Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis

Abstract

BackgroundThe diagnosis of myocarditis is challenging due to its varying clinical presentation. Since myocarditis can be associated with significant 5-year mortality, and postmortem data show myocarditis in almost 10% of all adults suffering sudden cardiac death, individual risk stratification for patients with suspected myocarditis is of great clinical interest. We sought to demonstrate that patients with clinically suspected myocarditis and a normal cardiovascular magnetic resonance (CMR) according to our definition have a good prognosis, independent of their clinical symptoms and other findings.MethodsProspective clinical long-term follow-up of consecutive patients undergoing CMR for work-up of clinically suspected myocarditis at our institution in 2007-2008.ResultsFollow-up was available for n = 405 patients (all-comers, 54.8% inpatients, 38% outpatient referrals from cardiologists). Median follow-up time was 1591 days. CMR diagnosis was “myocarditis” in 28.8%, “normal” in 55.6% and “other pathology” in 15.6%. Normal CMR was defined as normal left ventricular (LV) volumes and normal left ventricular ejection fraction (LV-EF) in the absence of late Gadolinium Enhancement (LGE). The overall mortality was 3.2%. There were seven cardiac deaths during follow-up, in addition one aborted SCD and two patients had appropriate internal cardioverter defibrillator (ICD) shocks – all of these occurred in patients with abnormal CMR. Kaplan-Meier analysis with log-rank test showed significant difference for major adverse cardiac events (cardiac death, sudden cardiac death (SCD), ICD discharge, aborted SCD) between patients with normal and abnormal CMR (p = 0.0003).ConclusionIn our unselected population of consecutive patients referred for CMR work-up of clinically suspected myocarditis, patients with normal CMR have a good prognosis independent of their clinical symptoms and other findings.

Prognosis of Myocardial Damage in Sarcoidosis Patients With Preserved Left Ventricular Ejection Fraction

“…LGE-CMR seems to be a useful predictor of outcome in patients with CS, as well as in other nonischemic myocardial diseases. 6,7 In the study mentioned above, 4 patients with myocardial damage indicated by LGE-CMR had a 9-fold higher rate of adverse events and an 11.5-fold higher rate of cardiac death compared with patients without LGE. Our group has extended these findings in a larger, international multicenter setting consisting of 155 patients with systemic sarcoidosis who underwent CMR for workup of suspected CS.…”

“…However, when discussing LGE imaging and its prognostic implications, it should be kept in mind that there is not a one-to-one relationship between the presence of LGE and the occurrence of adverse events in LGE-positive patients, although LGE-positive patients are at increased risk of having an event. Nevertheless, there is much evidence indicating that LGE-negative patients in nonischemic cardiomyopathies tend to have an excellent prognosis 6,8,11,12 consolidating the role of LGE as a gatekeeper for risk stratification in nonischemic myocardial disease.…”

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

“…W kohorcie 405 pacjentów z podejrzeniem zapalenia mięśnia sercowego wynik CMR był nieprawidłowy u wszystkich pacjentów, którzy zmarli nagłe, przebyli zresuscytowane nagłe zatrzymanie krążenia lub nastąpiło u nich wyładowanie ICD [601]. Ostatnio opisano skuteczną ablację przezcewnikową prądem o częstotliwości radiowej ognisk arytmogennych w nasierdziu u pacjentów z zapaleniem mięśnia sercowego [622].…”

Advanced Imaging of Athletes

“…51,53 CMR has become the noninvasive standard for investigation of myocarditis with sensitivity and specificity of 100% and 90%, respectively, and a diagnostic accuracy of approximately 80%. 54,55 Different CMR sequences have the ability to uncover the pathophysiology of myocarditis by illustrating the increased capillary permeability, myocyte necrosis, and increased extracellular space. 16,48 CMR offers a unique opportunity for assessment of LV dysfunction with LGE.…”