Skip to main content
SpringerLink
Log in

Cardiac magnetic resonance abnormalities in patients with acute myocarditis proven by septal endomyocardial biopsy

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

Previous studies suggest low diagnostic sensitivity of cardiac magnetic resonance (CMR) imaging based on Lake Louise criteria (LLC) to identify patients with complicated presentations of acute myocarditis (AM). We evaluated classic and updated LLC in patients with AM proven by right ventricular septal endomyocardial biopsy (RVS-EMB).

Methods

From an initial population of 499 patients with clinically suspected AM from a multicenter retrospective cohort, we included 74 patients with histologically proven myocarditis on RVS-EMB and available CMR within 30 days since admission. The prevalence of total and septal CMR abnormalities [namely, T2-weighted images (T2W), late gadolinium enhancement (LGE), T2 and T1 mapping, and extracellular volume (ECV)] were assessed in patients with complicated vs. uncomplicated AM.

Results

Among 74 patients [mean age 38 ± 15 years, 65% males, left ventricular ejection fraction (LVEF) 40 ± 18%] with RVS-EMB-proven AM, 53 (72%) had a complicated presentation. The classic LLC were positive in 56/74 patients (76%), whereas the updated ones were positive in 41/41 of cases (100%). Septal involvement, documented in 48/74 patients (65%) by conventional T2W/LGE and in 39/41 cases (95%) by mapping techniques (p < 0.001), was more common in patients with complicated AM. In the 41 patients undergoing both evaluations, CMR sensitivity for myocarditis was 85% for the classic LLC vs. 100% for the updated LLC (p = 0.006).

Conclusion

In patients with myocarditis on RVS-EMB, CMR using updated LLC has high sensitivity in the detection of AM when performed within 30 days. Septal abnormalities are more common in patients with complicated AM.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

ACS:

Acute coronary syndrome

AM:

Acute myocarditis

CMR:

Cardiac magnetic resonance

ECV:

Extracellular volume

EMB:

Endomyocardial biopsy

LGE:

Late gadolinium enhancement

LLC:

Lake Louise criteria

LVEF:

Left ventricular ejection fraction

RVS:

Right ventricular septum

STIR:

Short tau inversion recovery

References

  1. Tschöpe C, Ammirati E, Bozkurt B et al (2020) Myocarditis and inflammatory cardiomyopathy: current evidence and future directions. Nat Rev Cardiol 18(3):169–193

  2. Caforio AL, Pankuweit S, Arbustini E et al (2013) Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 34(33):2636–2648

    Article  PubMed  Google Scholar 

  3. Ammirati E, Frigerio M, Adler ED et al (2020) Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document. Circ Heart Fail 13:e007405

    Article  PubMed Central  PubMed  Google Scholar 

  4. Casella M, Dello Russo A, Bergonti M et al (2020) Diagnostic yield of electroanatomic voltage mapping in guiding endomyocardial biopsies. Circulation 142:1249–1260

    Article  CAS  PubMed  Google Scholar 

  5. Vaidya VR, Abudan AA, Vasudevan K et al (2018) The efficacy and safety of electroanatomic mapping-guided endomyocardial biopsy: a systematic review. J Interv Card Electrophysiol 53:63–71

    Article  PubMed  Google Scholar 

  6. Peretto G, Cappelletti A, Spoladore R et al (2021) Right ventricular endomyocardial biopsy in patients with cardiac magnetic resonance showing left ventricular myocarditis. J Cardiovasc Med 22(7):560–566

  7. Aquaro GD, Perfetti M, Camastra G et al (2017) Cardiac MR with late gadolinium enhancement in acute myocarditis with preserved systolic function: ITAMY study. J Am Coll Cardiol 70:1977–1987

    Article  PubMed  Google Scholar 

  8. Friedrich MG, Sechtem U, Schulz-Menger J et al (2009) International consensus group on cardiovascular magnetic resonance in myocarditis. Cardiovascular magnetic resonance in myocarditis: a JACC white paper. J Am Coll Cardiol 53:1475–1487

    Article  PubMed Central  PubMed  Google Scholar 

  9. Francone M, Chimenti C, Galea N et al (2014) CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis. JACC Cardiovasc Imaging 7:254–263

    Article  PubMed  Google Scholar 

  10. Ammirati E, Cipriani M, Moro C et al (2018) Clinical presentation and outcome in a contemporary cohort of patients with acute myocarditis: multicenter Lombardy registry. Circulation 138:1088–1099

    Article  PubMed  Google Scholar 

  11. Lurz P, Luecke C, Eitel I et al (2016) Comprehensive cardiac magnetic resonance imaging in patients with suspected myocarditis: the MyoRacer-Trial. J Am Coll Cardiol 67(15):1800–1811

    Article  PubMed  Google Scholar 

  12. Kramer CM, Barkhausen J, Flamm SD et al (2013) Standardized cardiovascular magnetic resonance protocols 2013 update. J Cardiovasc Magn Reson 15:91. https://doi.org/10.1186/1532-429X-15-91

    Article  PubMed Central  PubMed  Google Scholar 

  13. Ferreira VM, Schulz-Menger J, Holmvang G et al (2018) Cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations. J Am Coll Cardiol. 72:3158–3176

    Article  PubMed  Google Scholar 

  14. Palmisano A, Benedetti G, Faletti R et al (2020) Early T1 myocardial MRI mapping: value in detecting myocardial hyperemia in acute myocarditis. Radiology 295:316–325

    Article  PubMed  Google Scholar 

  15. Kellman P, Wilson JR, Xue H, Ugander M, Arai AE (2012) Extracellular volume fraction mapping in the myocardium, part 1: evaluation of an automated method. J Cardiovasc Magn Reason 14:63

    Article  Google Scholar 

  16. Aretz HT (1987) Myocarditis: the Dallas criteria. Hum Pathol 18(6):619–624

    Article  CAS  PubMed  Google Scholar 

  17. Ammirati E, Veronese G, Brambatti M et al (2019) Fulminant versus acute nonfulminant myocarditis in patients with left ventricular systolic dysfunction. J Am Coll Cardiol 74:299–311

    Article  PubMed  Google Scholar 

  18. Peretto G, Sala S, Rizzo S et al (2020) Ventricular arrhythmias in myocarditis: characterization and relationships with myocardial inflammation. J Am Coll Cardiol 75:1046–1057

    Article  PubMed  Google Scholar 

  19. Ammirati E, Sormani P, Moroni F et al (2018) Changes of late gadolinium enhancement extension compared with native T1 mapping early after acute myocarditis. Int J Cardiol 257:227

    Article  PubMed  Google Scholar 

  20. Imazio M, Angelico G, Andriani M et al (2018) Prevalence and prognostic impact of septal late gadolinium enhancement in acute myocarditis with or without preserved left ventricular function. Am J Cardiol 122(11):1955–1958

    Article  PubMed  Google Scholar 

  21. Peretto G, Sala S, Basso C et al (2020) Inflammation as a predictor of recurrent ventricular tachycardia after ablation in patients with myocarditis. J Am Coll Cardiol 76:1644–1656

    Article  PubMed  Google Scholar 

  22. Anzini M, Merlo M, Sabbadini G et al (2013) Long-term evolution and prognostic stratification of biopsy-proven active myocarditis. Circulation 128:2384–2394

    Article  PubMed  Google Scholar 

  23. Caforio ALP, Calabrese F, Angelini A et al (2007) A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. Eur Heart J 28:1326–1333

    Article  PubMed  Google Scholar 

  24. Aquaro GD, GhebruHabtemicael Y, Camastra G et al (2019) Prognostic value of repeating cardiac magnetic resonance in patients with acute myocarditis. J Am Coll Cardiol 74:2439–2448

    Article  PubMed  Google Scholar 

  25. Baccouche H, Mahrholdt H, Meinhardt G et al (2009) Diagnostic synergy of non-invasive cardiovascular magnetic resonance and invasive endomyocardial biopsy in troponin-positive patients without coronary artery disease. Eur Heart J 30:2869–2879

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Giovanni Peretto, Paolo Della Bella & Simone Sala

  2. School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, Milan, Italy

    Giovanni Peretto & Antonio Esposito

  3. Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy

    Marco Merlo, Aldostefano Porcari & Gianfranco Sinagra

  4. De Gasperis Cardio ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Piero Gentile, Paola Sormani, Enrico Ammirati & Patrizia Pedrotti

  5. Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Anna Palmisano, Davide Vignale & Antonio Esposito

  6. Department of Cardiac Thoracic Vascular Sciences and Public Health, Cardiovascular Pathology, Padua University, Padua, Italy

    Stefania Rizzo, Monica De Gaspari & Cristina Basso

Authors
  1. Giovanni Peretto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marco Merlo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Piero Gentile
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aldostefano Porcari
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Anna Palmisano
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Davide Vignale
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paola Sormani
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Stefania Rizzo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Monica De Gaspari
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Cristina Basso
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Paolo Della Bella
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Simone Sala
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Enrico Ammirati
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Gianfranco Sinagra
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Antonio Esposito
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Patrizia Pedrotti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Giovanni Peretto.

Ethics declarations

Conflict of interest

The authors declare that there is no conflict of interest.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Peretto, G., Merlo, M., Gentile, P. et al. Cardiac magnetic resonance abnormalities in patients with acute myocarditis proven by septal endomyocardial biopsy. Clin Res Cardiol 112, 392–400 (2023). https://doi.org/10.1007/s00392-022-02103-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-022-02103-1

Keywords

Search

Navigation