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Journal ArticleDOI

Comparison of Original and 2018 Lake Louise Criteria for Diagnosis of Acute Myocarditis: Results of a Validation Cohort

25 Jul 2019-Radiology: Cardiothoracic Imaging (Radiological Society of North America)-Vol. 1, Iss: 3
TL;DR: Multiparametric cardiac MRI has a high diagnostic value for the diagnosis of patients clinically suspected of having acute myocarditis and simultaneously validate previously reported cutoff values for parametric mapping techniques.
Abstract: The 2018 Lake Louise criteria provide a high diagnostic accuracy for the diagnosis of acute myocarditis and significantly increase the sensitivity compared with the original score.
Citations
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Journal ArticleDOI
TL;DR: Improved standardization of available invasive and noninvasive diagnostic tools and a consensus on their specific use are needed to allow specific diagnosis and stratification of patient cohorts for the implementation of aetiology-based therapies.
Abstract: Inflammatory cardiomyopathy, characterized by inflammatory cell infiltration into the myocardium and a high risk of deteriorating cardiac function, has a heterogeneous aetiology. Inflammatory cardiomyopathy is predominantly mediated by viral infection, but can also be induced by bacterial, protozoal or fungal infections as well as a wide variety of toxic substances and drugs and systemic immune-mediated diseases. Despite extensive research, inflammatory cardiomyopathy complicated by left ventricular dysfunction, heart failure or arrhythmia is associated with a poor prognosis. At present, the reason why some patients recover without residual myocardial injury whereas others develop dilated cardiomyopathy is unclear. The relative roles of the pathogen, host genomics and environmental factors in disease progression and healing are still under discussion, including which viruses are active inducers and which are only bystanders. As a consequence, treatment strategies are not well established. In this Review, we summarize and evaluate the available evidence on the pathogenesis, diagnosis and treatment of myocarditis and inflammatory cardiomyopathy, with a special focus on virus-induced and virus-associated myocarditis. Furthermore, we identify knowledge gaps, appraise the available experimental models and propose future directions for the field. The current knowledge and open questions regarding the cardiovascular effects associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are also discussed. This Review is the result of scientific cooperation of members of the Heart Failure Association of the ESC, the Heart Failure Society of America and the Japanese Heart Failure Society.

502 citations

Journal ArticleDOI
TL;DR: This research presents a novel probabilistic approach that allows us to assess the importance of knowing the carrier and removal status of canine coronavirus, as a source of infection for other animals.
Abstract: Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.

264 citations

Journal ArticleDOI
TL;DR: The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches for safe return to play as mentioned in this paper.
Abstract: Importance Myocarditis is a leading cause of sudden death in competitive athletes Myocardial inflammation is known to occur with SARS-CoV-2 Different screening approaches for detection of myocarditis have been reported The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches Objective To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play Design, Setting, and Participants Big Ten COVID-19 Cardiac Registry principal investigators were surveyed for aggregate observational data from March 1, 2020, through December 15, 2020, on athletes with COVID-19 For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities Myocarditis prevalence across universities was determined The utility of different screening strategies was evaluated Exposures SARS-CoV-2 by polymerase chain reaction testing Main Outcome and Measure Myocarditis via cardiovascular diagnostic testing Results Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [604%]) Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 23%; range per program, 0%-76%); 9 had clinical myocarditis and 28 had subclinical myocarditis If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 031%) Cardiac magnetic resonance imaging for all athletes yielded a 74-fold increase in detection of myocarditis (clinical and subclinical) Follow-up CMR imaging performed in 27 (730%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (407%) Conclusions and Relevance In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (23%) were diagnosed with clinical and subclinical myocarditis Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing These unique CMR imaging data provide a more complete understanding of the prevalence of clinical and subclinical myocarditis in college athletes after COVID-19 infection The role of CMR in routine screening for athletes safe return to play should be explored further

197 citations

Journal ArticleDOI
TL;DR: CMR parameters fulfilled the revised 2018 Lake Louise criteria for the diagnosis of myocarditis, and a 79-year-old male was moved to the intensive care unit.
Abstract: May 2020 1 Julian Alexander Luetkens, MD * Alexander Isaak, MD* Sebastian Zimmer, MD* Jacob Nattermann, MD Alois Martin Sprinkart, PhD Christoph Boesecke, MD Gereon Jonas Rieke, MD Christian Zachoval, MD Annkristin Heine, MD* Markus Velten, MD* Georg Daniel Duerr, MD* A 79-year-old male was hospitalized due to fatigue, shortness of breath, and recurrent syncopes. He denied symptoms of fever or pain. He had a previous history of asthma. No history of cardiovascular disease was reported, and previous cardiac check-ups were unremarkable (last described left ventricular ejection fraction was 65%). Initial physical examination in the emergency department revealed heart rate of 75 bpm, blood pressure of 101/64 mm Hg, body temperature of 35.6°C, oxygen saturation of 94%, and moderate wheezing on auscultation. On initial blood test, CRP (C-reactive protein) was measured at 13.80 mg/L and high sensitive troponin T at 18.8 ng/L, but leucocyte blood count and NT-proBNP (N-terminal prohormone of brain natriuretic peptide) were normal. Electrocardiogram, chest x-ray, and echocardiography were normal. Patient was referred for contrast-enhanced computed tomography to rule out pneumonia or pulmonary embolism that revealed pulmonary ground-glass peripheral infiltrates in the left upper lobe and discrete pleural and pericardial effusions (Figure 1). Because of the outbreak of coronavirus disease 2019 (COVID-19), a nasopharyngeal swab was performed at admission, real-time reverse transcriptasepolymerase chain reaction assay returned positive for severe acute respiratory syndrome coronavirus 2. Due to respiratory and hemodynamic worsening, the patient was moved to the intensive care unit. Blood tests showed an increase in CRP (64.23 mg/L), leucocyte blood count (14.60 g/L), troponin T (63.5 ng/L), and NT-proBNP (1178.0 pg/mL). Cardiac magnetic resonance (CMR) was performed at 1.5 T at day 10 after admission (Figure 2). CMR analysis showed normal left ventricular size (left ventricular end-diastolic volume index: 68 mL/ m2; left ventricular mass index 42 g/m2) and mild systolic dysfunction (left ventricular ejection fraction: 49%) with discrete global hypokinesis, and normal right ventricular volume and function (Movies I and II in the Data Supplement). Pericardial effusion was confirmed, localized mainly around the left ventricular lateral wall (≈10 mm). T2-weighted short TI inversion recovery sequences displayed diffuse interstitial myocardial edema with an increased T2 signal intensity ratio. Presence of diffuse myocardial inflammation was confirmed by T2 mapping (global T2 relaxation times: 62 ms; center-specific cutoff value for acute myocarditis: ≥55.9 ms; global myocardial T2 relaxation time represents a mean value of all 16 heart segments).1 Late-gadolinium enhancement imaging (inversion time by using the Look-Locker technique: 240 ms) was negative for focal myocardial lesions, but prolonged T1 relaxation times could be measured (global T1 relaxation times: 1035 ms; center-specific cutoff value for acute myocarditis: ≥1000 ms; global myocardial T1 relaxation time represents a mean value of all 16 heart segments).1 CMR parameters fulfilled the revised 2018 Lake Louise criteria for the diagnosis of myocarditis.2 Medical treatment © 2020 American Heart Association, Inc. CARDIOVASCULAR IMAGES

74 citations

References
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Journal ArticleDOI
TL;DR: The aims are to bridge the gap between clinical and tissue-based diagnosis, to improve management and provide a common reference point for future registries and multicentre randomised controlled trials of aetiology-driven treatment in inflammatory heart muscle disease.
Abstract: In this position statement of the ESC Working Group on Myocardial and Pericardial Diseases an expert consensus group reviews the current knowledge on clinical presentation, diagnosis and treatment of myocarditis, and proposes new diagnostic criteria for clinically suspected myocarditis and its distinct biopsy-proven pathogenetic forms. The aims are to bridge the gap between clinical and tissue-based diagnosis, to improve management and provide a common reference point for future registries and multicentre randomised controlled trials of aetiology-driven treatment in inflammatory heart muscle disease.

2,265 citations

Journal ArticleDOI
TL;DR: The International Consensus Group on CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis.

2,004 citations

Journal ArticleDOI
TL;DR: A novel pulse sequence scheme is presented that allows the measurement and mapping of myocardial T1 in vivo on a 1.5 Tesla MR system within a single breath‐hold and provides high‐resolution T1 maps of human myocardium in native and post‐contrast situations within asingle breath-hold.
Abstract: A novel pulse sequence scheme is presented that allows the measurement and mapping of myocardial T1 in vivo on a 1.5 Tesla MR system within a single breath-hold. Two major modifications of conventional Look-Locker (LL) imaging are introduced: 1) selective data acquisition, and 2) merging of data from multiple LL experiments into one data set. Each modified LL inversion recovery (MOLLI) study consisted of three successive LL inversion recovery (IR) experiments with different inversion times. We acquired images in late diastole using a single-shot steady-state free-precession (SSFP) technique, combined with sensitivity encoding to achieve a data acquisition window of <200 ms duration. We calculated T1 using signal intensities from regions of interest and pixel by pixel. T1 accuracy at different heart rates derived from simulated ECG signals was tested in phantoms. T1 estimates showed small systematic error for T1 values from 191 to 1196 ms. In vivo T1 mapping was performed in two healthy volunteers and in one patient with acute myocardial infarction before and after administration of Gd-DTPA. T1 values for myocardium and noncardiac structures were in good agreement with values available from the literature. The region of infarction was clearly visualized. MOLLI provides high-resolution T1 maps of human myocardium in native and post-contrast situations within a single breath-hold. Magn Reson Med 52:141–146, 2004. © 2004 Wiley-Liss, Inc.

1,131 citations

Journal ArticleDOI
TL;DR: This JACC Scientific Expert Panel provides consensus recommendations for an update of the cardiovascular magnetic resonance (CMR) diagnostic criteria for myocardial inflammation in patients with suspected acute or active myocardian inflammation (Lake Louise Criteria) that include options to use parametric mapping techniques.

1,092 citations

Journal ArticleDOI
TL;DR: This document provides a summary of the existing evidence for the clinical value of parametric mapping in the heart as of mid 2017, and gives recommendations for practical use in different clinical scenarios for scientists, clinicians, and CMR manufacturers.
Abstract: Parametric mapping techniques provide a non-invasive tool for quantifying tissue alterations in myocardial disease in those eligible for cardiovascular magnetic resonance (CMR). Parametric mapping with CMR now permits the routine spatial visualization and quantification of changes in myocardial composition based on changes in T1, T2, and T2*(star) relaxation times and extracellular volume (ECV). These changes include specific disease pathways related to mainly intracellular disturbances of the cardiomyocyte (e.g., iron overload, or glycosphingolipid accumulation in Anderson-Fabry disease); extracellular disturbances in the myocardial interstitium (e.g., myocardial fibrosis or cardiac amyloidosis from accumulation of collagen or amyloid proteins, respectively); or both (myocardial edema with increased intracellular and/or extracellular water). Parametric mapping promises improvements in patient care through advances in quantitative diagnostics, inter- and intra-patient comparability, and relatedly improvements in treatment. There is a multitude of technical approaches and potential applications. This document provides a summary of the existing evidence for the clinical value of parametric mapping in the heart as of mid 2017, and gives recommendations for practical use in different clinical scenarios for scientists, clinicians, and CMR manufacturers.

996 citations

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