A Review of the Role of Imaging Modalities in the Evaluation of Viral Myocarditis with a Special Focus on COVID-19-Related Myocarditis

Abstract

Viral myocarditis is inflammation of the myocardium secondary to viral infection. The clinical presentation of viral myocarditis is very heterogeneous and can range from nonspecific symptoms of malaise and fatigue in subclinical disease to a more florid presentation, such as acute cardiogenic shock and sudden cardiac death in severe cases. The accurate and prompt diagnosis of viral myocarditis is very challenging. Endomyocardial biopsy is considered to be the gold standard test to confirm viral myocarditis; however, it is an invasive procedure, and the sensitivity is low when myocardial involvement is focal. Cardiac imaging hence plays an essential role in the noninvasive evaluation of viral myocarditis. The current coronavirus disease 2019 (COVID-19) pandemic has generated considerable interest in the use of imaging in the early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related myocarditis. This article reviews the role of various cardiac imaging modalities used in the diagnosis and assessment of viral myocarditis, including COVID-19-related myocarditis.

The Clinical Utility of Molecular Imaging in COVID-19: An Update

“…Although, endomyocardial biopsy (EMB) is considered the gold standard for diagnosing acute myocarditis, there is no specific histopathologic features of COVID-19-related myocarditis, and at present, the European Society of Cardiology (ESC) guidelines do not recommend myocardial biopsy for diagnosing myocarditis in COVID-19 patients. 18 Therefore, noninvasive cardiac imaging such as cardiac MRI and nuclear cardiology exams play a role in diagnosis. 10 Few reports on FDG PET/CT have described increased focal or diffuse uptake as a possible signs of myocardial involvement in COVID-19 patients.…”

Myocarditis and Pericarditis Following the SARS-CoV-2 Infection and COVID-19 Vaccination

“…It is important to note that the American Heart Association (AHA) recommends using at least one imaging modality, like CMR and echocardiography, to confirm the diagnosis of myocarditis-associated COVID-19 [30]. Although CMR provides more high-quality images than echocardiography and is the paramount non-invasive diagnostic tool (31), it has some limitations and makes it unavailable for all COVID-19 patients. However, cardiac CT and ECG can be considered in the absence of CMR and as a suitable alternative to the CMR [23].…”

“…It was recognized that PET/CT is associated with some advantages compared to CMR and can provide a quantity of inflammation. Therefore, PET/CT is indicated for intensive observation of disease progression and response to treatment [31]. There was any study that assessed the sensitivity and specificity of PET scan for myocarditis following COVID-19 infection, but previous studies have shown that PET/CT scan has a 74% and 97% sensitivity and specificity, respectively [32].…”

Oncology and cardiology positron emission tomography/computed tomography faced with COVID-19: A review of available literature data

“…COVID-19 infection can trigger cardiac complications such as acute coronary syndrome (ACS), heart failure, cardiogenic shock, arrhythmias, and myocarditis ( 194 , 195 ). In patients with COVID-19, the pooled incidence of acute myocardial infarction (AMI), heart failure, arrhythmia, cardiac arrest, and ACS was 21, 14, 16, 3.46, and 1.3%, respectively.…”