CMR findings after COVID-19 and after COVID-19-vaccination—same but different?

Abstract

Cardiac involvement has been described in varying proportions of patients recovered from COVID-19 and proposed as a potential cause of prolonged symptoms, often described as post-COVID or long COVID syndrome. Recently, cardiac complications have been reported from COVID-19 vaccines as well. We aimed to compare CMR-findings in patients with clinical cardiac symptoms after COVID-19 and after vaccination. From May 2020 to May 2021, we included 104 patients with suspected cardiac involvement after COVID-19 who received a clinically indicated cardiac magnetic resonance (CMR) examination at a high-volume center. The mean time from first positive PCR to CMR was 112 ± 76 days. During their COVID-19 disease, 21% of patients required hospitalization, 17% supplemental oxygen and 7% mechanical ventilation. In 34 (32.7%) of patients, CMR provided a clinically relevant diagnosis: Isolated pericarditis in 10 (9.6%), %), acute myocarditis (both LLC) in 7 (6.7%), possible myocarditis (one LLC) in 5 (4.8%), ischemia in 4 (3.8%), recent infarction in 2 (1.9%), old infarction in 4 (3.8%), dilated cardiomyopathy in 3 (2.9%), hypertrophic cardiomyopathy in 2 (1.9%), aortic stenosis, pleural tumor and mitral valve prolapse each in 1 (1.0%). Between May 2021 and August 2021, we examined an additional 27 patients with suspected cardiac disease after COVID-19 vaccination. Of these, CMR provided at least one diagnosis in 22 (81.5%): Isolated pericarditis in 4 (14.8%), acute myocarditis in 9 (33.3%), possible myocarditis (acute or subsided) in 6 (22.2%), ischemia in 3 (37.5% out of 8 patients with stress test), isolated pericardial effusion (> 10 mm) and non-compaction-cardiomyopathy each in 1 (3.7%). The number of myocarditis diagnoses after COVID-19 was highly dependent on the stringency of the myocarditis criteria applied. When including only cases of matching edema and LGE and excluding findings in the right ventricular insertion site, the number of cases dropped from 7 to 2 while the number of cases after COVID-19 vaccination remained unchanged at 9. While myocarditis is an overall rare side effect after COVID-19 vaccination, it is currently the leading cause of myocarditis in our institution due to the large number of vaccinations applied over the last months. Contrary to myocarditis after vaccination, LGE and edema in myocarditis after COVID-19 often did not match or were confined to the RV-insertion site. Whether these cases truly represent myocarditis or a different pathological entity is to be determined in further studies.

Cardiovascular magnetic resonance imaging patterns of acute COVID-19 mRNA vaccine-associated myocarditis in young male patients: A first single-center experience

“…This agrees with previous studies on both, viral myocarditis and COVID-19 vaccination-related myocarditis (31). In contrast to this, viral COVID-19 myocarditis was observed to show more diffusely distributed inflammation within the myocardium or a non-typical demarcation at the right ventricular insertion point (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). The pattern of lateral damage even in non-infectious causes, such as vaccination-related myocarditis, indicates a common ground lying pathophysiology, which may be related to immunologic reactions, which should be further investigated in future basic and translational research.…”

“…Since some evidence suggests distinct differences between vaccination-associated myocarditis and cardiac COVID-19-related involvement (so-called COVID-19 myocarditis), we now add further data on comparing vaccination-associated myocarditis and classical myocarditis. In opposite to COVID-19-related cardiac injury, our data suggest that vaccine-associated myocarditis and regular viral myocarditis show the same CMR patterns of inflammation ( 15 ).…”

“…In addition to comparable functional and morphological parameters in CMR, both groups had a similar clinical presentation. In our cohort, all patients suffered from chest pain as the main symptom, which was previously described in other populations with COVID-19 vaccination-related myocarditis, already (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17).…”

“…While COVID-19-related myocarditis did not show major differences when compared to acute myocarditis of other causes, recent data demonstrated that particularly in COVID-19-related myocarditis, uncommon patterns of edema and late gadolinium enhancement (LGE) enhancement in contrast to COVID-19 vaccination-associated myocarditis were present (15,16). However, COVID-19 vaccine-induced myocarditis on the other hand was compared with myocarditis of other causes and found to share clinical and imaging appearances in a heterogeneous cohort of different age and sex groups (17,18).…”

Myocardial injury after COVID-19 infection and vaccination. Two sides of the same coin or different?

“…In this issue of the journal, Doeblin et al [ 1 ] report on a comparative cardiac magnetic resonance (CMR) study in patients after COVID-19 infection versus vaccination, presenting with suspected cardiac involvement due to limiting clinical cardiac symptoms in a tertiary cardiac center. The authors investigated several CMR metrics, including left ventricular (LV)-ejection fraction, myocardial fibrosis, and edema by T1 and T2 mapping techniques, respectively, extracellular volumes (ECV) and late gadolinium enhancement (LGE) extent and patterns in 104 patients after COVID-19 infection and 27 individuals after vaccination.…”