Natural History of Myocardial Injury and Chamber Remodeling in Acute Myocarditis A 12-Month Prospective Cohort Study Using Cardiovascular Magnetic Resonance Imaging

Background: Cardiovascular magnetic resonance (CMR) imaging is commonly used to diagnose acute myocarditis. However, the natural history of CMR-based tissue markers and their association with left ventricular recovery is poorly explored. We prospectively investigated the natural history of CMR-based myocardial injury and chamber remodeling over 12 months in patients with suspected acute myocarditis. Methods: One hundred patients with suspected acute myocarditis were enrolled. All underwent CMR evaluations at baseline and 12 months, inclusive of T2 and late gadolinium enhancement. Blinded quantitative analyses compared left ventricular chamber volumes, function, myocardial edema, and necrosis at each time point using predefined criteria. The predefined primary outcomes were improvement in left ventricular ejection fraction >= 10% and improvement in the indexed left ventricular end diastolic volume >= 10% at 12 months. Results: The mean age was 39.9 +/- 14.5 years (82 male) with baseline left ventricular ejection fraction of 57.1 +/- 11.2%. A total of 72 patients (72%) showed late gadolinium enhancement at baseline with 57 (57%) having any T2 signal elevation. Left ventricular volumes and EF improved significantly at 12 months. Global late gadolinium enhancement extent dropped from 8.5 +/- 9.2% of left ventricular mass to 3.0 +/- 5.2% (P=0.0001) with prevalence of any late gadolinium enhancement dropping to 48%. Reductions in global T2 signal ratio occurred at 12 months (1.85 +/- 0.3 to 1.56 +/- 0.2; P=0.0001) with prevalence of T2 ratio >= 2.0 dropping to 7%. Neither marker provided associations with the primary outcomes. Conclusions: In clinically suspected acute myocarditis, significant reductions in tissue injury markers occur during the first 12 months of convalescence. Neither the presence nor extent of the investigated CMR-based tissue injury markers were predictive of our pre-defined function or remodeling outcomes at 12 months in this referral population.