Advanced MR Imaging in Myocarditis

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1 Naeem Merchant MD FRCP Professor of Medicine Department of Radiology Department of Cardiac Sciences Cumming School of Medicine University of Calgary Advanced MR Imaging in Myocarditis

2 The Lake Louise Criteria Cine T2 ERE LGE

3 The Lake Louise Criteria Friedrich M, et al. JACC Vol. 53, No. 17, 2009 Cine LV dysfunction or pericardial effusion provides supportive evidence T2 ERE Regionally or globally elevated signal (edema) Elevated Early Relative Enhancement (hyperemia) Any 2/3 in setting of clinically suspected myocarditis LGE Non-ischemic Enhancement (necrosis)

4 Representative Case 1 37 yo male with chest pain, elevated troponin, no obstructive CAD on cath Cine T2 ERE LGE +55% Diagnosis: Acute Myocarditis

5 Representative Case 2 58 yo female with chest pain, elevated troponin, no obstructive CAD on cath Cine T2 ERE LGE Diagnosis: LAD Ischemia

6 Inter-site Reproducibility % positive (overall) for each site (N=35) % case agreement (N=35) Cine Site 1 Site 2 T2 BB ERE LGE T2 EE LL Criteria (2/3) LGE T2 EE LL Criteria LGE * LGE: visual presence of non-ischemic LGE * T2: T2 ratio 2 or visual presence of edema * EE: EE ratio 4 Abstract submitted - SCMR 2016 (courtesy Dr A. Howarth)

7 Performance of LLC Versus LV EMB Cine JACC Card Imag 2012; 5 (5) T2 BB ERE ( 14d) High PPV LGE (>14d) *Reference standard: 14 infiltrating leukocytes/mm 2 (CD3 T- lymphocytes and/or CD68 macro- phages) in addition to enhanced human leukocyte antigen class II expression in professional antigen- presenting immune cells. Poor PPV

8 Prognosis of T2 and ERE Cine T2 BB ERE LGE 203 patients with LGE+ Acute Myocarditis Followed for 18.9 mths for composite outcome: Cardiac death, SCA, transplant, VT, HF or recurrent myocarditis) -Occurred in 22 pts (11%) -50% of events were for recurrent myocarditis Prognostic value of OTHER CMR markers in patients with +LGE Presence of Edema: NS Presence of ERE: NS (*performed using SSFP cine) Extent of LGE: NS Baseline LVEF: Only independent predictor of MACE (HR 0.89 ( ) Bottom line: Once LGE is seen - other markers on CMR may not be prognostic LVEF is incremental to LGE as a prognostic marker Journal of Magnetic Resonance 2015, 17:78

9 Performance of LGE alone 82 pts with Troponin + but normal cath Comparison of CMR vs EMB diagnosis Cine T2 BB European Heart Journal (2009) 30, CMR Diagnosis EMB Diagnosis CMR based on cine and LGE imaging alone (T2 / ERE not used) ERE LGE

10 Prognosis of LGE alone Cine T2 BB ERE Univariate analysis: LGE+ HR 6.6 (p<0.0001) MV Analysis: LGE+ HR 2.9 (p=0.02) LVEF HR 0.97 per 1% (p=0.03) LGE Journal of Magnetic Resonance 2014, 16:14 *CMR Normal = LVEF 60% and no LGE

11 226 patients with biopsy-proven extra-cardiac Sarcoid Primary outcome: - Death (any cause) - Sustained ventricular arrhythmia ( 30 s or polymorphic VT), - Appropriate ICD shock

12 Prognosis of LGE alone - Sarcoidosis Cine T2 BB ERE LGE 153 pts with biopsy confirmed systemic sarcoid referred for exclusion of cardiac involvement Median LVEF: 63 [IQR 59-68] 11/153 patients had primary outcome: Cardiac death, Aborted SCD, Appropriate ICD Therapy Multivariable analysis: LGE+ was strongest predictor: HR 32 (p=0.0014) Neither LVEF or LVEDV was predictive J Am Coll Cardiol Img 2013;6:501 11

13 Improving Accuracy and Reproducibility Patients with suspected acute myocarditis 3D Strain 20 patients with clinical acute myocarditis Mean LVEF 50% 75% showed + LGE Native T2 mapping offers a robust alternative to standard T2 or LGE imaging in myocarditis T2 Mapping T1 Mapping 3D LGE Circ Cardiovasc Imaging. 2012;5:

14 TISSUE MAPPING Infarction Bulluck H, et al Circulation Journal (2015)

15 Improving Accuracy and Reproducibility Patients with recently detected severe dilated cardiomyopathy 3D Strain T2 Mapping 31 patients: duration of HF 6 to 77 days Mean LVEF 30% (19-35%), LVEDVi 150 ml/m2 15/31 (48%) showed active myocarditis by EMB T2 mapping only predictor of active myocarditis T2 mapping vs EMB T1 Mapping 3D LGE Circ Cardiovasc Imaging.2015;8:e

16 Improving Accuracy and Reproducibility Patients with suspected acute myocarditis 3D Strain T2 Mapping 50 patients suspected myocarditis 45 normal controls Mean LVEF 62 +/- 12% Assessed accuracy for differentiating the referral population from a normal population NO REFERENCE STANDARD T1 Mapping 3D LGE Emerging J Am Coll Cardiol Img 2013;6:

17 Improving Accuracy and Reproducibility Patients with clinically diagnosed acute myocarditis 3D Strain 165 patients with acute myocarditis +ve troponin, Flu-like illness, ECG changes, exclusion of CAD 40 normal controls T2 Mapping J Am Coll Cardiol Img 2015;8:37 46 Mean LVEF 49 +/- 15% Ability of Native T1 to supplant LGE & T2 Tested at both 1.5 and 3 Tesla T1 Mapping 3D LGE Emerging

18 Improving Accuracy and Reproducibility 3D Strain T2 Mapping T1 Mapping 3D LGE Emerging

19 PET- in Acute Myocarditis Acute Cardiac Sarcoidosis + Nuclear Imaging White JA, Rajchl, M, Bulter R, et al. Circulation 2013

20 Thank you