guide tailored management strategies.

Highlights of the Cardiovascular Magnetic Resonance 2024 Conference: the first joint European Association of Cardiovascular Imaging, European Society of Cardiovascular Radiology, and Society for Cardiovascular Magnetic Resonance conference

Cardiovascular Magnetic Resonance 2024 Conference (CMR2024) convened in London, UK, from 24 to 26 January 2024 and brought together 2705 learners and renowned cardiac imaging professionals to discuss and learn about the latest advancements. Organized by the Society for Cardiovascular Magnetic Resonance (SCMR) and the European Association of Cardiovascular Imaging (EACVI), in collaboration with the European Society of Cardiovascular Radiology (ESCR), CMR2024 was the largest international cardiac magnetic resonance conference to date. This conference underscored the collaboration between cardiologists, radiologists, scientists, and technologists by bringing together three major societies-SCMR, EACVI, and ESCR. Innovative session formats like 'Shark Tank' and 'Workflow, Innovations & Patients' facilitated expert opinion and practical experiences sharing in a 'TED-talk style'. With over 1168 abstract submissions and 75% acceptance rate, the programme featured multiple Early Career Award sessions, oral scientific sessions, oral case sessions, and rapid-fire sessions, all categorized by topic. Highlights included patient- and physician-centred imaging sessions, sharing referring physicians' and patients' insights of incremental value of cardiovascular magnetic resonance (CMR) in patient's management. The programme offered invited lectures in eight parallel tracks with three plenary and two keynote speakers. In addition, the interactive workshops and panel discussions provided a platform for knowledge exchange, support, and collaboration. A great emphasis was placed on collaboration between radiologists, cardiologists, scientists, and technologists, showcasing an ideal cardiac imaging marriage as a model for enhanced patient care around the globe. The event also featured exhibitions of the latest CMR technology and software, offering attendees a glimpse into the future cardiac imaging. CMR2024 emerged as a remarkable scientific, educational, and networking event, inspiring attendees to learn and collaborate within the global CMR community.

Myocarditis and Inflammatory Cardiomyopathy in Dilated Heart Failure

Inflammatory cardiomyopathy is a condition that is characterised by the presence of inflammatory cells in the myocardium, which can lead to a significant deterioration in cardiac function. The etiology of this condition involves multiple factors, both infectious and non-infectious causes. While it is primarily associated with viral infections, other potential causes include bacterial, protozoal, or fungal infections, as well as a wide variety of toxic substances and drugs, and systemic immune-mediated pathological conditions. In spite of comprehensive investigation, the presence of inflammatory cardiomyopathy accompanied by left ventricular dysfunction, heart failure or arrhythmia is indicative of an unfavourable outcome. The reasons for the occurrence of either favourable outcomes, characterised by the absence of residual myocardial injury, or unfavourable outcomes, marked by the development of dilated cardiomyopathy, in patients afflicted by the condition remain to be elucidated. The relative contributions of pathogenic agents, genomic profiles of the host, and environmental factors in disease progression and resolution remain subjects of ongoing discourse. This includes the determination of which viruses function as active inducers and which merely play a bystander role. It remains unknown which changes in the host immune profile are critical in determining the outcome of myocarditis caused by various viruses, including coxsackievirus B3 (CVB3), adenoviruses, parvoviruses B19 and SARS-CoV-2. The objective of this review is unambiguous: to provide a concise summary and comprehensive assessment of the extant evidence on the pathogenesis, diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Its focus is exclusively on virus-induced and virus-associated myocarditis. In addition, the extant lacunae of knowledge in this field are identified and the extant experimental models are evaluated, with the aim of proposing future directions for the research domain. This includes differential gene expression that regulates iron and lipid and metabolic remodelling. Furthermore, the current state of knowledge regarding the cardiovascular implications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is also discussed, along with the open questions that remain to be addressed.

Anti-RNApol3-Associated myocarditis: an emerging disease linking autoimmunity and infection

BACKGROUND

Fulminant myocarditis (FM) is a severe condition primarily triggered by viruses. Anti-RNA polymerase III autoantibodies (RNApol3) which are typically found in patients with severe systemic sclerosis, have been reported in patients with influenza-related FM. Our objective is to provide additional insight into RNApol3-associated FM.

METHODS

We retrospectively included all patients admitted to our institution between January 2013 and June 2023 with acute myocarditis and positive serum RNApol3. We compared their characteristics, etiologies, and outcomes with those of a cohort of RNApol3 negative acute myocarditis.

RESULTS

Twenty-nine RNApol3-positive patients, comprising 83% females with a mean age of 39 ± 12 years, were included in this study. Each patient was admitted to the intensive care unit at least once and 11 (38%) relapsed. Triggers included influenza virus in 55% and SARS-CoV-2 virus in 48% of cases. The lowest left ventricular ejection fraction was 10 [5-10] % and the highest troponin value was 82 [22-360] times the ULN. Patients required dobutamine (94%), veno-arterial extracorporeal membrane oxygenation (85%) and pericardiocentesis (38%). At the last follow-up, 76% of patients were still alive, while 7% had undergone cardiac transplantation, and 3% required a left ventricular assist device. Compared to RNApol3-negative cases, RNApol3-positive myocarditis was associated with female gender, fulminant evolution, tamponade, a higher likelihood of being caused by a proven viral infection, and a higher rate of relapse.

CONCLUSION

RNApol3-associated myocarditis is an emerging disease linking autoimmunity and infection and a unique cause of acquired, pathogen-specific, organ-specific immunodeficiency. RNApol3 should be screened in all cases of FM, especially in young women infected by RNA viruses. The risk of FM in RNApol3-positive systemic sclerosis needs further investigation.

Persistent somatostatin PET signs of inflammatory cells 4 to 5 months after acute myocarditis are linked to a poorer recovery of cardiac function

PURPOSE

Acute Myocarditis (AM) was recently shown to be detected by the Somatostatin Positron Emission Tomography (PET) criterion of > 18 cm3 Myocardial Uptake Volume (MUV), a sign of significant inflammatory cell infiltration. This study characterizes patients for whom this criterion persists 4 to 5 months after AM.

METHODS

Cardiac Magnetic Resonance (CMR) and [68 Ga]Ga-DOTA-TOC PET data from 27 AM patients (2 women, median age 26.5 years [interquartile range: 21.9-31.9]) were analyzed at the acute phase and at a 4.5 [4.3-5.0] month follow-up.

RESULTS

Eleven AM patients (41%) still had > 18 cm3 MUV at the follow-up (PET +). The left ventricular ejection fraction (LVEF) was correlated with MUV at baseline (p = 0.011) and follow-up (p = 0.001) and was lower at follow-up in PET + (52.9 [48.6; 55.0] %) than in the other patients (56.0 [54.3; 57.8] %, p = 0.001). However, this poorer recovery of the PET + LVEF was associated with two MUV evolution profiles evocative of different mechanisms: (i) a prolonged active disease in the 5 PET + patients for whom the MUV increased at follow-up, in association with a slight decrease in LVEF (p = 0.08), and (ii) a more severe initial insult in the 6 other PET + patients for whom the MUV decreased at follow-up with concomitant increases in LVEF (p = 0.028) but these improvements started from much worse baseline LVEF and MUV (respectively, p = 0.022 and 0.003 vs. the other patients).

CONCLUSIONS

Somatostatin PET monitoring of AM unveils numerous patients with signs of a persistent inflammatory cell infiltrate 4 to 5 months after acute myocarditis. This persistence is associated with poorer recovery of cardiac function and is seemingly due to active inflammation that is either more severe at baseline or continues to expand over the following months.

TRIAL REGISTRATION NUMBER

NCT03347760 on clinicaltrials.gov. Registration date: 22-11-2017.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

COLLABORATORS

Larry A. Allen, MD, MHS, FAHA, FACC; Mats Börjesson, MD, PhD, FACC; Alan C. Braverman, MD, FACC; Julie A. Brothers, MD; Silvia Castelletti, MD, MSc, FESC; Eugene H. Chung, MD, MPH, FHRS, FAHA, FACC; Timothy W. Churchill, MD, FACC; Guido Claessen, MD, PhD; Flavio D'Ascenzi, MD, PhD; Douglas Darden, MD; Peter N. Dean, MD, FACC; Neal W. Dickert, MD, PhD, FACC; Jonathan A. Drezner, MD; Katherine E. Economy, MD, MPH; Thijs M.H. Eijsvogels, PhD; Michael S. Emery, MD, MS, FACC; Susan P. Etheridge, MD, FHRS, FAHA, FACC; Sabiha Gati, BSc (Hons), MBBS, PhD, MRCP, FESC; Belinda Gray, BSc (Med), MBBS, PhD; Martin Halle, MD; Kimberly G. Harmon, MD; Jeffrey J. Hsu, MD, PhD, FAHA, FACC; Richard J. Kovacs, MD, FAHA, MACC; Sheela Krishnan, MD, FACC; Mark S. Link, MD, FHRS, FAHA, FACC; Martin Maron, MD; Silvana Molossi, MD, PhD, FACC; Antonio Pelliccia, MD; Jack C. Salerno, MD, FACC, FHRS; Ankit B. Shah, MD, MPH, FACC; Sanjay Sharma, BSc (Hons), MBChB, MRCP (UK), MD; Tamanna K. Singh, MD, FACC; Katie M. Stewart, NP, MS; Paul D. Thompson, MD, FAHA, FACC; Meagan M. Wasfy, MD, MPH, FACC; Matthias Wilhelm, MD.

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Multisystem Inflammatory Syndrome in Children: A Comprehensive Review Over the Past Five Years

Multisystem Inflammatory Syndrome in Children: A Comprehensive Review over the Past Five Years This review explores many facets of Multisystem Inflammatory Syndrome in Children (MIS-C) over the previous 5 years. In the time since the COVID 19 pandemic gripped our medical systems, we can now explore the data that has been collected from the previous years. The literature has allowed us to better understand the impact of COVID 19 and the post illness occurrence of a severe systemic inflammatory disease on our youngest patient populations. This paper will outline the pathophysiology of MIS-C, the treatments utilized, short and long-term patient outcomes including epidemiological factors.

Photon-counting CT-derived extracellular volume in acute myocarditis: Comparison with cardiac MRI

PURPOSE

The purpose of this study was to evaluate the feasibility and the accuracy of myocardial late iodine enhancement for extracellular volume (ECV) quantification using dual-source photon-counting detector computed tomography (PCD-CT) in patients with suspected acute myocarditis by comparison with cardiac MRI.

MATERIALS AND METHODS

Patients with clinical suspicion of myocarditis who were referred for coronary CT angiography (CCTA) to exclude coronary artery disease were included in this retrospective study. All patients underwent CCTA examination using a first-generation PCD-CT, which included slate iodine enhancement images. ECV was calculated from the iodine ratio of the myocardium to the blood pool on late iodine enhancement PCD-CT images. A comprehensive cardiac MRI protocol was used as the reference method to confirm myocarditis according to the Lake Louise 2018 criteria. All subjects underwent CCTA using PCD-CT and cardiac MRI within 24 h. The mean dose-length product of late enhancement PCD-CT scanning was calculated. Correlations between ECV PCD-CT (endocardial, epicardial, midcardial, and global), cardiac MRI-LGE, and right and left ventricular ejection fractions were assessed using Pearson correlation test. ECV values derived from PCD-CT and those from cardiac MRI were compared using Bland Altman plots and linear regression analysis. Areas under the receiver operating characteristic curves (AUCs) were used to determine the optimal thresholds of ECV-PCD-CT and ECV-MRI for differentiating patients with myocarditis from those not meeting the Lake Louise criteria.

RESULTS

Thirty-two patients were included. There were 19 men and 13 women with a mean age of 35.9 ± 15.0 (standard deviation [SD]) years; age range: 21-51). The mean dose-length product of late enhancement PCD-CT scanning was 96 ± 32 (SD) mGy.cm. No significant differences in mean global ECV were found between ECV calculated with the PCD-CT (29.4 ± 4.5 [SD] %) and that calculated with cardiac MRI (30.0 ± 4.1 [SD] %) (P = 0.69). ECV-CT was greater in patients with cardiac MRI-confirmed myocarditis (31.65 ± 3.6 [SD] %) by comparison with those with normal findings (25.6 ± 3.2 [SD] %) (P < 0.01). ECV-CT strongly correlated with LGE mass (r = 0.82) and showed strong segmental correlation with ECV-MRI (basal: r = 0.95; mid-ventricular: r = 0.91). An ECV-CT threshold of 26.9 % yielded an AUC of 0.95 (95 % CI: 0.84-1.00) for the diagnosis of myocarditis.

CONCLUSION

Calculation of ECV using iodine maps derived from late iodine enhancement cardiac PCD-CT images is both feasible and accurate at low radiation doses. PCD-CT appears as a promising non-invasive imaging modality for the diagnostic and prognostic assessment of acute myocarditis in the setting of chest pain.

Successful Management of Systemic Capillary Leak Syndrome Secondary to Coronavirus Disease 2019 Mimicking the Course of Fulminant Myocarditis by Venous-arterial Extracorporeal Membrane Oxygenation

We herein report a case of systemic capillary leak syndrome (SCLS) attributed to coronavirus disease (COVID-19) that emerged in 2019. A 56-year-old woman presented with a COVID-19 infection 7 days prior to the visit with upper respiratory symptoms, fatigue, and decreased appetite. Secondary SCLS due to COVID-19 was diagnosed, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated as mechanical support, and intravenous immunoglobulin was administered, marking the transition to the recovery phase with the initiation of fluid resuscitation. This case is noteworthy for successfully employing VA-ECMO in treating secondary SCLS due to COVID-19, mimicking the course of fulminant myocarditis.

Cardiovascular events in patients with myositis: results from a French retrospective cohort

INTRODUCTION

Idiopathic inflammatory myositis (IIM) are systemic diseases, including dermatomyositis (DM), inclusion body myositis (IBM), immune-mediated necrotising myopathy (IMNM), antisynthetase syndrome (ASSD) and overlap myositis (OM). Patients with IIM have an increased risk of premature death, largely due to cardiovascular events (CVE). The aim of this study was to describe specific and non-specific cardiac involvement in patients with IIM, and to assess the occurrence of CVE.

METHODS

We conducted a retrospective observational cohort study of patients with IIM from Saint Antoine University Hospital, Paris, between 1997 and 2020. Cardiac involvement was defined as abnormalities at baseline on ECG, Holter ECG, transthoracic echocardiography, cardiac MRI or elevated cardiac biomarkers. CVE were defined as heart failure due to ischaemia, arrhythmia or conductive block, inflammatory myocarditis or resuscitation department admission.

RESULTS

78 patients were included (median age 49 years; 67% female); 33 (42%) had DM, 18 (23%) ASSD, 12 (15%) OM, 11 (14%) IMNM and 4 (5%) IBM. Cardiac involvement at diagnosis was present in 12 (15%) patients; 15 (19%) had a CVE during follow-up. Patients with versus without cardiac involvement at diagnosis were more likely to present a CVE (6 (50%) vs 9 (14%); p=0.01). Median (IQR) time to CVE was shorter in patients with cardiac involvement (9 (0-34) vs 84 (26-156) months; p<0.01).

CONCLUSION

Patients with cardiac involvement at myositis diagnosis are at increased risk of CVE and experience them earlier than patients without and should be carefully followed up, particularly during the first months after diagnosis.

Gallium-Labeled PET Radiopharmaceuticals in Cardiovascular Disease

Gallium-labeled positron emission tomography (PET) probes targeting activated fibroblasts or somatostatin receptor expression are frequently used for varying applications in oncology. With the widespread availability of 68Ge/68Ga generators and cold kits, 68Ga tracers have become a main tool in molecular imaging. These tracers, such as [68Ga]Ga-DOTA-TATE, [68Ga]Ga-FAPI, and [68Ga]Ga-pentixafor, allow targeted imaging of the key pathological processes, including inflammation, fibrosis, and necrosis. This review highlights their potential in conditions like myocardial infarction, cardiac sarcoidosis, myocarditis, and other cardiomyopathies. Clinical and preclinical studies underscore their utility in visualizing active disease processes, predicting outcomes, and guiding therapeutic strategies. However, challenges remain, including the need for standardization, larger clinical trials, and integration into routine practice. These advancements position 68Ga-based PET as a promising modality for enhancing diagnostic precision and personalized treatment in cardiovascular disease.

Evaluation of Systemic Sclerosis Primary Heart Involvement and Chronic Heart Failure in the European Scleroderma Trials and Research Cohort

BACKGROUND

Systemic sclerosis (SSc) primary heart involvement (SSc-pHI) is one of the leading causes of mortality in SSc. We aimed to evaluate risk factors for SSc-pHI and its progression and the outcomes in the EUSTAR (European Scleroderma Trials and Research) cohort.

METHODS

SSc-pHI was defined according to the World Scleroderma Foundation/Heart Failure Association definition. Data from 5741 patients with SSc in the EUSTAR cohort were analyzed. Additional cardiovascular data were collected from a subcohort of 838 patients with SSc. Lasso regression was used for risk factor analyses. Kaplan-Meier estimator was used for survival analyses. Progression of SSc-pHI was evaluated by a study definition developed by rheumatology and cardiology experts.

RESULTS

Risk factors for the presence of SSc-pHI comprised skeletal muscle atrophy (odds ratio [OR], 2.00 [95% CI, 1.00-2.68]), age (OR, 1.91 [95% CI, 1.73-2.03]), male sex (OR, 1.77 [95% CI, 1.42-2.05]), swollen joints (OR, 1.70 [95% CI, 1.47-1.98]), skeletal muscle weakness (OR, 1.38 [95% CI, 1.00-1.85]), and tendon friction rubs (OR, 1.46 [95% CI, 1.00-1.77]) (n=3276). Telangiectasia (OR, 2.10 [95% CI, 1.38-2.72]), intestinal symptoms (OR, 1.70 [95% CI, 1.04-2.42]), age (OR, 1.47 [95% CI, 1.21-1.62]), and antitopoisomerase I antibodies (OR, 1.37 [95% CI, 1.00-1.77]) were associated with an increased risk for new onset of SSc-pHI (n=1000). Survival rate was significantly lower in patients with SSc-pHI than in those without (P value <0.0001, n=3768). Patients with SSc-pHI had a lower survival rate than patients with interstitial lung disease (n=3365). Swollen joints were associated with an increased risk of progressive SSc-pHI (OR, 2.49 [95% CI, 1.79-3.52]) (n=595). Tendon friction rubs (OR, 1.21 [95% CI, 0.94-1.90]) increased the risk of heart failure with preserved ejection fraction in patients with SSc-pHI.

CONCLUSIONS

We defined progressive SSc-pHI and identified risk factors for new onset and progression of SSc-pHI and for SSc-pHI-associated heart failure with preserved ejection fraction in the largest cohort with SSc. These findings may guide patient stratification for diagnostic workup and therapy.

Myocarditis and pericarditis during COVID-19 pandemic: a study of the Italian Society of Cardiology

AIMS

Some studies about myocarditis and pericarditis following COVID-19 vaccination raised concerns worldwide. However, the heterogeneous diagnostic criteria for postvaccination inflammatory heart diseases may result in overestimating incidence rates. The aim of this multicentre Italian registry is to evaluate the impact of COVID-19 vaccines on the incidence of myocarditis and pericarditis in the Italian population.

METHODS

Consecutive patients admitted to Italian hospitals for endomyocardial and/or cardiac magnetic resonance proven acute myocarditis and/or pericarditis in the same period (1 June-31 October) of 2019 and 2021 were enrolled, irrespective of the potential association with the COVID-19 vaccines. Acute pericarditis and/or myocarditis were defined as 'vaccine-related' if clinical presentation occurred within 15 days after COVID-19 vaccination, independently of the dose.

RESULTS

There was a comparable incidence rate ratio (IRR) for inflammatory heart diseases in 2019 and 2021 (2019: IRR 0.67 versus 2021: IRR 0.74, P = 0.45). In particular, the IRR did not differ in myocardial involvement (2019: IRR 0.33 versus 2021: IRR 0.33, P = 1) and pericarditis (2019: IRR 0.37 versus 2021: IRR 0.49, P = 0.09) in both periods. Among 125 cases registered in 2021, 32 (25.6%) were 'vaccine-related'. Among those who experienced 'vaccine-related' myocarditis and/or pericarditis, men with age under 40 years were over-represented (53.12%, P = 0.021).

CONCLUSION

In a nationwide Italian survey comparing pandemic with prepandemic periods, the overall data do not indicate significant concerns about an increased incidence of pericarditis and myocarditis, suggesting that the vaccine is generally well tolerated for these specific conditions.

Results From the Big Ten COVID-19 Cardiac Registry: Impact of SARS-COV-2 on Myocardial Involvement

OBJECTIVE

COVID-19 has been associated with myocardial involvement in collegiate athletes. The first report from the Big Ten COVID-19 Cardiac Registry (Registry) was an ecological study that reported myocarditis in 37 of 1597 athletes (2.3%) based on local clinical diagnosis. Our objective was to assess the relationship between athlete and clinical characteristics and myocardial involvement.

DESIGN

Cross-sectional study.

SETTING

We analyzed data from 1218 COVID-19 positive Big Ten collegiate athletes who provided informed consent to participate in the Registry.

PARTICIPANTS

1218 athletes with a COVID-19-positive PCR test before June 1, 2021.

ASSESSMENT OF INDEPENDENT VARIABLES

Demographic and clinical characteristics of athletes were obtained from the medical record.

MAIN OUTCOME MEASURES

Myocardial involvement was diagnosed based on local clinical, cardiac magnetic resonance (CMR), electrocardiography, troponin assay, and echocardiography. We assessed the association of clinical factors with myocardial involvement using logistic regression and estimated the area under the receiver operating characteristic (ROC) curve.

RESULTS

25 of 1218 (2.0%) athletes met criteria for myocardial involvement. The logistic regression model used to predict myocardial involvement contained indicator variables for chest pain, new exercise intolerance, abnormal echocardiogram (echo), and abnormal troponin. The area under the ROC curve for these indicators was 0.714. The presence of any of these 4 factors in a collegiate athlete who tested positive for COVID-19 would capture 55.6% of cases. Among noncases without missing data, 86.9% would not be flagged for possible myocardial involvement.

CONCLUSION

Myocardial involvement was infrequent. We predicted case status with good specificity but deficient sensitivity. A diagnostic approach for myocardial involvement based exclusively on symptoms would be less sensitive than one based on symptoms, echo, and troponin level evaluations. Abnormality of any of these evaluations would be an indication for CMR.

Design and rationale of the COVID vaccine-associated myocarditis/pericarditis (CAMP) study

BACKGROUND

Minimal data are available on mid- and long-term outcomes following COVID-19 vaccine-associated myocarditis/pericarditis. The COVID Vaccine-Associated Myocarditis/Pericarditis (CAMP) study aims to characterize the mid- and long-term sequelae of myocarditis/pericarditis following administration of any Pfizer-BioNTech COVID-19 vaccine (herein referred to as COMIRNATY®). Herein we describe the rationale and design of CAMP.

METHODS

This ongoing and actively enrolling multicenter observational cohort study across 32 North American pediatric cardiac centers will include at least 200 patients <21 years-old who presented ≤21 days from COMIRNATY® vaccination and meet the Centers for Disease Control and Prevention (CDC) case definition of probable or confirmed myocarditis/pericarditis or isolated pericarditis. The comparison cohort will consist of 100 patients <21 years-old with COVID-19 associated myocarditis/pericarditis, including those who meet the contemporaneous CDC case definition of multisystem inflammatory syndrome (MIS-C). The study will collect detailed hospital and follow-up data for up to 5 years following illness onset. Electrocardiograms, echocardiograms, and cardiac magnetic resonance (CMR) examinations will be interpreted in core laboratories. The primary outcomes are 1) composite of left ventricular ejection fraction <55% by echocardiogram, findings of myocarditis by original or revised Lake Louise criteria on CMR, and/or the presence of high-grade arrhythmias or conduction system disturbances at 6 months after myocarditis/pericarditis onset; 2) complications, such as death, and non-cardiac morbidities; and 3) patient-reported outcomes of global health, functional status, and quality of life. Analyses will include descriptive statistics and regression modeling.

CURRENT STATUS

Still enrolling, with 273 participants currently enrolled as of 10/16/2024 (173 vaccine-associated myocarditis/pericarditis, 100 COVID-19-associated myocarditis/pericarditis) CONCLUSIONS: With long-term follow-up and core laboratories for standardized assessments of cardiac testing, the CAMP study will make important contributions to our understanding of the mid- and long-term cardiac and non-cardiac sequelae of COVID-19 vaccine-associated myocarditis/pericarditis.

Multimodality Imaging and Immune-Related Adverse Events During Immune Checkpoint Inhibitors Treatment: Where Do We Stand?

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, significantly improving survival across various malignancies. However, these therapies are associated with various types of immune-related adverse events (irAEs), including cardiotoxicity, a spectrum of rare but potentially life-threatening complications impacting significantly morbidity and mortality. Cardiovascular imaging has become key in cardio-oncology, providing essential diagnostic tools for early detection and monitoring. This review synthesizes current evidence and underlines the pivotal role of early and tailored imaging strategies in managing ICI-induced cardiotoxicity. By bridging the knowledge gap, it aims to provide targetable insights to optimize the clinical management in patients undergoing immunotherapy.

Imaging of the Acute and Chronic Cardiovascular Complications of Radiation Therapy

Chest radiotherapy (XRT) plays a crucial role in the treatment of a multitude of cancers including breast, lung, esophageal, and lymphoma. Although XRT enhances cancer survival rates, it may also expose healthy bystander tissues to radiation, potentially leading to severe complications. Initially considered relatively resistant to radiation damage, the heart has been shown over the past 4 decades to be susceptible to radiation-induced cardiovascular toxicity and despite advances in XRT which can minimize radiation exposure to heart tissue, no cardiac radiation dose is entirely safe. The clinical spectrum of radiation-induced cardiovascular toxicity is broad, encompassing coronary artery disease, myocardial dysfunction, valvular abnormalities, and pericardial disorders. Radiation-induced cardiovascular toxicity may manifest acutely or many years after XRT, with each condition more likely to present at certain time points post-XRT. Cardiac imaging is a crucial tool in both the screening and diagnosis of radiation-induced cardiovascular toxicity with an understanding of its pathophysiology, incidence, and progression required to implement a comprehensive, multimodality imaging approach to detect and manage these complications effectively.

Myocarditis: Diagnostic Modalities and Treatment Options

Myocarditis is an underdiagnosed condition that affects people of all ages. It can be asymptomatic or present with a variety of symptoms. The etiology of myocarditis is broad and can be infectious, autoimmune, or toxin-induced. The diagnosis of myocarditis can be challenging at times due to varied clinical features that sometimes overlap with other cardiac conditions. It is essential to have a high index of suspicion and use appropriate diagnostic methods for timely detection. In this review, we discuss establishing the diagnosis of acute myocarditis with initial workup to gold standard noninvasive cardiac magnetic resonance imaging methods and the use of invasive techniques such as endomyocardial biopsy. Furthermore, we discuss the treatment options, including novel approaches based on the severity of the symptoms and the specific etiologies of myocarditis.

A Case of Nivolumab-Induced Multiorgan Toxicity: Concurrent Myocarditis and Interstitial Pneumonia

This is a rare case of nivolumab-induced multiorgan toxicity presenting as concurrent myocarditis and interstitial pneumonia in an 81-year-old patient with metastatic renal cell carcinoma. Immune checkpoint inhibitor (ICI)-associated myocarditis, a high-mortality immune-related adverse event (irAE), often presents with nonspecific symptoms, complicating early diagnosis, particularly when coexisting with other irAEs. In this case, the diagnosis was supported by elevated cardiac biomarkers, multimodal imaging findings (echocardiography, cardiac MRI, and coronary CT angiography), and electrocardiogram (ECG) abnormalities, including new-onset atrial fibrillation and right bundle branch block, indicative of myocardial involvement. High-dose methylprednisolone (1 g/day) was initiated on the second hospital day, followed by a gradual tapering regimen based on troponin trends and clinical improvement, leading to the resolution of myocarditis. This case underscores the importance of early recognition of ECG abnormalities as a diagnostic clue and highlights the diagnostic challenges of distinguishing myocarditis from other irAEs in patients receiving ICIs.

Utility of MRI and CT in Sports Cardiology

Sports cardiologists specialize in the care of competitive athletes and highly active people by detecting and managing cardiovascular diseases that can impact sports participation and counseling on return to sports after cardiovascular events. Preparticipation evaluation of athletes includes history, physical examination, and electrocardiography (ECG), with exercise ECG added when screening master athletes. If the findings are abnormal or inconclusive, echocardiography is used for further evaluation. Further imaging with MRI, CT, or stress test is performed for establishing a diagnosis when echocardiography is indeterminate or discordant with clinical features and for risk stratification if echocardiography provides a definitive diagnosis. MRI can help distinguish athlete's heart from similar-appearing pathologic entities when echocardiography is inconclusive. Athlete's heart can manifest as left ventricular hypertrophy (LVH), left ventricle (LV) dilatation, prominent LV trabeculations, and right ventricular (RV) dilatation. Adaptive LVH in athletes is concentric and typically measures less than 16 mm, which distinguishes it from pathologic LV thickening of hypertrophic cardiomyopathy, hypertension, valvular disease, and infiltrative cardiomyopathies. Adaptive LV dilatation with normal or mildly reduced ejection fraction can be seen in endurance athletes. LV ejection fraction greater than 40%, augmentation of LV ejection fraction with exercise, and normal or supranormal diastolic function distinguishes it from dilated cardiomyopathy. Physiologic RV dilatation in athletes is distinguished from arrhythmogenic cardiomyopathy (RV type) by global involvement and absence of major regional wall motion abnormalities or late gadolinium enhancement. MRI is also useful in diagnosis and risk stratification of athletes with cardiovascular symptoms and after major cardiovascular events such as arrhythmias, myocardial infarction, and resuscitated sudden cardiac death or arrest. CT angiography provides accurate evaluation of coronary artery anomalies and coronary artery disease. ©RSNA, 2025 Supplemental material is available for this article.

Taking ACTION to detect myocarditis related to recombinant gene transfer therapy for Duchenne Muscular Dystrophy; Consensus recommendations for cardiac surveillance

BACKGROUND

A viral vector recombinant gene transfer therapy (GTT) has recently been approved by the FDA for males of all ages with Duchenne Muscular Dystrophy (DMD) without limitations regarding preexisting cardiac impairment. Acute myocarditis is a potential life-threatening short-term complication that has been reported following GTT. This immune mediated response can range from troponin elevation to rapid cardiovascular compromise and death, particularly in those with abnormal cardiac status at baseline. Early detection of cardiac compromise is essential to optimize outcomes.

OBJECTIVES

The primary objective of this consensus statement is to advocate for caution with DMD GTT patient selection and to initiate preemptive monitoring for those who may be at increased risk for cardiac adverse events. Secondary objective is to deepen our understanding of short and long-term impact of DMD gene therapies on the heart.

METHODS

A national learning network of pediatric cardiologists with expertise in DMD developed recommendations for cardiac surveillance of DMD males receiving GTT based on available evidence and expert consensus opinion. A monitoring and treatment plan for standard and high cardiac risk patients was developed.

CONCLUSION

Partnership of cardiologists with GTT prescribers is essential to identify patient-specific considerations that might influence risk for adverse cardiac events and alter post infusion monitoring and management plans. Consistency in cardiac surveillance practices across centers will expedite our knowledge regarding potential short- and long-term cardiac effects of GTT for DMD.

Impact of the COVID-19 pandemic on cardiac magnetic resonance imaging practices: insights from the MRCT registry

PURPOSE

To assess the relationship between the COVID-19 pandemic and the spectrum of indications for cardiac magnetic resonance imaging (MRI) with a focus on myocarditis.

MATERIALS AND METHODS

This was a retrospective analysis of data from the MRCT registry of the European Society of Cardiovascular Radiology (ESCR). Data regarding indications and diagnoses of myocarditis between January 1, 2018, and April 30, 2024, were extracted. Data was analyzed for the periods before and after the beginning (i.e., March 11, 2020) of the COVID-19 pandemic.

RESULTS

Data from 112,361 cardiac MRI examinations was analyzed (63.5% male, median age 58 [IQR 44-69]). Over the entire period, assessment of myocarditis was the most common indication for cardiac MRI (31%, n = 34,906/112,361). Before the pandemic, this indication comprised 28% of examinations and increased to a maximum of 41% in 2022 after the onset of the pandemic. Simultaneously, the positivity rate of these examinations decreased from 21% before the pandemic to 14% in 2022. Male patients had a higher positivity rate than female patients both before and during the pandemic, with mirroring trends between sexes. The proportion of cardiac MRI examinations performed for suspected and known coronary artery disease showed an inverse relationship with those performed for myocarditis and decreased from 24% and 17% pre-pandemic to a minimum of 21% and 13% during the pandemic.

CONCLUSION

The COVID-19 pandemic considerably influenced the pattern of referrals for cardiac MRI examinations in Europe, leading to a higher proportion of examinations for suspected myocarditis but a reduced positivity rate, suggesting a lower referral threshold for this indication. At the same time, proportionally fewer examinations were performed for suspected and known coronary artery disease.

KEY POINTS

Question The COVID-19 pandemic may have influenced the spectrum and positivity rates of indications for cardiac MRI, especially examinations for myocarditis. Findings The COVID-19 pandemic led to a higher proportion of cardiac MRI examinations for suspected myocarditis but a reduced positivity rate. Clinical relevance The spectrum and proportions of indications for cardiac MRI give important information on the historical and current trends in cardiac imaging and provide insight into resource deployment.

Feasibility and Role of Cardiac Magnetic Resonance in Intensive and Acute Cardiovascular Care

Cardiac magnetic resonance (CMR) is established as a key imaging modality in a wide range of cardiovascular diseases and has an emerging diagnostic and prognostic role in selected patients presenting acutely. Recent technical advancements have improved the versatility of this imaging technique, which has become quicker and more detailed in both functional and tissue characterization assessments. Information derived from this test has the potential to change clinical management, guide therapeutic decisions, and provide risk stratification. This review aims to highlight the evolving diagnostic and prognostic role of CMR in this setting, whilst also providing practical guidance on which patients can benefit the most from CMR and which information can be derived from this test that will impact clinical management.

Behind the curtain lies the truth: a case of arrhythmogenic cardiomyopathy mistaken for COVID-19 vaccine-associated myocarditis

A 15-year-old male presented with vasovagal syncope and troponin leak 4 days after his second COVID-19 vaccine. Based on initial diagnostic work-up, he was thought to have COVID-19 vaccine-associated myocarditis. His cardiac dysfunction persisted and further work-up including genetic evaluation and serial MRI studies later confirmed a diagnosis of arrhythmogenic cardiomyopathy. This is a unique case of an incorrect diagnosis based on timing and context of vaccine-related myocarditis. Reports of mild and self-limited myocarditis post-COVID-19 vaccination may cause vaccine hesitancy among the public, and so case reports such as this one show the importance of discerning underlying conditions amongst rare COVID-19 vaccination complications.

Early detection of myocarditis caused by immune checkpoint inhibitor therapy with nivolumab and ipilimumab for advanced recurrent renal cell carcinoma

Combination therapy with nivolumab and ipilimumab for advanced renal cell carcinoma (RCC) may cause immune-related myocarditis; however, its incidence in this cancer type and regimen remains unknown. At our institution, we measure biomarkers, such as high-sensitivity Troponin (hsTn), and perform electrocardiograms (ECGs) and echocardiography before and every month after the initiation of this therapy, and the findings obtained and patients' symptoms are continuously monitored by physicians and pharmacists. A retrospective survey was conducted on physiological and biochemical test findings and immune-related adverse events in patients with advanced RCC who received combination therapy with nivolumab and ipilimumab between October 1, 2018 and December 31, 2023. Patients suspected of having myocarditis consulted with cardiologists. Myocarditis due to this therapy was detected in 5 of the 86 patients (5.8%) assessed using the European Society of Cardiology 2022 guidelines. There were no fatal symptoms or death due to myocarditis. The median time to the onset of myocarditis was 25 days (21-86 days). The early detection of myocarditis caused by this therapy requires the monitoring of changes by periodically measuring hsTn and other cardiac markers and performing ECGs and echocardiography from the early stages of administration through to the end of treatment. In addition to checking symptoms, if these abnormalities are detected and myocarditis is suspected, prompt collaboration with cardiologists is recommended. Our management strategy of care by a onco-cardiology team may contribute to the early diagnosis and treatment of myocarditis.

Cardiac involvement in eosinophilic granulomatosis with polyangiitis: acute eosinophilic myocarditis and chronic inflammatory cardiomyopathy

OBJECTIVES

Currently, cardiac involvement is used to describe all eosinophilic granulomatosis with polyangiitis (EGPA) cardiac problems. However, heterogeneity exists among them. We aimed to depict the disease spectrum of EGPA cardiac involvement and identify the high-risk population.

METHODS

We included EGPA patients hospitalized in our centre from 2012 to 2023 and in public databases. Based on the cardiac enzymes, cardiac MRI and endomyocardial biopsy results, the patients were divided into three groups: eosinophilic myocarditis (EGPA-EM), chronic inflammatory cardiomyopathy (EGPA-ICM) and EGPA-Control. Their clinical, laboratory, imaging results and prognoses were collected and compared.

RESULTS

A total of 193 EGPA patients were included, 118 with cardiac involvement (74 EGPA-EM, 44 EGPA-ICM) and 75 control. Among EGPA-Control, EGPA-ICM and EGPA-EM, eosinophil increased (6.12/8.71/10.42 × 109/l, P < 0.01), ANCA positivity decreased (41.33/31.82/14.86%, P < 0.01) and lung involvement was reduced (73.33/72.73/43.24%, P = 0.02). In EGPA-EM, cardiac troponin was further elevated (0.27 vs 6.00 ng/ml, P < 0.01), ejection fractions decreased (57.79 vs 33.20%, P < 0.01) while more ST-T abnormality was observed (41.89 vs 20.45%, P = 0.02). The prognosis of EGPA-EM was significantly worse, with a 14.86% death rate and 2-year event-free survival rate below 50%. Furthermore, we proposed a LATE-EAST diagnostic score (7 items, 9 points) to discriminate EGPA-EM from EGPA-ICM using 4 points as threshold [area under the receiver operating characteristic curve 0.85 (95% CI 0.78-0.92), sensitivity 0.78, specificity 0.86].

CONCLUSIONS

We first proposed different subtypes of cardiac involvement in EGPA. Identification and treatment of EGPA-EM needs improvement. LATE-EAST score could recognize the high-risk EGPA-EM effectively. Multi-disciplinary treatment is warranted, immunosuppressive therapy should be given in a timely manner and anti-IL-5 antibodies should be be tested in trials.

Diagnostic and Prognostic Value of Cardiac Magnetic Resonance for Cardiotoxicity Caused by Immune Checkpoint Inhibitors: A Systematic Review and Meta-Analysis

Background

The complex process of cardiac magnetic resonance (CMR) and the uncertainty of each parameter in the diagnosis and prognosis of cardiotoxicity limit its promotion in the cardiac evaluation of patients treated with immune checkpoint inhibitors (ICI).

Methods

A comprehensive search was conducted across PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Cochrane databases for relevant articles published up until September 28, 2024.

Results

After screening, 8 articles were included in this study. The analysis revealed that following ICI treatment, the left ventricular global longitudinal strain (GLS) increased significantly [weighted mean difference (WMD) 2.33; 95% confidence interval (CI) 1.26, 3.41; p < 0.01], while the global radial strain (GRS) decreased [WMD -4.73; 95% CI -6.74, -2.71; p < 0.01]. Additionally, T1 and T2 values increased [standardized mean difference (SMD) 1.14; 95% CI 0.59, 1.68; p < 0.01] and [SMD 1.11; 95% CI 0.64, 1.58; p < 0.01], respectively. An elevated T2 was associated with a higher occurrence of major adverse cardiovascular events (MACE), with a hazard ratio of 1.36 (95% CI 1.12, 1.64).

Conclusions

Our findings demonstrate that T1, T2, and GLS increase, while GRS decreases following ICI administration. By consolidating these critical metrics, we propose a streamlined, abbreviated (non-contrast) CMR protocol that can be completed within 15 minutes, thereby facilitating the integration of CMR in cardio-oncology.

The PROSPERO registration

CRD42023437238, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437238.