More than 50% of Persistent Myocardial Scarring at One Year in “Infarct-like” Acute Myocarditis Evaluated by CMR

Background: Cardiac magnetic resonance (CMR) has emerged as a reference tool for the non-invasive diagnosis of myocarditis. However, its role in follow-up (FU) after the acute event is unclear. The objectives were to assess the evolution of CMR parameters between the acute phase of infarct-like myocarditis and 12 months thereafter and to identify the predictive factors of persistent myocardial scarring at one year. Methods: All patients with infarct-like acute myocarditis confirmed by CMR were included. CMR was performed within 8 days following symptom onset, at 3 months and at one year. One-year FU included ECG, a cardiac stress test, Holter recording, biological assessments, medical history and a quality-of-life questionnaire. Patients were classified according to the presence or absence of complete recovery at one year based on the CMR evaluation. Results: A total of 174 patients were included, and 147 patients had three CMR. At one year, 79 patients (54%) exhibited persistent myocardial scarring on CMR. A multivariate analysis showed that high peak troponin at the acute phase (OR: 3.0—95%CI: 1.16–7.96—p = 0.024) and the initial extent of late gadolinium enhancement (LGE) (OR: 1.1—95%CI: 1.03–1.19—p = 0.006) were independent predictors of persistent myocardial scarring. Moreover, patients with myocardial scarring on the FU CMR were more likely to have premature ventricular contractions during the cardiac stress test (25% versus 9%, p = 0.008). Conclusion: Less than 50% of patients with infarct-like acute myocarditis showed complete recovery at one year. Although major adverse cardiac events were rare, ventricular dysrhythmias at one year were more frequent in patients with persistent myocardial scarring.

Insights on the left ventricular thrombus in patients with ischemic dilated cardiomyopathy

Background Left ventricular thrombus (LVT) formation represents a common complication of dilated cardiomyopathy (DCM). LVT is usually underestimated with transthoracic echocardiography (TTE) while cardiac magnetic resonance imaging (CMRI) is promising as an alternative imaging modality for cardiac thrombus detection. The study aims to compare TTE and CMRI in their ability to detect LVT, also, to assess the clinical and imaging parameters to determine variables that may predispose for thrombus formation. The study population includes seventy-six patients with ischemic DCM. They were divided into 2 groups based on the presence of LVT as detected by delayed-enhancement CMRI (DE-CMRI) [Group A included 20 patients with a LVT and Group B included 56 patients without]. Results All of the current study population had ischemic DCM with left ventricular ejection fraction (LVEF) < 50%. DE-CMR detected thrombus in 20 cases of the studied population that represented group A. From group A, conventional TTE detected LVT only in 8 and cine-CMR detected 13 cases out of the out of 20 cases. The ejection fraction of the left ventricle as measured by functional CMRI was significantly lower in group A (P = 0.045). Interestingly, the myocardial scarring in group A was seen significantly more extensive than in group B (the P value is < 0.00001), paralleling the increased prevalence of thrombus. Conclusions DE-CMRI provides superiority for the detection of LVT compared with standard TTE or cine-CMRI and the amount of myocardial scarring detected by DE-CMRI can be considered an independent marker for thrombus presence.

Myocardial Scar and Mortality in Chronic Aortic Regurgitation

Background Chronic aortic regurgitation (AR) can be associated with myocardial scarring. It is unknown if scarring in AR is linked to poor outcomes and whether aortic valve replacement impacts this association. We investigated the relationship of myocardial scarring to mortality in chronic AR using cardiac magnetic resonance. Methods and Results We enrolled patients with moderate or greater AR between 2009 and 2019 and performed a blinded assessment of left ventricle remodeling, AR severity, and presence and extent of myocardial scarring by late gadolinium enhancement. The primary outcome was all‐cause mortality. We followed 392 patients (median age 62 [interquartile range, 51–71] years), and 78.1% were men, and 25.8% had bicuspid valves. Median aortic valve regurgitant volume was 39 mL (interquartile range, 30–60). Myocardial scar was present in 131 (33.4%) patients. Aortic valve replacement was performed in 165 (49.1%) patients. During follow‐up, up to 10.8 years (median 32.3 months [interquartile range, 9.8–69.5]), 51 patients (13%) died. Presence of myocardial scar (hazard ratio [HR], 3.62; 95% CI, 2.06–6.36; P <0.001), infarction scar (HR, 4.94; 95% CI, 2.58–9.48; P <0.001), and noninfarction scar (HR, 2.75; 95% CI, 1.39–5.44; P <0.004) were associated with mortality. In multivariable analysis, the presence of scar remained independently associated with death (HR, 2.53; 95% CI, 1.15–5.57; P =0.02). Among patients with myocardial scar, aortic valve replacement was independently associated with a lower risk of mortality (HR, 0.34; 95% CI, 0.12–0.97; P =0.03), even after adjustment for confounders. Conclusions In aortic regurgitation, myocardial scar is independently associated with a 2.5‐fold increase risk in mortality. Aortic valve replacement was associated with a reduction in risk of mortality in patients with scarring.

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors

Aims Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation. Methods and results We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P &lt; 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass &gt;4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005). Conclusions We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

Evaluation of myocardial scarring and perfusion

Myocardial CT perfusion (CTP) imaging is increasingly being used in routine clinical practice as a technique for detecting myocardial ischaemia. CTP offers the advantage of combining anatomical and functional evaluation of coronary stenosis in the same examination and enhances the accuracy of CTA in both patients with suspected and known CAD. This chapter covers contrast pharmacokinetics, scan acquisition, image interpretation, delayed CCT, and evaluation of myocardial perfusion.

Cardiac function and incidence of unexplained myocardial scarring in patients with primary carnitine deficiency - a cardiac magnetic resonance study

Primary carnitine deficiency (PCD) not treated with L-Carnitine can lead to sudden cardiac death. To our knowledge, it is unknown if asymptomatic patients treated with L-Carnitine suffer from myocardial scarring and thus be at greater risk of potentially serious arrhythmia. Cardiac evaluation of function and myocardial scarring is non-invasively best supported by cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE). The study included 36 PCD patients, 17 carriers and 17 healthy subjects. A CMR cine stack in the short-axis plane were acquired to evaluate left ventricle (LV) systolic and diastolic function and a similar LGE stack to evaluate myocardial scarring and replacement fibrosis. LV volumes and ejection fraction were not different between PCD patients, carriers and healthy subjects. However, LV mass was higher in PCD patients with the severe homozygous mutation, c.95 A > G (p = 0.037; n = 17). Among homozygous PCD patients there were two cases of unexplained myocardial scarring and this is in contrast to no myocardial scarring in any of the other study participants (p = 0.10). LV mass was increased in PCD patients. L-carnitine supplementation is essential in order to prevent potentially lethal cardiac arrhythmia and serious adverse cardiac remodeling.