Persistence of Late Gadolinium Enhancement on Follow-Up CMR Imaging in Children with Acute Myocarditis

Abstract Background The natural history of acute myocarditis (AM) remains partially unknown and predictors of outcome are still debated. The study objectives were to determine the potential value of cardiovascular magnetic resonance (CMR) parameters for the long-term Major Adverse Cardiac Events (MACE) prediction in patients presenting with suspected AM. In our centre we published in 2015 a first analysis of the CMR myocarditis registry which included patients presenting with suspected AM in routine practice, clinically followed-up for 18 months (median follow up). This first analysis, in disagreement with the published data, did not find CMR predictors of MACE except for the LVEF. Purpose As in myocarditis MACE could have a gradual evolution, to confirm our initial results, the aim of this study is to reinvestigate in the same population, the potential value of CMR parameters with a longer follow-UP (median 8.34 years, interquartile range: 7.7 to 9.16 years). Methods In a single-centre longitudinal prospective study, 203 routine consecutive patients with clinical suspicion of AM and initial CMR-based diagnosis of AM (typical Late Gadolinium Enhancement, LGE) were clinically followed up. Various CMR parameters were evaluated as potential predictors of outcome. The primary endpoint was defined as the occurrence of at least one of the combined MACE: cardiac death or aborted sudden cardiac death, cardiac transplantation, sustained documented ventricular tachycardia, heart failure, recurrence of acute myocarditis, and the need for hospitalization for cardiac causes. Results The vast majority of patients (70,44%; N=143) presented with chest pain, mild to moderate troponin elevation and ST-segment or T wave abnormalities. Various CMR parameters were evaluated on initial CMR performed 3±2 days after acute clinical presentation (LV functional parameters, presence/extent of edema on T2, presence/extent of Early Gadolinium Enhancement (EGA) and extent of late gadolinium enhancement lesions). Out of the 203 patients, 35 (17.2%) experienced at least one major cardiovascular event during follow-up. Among all CMR parameters, initial alteration of LVEF was confirmed a MACE independent predictor by multivariate analysis (HR: 1.03 per 10% decrease, 95% CI: 1.01 to 1.06, p=0.04). Furthermore, at longer FU analysis, absence of EGA predicted adverse clinical outcome (HR: 2.7, 95% CI: 1.12 to 6.27, p=0.02) suggesting a potential protecting role of inflammatory response. Conclusions In routine clinical practice, in patients without severe hemodynamic compromise and a CMR-based diagnosis of AM, various CMR parameters such as the presence, extent and myocardial localisation of late gadolinium-enhanced LV myocardial lesions, were not predictive of events at long term follow up. CMR predictor of adverse clinical outcome were an initial alteration of LVEF and the absence of EGA.

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Prognostic assessment following acute myocarditis requires convalescent scanning: neither peak troponin nor index scan T2 signal predicts convalescent late gadolinium enhancement

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeab090.058 ◽

2021 ◽

Vol 22 (Supplement_2) ◽

Author(s):

S Zaman ◽

K Vimalesvaran ◽

I Johns ◽

JP Howard ◽

GD Cole

Keyword(s):

Late Gadolinium Enhancement ◽

Acute Myocarditis ◽

T2 Mapping ◽

Late Enhancement ◽

Troponin Level ◽

Gadolinium Enhancement ◽

Troponin Elevation ◽

Scar Burden

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiovascular magnetic resonance (CMR) is a key diagnostic investigation in acute myocarditis (1) and permits quantification of late gadolinium enhancement (LGE) and myocardial oedema. Follow-up CMR imaging is recommended to check for persistence of scar and oedema (2). Persistent late gadolinium enhancement is associated with a worse prognosis (3). It is not known whether all patients require follow-up scanning or whether the initial scan can provide useful information to identify which patients need convalescent assessment. Purpose In this study we considered whether extent of troponin elevation, extent of T2 elevation and initial late gadolinium enhancement burden predicted long-term late gadolinium enhancement at follow-up. Methods Index and follow-up CMR scans of consecutive patients presenting with a diagnosis of acute myocarditis between 2019 and 2020 across three hospitals were included. Inclusion criteria were: follow-up scan within 9 months of the index scan, CMR with LGE imaging and T2 mapping, and acute myocarditis being the primary diagnosis of the index scan. Myocardial T2 values in the area affected by myocarditis and percentage of LV myocardium showing late enhancement (using a threshold-based full height half width or manual region of interest strategy) were extracted. Results 20 patients were included in the study (80% male; mean age 37 years). Mean interval between the index and follow-up scan was 4.1 months. Peak troponin level during the acute illness was not associated with the proportion of LV myocardium affected by LGE in the index scan (R^2 <0.01) (Figure 1A). Myocardial T2 values in the first scan were not associated with the proportional resolution in LGE between the index and follow-up scans (R^2 0.02) (Figure 1B). The mean change in LGE was -61.7% (+/-22.8%) but the initial LGE burden did not predict the proportional degree of improvement in LGE between scans (R^2 <0.01)(Figure 1C). Conclusions The extent of troponin elevation and initial CMR phenotype was not a good predictor of the burden of long-term late gadolinium enhancement. Although most cases showed improvement in LGE scar burden between index and follow-up imaging, neither peak troponin level during the acute episode, nor T2 values at the first CMR scan were predictive of initial or change in scar burden. Serial CMR assessment is required to identify those patients who have residual long-term scarring.

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QRS fragmentation in children with suspected myocarditis: a possible additional diagnostic sign

Cardiology in the Young ◽

10.1017/s1047951120001262 ◽

2020 ◽

Vol 30 (7) ◽

pp. 962-966 ◽

Cited By ~ 1

Author(s):

Paolo Ferrero ◽

Isabelle Piazza

Keyword(s):

Cardiac Magnetic Resonance ◽

Late Gadolinium Enhancement ◽

Magnetic Resonance ◽

Ejection Fraction ◽

Acute Myocarditis ◽

Paediatric Population ◽

Gadolinium Enhancement ◽

Diagnostic Features ◽

Qrs Fragmentation

AbstractAims:We aim to assess the diagnostic role of QRS fragmentation in children with suspected acute myocarditis.Background:Diagnosis of myocarditis in the paediatric population is challenging. Clinical suspicion, electrocardiogram, and laboratory tests are the main diagnostic features at presentation. However, electrocardiogram in patients with myocarditis is usually considered aspecific. We have previously described QRS fragmentation in adult patients with acute myocarditis.Methods:Patients aged less than 18 years, admitted between 2003 and 2019, and discharged with a diagnosis of acute myocarditis were included. Standard electrocardiogram, laboratory, and echocardiographic findings at admission and follow-up were reviewed. QRS fragmentation was defined by the presence of multiphasic R′ spikes. Cardiac magnetic resonance and biopsy were performed in selected patients.Results:Twenty-one patients were analysed, 16 males (76%), median age 9.5 (2.5–16) years. At presentation, 12 patients (57%) displayed QRS fragmentation. Median ejection fraction was 40% (27–60). Nine patients (43%) underwent cardiac magnetic resonance and displayed late gadolinium enhancement. One patient underwent biopsy that showed borderline findings. Electrocardiogram leads showing QRS fragmentation correlated with distribution of late gadolinium enhancement. Median follow-up was 600 (190–2343) days. All patients were alive at last follow-up. Six patients (33%) patients displayed persistence of QRS fragmentation. Median ejection fraction was 60% (60–65%). In three patients (14%), ejection fraction remained depressed, two of which showed persistence of QRS fragmentation.Conclusion:In this cohort of children with suspected myocarditis, QRS fragmentation was confirmed as a new additional diagnostic finding to look for at admission and during follow-up.

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Predictors of the presence of septal late gadolinium enhancement in follow-up cardiac magnetic resonance imaging and its relation to acute myocarditis prognosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.328 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

M Martinho ◽

AR Pereira ◽

A Marques ◽

I Cruz ◽

R Cale ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Cardiac Magnetic Resonance ◽

Late Gadolinium Enhancement ◽

Magnetic Resonance ◽

Laboratory Tests ◽

Acute Myocarditis ◽

Adverse Outcomes ◽

Resonance Imaging ◽

Gadolinium Enhancement

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute myocarditis (AM) is generally a self-limited and benign disease. However, a minority of patients (pts) present or develop adverse outcomes. It has been proposed that the presence of late gadolinium enhancement (LGE) in the septum is associated with worse prognosis. Also, the presence of LGE without oedema in follow-up cardiac magnetic resonance imaging (CMR) seems to reflect more permanent lesions. Purpose The aim of this study was to determine if the presence of septal LGE in acute-phase CMR was associated with higher extent of disease in follow-up CMR and if initial laboratory tests help to predict the evolution to more permanent lesions. Methods Prospective single-centre study of pts admitted with AM diagnosed according to clinical findings, troponin T elevation and CMR criteria (Lake Louise), since 1/2013. Selection of those who underwent acute-phase (CMR-I) and follow-up CMR (CMR-II). Results Of 88 pts admitted with AM, 46 fulfilled our inclusion criteria: median age 31 ± 13 years, 85% males. CMR-I was performed at 6 ± 5days and LGE was present in 43 pts (93.5%). CMR-II was performed at 8 ± 4.3 months and 29 pts (63%) improved the number of LGE-positive segments, 10 pts (21.8%) had stable disease and 7 pts (15.2%) worsened CMR findings. Septal-LGE was detected in 10 pts (21.7%) in CMR-I and in 6 pts (13.0%) in CMR-II. Logistic regression analysis identified septal-LGE in CMR-I as a predictor of higher extent of LGE in CMR-II (OR 1.4, 95%CI 1.1-1.9, p = 0.020). Although median values of maximum high-sensitivity troponin and reactive-C protein (RCP) were not associated with septal LGE in CMR-I, increasing values of such tests were univariate predictors of a higher likelihood of septal involvement in CMR-II: maximum troponin (886 vs 1852ng/L; OR 1.00, 95%CI 1.00-1.00 p = 0.017) and RCP (4.2 vs 13.9mg/dL; OR 1.17, 95%CI 1.04-1.33, p = 0.012). After multivariate analysis, RCP was the independent predictor of septal LGE in CMR-II (AUC 80.8, 0.97-0.91, p = 0.012). RCP cut-off value >10.2mg/dL identified patients with septal LGE in CMR-II with a sensitivity and specificity of 83.3% and 85.0%, respectively. The presence of cardiovascular risk factors, clinical presentation and B-type natriuretic peptide values were not predictors of septal LGE in either CMR. In a mean clinical follow-up of 757 ± 476days, no patient died, 3 pts (6.5%) developed new-onset heart failure (NYHA class II functional symptoms) and 2 pts (4.3%) developed ventricular arrhythmias. Due to a small number of adverse events, neither laboratory tests nor LGE septal pattern predicted adverse outcomes. Conclusions In this population, septal LGE pattern was able to predict higher extent of LGE in follow-up CMR. Increased cardiac biomarkers and inflammatory proteins in the acute setting were also associated with septal involvement in follow-up and can potentially help to establish the risk of adverse events for patients admitted with acute myocarditis.

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Abstract 5920: Usefulness of Late Gadolinium Enhancement as Non-invasive Arrhythmic Risk Marker in Patients with Heart Failure and Systolic Dysfunction

Circulation ◽

10.1161/circ.118.suppl_18.s_1030 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Alfonso Valle ◽

Mercedes Nadal ◽

Jordi Estornell ◽

Nieves Martinez ◽

Miguel Corbi ◽

...

Keyword(s):

Heart Failure ◽

Late Gadolinium Enhancement ◽

Risk Stratification ◽

Systolic Dysfunction ◽

Total Mortality ◽

Left Ventricular ◽

Gadolinium Enhancement ◽

Non Invasive ◽

Patients With Heart Failure

The identification of prognostic markers in patients with heart failure of both ischemic and non ischemic etiology is an increasing need in the era of devices therapy. Risk stratification for sudden cardiac death (SCD) remains problematic with reliance on left ventricular function which predicts total mortality rather than arrhythmic events (AE). Recently cardiac magnetic resonance was employed to predict susceptibility for malignant arrhythmias. This study sought to determine the utility of late gadolinium enhancement (LGE) to predict AE. Three hundred consecutive patients with symptomatic heart failure and systolic dysfunction of both ischemic and non ischemic cause undergoing CMR, were classified into two groups attending to the presence (n 160) or absence of LGE (n 140), and were followed prospectively during 842 days. The primary endpoint was the combined of SCD or Ventricular tachycardia (VT). 23 patients had AE (8 SCD/15 VT) during the follow-up, 19 of them presenting LGE (83%). The presence of LGE was associated to a significantly higher AE rate (11.8.% vs 2.8% p< 0.001)(figure ). Compared to patients without LGE, midwall fibrosis and an ischemic pattern of LGE predicted AE. (3% vs 5% vs 14%, p= 0.001) LGE is a new non-invasive predictor of AE in patients with heart failure and systolic dysfunction. This suggest a potential role for risk stratification and better selection of patients who needs device therapy

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Abstract 17492: Extent and Pattern of Late Gadolinium Enhancement Predict Arrhythmic Events in Patients With Nonischemic Dilated Cardiomyopathy

Circulation ◽

10.1161/circ.132.suppl_3.17492 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Dong Geum Shin ◽

Hye-Jeong Lee ◽

Junbeom Park ◽

Young Jin Kim ◽

Jae-Sun Uhm ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Ventricular Arrhythmia ◽

Dilated Cardiomyopathy ◽

Cardiac Death ◽

Primary Outcome ◽

Multivariable Analysis ◽

Gadolinium Enhancement ◽

Nonischemic Dilated Cardiomyopathy ◽

The Impact

Background: Late gadolinium enhancement (LGE) by cardiac MR (CMR) has been related to adverse clinical outcomes in patients with nonischemic dilated cardiomyopathy (NIDC). But, a statistically significant association between LGE and arrhythmic risk in NIDC has not been demonstrated consistently. This study evaluated the impact of the presence, location and pattern of LGE on arrhythmic risk prediction in NICM. Methods: This study included 365 patients (54±15years) with NICM who underwent CMR. The extent, location and pattern of LGE were categorized. We analyzed for the primary outcome of ventricular arrhythmia (VA) including sustained or nonsustained ventricular tachycardia (VT), appropriate implantable cardioverter-defibrillator (ICD) intervention and ventricular fibrillation (VF). Cardiac death and hospitalization for heart failure (HF) were evaluated as secondary outcomes. Results: LGE was seen in 267 (73 %) patients. During median follow-up of 44±36 months, patients with LGE had higher incidence of cardiac death (15 % vs. 2 %, p<0.001), hospitalization for HF (40 % vs. 15 %, p<0.001) and VA (14% vs. 6%, p=0.03). In multivariable analysis, the presence of LGE (HR 2.78; 95% CI 1.10-7.02; p=0.03) was the independent predictor of arrhythmias. Patients with extensive LGE had higher VA (32% vs. 10%, p<0.001) with lower cumulative survival free of VA than those without extensive LGE (p=0.001). The frequent LGE location was as follows: LV septum 64%, LV-RV junction 42% and inferior 10%. VA was lower in patients with than without localized LGE limited to LV-RV junction (21% vs. 46%, p=0.005). Interestingly, while the incidence of ventricular arrhythmia was higher in patients with transmural LGE (29% vs. 10%, p=0.003), it was lower in those with patch LGE (2% vs. 16%, p=0.02) than the other patients. Conclusions: In patients with NICM, the LGE was an independent prognostic predictor of VA. Extensive LGE and specific location of LGE was related with the arrhythmic events.

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Association of left atrial pressure with late gadolinium enhancement extent in patient who underwent catheter ablation for atrial fibrillation

Scientific Reports ◽

10.1038/s41598-020-72929-0 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Seung-Young Roh ◽

Dae In Lee ◽

Sung Ho Hwang ◽

Kwang-No Lee ◽

Yong-soo Baek ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Late Gadolinium Enhancement ◽

Catheter Ablation ◽

Left Atrial ◽

Independent Predictor ◽

Atrial Remodeling ◽

Clinical Parameters ◽

Gadolinium Enhancement ◽

Cmr Imaging

Abstract Atrial remodeling with fibrosis has been well-described in patients with atrial fibrillation (AF). We hypothesized that the left atrial (LA)-late gadolinium enhancement (LGE) extent on cardiac magnetic resonance (CMR) imaging is associated with LA pressure and can be a marker for suitable candidates for non-paroxysmal AF ablation. A total of 173 AF patients with an LA-LGE area on CMR imaging were enrolled. The clinical parameters, including invasively measured LA pressure, were compared between the patients with extensive LA-LGE (E-LGE, LGE extent ≥ 20%, n = 78) and those with small LA-LGE (S-LGE, LGE extent < 20%, n = 95). The E-LGE group had higher peak LA pressures than the S-LGE group (23 versus 19 mmHg, p < 0.001). The E-LGE group had more patients with non-paroxysmal AF (non-PAF) (51% vs. 34%), heart failure (9% vs. 0%), and higher NT pro-B-type natriuretic peptide (472 vs. 265 pg/ml) (all p < 0.05). LA pressure ≥ 21 mmHg was an independent predictor of E-LGE (OR = 2.218; p = 0.019). In the paroxysmal AF (PAF) subgroup, freedom from atrial arrhythmia after catheter ablation was not different (81% vs 86%, log-rank p = 0.529). However, in the non-PAF subgroup, it was significantly higher in the S-LGE group than in the E-LGE group (81% vs 55%, log-rank p = 0.014). Increased LA pressure was related to the LA-LGE extent. LA-LGE was a good predictor of outcome after catheter ablation, but only in patients with non-PAF.

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Natural evolution of cardiac sarcoidosis in an asymptomatic patient: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz099 ◽

2019 ◽

Vol 3 (3) ◽

Cited By ~ 2

Author(s):

Ganna Degtiarova ◽

Olivier Gheysens ◽

Johan Van Cleemput ◽

Wim Wuyts ◽

Jan Bogaert

Keyword(s):

Computed Tomography ◽

Late Gadolinium Enhancement ◽

Cardiac Involvement ◽

Cardiac Sarcoidosis ◽

Clinical Signs ◽

Steroid Treatment ◽

Lung Pathology ◽

Gadolinium Enhancement ◽

18F Fdg

Abstract Background Sarcoidosis is a multi-organ granulomatous disease of unknown aetiology. Adverse outcome related with cardiac involvement, makes early diagnosis of cardiac sarcoidosis crucial. Case summary In a 55-year-old man presenting with recurrent pulmonary infections, computed tomography (CT) showed several enlarged mediastinal lymph nodes and no lung pathology. Subsequent mediastinoscopy revealed the diagnosis of sarcoidosis. Further screening for organ involvement showed multifocal cardiac involvement both on cardiac magnetic resonance (CMR) and 18-F-fluorodeoxyglucose-positron emission tomography-computed tomography (18F-FDG PET-CT). Because of the lack of functional deterioration and clinical symptoms, no steroid treatment was initiated and regular follow-up of cardiac abnormalities was performed by CMR. Unremarkable progression of cardiac involvement during the first 2 years of follow-up turned into a dramatic involvement after 4 years, with the increase in the number and size of lesions at late gadolinium enhancement (LGE) CMR. Late gadolinium enhancement areas matched the regions of strongly increased 18F-FDG uptake. For the first time, the patient started complaining on shortness of breath, electrocardiography showed an atrioventricular block Grade 1. Cardiac biomarkers and cardiac function were still preserved. Steroid treatment was started. Although an electrophysiology study was negative, Holter monitoring showed ventricular arrhythmia. Cardioverter-defibrillator was implanted. Discussion This case shows the progression of cardiac sarcoidosis on CMR in an asymptomatic untreated patient over a 4-year period, and rises the awareness of possible severe cardiac damage even in the absence of clinical signs of cardiac involvement. Combination of PET and CMR is appealing to better understand the evolution of cardiac sarcoidosis and may help in the management of such patients.

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Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging

PLoS ONE ◽

10.1371/journal.pone.0227134 ◽

2020 ◽

Vol 15 (1) ◽

pp. e0227134 ◽

Cited By ~ 2

Author(s):

Kady Fischer ◽

Maximilian Marggraf ◽

Anselm W. Stark ◽

Kyoichi Kaneko ◽

Ayaz Aghayev ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Clinical Suspicion ◽

Gadolinium Enhancement ◽

Cmr Imaging

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Myoglobin for Detection of High-Risk Patients with Acute Myocarditis

Journal of Cardiovascular Translational Research ◽

10.1007/s12265-020-09957-8 ◽

2020 ◽

Vol 13 (5) ◽

pp. 853-863 ◽

Cited By ~ 2

Author(s):

Jan Kottwitz ◽

Katelyn A. Bruno ◽

Jan Berg ◽

Gary R. Salomon ◽

DeLisa Fairweather ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Cardiac Magnetic Resonance ◽

Late Gadolinium Enhancement ◽

Roc Analysis ◽

Acute Myocarditis ◽

Unmet Need ◽

Receiver Operating Curve ◽

Resonance Imaging ◽

Gadolinium Enhancement ◽

Risk Patients

Abstract There is an unmet need for accurate and practical screening to detect myocarditis. We sought to test the hypothesis that the extent of acute myocarditis, measured by late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR), can be estimated based on routine blood markers. A total of 44 patients were diagnosed with acute myocarditis and included in this study. There was strong correlation between myoglobin and LGE (rs = 0.73 [95% CI 0.51; 0.87], p < 0.001), while correlation was weak between LGE and TnT-hs (rs = 0.37 [95% CI 0.09; 0.61], p = 0.01). Receiver operating curve (ROC) analysis determined myoglobin ≥ 87 μg/L as cutoff to identify myocarditis (92% sensitivity, 80% specificity). The data were reproduced in an established model of coxsackievirus B3 myocarditis in mice (n = 26). These data suggest that myoglobin is an accurate marker of acute myocarditis.

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