Research Presentation Session

Myocarditis and MINOCA syndromes

NOT AVAILABLE

Lectures

1
RPS 1803 - Mapping cardiac magnetic resonance (CMR) for early prediction of unfavourable left ventricle remodelling in acute myocarditis: a MIAMI study

RPS 1803 - Mapping cardiac magnetic resonance (CMR) for early prediction of unfavourable left ventricle remodelling in acute myocarditis: a MIAMI study

05:22A. Palmisano, Milan / IT

Purpose:

A pixel-wise mapping technique resulted in more sensitive than conventional CMR images in the diagnosis of acute myocarditis. The role in the detection of subtle inflammation is still under investigation and imaging predictors of outcomes are still largely unknown.

Methods and materials:

68 patients with clinical suspicions of myocarditis underwent cardiac MR (CMR) at a 1.5T scanner for the evaluation of morpho-functionality, hyperaemia with ce-SSFP images, oedema with STIR and T2 mapping, scarred myocardium with LGE, native-T1, and ECV. When clinically indicated endomyocardial biopsy (EMB) was performed, a second CMR was performed 2 months after baseline. 45 healthy volunteers underwent CMR as the control group.

Results:

Acute myocarditis was confirmed in 45 patients by both CMR and EMB. An Infarct-like presentation was the most frequent (25 patients, 56%).

At baseline CMR, LV-EDV was 135 ml with EF.53%, LL criteria were positive (T2-ratio: 2.8, Hyperemia: 13%, LGE: 6%), and T1, T2 mapping, and ECV were significantly higher than normal values without difference among clinical presentation (p>0.05).

Mapping parameters showed excellent diagnostic accuracy in the acute (AUC: 95%, 98%, and 90% for T1 map, T2 map, and ECV) and convalescent phases (90%, 85%, and 89% for T1 map, T2 map, and ECV).

At short-term follow-up, a slight recovery of EF was experimented on with a reduction of all LL and mapping parameters. The modification of native-T1 values correlated to the recovery of EDV (R=0.8242, p=0.0005) and ejection fraction (R= -0.4559, p=0.0378).

Conclusion:

Lower recovery of T1 value in the convalescent phase is associated with higher EDV and lower EF.

Limitations:

A imited sample size and relatively short follow-up.

Ethics committee approval

The study was approved by Institutional Review Board. Aall study participants signed informed consent.

Funding:

The study was granted by the Italian Ministery of Health.

2
RPS 1803 - Agreement between old and new Lake Louise criteria for the diagnosis of acute myocarditis with a different clinical onset

RPS 1803 - Agreement between old and new Lake Louise criteria for the diagnosis of acute myocarditis with a different clinical onset

05:56G. Cundari, Rome / IT

Purpose:

To compare the diagnostic performance of old and new Lake Louise criteria (oLLC and nLLC) in suspected acute myocarditis patients among various clinical presentations: infarct-like [IL], cardiomyopathic [CM], and arrhythmic [A].

Methods and materials:

110 patients with a clinical suspicion of acute myocarditis underwent 1.5T cardiac magnetic resonance. The protocol included cine–SSFP, T2wSTIR, early and late gadolinium-enhancement, T2-mapping, and native and post-Gd T1-mapping. 3 patients were excluded for unknown clinical hystory. Cohen’s k test was used to assess the level of agreement and a McNemar test to compare the diagnostic proportion between oLLC and nLLC among different clinical presentations.

Results:

The frequency of clinical presentations were 56/107 (52%) IL, 29/107 (27%) CM, and 22/107 (20.5%) A. A diagnosis was performed in 45/110 (40.9%) patients with oLLC and in 69/110 (62.7%) with nLLC [k=0,48[0,33-0,62], p<0.01. A statistically significant difference in the agreement of oLLC and nLLC was found for CM and A presentations [15/29(51,7%) vs 7/29(24,1%), k= 0,46[0,19-0,73] p<0.01 and 11/22(50%) vs 4/22(18,2%), k=0,36[0,063-0,66], p<0.05, respectively]. No statistical difference was found for IL onset [nLLC 41/56(73,2%) vs oLLC 33/56(58,9%), k=0,45[0,22-0,69], p>0.05].

Mapping sequences allowed for the diagnosis of acute myocarditis when oLCC were negative in 5/56 (9%) for IL, 3/29 (10%) for CM, and 4/22 (18%) for A. In particular, with T1-mapping and ECV, T1 criterion was met in 9/56 (16%) IL, 7/29 (24%) CM, and 8/22 (36%) A onset (p>0.05), and, with T2-mapping, T2 criterion in 13/56 (23%) IL, 9/29 (31%) CM, and 8/22 (36%) A onset (p>0.05).

Conclusion:

The degree of agreement between oLLC and nLLC was moderate for overall, IL, and CM presentations, and fair for A. nLLC allowed for a diagnosis of more acute myocardites than oLLC in CM and A onsets.

Limitations:

Bioptic diagnosis of acute myocarditis was made only in few patients.

Ethics committee approval

Informed consent was obtained.

Funding:

No funding was received for this work.

3
RPS 1803 - Early T1 shortening (eT1sh): a new CMR parameter to detect myocardial hyperemia in acute myocarditis

RPS 1803 - Early T1 shortening (eT1sh): a new CMR parameter to detect myocardial hyperemia in acute myocarditis

06:24A. Palmisano, Milan / IT

Purpose:

To evaluate T1-mapping based approaches for the quantification of hyperemia in patients with acute myocarditis.

Methods and materials:

55 subjects (40 patients with acute myocarditis [AM]; 15 age- and sex-matched healthy control subjects [HC]) underwent 1.5T CMR. T1 mapping was acquired before (native T1) and 2 minutes after gadoliunium administration (early-enhanced T1). 3 different T1 mapping-based parameters were calculated: early enhanced T1-rt (eT1), early T1-rt shortening (eT1sh), and early relative T1-rt shortening (erT1sh). Optimal cut-off values and their diagnostic performances in the identification of AM were calculated.

Results:

In AM patients, median eT1 was 275.6 ms [252-297], eT1sh was 75% [73%-78%], and erT1sh was 2.15 [1.83-2.59], all being significantly higher with respect to HC (p=0.0014, p<0.0001, and p<0.0001, respectively). eT1sh showed the best diagnostic performance with excellent AUC (97%, 95% confidence interval, CI: [93%-100%]). A reduction of eT1sh ≥69.5% identified AM with very high sensitivity (93%), specificity (100%), NPV (83%), PPV (100%), and accuracy (95%). eT1 had a good AUC (92.5%, 95% CI: [86%-99%]), slightly worse than eT1sh. eT1≤331 ms identified AM with 93% sensitivity, 87% specificity, 81% NPV, 95% PPV, and 91% accuracy. erT1sh showed the worst diagnostic performance with 78% AUC (95% CI: [66%-91%]). erT1sh>1.9 identified AM with 68% sensitivity, 87% specificity, 50% NPV, 93% PPV, and 73% accuracy.

Conclusion:

eT1sh showed the best diagnostic performance in the identification of AM. It can be a promising alternative method for the detection of hyperemia in AM.

Limitations:

A relatively small sample size.

Ethics committee approval

The study was approved by the Institutional Review Board. Written informed consent was obtained.

Funding:

The study was partially granted by the Italian Ministery of Health

4
RPS 1803 - Derived-CMR strain efficacy in myocardial inflammation: a retrospective comparison with standard practice

RPS 1803 - Derived-CMR strain efficacy in myocardial inflammation: a retrospective comparison with standard practice

06:14P. Palumbo, L'Aquila / IT

Purpose:

A major role in the diagnosis of myocarditis is played by new CMR-based biomarkers. The aim of the study was to investigate the diagnostic capabilities of tissue-tracking (TT) strain analysis in patients with a CMR-based diagnosis of myocarditis.

Methods and materials:

43 patients with a CMR-based diagnosis of myocarditis according to the standard Lake Louise criteria were retrospectively analysed. 27 healthy participants were selected as a control group. Cine-RM data was used for the analysis. Dedicated TT-software was used to perform radial, circumferential, and longitudinal strain for global, per-plane (basal, middle, and apical), and segmental (AHA 16-segments standard) evaluation in short and long-axis left ventricle images.

Results:

Patients with myocarditis showed significantly reduced LV radial and circumferential strain values, both in global and per-plane evaluation (GRS: 23.39 ±7.16% vs. 31 ±7.15%)(GCS: -14.90 ±3.69% vs. -18.21 ±2.52%)(RSbas: 21.92 ±6.47% vs. 29.25 ±6.28%)(CSbas: -14.21 ±3.38 vs. -17.50 ±2.46%), compared with healthy participants. Good accuracy was found according to the ROC analysis (AUC up to 0.824). No significant correlations were found with oedema, while a significant correlation was found between segmental radial and LE (p-value:0.019), and an interesting trend between segmental circumferential and LE (p-value:0.087).

Conclusion:

Tissue-tracking strain analysis has proved accurate in the evaluation of patients diagnosed with myocarditis based on standard Lake Louise criteria. Tissue-tracking strain analysis could improve diagnostic accuracy in clinical practice, adding useful information over the standard findings.

Limitations:

A lack of mapping sequence, especially in elderly examination, does not permit an adequate comparison with revisited Lake Louis criteria.

Ethics committee approval

The study was conducted in accordance with the declaration of Helsinki.

Funding:

No funding was received for this work.

5
RPS 1803 - A multiparametric native CMR approach to acute and chronic cardiac diseases with increased myocardial mass using mapping and feature-tracking strain

RPS 1803 - A multiparametric native CMR approach to acute and chronic cardiac diseases with increased myocardial mass using mapping and feature-tracking strain

06:17M. Halfmann, Mainz / DE

Purpose:

The diagnoses of acute myocarditis (AM) and hypertensive heart disease (HHD) remain difficult and are commonly based on a combination of clinical expertise and a multi-parameter diagnostic workup including contrast-enhanced cardiac magnetic resonance imaging (CMR). It was our purpose to evaluate a multiparametric set of native imaging parameters for their diagnostic accuracy.

Methods and materials:

A total of 33 AM and 21 HHD patients who had been referred to our department between 09/2014 and 09/2017, as well as 50 carefully selected healthy volunteers, (HV) underwent CMR at 3T. Subsequent feature-tracking strain analysis and native T1/T2 mapping were performed and results were processed in the form of binary logistic regressions. Cut-off values, areas under the curve (AUC), and corresponding sensitivities and specificities were derived from receiver operator characteristic curves.

Results:

For HV vs AM, the combination of global circumferential strain, myocardial mass per body surface area (MYM), and T1 values performed best (AUC .92, 94% sensitivity, 76% specificity). In HV vs HHD, the triad of global longitudinal strain, MYM, and T1 values discriminated best between groups (AUC of .99, 100% sensitivity, 84% specificity), and in AM vs HHD, the combination of GLS, MYM, and T2 values outperformed all others (AUC .92, 90% sensitivity, 76% specificity).

Conclusion:

Different distinct pathophysiologies behind the diseases lead to different sets of best-performing parameters. The proposed multiparametric approaches were able to precisely discriminate between healthy individuals and patients, as well as different patient populations, without the need for contrast agents.

Limitations:

The retrospective design prevented endomyocardial biopsies as the current gold standard for diagnosing AM. However, because of the invasiveness and possible sampling errors, only few patients routinely have biopsies in clinical routine.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

6
RPS 1803 - Gender-neutral FT-CMR strain ratios improve the discriminatory accuracy in acute and chronic heart conditions

RPS 1803 - Gender-neutral FT-CMR strain ratios improve the discriminatory accuracy in acute and chronic heart conditions

06:10M. Halfmann, Mainz / DE

Purpose:

Hypertensive heart disease (HHD) and acute myocarditis (AM) can both present with increased myocardial mass despite different pathophysiology. The differentiation between them remains difficult. The accompanying distinct patterns of altered myocardial deformation, however, can be investigated using a feature tracking (FT)-CMR strain. Hence, the aim was to evaluate whether new strain ratios including the myocardial mass per body surface area (MyoMass/BSA) yield additional value in the differentiation between both diseases and healthy volunteers.

Methods and materials:

Patients with AM (n=43) and HHD (n=28) underwent CMR at 3T between 09/2014 and 09/2017. A group of 61 healthy volunteers (HV) served as normal controls. FT-strain analysis was performed and natural strain values were evaluated for gender and age-specific differences. Subsequently, gender-neutral strain parameters were calculated and indexed to the MyoMass/BSA, leading to ratio strains. These were then evaluated for their discriminatory accuracy by means of areas under the curve (AUC), sensitivity, and specificity.

Results:

There were statistically significant differences in strains between genders (p<0.05) but not between age groups. For the differentiation between HV and AM, the global circumferential strain ratio performed best (AUC 0.86, 79% sensitivity, and 82% specificity). In discriminating between HV and HHD, as well as AM and HHD, the global longitudinal strain ratio outperformed all other parameters (AUCs 0.96/0.79, 92%/89% sensitivity, and 86%/66% specificity, respectively).

Conclusion:

The calculated ratios provide additional value in the differentiation of diseases with increased myocardial mass. As there is no need for additional sequences, time, or even contrast agents, strain ratios have the potential to be a powerful addition into currently developing multiparametric native diagnostic approaches.

Limitations:

The etrospective design did not allow for endomyocardial biopsies.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

7
RPS 1803 - Cardiac CT with triple-rule-out (TRO) and late iodine enhancement (LIE) acquisition in the evaluation of patients presenting with acute troponin elevation

RPS 1803 - Cardiac CT with triple-rule-out (TRO) and late iodine enhancement (LIE) acquisition in the evaluation of patients presenting with acute troponin elevation

06:03D. Vignale, Milan / IT

Purpose:

To evaluate the diagnostic yield of the late iodine enhancement (LIE) acquisition added to the triple-rule-out CT (TRO-CT) performed in patients presenting with acute symptoms and troponin elevation without clinical/electrocardiography criteria for acute myocardial infarction (AMI).

Methods and materials:

60 consecutive patients with acute symptoms, troponin elevation, and no diagnostic criteria for AMI underwent TRO-CT to diagnose acute aortic syndromes, obstructive coronary artery disease (CAD-RADS≥4), and pulmonary embolism (PE).

Patients with a negative TRO-CT underwent LIE acquisition to evaluate the presence and pattern of LIE and to quantify the myocardial extracellular volume fraction (ECV).

Obstructive CAD was confirmed by invasive coronary angiography and myocardial disease by cardiac magnetic resonance.

Results:

The male to female ratio was 35:25. The median age was 71 years [IQR=47-78]. Peak median troponinT (n=46) was 49.0 ng/L[IQR=20.4-195.7] and peak median troponinI (n=14) was 4.1 ng/L[IQR=1.2-11.8]. Reported symptoms were chest pain (n=31[51%]), dyspnoea (n=16[26%]), palpitations (n=6[11%]), loss of consciousness (n=5[8%]), and other (n=14[23%]).

TRO-CT identified 19 (32%) obstructive CAD, 1 (1%) acute aortic syndrome, 5 (8%) PE, 1 (1%) CAD+PE, and 1 (1%) CAD+acute aortic syndrome.

LIE acquisition was performed in the remaining 33 (55%) TRO-negative patients.

2 (3%) had LIE with ischemic pattern, 16 (27%) LIE with non-ischemic pattern [13 (22%) myocarditis, 3 (5%) idiopathic dilated cardiomyopathy], 3 (5%) increased ECV suggestive for amyloidosis, 2 (3%) cardiac metastasis, 2 (3%) tako-tsubo cardiomyopathy, 1 (1%) pericarditis, and 1 (1%) basal hyperdensity of myocardium suggestive for haemosiderosis.

6 (10%) patients were negative to TRO and LIE and did not report major cardiovascular adverse events after a mean follow-up of 419 days.

Conclusion:

LIE acquisition increases the diagnostic value of TRO-CT, finding a diagnosis in 82% of TRO-negative patients and allowing a safe discharge of TRO- and LIE-negative patients.

Limitations:

A single-centre study, small sample size, and short follow-up.

Ethics committee approval

The study was approved by the institutional review board.

Funding:

No funding was received for this work.

8
RPS 1803 - Pericardial effusion is a marker of increased cardiac mortality in thalassemia major patients

RPS 1803 - Pericardial effusion is a marker of increased cardiac mortality in thalassemia major patients

05:09A. Meloni, Pisa / IT

Purpose:

This is the first prospective study evaluating if the presence of pericardial effusion (PE) is associated with increased cardiac mortality in thalassemia major (TM).

Methods and materials:

1,259 patients (648 females, 31.02±8.64 years) enrolled in the MIOT were prospectively followed from their first CMR scan. CMR was used to quantify myocardial iron overload (MIO) by a multislice T2* approach and to assess biventricular function parameters and PE by cine sequences.

Results:

PE was present in 25 (2.0%) patients. Patients with and without PE were comparable for age, sex, percentage of patients with MIO (global heart T2*<20 ms), and biventricular parameters. The mean follow-up time was 44.55±20.35 months and there were 15 deaths, 9 due to cardiac causes. Cardiac mortality was greater for patients with PE versus those without PE (8.0% vs 0.6%, P=0.013). PE was a significant predictive factor for cardiac death (hazard ratio-HR=19.25, 95%CI=3.96-93.66, P<0.0001. PE remained a significant prognosticator for death also in a multivariate model including MIO.

Conclusion:

PE is quite rare in TM patients and is not related to MIO, but an important role in its development could be played by the 'iron-induced' pericardial siderosis. PE is a strong predictor for cardiac death, independent from the presence of MIO. The non-invasive diagnosis of PE is important for a more complete definition of the cardiac involvement of TM patients and the estimation of the prognosis.

Limitations:

A low number of events.

Ethics committee approval

The study complied with the Declaration of Helsinki. All patients gave their informed consent. The project was approved by the institutional ethics committee.

Funding:

The MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and ApoPharma Inc.).