Abstract
BackgroundAlthough the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method.MethodsSix hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods.ResultsNinety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02–1.08, p = 0.001; HR 1.02, 95%CI:1.00–1.04; p = 0.001; HR 1.02, 95%CI: 1.00–1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04–1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values.ConclusionsFWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients.Trial registration numberNCT03470571. Registered 13th March 2018. Retrospectively registered.
Highlights
The presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method
Takotsubo cardiomyopathy was defined as previously published with apical ballooning [11], elevated troponin, absence of CMR features suggesting of myocarditis and absence of coronary artery disease
A total of 670 patients represented our study group with 2 (0.3%) patients lost to follow-up and a median follow-up of 4.7 [Interquartile range (IQR) 2.3–7.3] years
Summary
The presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method. Myocarditis has diverse pattern of clinical signs and symptoms at presentations [2, 3] and its diagnosis may be challenging, as the sensitivity of the main diagnostic tools may vary greatly [1, 4, 5]. Cardiovascular magnetic resonance imaging (CMR) has become the primary imaging tool for establishing the diagnosis by the use of late gadolinium enhancement (LGE) imaging [2, 5,6,7,8]. We sought to compare LGE quantification techniques including thresholding by 2, 3, 4, 5, 6 or 7 standard deviations (SDs) above remote myocardium, the full width at half maximum (FWHM) technique, and visual quantification, as well as their respective association with clinical outcome in a post-hoc analysis of patients with suspected myocarditis [9]
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