Myocarditis MRI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.

Overview

Cardiac MRI findings associated with myocarditis include myocardial inflammation, myocardial edema, capillary leak, and reduced left ventricular function. While the cardiac MRI pattern of gadolinium hyperenhancement in ST segment elevation myocardial infarction is transmural and extends from the endocardium to the epicardium, the patchy, non-segmental hyperenhancement pattern in myocarditis in contrast involves the epicardium and spares the subendocardium.[1][2]

ACC/AHA Guidelines- ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: Indications to Perform Cardiac MRI in the Patient with Suspected Myocarditis[3] (DO NOT EDIT)

CMR may be used for assessment of patients with LV dysfunction or hypertrophy or suspected forms of cardiac injury not related to ischemic heart disease. When the diagnosis is unclear, CMR may be considered to identify the etiology of cardiac dysfunction in patients presenting with heart failure, including

Performance of cardiac MRI is generally indicated in those patients with new or persisting symptoms of chest pain and congestive heart failure, who have evidence of significant myocardial injury, in the absence of or in whom there is a low suspicion of coronary atherosclerosis.[2]

Findings on MRI

  • Myocardial inflammation: Myocardial inflammation associated with myocarditis appears as a high intensity signal with delayed gadolinium hyperenhancement on cardiac MRI (cMRI).[4] While the cMRI pattern of gadolinium hyperenhancement in ST segment elevation myocardial infarction is transmural and extends from the endocardium to the epicardium, the patchy, non-segmental hyperenhancement pattern in myocarditis in contrast involves the epicardium and spares the subendocardium.[5] The areas of hyperenhancement are often observed in the lateral and inferior territories of the heart. When used in conjunction with the findings on coronary angiography, cardiac MRI is useful in distinguishing between a diagnosis of myocarditis and myonecrosis associated with myocardial ischemia. Among 79 patients with elevated cardiac biomarkers who were suspected of having ACS and had normal coronary arteries on coronary angiography, 81% of the patients (including those with preserved ejection fraction) were diagnosed with myocarditis based on cMRI findings.[6]
  • Myocardial edema: High T2 signal intensity areas suggests myocardial edema.[7]
  • Myocardial scar: Gadolinium-enhanced magnetic resonance imaging (MRI) may also aid in assessing the extent of myocardial scarring (areas of delayed gadolinium enhancement) which is largely confined to the epicardium.[7]
  • Myocardial capillary leak: Myocardial early gadolinium enhancement ratio (ratio between myocardium and skeletal muscle) ≥ 4.0 is suggestive of hyperemia and capillary leakage.[2]
  • Myocardial dysfunction: Cardiac MRI can be used to assess for the presence of and severity of myocardial dysfunction associated with myocarditis.[2]

Sensitivity and Specificity

CMR was reported to have a sensitivity of 76%, specificity of 95.5%, and overall diagnostic accuracy of 85% when any-two of the following three sequences were used.[4]

  • Focal and global T2 signal intensity
  • Myocardial global relative enhancement
  • Delayed gadolinium enhancement

Among 21 patients who underwent biopsy of contrast enhanced regions in a series in Germany, histopathologic findings in 19 patients were consistent with myocarditis.[8]

References

  1. Skouri HN, Dec GW, Friedrich MG, Cooper LT (2006). "Noninvasive imaging in myocarditis". J. Am. Coll. Cardiol. 48 (10): 2085–93. PMID 17112998. doi:10.1016/j.jacc.2006.08.017. 
  2. 2.0 2.1 2.2 2.3 2.4 Friedrich MG, Sechtem U, Schulz-Menger J, Holmvang G, Alakija P, Cooper LT; et al. (2009). "Cardiovascular magnetic resonance in myocarditis: A JACC White Paper.". J Am Coll Cardiol. 53 (17): 1475–87. PMC 2743893Freely accessible. PMID 19389557. doi:10.1016/j.jacc.2009.02.007. 
  3. American College of Cardiology Foundation Task Force on Expert Consensus Documents. Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA; et al. (2010). "ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents.". Circulation. 121 (22): 2462–508. PMC 3034132Freely accessible. PMID 20479157. doi:10.1161/CIR.0b013e3181d44a8f. 
  4. 4.0 4.1 Abdel-Aty H, Boyé P, Zagrosek A, Wassmuth R, Kumar A, Messroghli D; et al. (2005). "Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches.". J Am Coll Cardiol. 45 (11): 1815–22. PMID 15936612. doi:10.1016/j.jacc.2004.11.069. 
  5. Skouri HN, Dec GW, Friedrich MG, Cooper LT (2006). "Noninvasive imaging in myocarditis". J. Am. Coll. Cardiol. 48 (10): 2085–93. PMID 17112998. doi:10.1016/j.jacc.2006.08.017. 
  6. Monney PA, Sekhri N, Burchell T, Knight C, Davies C, Deaner A; et al. (2011). "Acute myocarditis presenting as acute coronary syndrome: role of early cardiac magnetic resonance in its diagnosis.". Heart. 97 (16): 1312–8. PMID 21106555. doi:10.1136/hrt.2010.204818. 
  7. 7.0 7.1 Al-Mallah M, Kwong RY (2009). "Clinical application of cardiac CMR.". Rev Cardiovasc Med. 10 (3): 134–41. PMID 19898290. 
  8. Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiadis A, Vogelsberg H; et al. (2004). "Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology.". Circulation. 109 (10): 1250–8. PMID 14993139. doi:10.1161/01.CIR.0000118493.13323.81. 

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