Comprehensive Cardiac Magnetic Resonance Imaging in Patients With Suspected Myocarditis

Lurz, Philipp; Luecke, Christian; Eitel, Ingo; Föhrenbach, Felix; Frank, Clara; Waha, Suzanne de; Rommel, Karl‐Philipp; Lurz, Julia; Klingel, Karin; Kandolf, Reinhard; Schuler, Gerhard; Thiele, Holger; Gutberlet, Matthias

doi:10.1016/j.jacc.2016.02.013

Cited by 338 publications

(267 citation statements)

References 34 publications

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“…20 The recognition of acute inflammation by T1 mapping was shown to be superior to edema imaging with T2-weighted sequences [62][63][64] and to LGE. 54,63 This evidence supports a shift in thinking about the current CMR approach to myocarditis. First, native T1 provides excellent positive and negative predictive values Types of sequences and a staining method used, as well as several patients included, are also reported.…”

Section: T1 Mapping In Myocardial Inflammationmentioning

confidence: 57%

“…Endomyocardial biopsy is a proposed, albeit imperfect gold standard for the diagnosis of definitive myocarditis. 52,54 Owing to the variable availability of endomyocardial biopsy expertise, its procedural risks, and a commonly low diagnostic yield, this diagnostic strategy is widely perceived as impractical in most cases of suspected myocarditis. 55,56 In clinical practice, a noninvasive diagnostic pathway, which allows appreciation of disease activity/stage, may also support development of specific therapeutic options, both of which are currently limited.…”

Section: T1 Mapping In Myocardial Inflammationmentioning

confidence: 99%

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T1 Mapping in Characterizing Myocardial Disease

Püntmann

Peker

Chandrashekhar

et al. 2016

Circulation Research

261

202

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Cardiovascular magnetic resonance provides insights into myocardial structure and function noninvasively, with high diagnostic accuracy and without ionizing radiation. Myocardial tissue characterization in particular gives cardiovascular magnetic resonance a prime role among all the noninvasive cardiovascular investigations. Late gadolinium enhancement imaging is an established method for visualizing replacement scar, providing diagnostic and prognostic information in a variety of cardiac conditions. Late gadolinium enhancement, however, relies on the regional segregation of tissue characteristics to generate the imaging contrast. Thus, myocardial pathology that is diffuse in nature and affecting the myocardium in a rather uniform and global distribution is not well visualized with late gadolinium enhancement. Examples include diffuse myocardial inflammation, fibrosis, hypertrophy, and infiltration. T1 mapping is a novel technique allowing to diagnose these diffuse conditions by measurement of T1 values, which directly correspond to variation in intrinsic myocardial tissue properties. In addition to providing clinically meaningful indices, T1-mapping measurements also allow for an estimation of extracellular space by calculation of extracellular volume fraction. Multiple lines of evidence suggest a central role for T1 mapping in detection of diffuse myocardial disease in early disease stages and complements late gadolinium enhancement in visualization of the regional changes in common advanced myocardial disease. As a quantifiable measure, it may allow grading of disease activity, monitoring progress, and guiding treatment, potentially as a fast contrast-free clinical application. We present an overview of clinically relevant technical aspects of acquisition and processing, and the current state of art and evidence, supporting its clinical use.

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Section: T1 Mapping In Myocardial Inflammationmentioning

confidence: 57%

Section: T1 Mapping In Myocardial Inflammationmentioning

confidence: 99%

T1 Mapping in Characterizing Myocardial Disease

Püntmann

Peker

Chandrashekhar

et al. 2016

Circulation Research

261

202

View full text Add to dashboard Cite

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“…[13][14][15][16] In addition, relevant coronary artery disease had to be ruled out on selective angiography. Patients with contraindication to cardiac catheterization or EMB were excluded.…”

Section: Patient Samplementioning

confidence: 99%

Plasma and Cardiac Galectin-3 in Patients With Heart Failure Reflects Both Inflammation and Fibrosis

Besler

Lang

Urban

et al. 2017

Circ: Heart Failure

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Background— Galectin (Gal)-3 is a β-galactoside-binding lectin and currently intensely studied as a biomarker in heart failure. Gal-3 also exerts proinflammatory effects, at least in extracardiac tissues. Objective of this study was to characterize the relationship of plasma and myocardial Gal-3 levels with cardiac fibrosis and inflammation in patients with nonischemic dilated cardiomyopathy and inflammatory cardiomyopathy (iCMP). Methods and Results— Endomyocardial biopsies and blood samples were obtained from patients with newly diagnosed cardiomyopathy and clinical suspicion of myocarditis. According to histopathologic findings, patients were classified as having dilated cardiomyopathy (n=40) or iCMP (n=75). Cardiac fibrosis was assessed histologically on endomyocardial biopsy sections. In patients with iCMP, myocardial Gal-3 expression significantly correlated with inflammatory cell count on endomyocardial biopsy ( r =0.56; P <0.05). In contrast, an inverse association was observed between myocardial Gal-3 expression and cardiac fibrosis in patients with iCMP ( r =−0.59; P <0.05). In patients with dilated cardiomyopathy, myocardial Gal-3 expression correlated with cardiac fibrosis on left ventricular biopsy ( P =0.63; P <0.01). Of note, in both groups, plasma Gal-3 levels did not correlate with myocardial Gal-3 levels or left ventricular fibrosis, whereas a positive correlation between plasma Gal-3 levels and inflammatory cell count on endomyocardial biopsy was observed in patients with iCMP. Conclusions— The present study suggests that myocardial Gal-3 can be considered as a possible marker for both cardiac inflammation and fibrosis, depending on the pathogenesis of heart failure. However, circulating concentrations of Gal-3 do not seem to reflect endomyocardial Gal-3 levels or cardiac fibrosis.

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“…16 Recently, CMR has evolved as the gold standard for noninvasive testing. [25][26][27][28] Quantification of LGE can represent a wide variety of tissue processes and has emerged as a diagnostic tool in ischemic heart disease to measure areas of infarction 29 and for risk stratification in ischemic 30,31 and nonischemic heart disease. [32][33][34] Although in clinical practice decreasing cardiac enzymes and inflammatory markers are commonly interpreted as being indicative of resolving myocarditis, no cardiac imaging studies have confirmed this assumption as of today.…”

mentioning

confidence: 99%

Cardiac Magnetic Resonance Imaging in Myocarditis Reveals Persistent Disease Activity Despite Normalization of Cardiac Enzymes and Inflammatory Parameters at 3-Month Follow-Up

Berg

Kottwitz

Baltensperger

et al. 2017

Circ: Heart Failure

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BACKGROUND:There is a major unmet need to identify high-risk patients in myocarditis. Although decreasing cardiac and inflammatory markers are commonly interpreted as resolving myocarditis, this assumption has not been confirmed as of today. We sought to evaluate whether routine laboratory parameters at diagnosis predict dynamic of late gadolinium enhancement (LGE) as persistent LGE has been shown to be a risk marker in myocarditis. METHODS AND RESULTS:Myocarditis was diagnosed based on clinical presentation, high-sensitivity troponin T, and cardiac magnetic resonance imaging, after exclusion of obstructive coronary artery disease by angiography. Cardiac magnetic resonance imaging was repeated at 3 months.LGE extent was analyzed with the software GT Volume. Change in LGE >20% was considered significant. Investigated cardiac and inflammatory markers included high-sensitivity troponin T, creatine kinase, myoglobin, N-terminal B-type natriuretic peptide, C-reactive protein, and leukocyte count. Twenty-four patients were enrolled. Absolute levels of cardiac enzymes and inflammatory markers at baseline did not predict change in LGE at 3 months. Cardiac and inflammatory markers had normalized in 21 patients (88%). LGE significantly improved in 16 patients (67%); however, it persisted to a lesser degree in 17 of them (71%) and increased in a small percentage (21%) despite normalization of cardiac enzymes.CONCLUSIONS: This is the first study reporting that cardiac enzymes and inflammatory parameters do not sufficiently reflect LGE in myocarditis. Although a majority of patients with normalizing laboratory markers experienced improved LGE, in a small percentage LGE worsened. These data suggest that cardiac magnetic resonance imaging might add value to currently existing diagnostic tools for risk assessment in myocarditis. Cardiac Magnetic Resonance Imaging in Myocarditis is a common cardiac disease of varying degree of severity. [1][2][3][4][5] Clinical presentation may range from mild symptoms to severe heart failure and ventricular arrhythmias. 6,7 Myocarditis has been reported in up to 25% of young adults presenting with sudden death. [8][9][10][11][12] As of today, there is a major unmet need to accurately diagnose patients with myocarditis and to identify individuals at highest risk for adverse cardiovascular events. One known indicator of poor outcome is persistent late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR). 13,14 Although cardiac enzymes and inflammatory markers may be elevated in acute myocarditis, 3,7,15,16 their role in predicting disease progression remains unknown. Transcriptomic biomarkers derived from a single endomyocardial biopsy have recently demonstrated promising results as highly accurate diagnostic test for lymphocytic myocarditis. 17,18 However, endomyocardial biopsy is an invasive procedure with the risk of complications and the limitation of sampling error. [19][20][21][22] Furthermore, it can only be performed in experienced centers. Therefore, its use is limit...

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Comprehensive Cardiac Magnetic Resonance Imaging in Patients With Suspected Myocarditis

Cited by 338 publications

References 34 publications

T1 Mapping in Characterizing Myocardial Disease

T1 Mapping in Characterizing Myocardial Disease

Plasma and Cardiac Galectin-3 in Patients With Heart Failure Reflects Both Inflammation and Fibrosis

Cardiac Magnetic Resonance Imaging in Myocarditis Reveals Persistent Disease Activity Despite Normalization of Cardiac Enzymes and Inflammatory Parameters at 3-Month Follow-Up

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