Cardiovascular magnetic resonance in immune checkpoint inhibitor-associated myocarditis

Abstract

Aims Myocarditis is a potentially fatal complication of immune checkpoint inhibitors (ICI). Sparse data exist on the use of cardiovascular magnetic resonance (CMR) in ICI-associated myocarditis. In this study, the CMR characteristics and the association between CMR features and cardiovascular events among patients with ICI-associated myocarditis are presented. Methods and results From an international registry of patients with ICI-associated myocarditis, clinical, CMR, and histopathological findings were collected. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. In 103 patients diagnosed with ICI-associated myocarditis who had a CMR, the mean left ventricular ejection fraction (LVEF) was 50%, and 61% of patients had an LVEF ≥50%. Late gadolinium enhancement (LGE) was present in 48% overall, 55% of the reduced EF, and 43% of the preserved EF cohort. Elevated T2-weighted short tau inversion recovery (STIR) was present in 28% overall, 30% of the reduced EF, and 26% of the preserved EF cohort. The presence of LGE increased from 21.6%, when CMR was performed within 4 days of admission to 72.0% when CMR was performed on Day 4 of admission or later. Fifty-six patients had cardiac pathology. Late gadolinium enhancement was present in 35% of patients with pathological fibrosis and elevated T2-weighted STIR signal was present in 26% with a lymphocytic infiltration. Forty-one patients (40%) had MACE over a follow-up time of 5 months. The presence of LGE, LGE pattern, or elevated T2-weighted STIR were not associated with MACE. Conclusion These data suggest caution in reliance on LGE or a qualitative T2-STIR-only approach for the exclusion of ICI-associated myocarditis.

ECG Changes in Melanoma Patients Undergoing Cancer Therapy—Data from the ECoR Registry

“…Development of a LBBB or RBBB can occur during anti-cancer therapies, but reports remain rare [ 27 ]. Complete heart blocks have been described in single cases of doxorubicin-induced cardiotoxicity [ 28 ] and seem to be common in ir-myocarditis [ 29 , 30 ].…”

Cardiotoxicity of Contemporary Anticancer Immunotherapy

“…Additionally, recent data from an international registry show that the majority of patients with ICI-associated myocarditis had normal LVEF on CMR and only 46% had late gadolinium enhancement (LGE), which makes the current CMR diagnostic criteria a subpar tool for diagnosis of ICI-associated myocarditis. Although LGE on CMR has been shown to be an effective tool for risk stratification and prognostication for myocarditis of other causes, for ICI-associated myocarditis, LGE was not associated with MACE [ 25 ]. These data suggest that the LGE-only approach to diagnosing ICI-associated myocarditis is likely not adequate and additional parameters of tissue characterization may need to be routinely utilized in the evaluation of these patients.…”

Myocarditis associated with immune check-point inhibitors: Practical considerations in diagnosis and management

“…However, nearly 90% of these patients have been reported to have various new-onset ECG changes ( 7 ). An ECG finding has been suggested to include sinus tachycardia, bundle branch block, atrial fibrillation, AV block, bigeminy ventricular premature beats, ventricular tachycardia, and ST-segment elevation ( 8 , 17 , 24 , 25 ). Even though ECG generally has a limited diagnostic value in ICI-associated myocarditis, it is an easily accessible and low-cost test and, hence is recommended at the beginning and before every consecutive dose of ICI treatment ( 26 ) so potential changes can be monitored in time.…”

“…Cardiac MRI, a noninvasive method, plays a pivotal role in the early detection and serial monitoring of myocardial inflammation. In T1-/T2-weighted MRI of patients with ICI-related myocarditis, mid-myocardial edema and late gadolinium enhancement that does not correspond to coronary anatomy are of particular importance ( 25 , 26 , 28 ). The specificity and sensitivity of MRI in the diagnosis of myocarditis are 91% and 67%, respectively.…”