XVth Balkan Congress of Radiology Danubius Hotel Helia, October 2017, Budapest, Hungary

Transcription

1 XVth Balkan Congress of Radiology Danubius Hotel Helia, October 2017, Budapest, Hungary Ružica Maksimović MRI in Myocarditis Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia

2 Dg & Treatment of Myocarditis: ESC Consensus 2013 Definition of Inflammatory Cardiomyopathy Caforio, Pankuweit et al. Eur Heart J 2013 Myocarditis in association with cardiac dysfunction (involved in the pathogenesis of DCM) Idiopathic Autoimmune Infectious subtypes WHF/ISFC expert pannel in 1997 set the immunhistochemical criteria: Minimum of 14 activated lymphocytes/mm 2 is neccessary for the diagnosis (diffuse or focal infiltrates with or without signs of hypertrophy or fibrosis Viral cardiomyopathy: viral persistence in a dilated heart Inflammatory viral cardiomyopathy (or viral myocarditis with cardiomegaly)

3 Etiology of Myocarditis Caforio, Pankuweit et al. Eur Heart J 2013

4 Development of Myocarditis Kawai C. From myocarditis to cardiomyopathy: mechanisms of inflammation and cell death: learning from the past for the future. Circulation 1999;99:

5 Dg & Treatment of Myocarditis: ESC Consensus 2013 Diagnostic Criteria for Suspected Myocarditis Clinical Presentations: Caforio, Pankuweit et al. Eur Heart J 2013 Acute chest pain, pericarditic or pseudoischaemic New-onset (days up to 3 mths) or worsening of: dyspnoea at rest or exercise, and/or fatigue, with or without left and/or right heart failure signs Subacute/Chronic (>3 months) or worsening of: dyspnoea at rest or exercise, and/or fatigue, with or without left and/or right heart failure signs Palpitation, and/or unexplained arrhythmia symptoms and/or syncope, and/or aborted sudden cardiac death Unexplained cardiogenic shock

6 Dg & Treatment of Myocarditis: ESC Consensus 2013 Diagnostic Criteria for Suspected Myocarditis Caforio, Pankuweit et al. Eur Heart J 2013 I ECG/Holter/stress test features I II III avr avl avf V 1 V 2 V 3 V 4 V 5 V 6 Newly abnormal 12 lead ECG and/or Holter and/or stress testing: I to III AV, or bundle branch block, ST/T wave change sinus arrest VT or VF and asystole, AF reduced R wave height, intraventricular conduction delay (widened QRS complex), abnormal Q waves, low voltage, frequent PVCs, PSVT

7 Dg & Treatment of Myocarditis: ESC Consensus 2013 Diagnostic Criteria for Suspected Myocarditis Caforio, Pankuweit et al. Eur Heart J 2013 II. Myocardiocytolysis markers Eevated TnT/TnI III. Functional and structural abnormalities on cardiac imaging (echo/angio/cmr) Before Treatment New, otherwise unexplained LV and/or RV structure and function abnormality: regional wall motion or global systolic or diastolic function abnormality, with or without ventricular dilatation, with or without increased wall thickness, with or without pericardial effusion, with or without endocavitary thrombi. IV. Tissue characterisation by CMR After Treatment Oedema and/or LGE of myocarditic pattern

8 Dg & Treatment of Myocarditis: ESC Consensus 2013 Diagnostic Criteria for Suspected Myocarditis Lake Louise Consensus Criteria Caforio, Pankuweit et al. Eur Heart J criteria

9 Most Important Indications for CMR in Patients with Suspected Myocarditis Friedrich M. Circ Cardiovasc Imaging 2013:6:833. Kindermann I. J Am Coll Cardiol 2012;59:779.

10 Case Presentation Biopsy Positive Myocarditis MRI LV EDD 57 mm LV ESD 36 mm IVS 10 mm PW 10 mm EF 62%, EDV 159 mm, ESV 64 ml RV EDD 24 mm EF 58%, EDV 149 mm, ESV 63 ml

11 Case Presentation Biopsy Positive Myocarditis MRI Before CM After CM

12 Case Presentation Medical History Male, 18 years, was examined due to dry cough, chest pain Echocardiography revealed enlarged, hypocontractile LV LV EDD LV ESD IVS PW RV EDD 80 mm 74 mm 9 mm 9 mm 41 mm LV EF 25% LVEDV 340 ml LVESV 240 ml

13 Case Presentation Medical History

14 Case Presentation Myopericarditis Medical History Cine TrueFISP Male, JS, 20 years Echocardiography showed transient pericardial effusion with constrictive physiology, no regional wall motion abnormalities of the LV Elevated serum troponin Chest x-ray, bilateral pleural effusion Therapy: nonsteroidal anti-inflammatory drugs TSE T2w FS

15 Case Presentation Myopericarditis MRI LV EDD LV ESD IVS PW 53 mm 31 mm 10 mm 9 mm LVEF 66% LVEDV 151 mm LVESV 51 ml SV 100 ml

16 Case Presentation Medical History Male, 22 years admitted to the hospital due to suspected acute coronary syndrom Had acute chest pain for an hour Coronarography Normal finding ECG Sinus rhythm, elevation of ST segment Laboratory Troponin L ( ug/l) BNP 894 (0-73 pg/ml) C reactive protein (0-8 mg/l) Variations of Troponin L (April 22, 7680, April 23, 10720, April 27, 4 230) Treatment Antiaggregation therapy Nonsteroid antrheumatic Blockers of H2 receptors and inhibitors of proton pump Electron Micrograph of a Parvovirus

17 Case Presentation MRI April 29, 2015 LV EDD LV ESD IVS PW RV EDD 52 mm 33 mm 9 mm 9 mm 32 mm LV EF 35% LV EDV 180 ml LV ESV 117 ml

18 Case Presentation MRI

19 Case Presentation MRI

20 Case Presentation MRI Follow-up July 8, 2015 LV EDD LV ESD IVS PW RV EDD 50 mm 38 mm 9 mm 9 mm 25 mm LV EF 64% LV EDV 145 ml LV ESV 117 ml Recovery!

21 Case Presentation MRI Follow-up

22 Case Presentation MRI Myocarditis Before Contrast After Contrast

23 Case Presentation US Peak Longitudinal Strain in Myocarditis X X

24 CMR Results in Relation to ECG and Troponin Florian A. Clin Res Cardiol 2015:104:154. ECG ST elevation (I, V2-V6)

25 Clinical and MRI Parameters as Predictors of Outcome In Pediatric Myocarditis Sachdeva S. Am J Cardiol 2015:15:499. N-58 pts 16 year old male patient with chest pain, dyspnea and flu-like symptoms with troponin T elevation, ECG ST elevation V2 to V6. LGE showed extensive hyperenchancement with subepicardial distribution in the inferior, lateral and anterior wall and septum.

26 Summary of Recommended Components of The CMR Report for Myocarditis Friedrich M. JACC 2009:53:17. LV volume and function LV end-diastolic volume and volume index LV end-systolic volume and volume index Ejection fraction Cardiac index LV mass and mass index Presence or absence of markers for inflammatory activity and injury of ST T2 signal/edema (regional edema or global T2 ratio) Calculated global myocardial myocardial early gadolinium enhancement ratio Myocardial late gadolinium enhancement with nonischemic regional distribution Conclusion Recommendation for follow up Based on the presence or absence of 2 or more criteria, considering additional evidence by the presence of LV dysfunction and/or pericardial effusion Based on clinical setting A follow-up >4 weeks after the onset of symptoms may have prognostic implications and thus is recommended.

27 Conclusions M. Friedrich. Circ Cardiovasc Imaging 2013:6:833. Structured Reporting Heart Function and Morfology Edema Hyperemia Necrosis/Scar Pericardial Effusion Associate Finding in Thorax MRI has the most comprehensive and accurate disgnostic tool in patients with suspected myocarditis; Verifies or exculeds myocardial inflammation and reversibel irreversible injury; MRI has an impact on therapeutic decision making and could provide a new, unexpected diagnosis; MRI is a predictor of functional and clinical recovery and death; Important for selection of patients for endomyocardial biopsy.

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29 XVth Balkan Congress of Radiology Danubius Hotel Helia, October 2017, Budapest, Hungary Ružica Maksimović MRI in Myocarditis Faculty of Medicine, University of Belgrade, Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, Belgrade, Serbia