The Double-Edged Sword of T1-Mapping in Systemic Sclerosis—A Comparison with Infectious Myocarditis Using Cardiovascular Magnetic Resonance

Abstract

Aims: T1-mapping is considered a surrogate marker of acute myocardial inflammation. However, in diffuse cutaneous systemic sclerosis (dcSSc) this might be confounded by coexisting myocardial fibrosis. We hypothesized that T1-based indices should not by themselves be considered as indicators of myocardial inflammation in dcSSc patients. Methods/Results: A cohort of 59 dcSSc and 34 infectious myocarditis patients was prospectively evaluated using a 1.5-Tesla system for an indication of suspected myocardial inflammation and was compared with 31 healthy controls. Collectively, 33 (97%) and 57 (98%) of myocarditis and dcSSc patients respectively had ≥1 pathologic T2-based index. However, 33 (97%) and 45 (76%) of myocarditis and dcSSc patients respectively had ≥1 pathologic T2-based index. T2-signal ratio was significantly higher in myocarditis patients compared with dcSSc patients (2.5 (0.6) vs. 2.1 (0.4), p < 0.001). Early gadolinium enhancement, late gadolinium enhancement and T2-mapping did not differ significantly between groups. However, both native T1-mapping and extracellular volume fraction were significantly lower in myocarditis compared with dcSSc patients (1051.0 (1027.0, 1099.0) vs. 1120.0 (1065.0, 1170.0), p < 0.001 and 28.0 (26.0, 30.0) vs. 31.5 (30.0, 33.0), p < 0.001, respectively). The original Lake Louise criteria (LLc) were positive in 34 (100%) myocarditis and 40 (69%) dcSSc patients, while the updated LLc were positive in 32 (94%) and 44 (76%) patients, respectively. Both criteria had good agreement with greater but nonsignificant discordance in dcSSc patients. Conclusions: ~25% of dcSSc patients with suspected myocardial inflammation had no CMR evidence of acute inflammatory processes. T1-based indices should not be used by themselves as surrogates of acute myocardial inflammation in dcSSc patients.

COVID-19 myocarditis and prospective heart failure burden

“…Only 69% of SSc patients met LLC and LGE was detected in 86%. Similar CMR findings were also described in asymptomatic SSc patients [46]. Although, prognostic significance of described myocardial abnormalities needs to be further clarified, histology data indicates that prominent myocardial inflammation in SSc patient is strongly associated with unfavorable prognosis [47].…”

“…Usage of a different cutoff value for T1 time (with ≥5SD higher than normal range for acute and ≥2SD for residual changes), as well as T2 value, helps to distinguish between acute and chronic processes [37,74], as elevated T2 will inform on residual inflammation [65]. Therefore, we can distinguish acute and chronic inflammatory processes, as well as detect the diseased myocardium at the subclinical phase before the disease progresses to the advanced stages [44,46]. All these unique features of mapping tools are particularly important for COVID-19 patients, for whom, early CMR studies revealed diffusely diseased myocardium even in asymptomatic COVID-19 patients.…”

Cardiovascular Magnetic Resonance Detects Inflammatory Cardiomyopathy in Symptomatic Patients with Inflammatory Joint Diseases and a Normal Routine Workup

“…Lastly, another point that merits discussion is the significantly lower LV mass that was identified in patients with IJD when compared with controls in our study. Such findings have also been reported in the past by our group in patients with antiphospholipid syndrome and systemic sclerosis with concomitant cardiac involvement [ 19 , 32 ], as well as in patients with RA by other researchers [ 33 ]. However, other studies have not been able to reproduce this finding [ 12 ].…”

“…The introduction of mapping techniques and extracellular volume fraction (ECV) quantification has further increased the diagnostic yield of CMR regarding the detection of diffuse edema/fibrosis in the myocardium [ 16 , 17 , 18 ]. However, ECV may be confounded by co-existing myocardial inflammation [ 19 , 20 ].…”

Sclerodermic Cardiomyopathy—A State-of-the-Art Review

“…Supplementary, in the setting of suspected myocardial inflammation, Markousis-Mavrogenis et al demonstrated that one-quarter of symptomatic SSc patients from their study did not show any significant signs of an active inflammatory response on T2-based analysis [91]. In contrast, by T1-analysis, almost all patients with SSc and infective myocarditis displayed abnormalities, so the authors conclude that both T1 and T2 indices should be used in evaluating this specific category of patients [91].…”