Cardiac Magnetic Resonance Monitors Reversible and Irreversible Myocardial Injury in Myocarditis

OBJECTIVES We sought to assess the value of cardiac magnetic resonance (CMR) to monitor the spectrum of myocarditis-related injuries over the course of the disease. BACKGROUND Myocarditis is associated with a wide range of myocardial tissue injuries, both reversible and irreversible. Differentiating these types of injuries is a clinical demand. METHODS We studied 36 patients (31 males, age 33 +/- 14 years) hospitalized with myocarditis during the acute phase and 18 +/- 10 months thereafter. CMR was performed on 2 1.5T scanners and included the following techniques: steady-state free precession (to assess left ventricular function and volumes), T2-weighted (myocardial edema), early (global relative enhancement [gRE], reflecting increased capillary leakage) and late T1-weighted after gadolinium-DTPA injection (late gadolinium enhancement [LGE], reflecting irreversible injury). RESULTS In the acute phase, T2 ratio was elevated in 86%, gRE in 80%, and LGE was present in 63%. At follow-up, ejection fraction increased from 56 +/- 8% to 62 +/- 7% (p < 0.0001) while both T2 ratio (2.4 +/- 0.5 to 1.9 +/- 0.2; p < 0.0001) and gRE (7.6 +/- 8 to 4.4 +/- 4; p = 0.018) significantly decreased. LGE persisted in all but 1 patient in whom LGE completely resolved. No patient had simultaneous elevation of T2 and gRE during the convalescent phase, resulting in a negative predictive value of 100% to differentiate the 2 phases of the disease. The acute phase T2 ratio correlated significantly with the change of end-diastolic volume over time (beta = 0.47; p = 0.008). This relation remained significant in a stepwise regression analysis model including T2 ratio, gRE, LGE extent, baseline ejection fraction, age, and creatine kinase, in which only T2 emerged as an independent predictor of the change in end-diastolic volume. CONCLUSIONS A comprehensive CMR approach is a useful tool to monitor the reversible and irreversible myocardial tissue injuries over the course of myocarditis and to differentiate acute from healed myocarditis in patients with still-preserved ejection fraction. (J Am Coll Cardiol Img 2009; 2: 131-8) (c) 2009 by the American College of Cardiology Foundation