Abstract
Myocarditis is an acute or chronic inflammatory disease of the myocardium which can be viral, postinfectious immune or primarily organ-specific autoimmune. Clinical manifestations of acute and chronic myocarditis are extremely varied, ranging from mild to severe. Affected patients may recover or develop (dilated) cardiomyopathy (DCM) with life-threatening symptoms including heart failure, conduction disturbances, arrhythmias, cardiogenic shock or sudden cardiac death.
The diagnosis of myocarditis is a challenging process and not only because of a diverse presentation; other problems are limited sensitivity of endomyocardial biopsies (EMB) and overlapping symptoms. Furthermore, the diagnosis is not well defined. However, early diagnosis is mandatory to address specific aetiology-directed therapeutic management in myocarditis that influences patient morbidity and mortality.
Currently, EMB remains the only way to confirm the presence of a viral genome and other histopathological findings allowing proper treatment to be implemented in cases of myocarditis. Increased recognition of the role of myocardial inflammatory changes has given rise to interest in noninvasive imaging as a diagnostic tool, especially cardiovascular magnetic resonance imaging (CMR). In this review we discuss the current role of CMR in the evaluation of myocarditis-induced inflammatory cardiomyopathies. (Neth Heart J 2009;17:481–6.)
Similar content being viewed by others
References
Caforio AL, Mahon NJ, Tona F, McKenna WJ. Circulating cardiac autoantibodies in dilated cardiomyopathy and myocarditis: pathogenetic and clinical significance. Eur J Heart Fail. 2002;4: 411–7.
Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation. 2006;113:593–5.
Liu PP, Mason JW. Advances in the understanding of myocarditis. Circulation. 2001;104:1076–82.
Kadalie CT. [MRI in chronic myocarditis]. Z Kardiol. 2005;94(Suppl 4):IV/94–IV/96.
Esfandiarei M, McManus BM. Molecular biology and pathogenesis of viral myocarditis. Annu Rev Pathol. 2008;3:127–55.
Caforio AL, Calabrese F, Angelini A, Tona F, Vinci A, Bottaro S. A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. Eur Heart J. 2007;28:1326–33.
Kindermann I, Kindermann M, Kandolf R, Klingel K, Bultmann B, Muller T, et al. Predictors of outcome in patients with suspected myocarditis. Circulation. 2008;118:639–48.
Skouri HN, Dec GW, Friedrich MG, Cooper LT. Noninvasive imaging in myocarditis. J Am Coll Cardiol. 2006;48:2085–93.
Lieberman EB, Herskowitz A, Rose NR, Baughman KL. A clinicopathologic description of myocarditis. Clin Immunol Immunopathol. 1993;68:191–6.
Mahrholdt H, Wagner A, Deluigi CC, Kispert E, Hager S, Meinhardt G, et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation. 2006;114: 1581–90.
McCarthy RE, III, Boehmer JP, Hruban RH, Hutchkins G.M, Kasper E.K, Hare J.M et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med. 2000;342:690–5.
Kodama M, Oda H, Okabe M, Aizawa Y, Izumi T. Early and longterm mortality of the clinical subtypes of myocarditis. Jpn Circ J. 2001;65:961–4.
De CF, Pieroni M, Esposito A, Chimenti C, Belloni E, Mellone R, et al. Delayed gadolinium-enhanced cardiac magnetic resonance in patients with chronic myocarditis presenting with heart failure or recurrent arrhythmias. J Am Coll Cardiol. 2006;47:1649–54.
Gutberlet M, Spors B, Thoma T, Bertram H, Denecke T, Felix R, et al. Suspected chronic myocarditis at cardiac MR: diagnostic accuracy and association with immunohistologically detected inflammation and viral persistence. Radiology. 2008;246:401–9.
Zagrosek A, Wassmuth R, Abdel-Aty H, Rudolph A, Dietz R, Schulz-Menger J. Relation between myocardial edema and myocardial mass during the acute and convalescent phase of myocarditis – a CMR study. J Cardiovasc Magn Reson. 2008;10:19.
Kuhl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. 2005;27; 112:1965–70.
Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000;343:1388–98.
Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. 2008;29:2073–82.
Kawai C. From myocarditis to cardiomyopathy: mechanisms of inflammation and cell death: learning from the past for the future. Circulation. 1999;99:1091–100.
Noutsias M, Pauschinger M, Kuhl U, Schultheiss HP. [Myocarditis and dilated cardiomyopathy. New methods in diagnosis and therapy]. MMW Fortschr Med. 2002;144:36–40.
Spotnitz MD, Lesch M. Idiopathic dilated cardiomyopathy as a late complication of healed viral (Coxsackie B virus) myocarditis: historical analysis, review of the literature, and a postulated unifying hypothesis. Prog Cardiovasc Dis. 2006;49:42–57.
Caforio AL, Iliceto S. Genetically determined myocarditis: clinical presentation and immunological characteristics. Curr Opin Cardiol. 2008;23:219–26.
Shehata ML, Turkbey EB, Vogel-Claussen J, Bluemke DA. Role of cardiac magnetic resonance imaging in assessment of nonischemic cardiomyopathies. Top Magn Reson Imaging. 2008;19:43–57.
Abdel-Aty H, Boye P, Zagrosek, Wassmuth R, Kumar A, Messroghli D, et al. Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. J Am Coll Cardiol. 2005;45:1815–22.
Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiasdis A, Vogelsberg H, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 2004;109:1250–8.
Yelgec NS, Dymarkowski S, Ganame J, Bogaert J. Value of MRI in patients with a clinical suspicion of acute myocarditis. Eur Radiol. 2007;17:2211–7.
Bohl S, Wassmuth R, Abdel-Aty H, Rudolph A, Messroghli D, Dietz R, et al. Delayed enhancement cardiac magnetic resonance imaging reveals typical patterns of myocardial injury in patients with various forms of non-ischemic heart disease. Int J Cardiovasc Imaging. 2008;24:597–607.
Deb K, Djavidani B, Buchner S, Poschenrieder F, Heinicke N, Feuerbach S, et al. Time course of eosinophilic myocarditis visualized by CMR. J Cardiovasc Magn Reson. 2008;10:21.
Kellman P, Aletras AH, Mancini C, McVeigh ER, Arai AE. T2-prepared SSFP improves diagnostic confidence in edema imaging in acute myocardial infarction compared to turbo spin echo. Magn Reson Med. 2007;57:891–7.
Kuhl U, Pauschinger M, Schwimmbeck PL, Seeberg B, Lober C, Noutsias M, et al. Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation. 2003;107:2793–8.
McNamara DM, Rosenblum WD, Janosko KM, Trost MK, Villaneuva FS, Demetris AJ, et al. Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation. 1997;95:2476–8.
Karatolios K, Pankuweit S, Maisch B. Diagnosis and treatment of myocarditis: the role of endomyocardial biopsy. Curr Treat Options Cardiovasc Med. 2007;9:473–81.
McNamara DM, Holubkov R, Starling RC, Dec GW, Mc Manus BM, Billingham ME, et al. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation. 2001;103:2254–9.
Mason JW, O'Connell JB, Herskowitz A, Yang E, Mc Connell M.V. Berry C.J, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med. 1995;333:269–75.
Allanore Y, Vignaux O, Arnaud L, Puechal X, Pavy S, Dubo D, et al. Effects of corticosteroids and immunosuppressors on idiopathic inflammatory myopathy related myocarditis evaluated by magnetic resonance imaging. Ann Rheum Dis. 2006;65:249–52.
Fenster BE, Chan FP, Valentine HA, Yang E, Mc Connell MV, Berry CJ, et al. Images in cardiovascular medicine. Cardiac magnetic resonance imaging for myocarditis: effective use in medical decision making. Circulation. 2006;113:e842–e843.
Dill T, Ekinci O, Hansel J, Kluge A, Breidenbach C, Hamm CW. Delayed contrast-enhanced magnetic resonance imaging for the detection of autoimmune myocarditis and long-term follow-up. J Cardiovasc Magn Reson. 2005;7:521–3.
Author information
Authors and Affiliations
Additional information
Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands
M.A. Galjee Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, PO Box 7500, KA Enschede, the Netherlands
Rights and permissions
About this article
Cite this article
Olimulder, M.A.G.M., van Es, J. & Galjee, M.A. The importance of cardiac MRI as a diagnostic tool in viral myocarditis-induced cardiomyopathy. NHJL 17, 481–486 (2009). https://doi.org/10.1007/BF03086308
Issue Date:
DOI: https://doi.org/10.1007/BF03086308