MRI in Myocarditis MRI in Myocarditis Faculty of Medicine, - - PowerPoint PPT Presentation

Ružica Maksimović Ružica Maksimović

MRI in Myocarditis MRI in Myocarditis

Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia

XVth Balkan Congress of Radiology

Danubius Hotel Helia, 12-14 October 2017, Budapest, Hungary

XVth Balkan Congress of Radiology

Danubius Hotel Helia, 12-14 October 2017, Budapest, Hungary

Myocarditis in association with cardiac dysfunction (involved in the pathogenesis of DCM) Idiopathic Autoimmune Infectious subtypes

Caforio, Pankuweit et al. Eur Heart J 2013

Dg & Treatment of Myocarditis: ESC Consensus 2013

Definition of Inflammatory Cardiomyopathy

• WHF/ISFC expert pannel in 1997 set the immunhistochemical criteria:

Minimum of 14 activated lymphocytes/mm2 is neccessary for the diagnosis (diffuse or focal infiltrates with or without signs of hypertrophy or fibrosis Viral cardiomyopathy: viral persistence in a dilated heart Inflammatory viral cardiomyopathy (or viral myocarditis with cardiomegaly)

Caforio, Pankuweit et al. Eur Heart J 2013

Etiology of Myocarditis

Kawai C. From myocarditis to cardiomyopathy: mechanisms of inflammation and cell death: learning from the past for the future. Circulation 1999;99:1091–100.

Development of Myocarditis

Clinical Presentations:

Caforio, Pankuweit et al. Eur Heart J 2013

• Acute chest pain, pericarditic or pseudo-

ischaemic

• New-onset (days up to 3 mths) or

worsening of: dyspnoea at rest or exercise, and/or fatigue, with or without left and/or right heart failure signs

• Subacute/Chronic (>3 months) or

worsening of: dyspnoea at rest or exercise, and/or fatigue, with or without left and/or right heart failure signs

• Palpitation, and/or unexplained

arrhythmia symptoms and/or syncope, and/or aborted sudden cardiac death

• Unexplained cardiogenic shock

Dg & Treatment of Myocarditis: ESC Consensus 2013

Diagnostic Criteria for Suspected Myocarditis

Newly abnormal 12 lead ECG and/or Holter and/or stress testing:

• I to III° AV, or bundle branch

block,

• ST/T wave change
• sinus arrest
• VT or VF and asystole, AF
• reduced R wave height,

intraventricular conduction delay (widened QRS complex), abnormal Q waves,

• low voltage, frequent PVCs,

PSVT

I I I I I I I I II II II II II II II II III III III III III III III III aVR aVR aVR aVR aVR aVR aVR aVR aVL aVL aVL aVL aVL aVL aVL aVL aVF aVF aVF aVF aVF aVF aVF aVF V V V V1

1 1 1

V V V V1

1 1 1 2 2 2 2

V V V V V V V V2

2 2 2

V V V V3

3 3 3

V V V V3

3 3 3

V V V V4

4 4 4

V V V V4

4 4 4

V V V V5

5 5 5

V V V V5

5 5 5

V V V V6

6 6 6

V V V V6

6 6 6

Dg & Treatment of Myocarditis: ESC Consensus 2013

Diagnostic Criteria for Suspected Myocarditis

Caforio, Pankuweit et al. Eur Heart J 2013

I ECG/Holter/stress test features

• Eevated TnT/TnI
• II. Myocardiocytolysis markers
• III. Functional and structural abnormalities on

cardiac imaging (echo/angio/CMR)

New, otherwise unexplained LV and/or RV structure and function abnormality:

• regional wall motion or global systolic or diastolic

function abnormality,

• with or without ventricular dilatation,
• with or without increased wall thickness,
• with or without pericardial effusion,
• with or without endocavitary thrombi.
• IV. Tissue characterisation by CMR
• Oedema and/or LGE of myocarditic pattern

Dg & Treatment of Myocarditis: ESC Consensus 2013

Diagnostic Criteria for Suspected Myocarditis

Caforio, Pankuweit et al. Eur Heart J 2013 Before Treatment After Treatment

Caforio, Pankuweit et al. Eur Heart J 2013

≥2 criteria

Dg & Treatment of Myocarditis: ESC Consensus 2013

Diagnostic Criteria for Suspected Myocarditis Lake Louise Consensus Criteria

Friedrich M. Circ Cardiovasc Imaging 2013:6:833.

Most Important Indications for CMR in Patients with Suspected Myocarditis

Kindermann I. J Am Coll Cardiol 2012;59:779.

Case Presentation – Biopsy Positive Myocarditis

MRI

LV EDD 57 mm LV ESD 36 mm IVS 10 mm PW 10 mm EF 62%, EDV 159 mm, ESV 64 ml RV EDD 24 mm EF 58%, EDV 149 mm, ESV 63 ml

Case Presentation – Biopsy Positive Myocarditis

MRI

Before CM After CM

• Male, 18 years, was examined

due to dry cough, chest pain

• Echocardiography revealed

enlarged, hypocontractile LV Case Presentation

Medical History

LV EDD 80 mm LV ESD 74 mm IVS 9 mm PW 9 mm RV EDD 41 mm LV EF 25% LVEDV 340 ml LVESV 240 ml

Case Presentation

Medical History

• Male, JS, 20 years
• Echocardiography showed

transient pericardial effusion with constrictive physiology, no regional wall motion abnormalities of the LV

• Elevated serum troponin
• Chest x-ray, bilateral pleural

effusion

• Therapy:

nonsteroidal anti-inflammatory drugs

Case Presentation –Myopericarditis

Medical History

Cine TrueFISP TSE T2w FS

LV EDD 53 mm LV ESD 31 mm IVS 10 mm PW 9 mm

Case Presentation –Myopericarditis

MRI

LVEF 66% LVEDV 151 mm LVESV 51 ml SV 100 ml

Case Presentation

Medical History

• Male, 22 years admitted to the

hospital due to suspected acute coronary syndrom

• Had acute chest pain for an hour
• Coronarography

Normal finding

• ECG

Sinus rhythm, elevation of ST segment

• Laboratory

Troponin L 4 230 (0-0.04 ug/L) BNP 894 (0-73 pg/ml) C reactive protein 295.6 (0-8 mg/L) Variations of Troponin L (April 22, 7680, April 23, 10720, April 27, 4 230)

• Treatment

Antiaggregation therapy Nonsteroid antrheumatic Blockers of H2 receptors and inhibitors of proton pump

Electron Micrograph of a Parvovirus

Case Presentation

MRI

LV EDD 52 mm LV ESD 33 mm IVS 9 mm PW 9 mm RV EDD 32 mm April 29, 2015 LV EF 35% LV EDV 180 ml LV ESV 117 ml

Case Presentation

MRI

Case Presentation

MRI

Case Presentation

MRI – Follow-up

LV EDD 50 mm LV ESD 38 mm IVS 9 mm PW 9 mm RV EDD 25 mm July 8, 2015 LV EF 64% LV EDV 145 ml LV ESV 117 ml Recovery !

Case Presentation

MRI – Follow-up

Before Contrast After Contrast

Case Presentation

MRI – Myocarditis

X X

Case Presentation

US – Peak Longitudinal Strain in Myocarditis

CMR Results in Relation to ECG and Troponin

Florian A. Clin Res Cardiol 2015:104:154. ECG – ST elevation (I, V2-V6)

Clinical and MRI Parameters as Predictors of Outcome In Pediatric Myocarditis

Sachdeva S. Am J Cardiol 2015:15:499. N-58 pts

16 year old male patient with chest pain, dyspnea and flu-like symptoms with troponin T elevation, ECG ST elevation V2 to

• V6. LGE showed extensive hyperenchancement with

subepicardial distribution in the inferior, lateral and anterior wall and septum.

Summary of Recommended Components of The CMR Report for Myocarditis

Friedrich M. JACC 2009:53:17. Presence or absence of markers for inflammatory activity and injury of ST

• T2 signal/edema (regional edema or global T2 ratio)
• Calculated global myocardial myocardial early

gadolinium enhancement ratio

• Myocardial late gadolinium enhancement with non-

ischemic regional distribution

• LV end-diastolic volume and volume index
• LV end-systolic volume and volume index
• Ejection fraction
• Cardiac index
• LV mass and mass index

LV volume and function Conclusion

Based on the presence or absence of 2 or more criteria, considering additional evidence by the presence of LV dysfunction and/or pericardial effusion

Recommendation for follow up

Based on clinical setting A follow-up >4 weeks after the onset of symptoms may have prognostic implications and thus is recommended.

• M. Friedrich. Circ Cardiovasc Imaging 2013:6:833.

Conclusions

• MRI has the most comprehensive and

accurate disgnostic tool in patients with suspected myocarditis;

• Verifies or exculeds myocardial

inflammation and reversibel irreversible injury;

• MRI has an impact on therapeutic

decision making and could provide a new, unexpected diagnosis;

• MRI is a predictor of functional and

clinical recovery and death;

• Important for selection of patients for

endomyocardial biopsy.

Structured Reporting

Heart Function and Morfology Edema Hyperemia Necrosis/Scar Pericardial Effusion Associate Finding in Thorax

Ružica Maksimović Ružica Maksimović

MRI in Myocarditis MRI in Myocarditis

Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia

XVth Balkan Congress of Radiology

Danubius Hotel Helia, 12-14 October 2017, Budapest, Hungary

XVth Balkan Congress of Radiology

Danubius Hotel Helia, 12-14 October 2017, Budapest, Hungary

ruzica.maksimovic@med.bg.ac.rs ruzica.maksimovic@med.bg.ac.rs