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

Application of radiomics in acute and severe non-neoplastic diseases: A literature review

Radiomics involves the integration of computer technology, big data analysis, and clinical medicine. Currently, there have been initial advancements in the fields of acute cerebrovascular disease and cardiovascular disease. The objective of radiomics is to extract quantitative features from medical images for analysis to predict the risk or treatment outcome, help in differential diagnosis, and guide clinical decisions and management. Radiomics applied research has reached a more advanced stage yet encounters several obstacles, including the need for standardization of radiomics features and alignment with treatment requirements for acute and severe illnesses. Future research should aim to seamlessly incorporate radiomics with various disciplines, leverage big data and artificial intelligence advancements, cater to the requirements of acute and critical medicine, and enhance the effectiveness of technological innovation and application in diagnosing and treating acute and critical illnesses.

Acute Non-Rheumatic Myocarditis Following Group G Streptococcal Pharyngitis: A Rare Mimic of Acute Myocardial Ischemia in a Young Adult

Background

Acute myocarditis is a rare but serious inflammatory condition of the myocardium, often triggered by infections or rheumatic heart disease. While group A Streptococcus is commonly associated with bacterial myocarditis, group G Streptococcus is rarely implicated. This case highlights a rare instance of non-rheumatic acute myocarditis also known as Streptococcal pharyngitis acute myocarditis caused by group G Streptococcus in a 19-year-old male without rheumatic fever.

Case report

A previously healthy 19-year-old male presented with chest pain, fever, and sore throat, prompting hospitalization. The diagnosis of acute myocarditis was based on elevated cardiac biomarkers, electrocardiographic abnormalities, and cardiac magnetic resonance imaging, with group G Streptococcus infection confirmed by throat polymerase chain reaction. The patient responded well to antibiotics and anti-inflammatory therapy.

Conclusions

This case highlights group G Streptococcus-induced pharyngitis acute myocarditis, stressing the need for prompt diagnosis and treatment in young adults presenting with recent streptococcal pharyngitis.

LEARNING POINTS

This case highlights a rare instance of non-rheumatic acute myocarditis also known as Streptococcal pharyngitis acute myocarditis, caused by group G streptococcus in a 19-year-old male without rheumatic fever.Streptococcal pharyngitis acute myocarditis may present with clinical features closely resembling an acute coronary syndrome; hence advance cardiac imaging is essential to confirm myocarditis and rule out true ischemic heart disease.Cardiac magnetic resonance imaging was used to diagnose Streptococcal pharyngitis acute myocarditis which showed subepicardial hyper-enhancement 4 weeks after discharge and resolution of symptoms.Prompt diagnosis was achieved, and the patient was treated with antibiotics and anti-inflammatory therapy in a timely fashion with good response.

Assessment of myocardial dysfunction of patients with systemic lupus erythematosus based on myocardial perfusion imaging and analysis of potential influencing factors

The incidence and prevalence of systemic lupus erythematosus (SLE) have increased annually over the past decade. The involvement of myocardium is one of the main reasons for the poor prognosis of patients with SLE. Identifying myocardial involvement in patients with autoimmune diseases and providing early targeted treatment can improve patient outcomes. The aim of this study is to evaluate myocardial dysfunction in patients with SLE using 99mTc-MIBI rest gated myocardial perfusion imaging (rGMPI) and to investigate factors associated with myocardial dysfunction. 76 patients with SLE were prospectively enrolled in the study and 46 patients without autoimmune diseases or other inflammatory diseases who had undergone 99mTc-MIBI rGMPI were selected as a control group. Results of relevant blood test indicators, echocardiography and rGMPI were recorded, and comparison was made between the two groups. Meanwhile, based on diagnostic results of rGMPI, SLE patients were divided into myocardial dysfunction group and normal myocardial function group and to analyze the influencing factors of myocardial dysfunction in SLE patients. The incidence of myocardial dysfunction was significantly higher in SLE patients than in controls (30.3% vs 0%, 2= 16.131, p < .001). Moderate/severe disease activity, decreased myocardial perfusion and positive anti-SSA/Ro52kDa antibody were associated with impaired myocardial function in SLE patients (OR = 2.753, 5.359, 3.646; p = .049, 0.015, 0.014). Positive anti-SSA/Ro52kDa antibody was is independently correlated with myocardial dysfunction in SLE patients [OR (95% CI) = 3.159 (1.071-9.316), p = .037]. In conclusion, 99mTc-MIBI rGMPI can noninvasively evaluate myocardial dysfunction in patients with SLE and provide evidence for clinical treatment decisions. Positive anti-SSA/Ro52kDa antibody was an independent risk factor for myocardial dysfunction in SLE patients.

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.

Incremental Prognostic Value of Left Atrial Strain in Patients With Suspected Myocarditis and Preserved Left Ventricular Ejection Fraction

BACKGROUND

Analysis of left atrial (LA) strain and left atrioventricular coupling index (LACI) have prognostic value in cardiovascular diseases. However, the prognostic value of LA strain and LACI in patients with suspected myocarditis and preserved left ventricular ejection fraction (LVEF) is unclear.

PURPOSE

To investigate the prognostic value of LA strain and LACI in patients with suspected myocarditis and preserved LVEF in comparison with conventional MRI outcome predictors.

STUDY TYPE

Retrospective.

POPULATION

One hundred sixty-five patients with clinically suspected myocarditis and preserved LVEF with available follow-up data.

FIELD STRENGTH/SEQUENCE

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

ASSESSMENT

Left ventricular (LV) and LA strain were evaluated using feature tracking. LACI was calculated as the ratio of LA and LV volumes at LV end-diastole. Patients were followed-up with the primary endpoint being major adverse cardiovascular events (MACE).

STATISTICAL TESTS

Independent-samples t-test and Mann-Whitney U test to compare patients with and without MACE, receiver operating characteristic (ROC) curve analysis to define high/low risk groups, Kaplan-Meier survival analysis and Cox proportional hazards regression to assess prognosis. A P value of <0.05 was considered statistically significant.

RESULTS

The associations of LV strain parameters (including global radial, circumferential, and longitudinal strain) and LACI with MACE were not significant (P = 0.511, 0.108, 0.148, and 0.847, respectively). An optimal LA conduit strain (Ԑe) cutoff value of 10.4% was identified to best classify patients into low- and high-risk groups. Only Ԑe was significantly associated with MACE in both univariable (hazards ratio [HR] 0.936, 95% confidence interval [CI] 0.884-0.991) and multivariable Cox survival analyses (HR 0.937, 95% CI 0.884-0.994).

DATA CONCLUSION

LA conduit strain has prognostic value in patients with suspected myocarditis and preserved LVEF, incremental to conventional MRI outcome predictors, whereas LACI was not associated with MACE occurrence.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Cardiovascular magnetic resonance parametric mapping in the risk stratification of patients affected by chronic myocarditis

OBJECTIVES

Chronic myocardial inflammation is the substrate for arrhythmias and dilated cardiomyopathy onset, causing morbidity and mortality. Cardiovascular magnetic resonance (CMR) is the noninvasive gold standard for myocardial inflammation detection, due to the high sensitivity of the parametric mapping techniques. However, the potential prognostic capabilities of CMR mapping have not been studied in the setting of chronic myocarditis.

METHODS

This is a retrospective study on consecutive patients undergoing CMR with suspicion of chronic myocarditis from September 2017 to November 2021. CMR was acquired according to 2018 Lake Louise Criteria recommendations. The outcome (chronic heart failure, recurrent chronic myocarditic chest pain, ICD/PM implantation, arrhythmias [Lown class ≥ 2]) was collected at follow-up. The extent and degree of native T1, T2, and extracellular volume fraction alterations were used to create multivariate binary logistic regression models for outcome prediction, with or without left ventricle ejection fraction; their AUCs were compared with DeLong test. Differences between other parameters were assessed using Chi-square test, Fisher's exact test, or Mann-Whitney U-test.

RESULTS

The population included 88 patients (age 43 [32-52] yo), mostly male (53/88, 60%). After a median follow-up of 21 (17-34) months, 31/88 (35%) patients experienced the outcome. The model based on the extension of mapping alterations and LV dysfunction reached a good predictability (AUC 0.71). The model based on the intensity of mapping alterations and LV dysfunction had a very good performance (AUC 0.80).

CONCLUSION

The quantitative analysis of CMR mapping parameters indicative of myocardial damage severity may improve risk stratification in patients with chronic myocarditis.

CLINICAL RELEVANCE STATEMENT

The intensity of myocardial damage, assessed as the degree of native T1, T2, and ECV alteration, together with left ventricle dysfunction, improved patient risk stratification. Further prospective studies will be necessary for validation before clinical application.

KEY POINTS

Risk stratification of patients affected by chronic myocarditis is an unmet clinical need. Cardiovascular MRI (CMR) can role in risk stratification thanks to its multiparametric capabilities of tissue characterization. A model based on CMR parametric mapping and left ventricle ejection fraction can predict arrhythmia, heart failure, and recurrent symptoms.

Prognostic Value of Myocardial Parametric Mapping in Patients with Acute Myocarditis: A Retrospective Study

Purpose To investigate the prognostic value of T1 mapping, extracellular volume fraction (ECV), and T2 mapping in a large cohort of patients with acute myocarditis. Materials and Methods This retrospective study included patients with acute myocarditis who underwent cardiac MRI (3.0 T) between March 2016 and October 2022. Diagnosis was confirmed by diagnostic cardiac MRI criteria or endomyocardial biopsy. The primary end point was major adverse cardiovascular events (MACEs), defined as the composite of cardiac death, heart failure hospitalization, heart transplantation, sustained ventricular arrhythmia, and recurrent myocarditis. Univariable and multivariable Cox regression analyses were performed to assess the association of clinical and cardiac MRI variables with the primary end point. The prognostic value of each model was assessed using the Harrell C index. Results A total of 235 patients (mean age, 32 years ± 13 [SD]; 150 [63.8%] men) were included. During a mean follow-up of 1637 days (IQR: 1441-1833 days), MACEs occurred in 45 (19%) patients. Patients with MACEs had higher global native T1, ECV, and T2 values (1342 msec ± 64 vs 1263 msec ± 48; P < .001; 39.1% ± 8.7 vs 32.7% ± 5.7; P < .001; 61.1 msec ± 10.0 vs 55.3 msec ± 9.4; P = .03, respectively). In a series of multivariable Cox regression models, native T1 (per 10-msec increase: hazard ratio, 1.61; 95% CI: 1.31, 1.98; P < .001) and ECV (per 5% increase: hazard ratio, 1.70; 95% CI: 1.38, 2.08; P < .001) independently predicted MACE occurrence, and the addition of native T1 (Harrell C index = 0.76) or ECV (Harrell C index = 0.79) to the model including only clinical variables, left ventricular ejection fraction, and septal late gadolinium enhancement (Harrell C index = 0.72) improved discrimination for the primary end point. Conclusion Cardiac MRI-derived native T1 and ECV were independent predictors of MACEs in patients with acute myocarditis and provided incremental prognostic value when combined with conventional parameters. Keywords: MRI, Cardiac, Heart, Inflammation Supplemental material is available for this article. © RSNA, 2025.

Acute Myocarditis and Inflammatory Cardiomyopathies: Insights From Cardiac Magnetic Resonance Findings

Myocardial inflammation encompasses a broad spectrum of conditions, including acute myocarditis, chronic inflammatory cardiomyopathy, and several overlapping entities that differ in clinical presentation, pathophysiology, and progression. These conditions range from self-limiting acute inflammation to chronic myocardial injury and dysfunction. The etiologic classification of myocardial inflammation highlights the complexity of its pathogenesis, involving direct tissue damage, immune-mediated mechanisms, and environmental triggers. Cardiac magnetic resonance (CMR) imaging has become a central diagnostic tool in the assessment of myocardial inflammation, providing precise characterization of myocardial tissue, assessing cardiac function, and stratifying prognosis. Advanced techniques such as T1 and T2 mapping and extracellular volume quantification have further expanded its diagnostic capabilities. This review highlights the essential role of CMR in diagnosing myocardial inflammation, recognizing various imaging findings associated with different underlying causes, and informing clinical management. The standardization of CMR protocols, along with advancements in imaging techniques and strengthened interdisciplinary collaboration, represents a fundamental step toward improving diagnostic accuracy, patient outcomes, and the understanding of the broad spectrum of myocardial inflammatory diseases.

Feasibility of fractal dimension analysis for left ventricular trabecular complexity using cardiac computed tomography

AIMS

To evaluate the consistency between fractal dimensions (FD) derived from cardiac computed tomography (CT-FD) and cardiac magnetic resonance (MR-FD) in assessing left ventricular trabecular complexity.

METHODS

This retrospective study included 170 patients who underwent CCT and CMR scans within two weeks. Five short-axis cine images were selected at end-diastole: one basal, three mid, and one apical slice. Short-axis CCT views were reconstructed and aligned with the cine images. CT-FD and MR-FD values were calculated for each slice, with mean values determined for each patient. Severe left ventricular hypertrophy (LVH) was defined as a maximum wall thickness > 15 mm in end-diastolic cine images.

RESULTS

The diastolic CT-FD and MR-FD values exhibited high consistency, with values of 1.253 ± 0.091 and 1.250 ± 0.102, respectively (n = 535, ICC = 0.882, 95 % CI: 0.861-0.899, P < 0.001). Similarly, the systolic CT-FD and MR-FD values demonstrated good consistency, with values of 1.268 ± 0.072 and 1.286 ± 0.093, respectively (n = 390, ICC = 0.720, 95 % CI: 0.669-0.765, P < 0.001). For subgroups of systolic NLVH and LVH, the ICCs were 0.773 (n = 305, CI: 0.723-0.814, P < 0.001) and 0.565 (n = 85, 95 % CI: 0.402-0.694, P < 0.001), respectively. The diagnostic efficacy of mean CT-FD aligned with that of mean MR-FD in distinguishing abnormal cardiac conditions from the CMR-negative group.

CONCLUSIONS

CCT is a feasible method for assessing left ventricular trabecular complexity, with good agreement with CMR, except in cases of severe left ventricular hypertrophy during systole.

Global, regional, and national burden of myocarditis in children aged 0-14 years, 1990-2021: analysis for the global burden of disease study 2021

Objective

There are limited epidemiological data on myocarditis in children aged 0-14 years. This study aims to investigate the trends in incidence, mortality, disability-adjusted life years (DALYs), and corresponding estimated annual percentage change (EAPC) of myocarditis in children aged 0-14 years from 1990 to 2021.

Methods

We utilized the 2021 Global Burden of Disease, Injuries, and Risk Factors Study (GBD) analytical tools to examine the incidence, mortality, and DALYs of myocarditis in children aged 0-14 years, considering factors such as age, sex, region, sociodemographic index (SDI), and data from 204 countries or regions.

Results

In 2021, a total of 155.45/1000 people cases of myocarditis were reported globally in children. The cases of myocarditis in children increased from 143.80/1000 people (95% uncertainty interval [UI], 93.13-214.67) in 1990 to 155.45/1000 people (95% UI, 100.31-232.31) in 2021, increasing by 8.1% (95% UI, 6.04-9.73%). Over 30 years, the global incidence rate decreased from 8.27 (95% UI, 5.35-12.34) to 7.73 (95% UI, 4.99-11.55) per 100,000 population. The myocarditis-associated mortality rate decreased from 0.36 (95% UI, 0.25-0.51) to 0.13 (95% UI, 0.10-0.16) per 100,000 population. In 2021, the highest incidence of myocarditis in children occurred in High SDI regions. Regionally, High-income Asia Pacific had the greatest increase in incidence (EAPC, 0.25; 95% CI, 0.22-0.28). Japan had the highest incidence rate of myocarditis in children, while Haiti reported the highest myocarditis-associated mortality rate and DALYs rate. Globally, environmental/occupational risk, nonoptimal temperature, high temperature, and low temperature were key risk factors for myocarditis-associated mortality in children.

Conclusion

Between 1990 and 2021, myocarditis in children saw declining mortality and DALYs but rising incidence, especially in males. Children under 1 year face higher mortality and DALY rates despite lower incidence, stressing early diagnosis. High SDI regions report higher incidence but lower mortality, while low SDI areas need standardized treatment. Japan had the highest 2021 incidence, and China had the most deaths. Underscoring the urgency for enhanced medical resources, comprehensive research into the disease's etiology, and improved prevention strategies.

Long-term prognostic performance of cardiac magnetic resonance imaging markers versus complicated clinical presentation after an acute myocarditis

BACKGROUND

Identifying markers associated with adverse events after acute myocarditis (AM) is relevant to plan follow-up. We assessed the prognostic performance of previously described cardiac magnetic resonance imaging (CMRI) markers and their combination: septal late gadolinium enhancement (LGE) localization and left ventricular ejection fraction (LVEF) < 50 % on baseline CMRI versus complicated clinical presentation (CCP: the presence of sustained ventricular tachycardia, or LVEF<50 % on the first echocardiogram or fulminant presentation).

METHODS

We retrospectively assessed 248 AM patients (median age of 34 years, 87.1 % male) from 6 hospitals with onset of cardiac symptoms<30 days, increased troponin, and CMRI/histology consistent with myocarditis to identify those at risk of major cardiac events (cardiac death, heart transplantation, aborted sudden cardiac death, sustained ventricular tachycardia, or heart failure hospitalization).

RESULTS

Thirteen patients (5.2 %) experienced at least one major cardiac event after a median follow-up of 4.7 years with a significant hazard ratio of 35.8 for CCP vs. 9.2 for septal LGE vs. 12.4 for LVEF<50 % on baseline CMRI (p = 0.001). CCP had the best c-index to identify patients with events: 0.836 vs. 0.786 for septal LGE and 0.762 for LVEF<50 %, while the combination of CCP plus LVEF<50 % or septal LGE has the highest c-index of 0.866. All 3 markers had high negative predictive value (NPV) of ≥0.98.

CONCLUSIONS

Major cardiac events after an AM are relatively low, and CCP, septal LGE, and LVEF<50 % are significantly associated with events. These markers have especially high NPV to identify patients without events after an AM. These observations can help clinicians to monitor the patients after an AM.

Identification of patients with unstable angina based on coronary CT angiography: the application of pericoronary adipose tissue radiomics

Objective

To explore whether radiomics analysis of pericoronary adipose tissue (PCAT) captured by coronary computed tomography angiography (CCTA) could discriminate unstable angina (UA) from stable angina (SA).

Methods

In this single-center retrospective case-control study, coronary CT images and clinical data from 240 angina patients were collected and analyzed. Patients with unstable angina (n = 120) were well-matched with those having stable angina (n = 120). All patients were randomly divided into training (70%) and testing (30%) datasets. Automatic segmentation was performed on the pericoronary adipose tissue surrounding the proximal segments of the left anterior descending artery (LAD), left circumflex coronary artery (LCX), and right coronary artery (RCA). Corresponding radiomic features were extracted and selected, and the fat attenuation index (FAI) for these three vessels was quantified. Machine learning techniques were employed to construct the FAI and radiomic models. Multivariate logistic regression analysis was used to identify the most relevant clinical features, which were then combined with radiomic features to create clinical and integrated models. The performance of different models was compared in terms of area under the curve (AUC), calibration, clinical utility, and sensitivity.

Results

In both training and validation cohorts, the integrated model (AUC = 0.87, 0.74) demonstrated superior discriminatory ability compared to the FAI model (AUC = 0.68, 0.51), clinical feature model (AUC = 0.84, 0.67), and radiomic model (AUC = 0.85, 0.73). The nomogram derived from the combined radiomic and clinical features exhibited excellent performance in diagnosing and predicting unstable angina. Calibration curves showed good fit for all four machine learning models. Decision curve analysis indicated that the integrated model provided better clinical benefit than the other three models.

Conclusions

CCTA-based radiomics signature of PCAT is better than the FAI model in identifying unstable angina and stable angina. The integrated model constructed by combining radiomics and clinical features could further improve the diagnosis and differentiation ability of unstable angina.

Coexistent pleural effusion is found to be associated with aggravated subclinical myocardial injury in systemic lupus erythematous using cardiovascular magnetic resonance imaging

Objective

Pleural effusion (PE) is a common pulmonary manifestation in patients with systemic lupus erythematosus (SLE), and is associated with disease activity. However, little is known regarding the additive effects of PE on cardiac function. Therefore, this study aimed to investigate multi-parameter cardiovascular magnetic resonance imaging (CMR) findings in SLE patients with PE and to explore whether cardiac involvement is associated with PE.

Methods

Patients with SLE and age-matched/sex-matched healthy controls were included in this study. Patients with SLE were diagnosed according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria. Moreover, the PE diagnosis was based on computed tomography, and the height of the effusion was > 5 mm. All enrolled individuals underwent CMR imaging, including cine and late gadolinium enhancement (LGE), T1, and T2 mapping imaging. The left and right ventricular function, LGE, T1, extracellular volume (ECV), and T2 values were evaluated.

Results

A total of 111 patients with SLE were enrolled, of whom 26 (23.42%) had PE. White cell count, hemoglobin, CRP, ESR, and lactate dehydrogenase levels were higher in SLE patients with PE than in SLE patients without PE (P<0.05). LGE was more prevalent in SLE patients with PE compared with those without PE (P<0.001). In addition, Native T1 (1348 ± 65 ms vs. 1284 ± 67 ms vs. 1261 ± 41 ms; P<0.001), ECV (31.92 ± 4.16% vs. 28.61 ± 3.60% vs. 26.54 ± 2.94%; P<0.001), and T2 (44.76 ± 3.68 ms vs. 41.96 ± 3.62 ms vs. 39.21 ± 2.85 ms; P<0.001) values were high in SLE patients with PE, intermediate in SLE patients without PE, and the lowest in the control group. Linear regression analysis demonstrated that PE was independently associated with LGE (β=0.329; P<0.05), T1 (β=0.346; P<0.05), ECV (β=0.353; P<0.05), and T2 (β=0.201; P<0.05).

Conclusions

SLE patients with PE have a higher prevalence of LGE and more diffuse myocardial fibrosis and edema than SLE patients without PE. Moreover, PE is associated with increased diffuse interstitial fibrosis and edema.

A real-life clinical application of cardiac magnetic resonance imaging in patients with acute myocarditis - one-center observational retrospective study

BACKGROUND

The diagnosis of acute myocarditis is complex, with cardiac magnetic resonance (CMR) being a recommended diagnostic method. This study aimed to evaluate the real-life use of CMR in the diagnosis of acute myocarditis and to correlate CMR results with the degree of myocardial damage.

METHODS

This is a retrospective, observational tertiary single-center study of 90 consecutive patients (F/M:18/72, mean age:39 ± 14 years) hospitalized between 2015-2022 with a clinical diagnosis of acute myocarditis. The study population was divided into two groups: patients who underwent CMR+ and those who did not undergo CMR - In the CMR+ group, various sequences, including T1/T2-weighted imaging, late gadolinium enhancement (LGE), and mapping techniques, were used to assess myocardial inflammation and damage.

RESULTS

CMR was performed in 39 patients (43.3%, F/M:10/29, mean age:41 ± 16 years). In this group, myocardial edema (increased T2 signal intensity) was detected in 29 patients, and LGE (signal intensity 2 standard deviations cabove normal on T1 images) was found in 39 patients. Diagnosis based on Lake Louise Criteria was possible in 29 cases. Edema negatively correlated with TnT levels (r = -0.412, p < 0.05) and positively with the number of LGE segments (r = 0.372, p < 0.05). Significant correlations were found between LVEF and LGE mass (r = -0.360, p < 0.05), and maximal TnT levels (r = -0.38, p < 0.05). CMR+ patients had lower myocardial damage markers and CRP concentrations compared to CMR- patients.

CONCLUSIONS

CMR is underused in diagnosing acute myocarditis. Myocardial damage markers correlate with CMR-detected edema and volumetric measures, but not LGE extent. More research is needed to enhance risk assessment and treatment.

Comparative analysis of late gadolinium enhancement assessment techniques for monitoring fibrotic changes in myocarditis follow-up

OBJECTIVES

To compare the repeatability and interrelation of various late gadolinium enhancement (LGE) assessment techniques for monitoring fibrotic changes in myocarditis follow-up.

MATERIALS AND METHODS

LGE extent change between baseline and 3-month cardiovascular magnetic resonance (CMR) was compared in patients with acute myocarditis using the full width at half maximum (FWHM), gray-scale thresholds at 5 and 6 standard deviations (SD5 and SD6), visual assessment with threshold (VAT) and full manual (FM) techniques. In addition, visual presence score (VPS), visual transmurality score (VTS), and a simplified visual change score (VCS) were assessed. Intraclass-correlation (ICC) was used to evaluate repeatability, and methods were compared using Spearman's correlation.

RESULTS

Forty-seven patients (38 male, median age: 27 [IQR: 21; 38] years) were included. LGE extent change differed among quantitative techniques (p < 0.01), with variability in the proportion of patients showing LGE change during follow-up (FWHM: 62%, SD5: 74%, SD6: 66%, VAT: 43%, FM: 60%, VPS: 53%, VTS: 77%, VCS: 89%). Repeatability was highest with FWHM (ICC: 0.97) and lowest with SD5 (ICC: 0.89). Semiquantitative scoring had slightly lower values (VPS ICC: 0.81; VTS ICC: 0.71). VCS repeatability was excellent (ICC: 0.93). VPS and VTS correlated with quantitative techniques, while VCS was positively associated with VPS, VTS, VAT, and FM, but not with FWHM, SD5, and SD6.

CONCLUSION

FWHM offers the least observer-dependent LGE follow-up after myocarditis. VPS, VTS, and VCS are practical alternatives, showing reliable correlations with quantitative methods. Classification of patients exhibiting either stable or changing LGE relies on the assessment technique.

CLINICAL RELEVANCE STATEMENT

This study shows that LGE monitoring in myocarditis is technique-dependent; the FWHM method yields the most consistent fibrotic tracking results, with scoring-based techniques as reliable alternatives.

KEY POINTS

Recognition of fibrotic changes during myocarditis follow-up is significantly influenced by the choice of the quantification technique employed. The FWHM technique ensures highly repeatable tracking of myocarditis-related LGE changes. Segment-based visual scoring and the simplified visual change score offer practical, reproducible alternatives in resource-limited settings.

The global, regional, and national burden of myocarditis in 204 countries and territories, 1990-2021: Results from the Global Burden of Disease Study 2021

AIMS

To estimate the global burden of myocarditis in the general population from 1990 to 2021.

METHODS AND RESULTS

Data on myocarditis were retrieved from the Global Burden of Disease Study 2021. Incidence, deaths, and disability-adjusted life years (DALYs), along with their age-standardized rates (ASRs) per 100 000 population, were used to measure the burden of myocarditis. Global, regional, and national analyses were performed for the period between 1990 and 2021. Further sub-analyses were conducted based on age group, sex, and sociodemographic index (SDI). In 2021, there were 1.3 million (95% uncertainty interval [UI]: 1.1 to 1.6) incident cases, 31.7 thousand (95% UI: 25.5 to 37.1) deaths, and 96.3 thousand (95% UI: 79.6 to 114.8) DALY cases globally. The ASRs of incidence, death, and DALYs significantly decreased from 1990 to 2021, with percentage changes of -3.9% (95% UI: -4.7% to -2.9%), -28.2% (95% UI: -42.2% to -12.5%), and -37.8% (95% UI: -50.5% to -24.3%), respectively. The global burden of myocarditis was higher in males, children, and the elderly. Additionally, the burden of myocarditis varied widely across different SDI regions, with high SDI regions having the highest ASR of incidence, and high-middle SDI regions having the highest ASRs of deaths and DALYs.

CONCLUSION

Although the ASRs of incidence, deaths, and DALYs significantly decreased from 1990 to 2021, the global number of incidences, deaths, and DALYs increased substantially. Certain populations, including males, children, the elderly, and regions with advanced sociodemographic levels, experienced a heavier burden of myocarditis.

Prognostic Implications of Clinical and Imaging Diagnostic Criteria for Myocarditis

BACKGROUND

The European Society of Cardiology (ESC), the American College of Cardiology, the American Heart Association, and expert consensus documents provide different diagnostic criteria for myocarditis. Their overlap and prognostic value have never been compared.

OBJECTIVES

This study aims to assess and compare the predictive value of ESC criteria for clinically suspected myocarditis, updated Lake-Louise criteria (LLC), American Heart Association criteria for probable acute myocarditis (pAM), and expert consensus criteria for acute myocarditis (AM) and complicated myocarditis (CM).

METHODS

Patients with a clinical suspicion of myocarditis referred for cardiac magnetic resonance were enrolled at 2 centers. Those with any prior cardiomyopathy were excluded. The association of composite outcome events (heart failure hospitalization, recurrent myocarditis, sustained ventricular tachycardia, or death) with ESC diagnostic criteria, LLC, pAM, AM, and CM were compared.

RESULTS

Among 1,557 consecutive patients referred for cardiac magnetic resonance with possible myocarditis, 1,050 (62.6% male; 48.9 ± 16.8 years of age) were without an alternative diagnosis. Of those, 938 (89.3%) met ESC criteria for clinically suspected myocarditis, 299 (28.5%) LLC, and 356 (33.9%), 216 (20.6%), and 77 (7.3%) pAM, AM, and CM, respectively. Adverse events occurred in 161 patients (15.3%) during a median follow-up of 3.4 years. The highest annualized event rates (6.6%) were observed in patients meeting LLC, whereas negative ESC criteria indicated excellent prognosis (0.7% annualized event rate). Among all myocarditis definitions, ESC criteria and LLC were the strongest multivariable outcome predictors and had independent and incremental prognostic value (HRadjusted: 3.87; 95% CI: 1.22-12.2; P = 0.021, and HRadjusted: 2.53; 95% CI: 1.83-3.49; P < 0.001, respectively) when adjusted for clinical characteristics.

CONCLUSIONS

In a real-world cohort of patients with possible myocarditis, diagnosis was reached in most patients using ESC criteria whereas only approximately one-quarter of patients reached a diagnosis with LLC. The independent prognostic value of ESC-criteria and LLC highlights the complementary role of clinical and CMR-based findings in the diagnosis and risk stratification of myocarditis.

Multiparametric Cardiac Magnetic Resonance Imaging to Discriminate Endomyocardial Biopsy-Proven Chronic Myocarditis From Healed Myocarditis

BACKGROUND

Detecting ongoing inflammation in myocarditis patients has prognostic relevance, but there are limited data on the detection of chronic myocarditis and its differentiation from healed myocarditis.

OBJECTIVES

This study sought to assess the performance of cardiac magnetic resonance (CMR) for the detection of ongoing inflammation and the discrimination of chronic myocarditis from healed myocarditis.

METHODS

Consecutive patients with persistent symptoms (>30 days) suggestive of myocarditis were prospectively enrolled from a single tertiary center. All patients underwent a multiparametric 1.5-T CMR protocol including biventricular strain, T1/T2 mapping, and late gadolinium enhancement (LGE). Endomyocardial biopsy was chosen for the reference standard diagnosis.

RESULTS

Among 452 consecutive patients, 103 (median age: 50 years; 66 men) had evaluable CMR and cardiopathologic reference diagnosis: 53 (51%) with chronic lymphocytic myocarditis and 50 (49%) with healed myocarditis. T2 mapping as a single parameter showed the best accuracy in detecting chronic myocarditis, if abnormal in ≥3 segments (92%; 95% CI: 85-97), and provided the best discrimination from healed myocarditis, as defined by the area under the receiver-operating characteristic curve (0.87 [95% CI: 0.79-0.93]; P < 0.001), followed by radial peak systolic strain rate of the left ventricle (0.86) and the right ventricle (0.84); T1 mapping (0.64), extracellular volume fraction (0.62), and LGE (0.57). Specificity increased when T2 mapping was combined with elevation of either troponin or C-reactive protein.

CONCLUSIONS

A multiparametric CMR protocol allows detection of ongoing myocardial inflammation and discrimination of chronic myocarditis from healed myocarditis, with segmental T2 mapping and biventricular strain analysis showing higher diagnostic accuracy compared with T1 mapping, extracellular volume fraction, and LGE. The use of biomarkers (troponin or C-reactive protein) may improve specificity.

Prognosis of myocarditis stratified by initial clinical presentation: Does "intermediate" risk still play a role?

Background/aims

Myocarditis is an inflammatory disease with diverse clinical presentations. It is known that low-risk patients have a good prognosis compared to high-risk patients. There are few data regarding the prognosis of intermediate-risk patients. This study aimed to analyze the long-term outcomes of patients with acute myocarditis with different risk profiles at presentation, focusing on the intermediate risk one.

Methods

A retrospective multicenter study was conducted, enrolling patients who met the diagnostic criteria for clinically suspected myocarditis with acute presentation. Patients were stratified into high, intermediate and low risk, according to the classification proposed by Sinagra and his team. Cardiovascular adverse events (AEs) were assessed after a median follow-up of 19 months. Echocardiographic and cardiac magnetic resonance (CMR) parameters predictive of adverse events have been reported.

Results

We enrolled 127 patients (mean age 30 ± 13 years; 103 men, 24 women). High-risk patients had a higher frequency of adverse events (80 %) compared to other groups (16 %-16 %, p < 0.0001). An association was observed between the number of segments with late gadolinium enhancement (LGE) at baseline CMR and the occurrence of adverse events (p < 0.0037). The sum of segments with LGE was statistically correlated with lower left ventricular GLS (p < 0.009). The number of segments with LGE that most accurately identified the occurrence of adverse events was 2.5 [AUC 0.5; p = 0.24].

Conclusions

Our study confirms the higher incidence of AE in the high group; the prognosis of patients at intermediate risk is not very different from those at low risk. It can be hypothesized that the extent of LGE at baseline is the main predictor of adverse events in patients at intermediate risk.

Risk Stratification in Nonischemic Dilated Cardiomyopathy Using CMR Imaging: A Systematic Review and Meta-Analysis

Importance

Accurate risk stratification of nonischemic dilated cardiomyopathy (NIDCM) remains challenging.

Objective

To evaluate the association of cardiac magnetic resonance (CMR) imaging-derived measurements with clinical outcomes in NIDCM.

Data Sources

MEDLINE, Embase, Cochrane Library, and Web of Science Core Collection databases were systematically searched for articles from January 2005 to April 2023.

Study Selection

Prospective and retrospective nonrandomized diagnostic studies reporting on the association between CMR imaging-derived measurements and adverse clinical outcomes in NIDCM were deemed eligible.

Data Extraction and Synthesis

Prespecified items related to patient population, CMR imaging measurements, and clinical outcomes were extracted at the study level by 2 independent reviewers. Random-effects models were fitted using restricted maximum likelihood estimation and the method of Hartung, Knapp, Sidik, and Jonkman.

Main Outcomes and Measures

All-cause mortality, cardiovascular mortality, arrhythmic events, heart failure events, and major adverse cardiac events (MACE).

Results

A total of 103 studies including 29 687 patients with NIDCM were analyzed. Late gadolinium enhancement (LGE) presence and extent (per 1%) were associated with higher all-cause mortality (hazard ratio [HR], 1.81 [95% CI, 1.60-2.04]; P < .001 and HR, 1.07 [95% CI, 1.02-1.12]; P = .02, respectively), cardiovascular mortality (HR, 2.43 [95% CI, 2.13-2.78]; P < .001 and HR, 1.15 [95% CI, 1.07-1.24]; P = .01), arrhythmic events (HR, 2.69 [95% CI, 2.20-3.30]; P < .001 and HR, 1.07 [95% CI, 1.03-1.12]; P = .004) and heart failure events (HR, 1.98 [95% CI, 1.73-2.27]; P < .001 and HR, 1.06 [95% CI, 1.01-1.10]; P = .02). Left ventricular ejection fraction (LVEF) (per 1%) was not associated with all-cause mortality (HR, 0.99 [95% CI, 0.97-1.02]; P = .47), cardiovascular mortality (HR, 0.97 [95% CI, 0.94-1.00]; P = .05), or arrhythmic outcomes (HR, 0.99 [95% CI, 0.97-1.01]; P = .34). Lower risks for heart failure events (HR, 0.97 [95% CI, 0.95-0.98]; P = .002) and MACE (HR, 0.98 [95% CI, 0.96-0.99]; P < .001) were observed with higher LVEF. Higher native T1 relaxation times (per 10 ms) were associated with arrhythmic events (HR, 1.07 [95% CI, 1.01-1.14]; P = .04) and MACE (HR, 1.06 [95% CI, 1.01-1.11]; P = .03). Global longitudinal strain (GLS) (per 1%) was not associated with heart failure events (HR, 1.06 [95% CI, 0.95-1.18]; P = .15) or MACE (HR, 1.03 [95% CI, 0.94-1.14]; P = .43). Limited data precluded definitive analysis for native T1 relaxation times, GLS, and extracellular volume fraction (ECV) with respect to mortality outcomes.

Conclusion

The presence and extent of LGE were associated with various adverse clinical outcomes, whereas LVEF was not significantly associated with mortality and arrhythmic end points in NIDCM. Risk stratification using native T1 relaxation times, extracellular volume fraction, and global longitudinal strain requires further evaluation.

Imaging for the diagnosis of acute myocarditis: can artificial intelligence improve diagnostic performance?

Myocarditis is a cardiovascular disease characterised by inflammation of the heart muscle which can lead to heart failure. There is heterogeneity in the mode of presentation, underlying aetiologies, and clinical outcome with impact on a wide range of age groups which lead to diagnostic challenges. Cardiovascular magnetic resonance (CMR) is the preferred imaging modality in the diagnostic work-up of those with acute myocarditis. There is a need for systematic analytical approaches to improve diagnosis. Artificial intelligence (AI) and machine learning (ML) are increasingly used in CMR and has been shown to match human diagnostic performance in multiple disease categories. In this review article, we will describe the role of CMR in the diagnosis of acute myocarditis followed by a literature review on the applications of AI and ML to diagnose acute myocarditis. Only a few papers were identified with limitations in cases and control size and a lack of detail regarding cohort characteristics in addition to the absence of relevant cardiovascular disease controls. Furthermore, often CMR datasets did not include contemporary tissue characterisation parameters such as T1 and T2 mapping techniques, which are central to the diagnosis of acute myocarditis. Future work may include the use of explainability tools to enhance our confidence and understanding of the machine learning models with large, better characterised cohorts and clinical context improving the diagnosis of acute myocarditis.

Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis

Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.

Cardiac magnetic resonance imaging (MRI) for detecting acute myocardial injury of fulminant myocarditis survivors after extracorporeal membrane oxygenation (ECMO) treatment in adults

AIMS

To detect the acute myocardial injury in fulminant myocarditis (FM) survivors after extracorporeal membrane oxygenation (ECMO) and to demonstrate its significant differences from non-FM patients by cardiac magnetic resonance (CMR).

MATERIALS AND METHODS

This retrospective study enrolled 59 patients with acute myocarditis (AM), including 35 non-FM patients, 24 FM patients, and 54 controls. The peak value of cardiac troponin T (cTnT) was recorded. Tissue parameters, including native T1, extracellular volume (ECV), late gadolinium-enhancement (LGE)%, and T2 by CMR were assessed.

RESULTS

The mean age was 35 ± 14 years, and 45.8% of the population were males in the AM group. Patients had higher levels of peak cTnT, peak NT-proBNP and peak C-reactive protein in the FM group (all p<0.05). Comparing with non-FM, the values of T1-based imaging parameters were significantly higher in the FM group (all p<0.05). In contrast, no difference was observed among the two groups in terms of T2 value (p=0.707). The septal area was more frequently involved in FM survivors after ECMO treatment, both in T1 and T2-based images. In addition, the cubic relationship was the relative best fit of LGE% against logcTnT and indicated that cTnT value exceeding 300ng/L exhibited a rapid upward trend of LGE%.

CONCLUSION

Comparing to non-FM, higher myocardial necrosis and fibrosis but similar edema determined by T1 and T2 based imaging was found in FM survivors after ECMO treatment. Furthermore, the inter-ventricular septal area was more frequently involved by acute myocardial injury in FM survivors after ECMO treatment. In addition, LGE% showed an overall increasing trend with cTnT values elevating with rapidly increasing with cTnT exceeding 300 ng/L.

Multiple recurrences of a left ventricular pseudoaneurysm: a case report

Background

Takotsubo syndrome (TTS) is being diagnosed more often with its increased recognition over the past 2 decades and with the availability of imaging such as point-of-care echocardiography and tissue characterization by cardiovascular magnetic resonance (CMR).

Case summary

A young man developed pericarditis and was treated with steroids. A few weeks later, he suffered classic TTS and then presented a week later with the rare complication of apical myocardial rupture and a left ventricular (LV) pseudoaneurysm. He subsequently sustained two recurrences, likely secondary to the poor tensile strength of the repair in the region of necrotic myocardium.

Discussion

Various features of both syndromes are discussed herein (myopericarditis and TTS) as well as their classic imaging findings with an emphasis on the echocardiographic diagnosis of an LV pseudoaneurysm and differentiating it from an aneurysm. Furthermore, we elucidate the classic imaging findings of CMR in myocarditis, myocardial infarction with non-obstructive coronary arteries, and TTS. Lastly, we discuss treatment options for LV pseudoaneurysms and strategies to prevent recurrence.

Unveiling the Diagnostic Value of Strain Parameters Across All 4 Cardiac Chambers in Patients With Acute Myocarditis With Varied Ejection Fraction: A Cardiovascular Magnetic Resonance Feature-Tracking Approach

BACKGROUND

This study assesses the diagnostic utility of strain parameters from cardiovascular magnetic resonance feature tracking across all cardiac chambers in patients with acute myocarditis, stratified by ejection fraction.

METHODS AND RESULTS

Our cohort included 65 patients with acute myocarditis and 25 healthy controls; all underwent cardiac magnetic resonance imaging. Patients were divided into 2 groups based on left ventricular ejection fraction (EF)with a 55% cutoff: acute myocarditis with preserved EF, EF ≥55%, n=48; and acute myocarditis with reduced EF, EF <55%, n=17. The control group matched for age and sex. Cardiovascular magnetic resonance feature tracking evaluated strain parameters across all cardiac chambers. Both acute myocarditis with preserved EF and acute myocarditis with reduced EF groups showed significant decreases in left atrial peak early negative strain rate compared with controls. The acute myocarditis with reduced EF group had significantly reduced left ventricular circumferential strain relative to acute myocarditis with preserved EF and controls. Receiver operating characteristic curve analysis confirmed the diagnostic accuracy in distinguishing patients with acute myocarditis with preserved EF from controls, with left atrial peak early negative strain rate achieving 92.9% specificity, left ventricular circumferential strain demonstrating an area under the curve of 0.832, and similarly effective results for left ventricular longitudinal strain and right ventricular longitudinal strain. Additionally, left atrial peak early negative strain rate and left ventricular circumferential strain showed significant correlations with troponin I levels, indicating myocardial injury.

CONCLUSIONS

Cardiovascular magnetic resonance feature-tracking-derived strain parameters, particularly left atrial peak early negative strain rate and left ventricular circumferential strain, effectively diagnose acute myocarditis across different EFs, enhancing diagnostic accuracy and facilitating early detection, notably in patients with preserved EF.

European Association of Cardiovascular Imaging survey on cardiovascular multimodality imaging in acute myocarditis

AIMS

To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through a European Association of Cardiovascular Imaging survey.

METHODS AND RESULTS

A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres (56%). All participants had access to echocardiography, while 79 and 75% had access to cardiac computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half (47%) had access to myocardial biopsy, and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischaemic late gadolinium enhancement (LGE, 88%) and high-signal intensity in T2-weighted images (74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and angiotensin-converting enzyme inhibitors was reported by 38 and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction (89%), followed by LGE regression (60%). In two-thirds of participants, the decision to resume high-intensity sport was influenced by residual LGE.

CONCLUSION

This survey confirms the high utilization of cardiac imaging in AM but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

Improving the efficiency and accuracy of cardiovascular magnetic resonance with artificial intelligence-review of evidence and proposition of a roadmap to clinical translation

BACKGROUND

Cardiovascular magnetic resonance (CMR) is an important imaging modality for the assessment of heart disease; however, limitations of CMR include long exam times and high complexity compared to other cardiac imaging modalities. Recently advancements in artificial intelligence (AI) technology have shown great potential to address many CMR limitations. While the developments are remarkable, translation of AI-based methods into real-world CMR clinical practice remains at a nascent stage and much work lies ahead to realize the full potential of AI for CMR.

METHODS

Herein we review recent cutting-edge and representative examples demonstrating how AI can advance CMR in areas such as exam planning, accelerated image reconstruction, post-processing, quality control, classification and diagnosis.

RESULTS

These advances can be applied to speed up and simplify essentially every application including cine, strain, late gadolinium enhancement, parametric mapping, 3D whole heart, flow, perfusion and others. AI is a unique technology based on training models using data. Beyond reviewing the literature, this paper discusses important AI-specific issues in the context of CMR, including (1) properties and characteristics of datasets for training and validation, (2) previously published guidelines for reporting CMR AI research, (3) considerations around clinical deployment, (4) responsibilities of clinicians and the need for multi-disciplinary teams in the development and deployment of AI in CMR, (5) industry considerations, and (6) regulatory perspectives.

CONCLUSIONS

Understanding and consideration of all these factors will contribute to the effective and ethical deployment of AI to improve clinical CMR.

Cardiovascular involvement in children with COVID-19 temporally related multisystem inflammatory syndrome (MIS-C): can cardiac magnetic resonance arrive to the heart of the problem?

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) shows a significant overlap of symptoms with other hyper-inflammatory diseases such as Kawasaki disease (KD), but the real difference of the two conditions is still matter of debate. Coronary artery lesions (CAL) are the most relevant complication in KD. Nonetheless, CAL, myocarditis, pericarditis, arrhythmia are the main cardiovascular complications in MIS-C. A close clinical assessment is mandatory, both at the diagnosis and during the follow-up, by ECG and echocardiography. Cardiac magnetic resonance (MRI) adds important data to ultrasound findings. However, cardiac MRI studies in MIS-C are limited to a small number of cohorts.

METHODS

We enrolled 20 children (age:1-16 years; 11 F; 9 M) with cardiac involvement secondary to MIS-C, all evaluated by cardiac MRI.

RESULTS

8 children showed pathological cardiac MRI: 2 showed pericardial effusion; 2 showed myocardial oedema; 1 showed aortic insufficiency; 3 showed delayed enhancement (one for acute myocarditis with oedema; 2 for myocardial fibrosis). Delayed enhancement was reduced significantly 5.6-9 months after the first MRI evaluation. 25% of patients with pathological MRI had CAL associated with valvular insufficiency of 2 valves. 17% of patients with normal MRI had CAL, associated with valvular insufficiency of 1 valve in 1 patient. The correlations between haematological, clinical, cardiologic parameters, treatment, did not reach the statistical significance. 4 patients were treated with anakinra. Among those, 2 patients showed a normal cardiac MRI. Cardiac lesions resolved in all the patients during the follow-up. Some patients with pathological cardiac MRI could not underwent a control with MRI, for the low compliance. However, echocardiography and ECG, documented the resolution of the pathological data in these cases.

CONCLUSIONS

A higher risk of CAL was documented in patients with an association of other cardiac lesions. Cardiac MRI is difficult to perform routinely; however, it is useful for evaluating the acute myocardial damage and the outcome of patients with MIS-C.

Myocarditis: A Rare Complication of Immune Checkpoint Inhibitor Therapy

Immune checkpoint inhibitors (ICIs) are a class of immunotherapy agents that are often used in cancer treatment. A rare but life-threatening complication that can be seen is ICI-induced myocarditis. We discuss a case of pembrolizumab-induced myocarditis and the nuances involved in timely diagnosis and treatment. A 64-year-old female with a past medical history significant for metastatic right-sided colorectal adenocarcinoma undergoing immunotherapy with pembrolizumab presented with worsening shortness of breath and was found to be hypoxic. Initial laboratory analysis was remarkable for troponin of 0.35 ng/mL, which later peaked at 6.01 ng/mL. The electrocardiogram showed non-specific ST segment changes in the anteroseptal leads, and a subsequent echocardiogram revealed severely reduced left ventricular systolic function with an ejection fraction of 25%. Coronary angiography showed non-obstructive coronary arteries. As the patient was on pembrolizumab immunotherapy for cancer, there was high suspicion of ICI-induced myocarditis, and the patient was started empirically on steroids. Subsequently, cardiac magnetic resonance imaging was done, which confirmed the diagnosis of myocarditis. Pembrolizumab therapy was discontinued, and she was started on guideline-directed medical therapy for heart failure. While ICIs have transformed cancer therapy, healthcare providers must be vigilant for immune-related adverse events such as myocarditis. Early recognition, prompt management, and close monitoring are crucial for optimizing patient outcomes.

Precision Cardio-oncology: Update on Omics-Based Diagnostic Methods

OPINION STATEMENT

Cardio-oncology is an emerging interdisciplinary field dedicated to the early detection and treatment of adverse cardiovascular events associated with anticancer treatment, and current clinical management of anticancer-treatment-related cardiovascular toxicity (CTR-CVT) remains limited by a lack of detailed phenotypic data. However, the promise of diagnosing CTR-CVT using deep phenotyping has emerged with the development of precision medicine, particularly the use of omics-based methodologies to discover sensitive biomarkers of the disease. In the future, combining information produced by a variety of omics methodologies could expand the clinical practice of cardio-oncology. In this review, we demonstrate how omics approaches can improve our comprehension of CTR-CVT deep phenotyping, discuss the positive and negative aspects of available omics approaches for CTR-CVT diagnosis, and outline how to integrate multiple sets of omics data into individualized monitoring and treatment. This will offer a reliable technical route for lowering cardiovascular morbidity and mortality in cancer patients and survivors.

Cardiovascular Magnetic Resonance Imaging in Myocardial Disease

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

Quantitative Assessment of Myocardial Edema by MR T2 Mapping in Children With Kawasaki Disease

BACKGROUND

Few studies assessed myocardial inflammation using Cardiovascular Magnetic Resonance Imaging in Kawasaki disease (KD) patients.

PURPOSE

To quantify myocardial edema in KD patients using T2 mapping and explore the independent predictors of T2 values.

STUDY TYPE

Prospective.

SUBJECTS

Ninety KD patients including 40 in acute phase (26 males, 65.0%) and 50 in chronic phase (34 males, 68.0%). Thirty-one healthy volunteers (21 males, 70.0%).

FIELD STRENGTH/SEQUENCE

3.0 T T2-weighted Turbo Spin Echo-Short Time of Inversion Recovery sequence, True fast imaging with steady precession flash sequence and fast low-angle shot 3D spoiled gradient echo sequence.

ASSESSMENT

T2 values were compared among KD groups and controls.

STATISTICAL TEST

Student's t test and Fisher's exact test; One-way analysis of variance; Pearson correlation analysis; Receiver operating curve analysis; Multivariable linear regression.

RESULTS

Global T2 value of KD patients in acute phase was the highest, followed by those of chronic-phase patients and controls (38.83 ± 2.41 msec vs. 37.55 ± 2.28 msec vs. 36.05 ± 1.64 msec). Regional T2 values showed a same trend. There were no significant differences in global and regional T2 values between KD patients with and without coronary artery (CA) dilation, no matter in acute or chronic phase (all KD patients: P = 0.51, 0.51, 0.53, 0.72; acute KD: P = 0.61, 0.37, 0.33, 0.83; chronic KD: P = 0.65, 0.79, 0.62, 0.79). No significant difference was observed in global T2 values between KD patients with Z score > 5.0 and 2.0 < Z score ≤ 5.0 (P = 0.65). Multivariate analysis demonstrated that stage of disease (β = -0.123) and heart rate (β = 0.280) were independently associated with global T2 values.

DATA CONCLUSION

The degree of myocardial edema was more severe in acute-phase than in chronic-phase KD patients. Myocardial edema persists in patients regardless of the existence or degree of CA dilation.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Reference Ranges of Ventricular Morphology and Function in Healthy Chinese Adults: A Multicenter 3 T MRI Study

BACKGROUND

Magnetic resonance imaging (MRI) reference ranges for ventricular morphology and function in the Chinese population are lacking.

PURPOSE

To establish the MRI reference ranges of left and right ventricular (LV and RV) morphology and function based on a large multicenter cohort.

STUDY TYPE

Prospective.

POPULATION

One thousand and twelve healthy Chinese Han adults.

FIELD STRENGTH/SEQUENCE

Balanced steady-state free procession cine sequence at 3.0 T.

ASSESSMENT

Biventricular end-diastolic, end-systolic, stroke volume, and ejection fraction (EDV, ESV, SV, and EF), LV mass (LVM), end-diastolic and end-systolic dimension (LVEDD and LVESD), anteroseptal wall thickness (AS), and posterolateral wall thickness (PL) were measured. Body surface area (BSA) and height were used to index biventricular parameters. Parameters were compared between age groups and sex.

STATISTICAL TESTS

Independent-samples t-tests or Mann-Whitney U test to compare mean values between sexes; ANOVA or Kruskal-Wallis test to compare mean values among age groups; linear regression to assess the relationships between cardiac parameters and age (correlation coefficient, r). A P value <0.05 was considered statistically significant.

RESULTS

The biventricular volumes, LVM, LVEDD, RVEDV/LVEDV ratio, LVESD, AS, and PL were significantly greater in males than in females, even after indexing to BSA or height, while LVEF and RVEF were significantly lower in males than in females. For both sexes, age was significantly negatively correlated with biventricular volumes (male and female: LVEDV [r = -0.491; r = -0.373], LVESV [r = -0.194; r = -0.184], RVEDV [r = -0.639; r = -0.506], RVESV [r = -0.270; r = -0.223]), with similar correlations after BSA normalization. LVEF (r = 0.043) and RVEF (r = 0.033) showed a significant correlation with age in females, but not in males (P = 0.889; P = 0.282).

DATA CONCLUSION

MRI reference ranges for biventricular morphology and function in Chinese adults are presented and show significant associations with age and sex.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

Post-acute midterm follow-up cardiac MRI findings and clinical outcomes in patients with COVID-19 vaccine-associated myocarditis: a comprehensive systematic review and meta-analysis

PURPOSE

Although previous investigations revealed favourable in-hospital outcomes of COVID-19 vaccine-related myocarditis, the mid-term prognosis is still unclear. Hence, we aim to summarise existing evidence on the follow-up imaging and clinical findings in patients with COVID-19 vaccine-related myocarditis.

METHODS

We performed a systematic search in online databases using relevant key terms covering COVID-19 vaccine, myocarditis, follow-up, and cardiac MRI. We included all observational studies that reported cardiac MRI findings of patients with myocarditis following COVID-19 vaccination in both acute and follow-up phases. Data on clinical outcomes and cardiac MRI findings were extracted and pooled using a random-effect model.

RESULTS

A total of 27 studies (126 patients) met our eligibility criteria. At the time of follow-up, myocarditis symptoms were resolved in all patients, but abnormal electrocardiography and elevated troponin levels were detected in 18.7% and 3.8% of them, respectively. Median imaging follow-up times varied from 3 to 6.3 months. On follow-up cardiac MRI, the persistence of LGE was observed in 76% (95%CI: 62 to 85%), but its extension declined compared to the baseline in almost all patients. Persistent LGE was accompanied by myocardial edoema in six patients, and it was consistent with myocardial fibrosis (LGE without edoema) in the remaining cases. Mean changes (95%CI) of cardiac MRI left ventricular ejection fraction (LVEF) (%) was +2.97 (+1.59 to +4.34) from baseline.

CONCLUSION

In conclusion, although most patients likely experience favourable clinical outcomes without serious complications, cardiac MRI abnormalities, mainly LGE, may persist in a notable proportion of them beyond the acute phase.

CMR Mapping: The 4th-Era Revolution in Cardiac Imaging

Cardiac magnetic resonance (CMR) imaging has witnessed substantial progress with the advent of parametric mapping techniques, most notably T1 and T2 mapping. These advanced techniques provide valuable insights into a wide range of cardiac conditions, including ischemic heart disease, cardiomyopathies, inflammatory cardiomyopathies, heart valve disease, and athlete's heart. Mapping could be the first sign of myocardial injury and oftentimes precedes symptoms, changes in ejection fraction, and irreversible myocardial remodeling. The ability of parametric mapping to offer a quantitative assessment of myocardial tissue properties addresses the limitations of conventional CMR methods, which often rely on qualitative or semiquantitative data. However, challenges persist, especially in terms of standardization and reference value establishment, hindering the wider clinical adoption of parametric mapping. Future developments should prioritize the standardization of techniques to enhance their clinical applicability, ultimately optimizing patient care pathways and outcomes. In this review, we endeavor to provide insights into the potential contributions of CMR mapping techniques in enhancing the diagnostic processes across a range of cardiac conditions.

Role of CCRL2 in the Pathogenesis of Experimental Autoimmune Myocarditis via P21-Activated Kinase 1/NOD-Like Receptor Protein 3 Pathway

Myocarditis, a severe inflammatory disease, is becoming a worldwide public health concern. This study aims to elucidate the effect of Chemokine (C C motif) receptor-like 2 (CCRL2) in experimental autoimmune myocarditis (EAM) occurrence and its potential regulatory mechanisms.EAM was simulated in a mouse model injected with α-myosin-heavy chain. The changes on EAM were assessed through histological staining of heart tissues, including measuring cardiac troponin I (cTnI), proinflammatory cytokines, transferase-mediated dUTP nick end labeling (TUNEL) assay, and cardiac function. Then, the heart tissues from the EAM mouse model and control groups were analyzed through transcriptome sequencing to identify the differential expressed genes (DEGs) and hub genes related to pyroptosis. Downregulation of CCRL2 further verified the function of CCRL2 on EAM and p21-activated kinase 1/NOD-like receptor protein 3 (PAK/NLRP3) signaling pathways in vivo.The EAM model was constructed successfully, with the heart weight/body weight ratio, serum level of cTnI, and concentrations of proinflammatory cytokines elevation. Moreover, cell apoptosis was also significantly increased. Transcriptome sequencing revealed 696 and 120 upregulated and downregulated DEGs, respectively. After functional enrichment, CCRL2 was selected as a potential target. Then, we verified that CCRL2 knockdown improved cardiac function, alleviated EAM occurrence, and reduced PAK/NLRP3 protein expression.CCRL2 may act as a novel potential treatment target in EAM by regulating the PAK1/NLRP3 pathway.

Transcriptional and functional analysis of plasma exosomal microRNAs in acute viral myocarditis

AIM

To assess the differential expression profiles of exosome-derived microRNA (miRNA) and reveal their potential functions in patients with acute viral myocarditis (AVMC).

MATERIALS & METHODS

Peripheral blood samples were collected from 9 patients diagnosed with AVMC and 9 healthy controls (HC) in the Affiliated Hospital of Qingdao University from July 2021 to September 2022. The exosomal miRNA expression were tested using RNA high-throughput sequencing. We conducted the GO and KEGG functional analysis to predict the potential molecular, biological functions and related signaling pathways of miRNAs in exosomes. Target genes of exosomal miRNAs were predicted and miRNA-target gene network was mapped using gene databases. Differentially expressed exosomal miRNAs were selected and their expression levels were detected by quantitative real-time polymerase chain reaction (qRT-PCR) to verify the sequencing results.

RESULTS

P < 0.05 and Fold Change>2 were considered as cut-off value to screen miRNAs that were differently expressed. This study identified 14 upregulated and 14 downregulated exosome-derived miRNAs. GO and KEGG analysis showed that differentially expressed miRNAs may be related to β-catenin binding, DNA transcription activities, ubiquitin ligase, PI3K-Akt, FoxO, P53, MAPK, and etc.. The target genes of differentially expressed miRNAs were predicted using gene databases. Real-time PCR confirmed the upregulation of hsa-miR-548a-3p and downregulation of hsa-miR-500b-5p in AVMC.

CONCLUSIONS

Hsa-miR-548a-3p and hsa-miR-500b-5p could serve as a promising biomarker of AVMC. Exosomal miRNAs may have substantial roles in the mechanisms of AVMC.

Society for Cardiovascular Magnetic Resonance 2022 Cases of SCMR case series

"Cases of SCMR" is a case series on the SCMR website (https://www.scmr.org) for the purpose of education. The cases reflect the clinical presentation, and the use of cardiovascular magnetic resonance (CMR) in the diagnosis and management of cardiovascular disease. The 2022 digital collection of cases are presented in this manuscript.

Cardiac magnetic resonance biomarkers as surrogate endpoints in cardiovascular trials for myocardial diseases

Cardiac magnetic resonance offers multiple facets in the diagnosis, risk stratification, and management of patients with myocardial diseases. Particularly, its feature to precisely monitor disease activity lends itself to quantify response to novel therapeutics. This review critically appraises the value of cardiac magnetic resonance imaging biomarkers as surrogate endpoints for prospective clinical trials. The primary focus is to comprehensively outline the value of established cardiac magnetic resonance parameters in myocardial diseases. These include heart failure, cardiac amyloidosis, iron overload cardiomyopathy, hypertrophic cardiomyopathy, cardio-oncology, and inflammatory cardiomyopathies like myocarditis and sarcoidosis.

Latest Updates in Heart Failure Imaging

Heart failure (HF), a challenging and heterogeneous syndrome, still remains a major health problem worldwide, despite all the advances in prevention, diagnosis, and treatment of cardiovascular disease. Cardiac imaging plays a pivotal role in the classification of HF, accurate diagnosis of underlying etiology and decision-making. Integration of other imaging techniques such as cardiac magnetic resonance, nuclear imaging, and exercise imaging testing is important to characterize HF accurately. This article reviews the role of multimodality imaging to diagnose patients with HF.

COVID myocarditis in a collegiate athlete: Timeline and return to play

Background

Studies in collegiate athletes have demonstrated a prevalence of cardiac involvement between 0.5 and 3 % after SARS-CoV-2 infection. When post-COVID cardiac involvement occurs in athletes, the ideal return to play timeline and many possible long-term sequela or complications are unknown.

Case summary

A 20 yo female collegiate athlete tested positive for SARS-CoV-2 and underwent routine cardiac screening prior to her return to play (RTP). Evaluation demonstrated an elevated high-sensitivity troponin-I and an ECG showed some mild T wave changes. She had a normal transthoracic echocardiogram, and her Cardiac magnetic imaging (CMR) met Lake Louise Criteria for acute myocarditis. She was diagnosed with acute myocarditis and restricted from sports. CMR was repeated at 3.5 months after normalization of troponin I HS and demonstrated continued active inflammation. She continued to be restricted from exertion. A third CMR was obtained at 6.5 months and showed resolution of active inflammation but a small area of fibrosis, and the remainder of her cardiac testing was normal. She was allowed to slowly progress back into sport and returned to competition at 9 months and successfully completed her season.

Discussion

CMR is not typically repeated prior to RTP after a diagnosis of myocarditis in athletes, but in this case, repeat CMR at 3.5 months initially demonstrated continued active inflammation, and a second repeat CMR at 6.5 months demonstrated abnormal cardiac fibrosis. This may suggest utility in repeating CMR and raises questions about possible long-term implications of cardiac fibrosis once the acute inflammation of myocarditis has resolved.