Presentation
Mildly reduced ejection fraction (EF ~45%) on echo during a yearly routine check-up. History of hypertension and family history of coronary artery disease.
Patient Data
Myocardial perfusion scintigraphy
No evidence of stress-induced myocardial ischemia. Unable to exclude balanced 3-vessel CAD.
Mildly reduced ejection fraction of ~45%.
Invasive coronary angiography
Left coronary arterial dominance.
Separate ostia of the LAD and CX with few wall irregularities of both vessels.
No evidence of obstructive coronary artery disease.
Heart rate: 75 bpm
Image quality: mild to moderate respiratory artifacts, otherwise no limitations
Morphology and functional analysis (endo-volume - including papillary muscles):
LV-EDVI: 103 mL/m²
LV-ESVI: 50 mL/m²
LV-SVI: 53 mL/m²
LV-EF: 52%
cardiac output: 7.3 L/min
cardiac index: 3.7 L/min/m²
LV-ED wall mas index (without papillary muscles): 62 g/cm
septum thickness: 11 mm
Findings:
Mild hypokinesia especially in basal inferoseptal and inferior segments.
Visually normal atrial size.
No significant cardiac valve pathology.
No intracavitary thrombi.
No pericardial effusion.
Myocardial tissue properties
Subepicardial late gadolinium enhancement in the basal and midventricular inferior segments.
STIR imaging was suspicious for myocardial edema in the basal and midventricular inferoseptal, inferior and inferolateral segments.
T1 mapping native: elevated especially in the basal and midventricular inferior wall
extracellular volume (ECV): elevated (>32%) in basal inferior and inferolateral segments
T2 mapping: very mildly elevated (56 +/-10 ms) in the basal inferior segment with normal values in the remote myocardium (48 +/-4 ms)
*Normal reference ranges based on local data:
native T1: 940-1060 ms; ECV: <32%; T2: 44-56 ms
Impression:
Cardiac MRI findings are consistent with chronic myocarditis.
Exam courtesy: Gabriele Kaps & Kirsten Fleckstein (radiographers)
Case Discussion
MR imaging findings of mild myocardial inflammation with mild myocardial edema and signs of non-ischemic myocardial injury in a patient who was found to have mildly reduced ejection fraction on a routine airworthiness check-up for pilots. During a short hospital stay the diagnosis of heart failure with mildly reduced ejection fraction (HFmrEF) was made. Coronary artery disease, valvular disease and arrhythmias were all ruled out as potential causes 1 and a subsequent outpatient cardiac MRI with myocardial tissue characterization was performed as part of the routine diagnostic workup 2. The fact that the myocardial edema was only very mild suggests that the inflammation is chronic. Digging into the patient's past medical history revealed a severe course of COVID-19 about 1 year ago further supporting the diagnosis.
An outpatient appointment with his cardiologist including an echocardiographic follow-up was recommended and another cardiac MRI will be considered depending on the results.
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