Presentation
Known myocarditis, external cardiac MRI three months prior, directly after COVID-19 infection. Coronary artery disease was ruled out by a coronary angiogram at the time.
Patient Data
Heart rate: 85-90 bpm, hematocrit: 0.44
Image quality: some artifacts especially on the T2 mapping sequence, no other limitations
Morphology and functional analysis:
LV-EDVI: 82 mL/m²
LV-ESVI: 37 mL/m²
LV-SVI: 45 mL/m²
LV-EF: 55%
cardiac output: 7.7 L/min
cardiac index: 3.7 L/min/m²
LV-ED wall mass/BSA: 46 g/m²
septum thickness: 8 mm
Findings:
No regional left ventricular wall motion abnormalities
Visually normal atrial size.
Mild mitral prolapse of the anterior leaflet.
No pericardial effusion or pericardial enhancement.
Myocardial tissue properties (according to updated Lake Louise criteria)1:
Myocardial edema: questionable milad in the apical septal and anterior segments
Late gadolinium enhancement (LGE): subepicardial in the lateral and inferior segments and linear-patchy mid-myocardial in the septum and anterior wall
T1 mapping: 1050-1090 ms* (z-score: ~2-3) especially in lateral and inferior segments as well as in apical segments
Extracellular volume (ECV): <32%
T2 mapping: ~56-57 ms* in the apical anteroseptal wall, severe artifacts in the basal slice, otherwise within normal limits
*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 - myocardial edema has regressed compared to the external examination three months prior (not shown).
Image quality: some artifacts, no other limitations
Functional analysis: mild improvement in comparison to the previous examination
No regional left ventricular wall motion abnormalities
No pericardial effusion.
Myocardial tissue properties:
T2 mapping: ~47-52 ms (within normal range): no myocardial edema
Patchy and subepicardial late gadolinium enhancement (LGE), similar in distribution to the previous study.
Impression:
Known chronic myocarditis with persistent patchy subepicardial late gadolinium enhancement.
Case Discussion
A follow-up examination of a patient with known myocarditis, which after three months can be already called chronic 1 or even postinflammatory non-dilated left ventricular cardiomyopathy 2. There is still a typical subepicardial and patchy midwall late gadolinium enhancement pattern as well as correspondingly abnormal T1 mapping values after three and eight months 3-5. Myocardial edema has regressed expectedly 5,6 with mild residual after three months compared to the original cardiac MRI examination (not shown here because of copyright issues) which eventually subsided after eight months. Persisting late gadolinium enhancement in the absence of myocardial edema is considered an adverse or unfavorable prognostic indicator, especially in the setting where the cardiac septum is involved 7.
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