Abstract
BackgroundMultiple studies in adult patients suggest that tissue mapping performed by cardiovascular magnetic resonance (CMR) has excellent diagnostic accuracy in acute myocarditis, however, these techniques have not been studied in depth in children.MethodsCMR data on 23 consecutive pediatric patients from 2014 to 2017 with a clinical diagnosis of acute myocarditis were retrospectively analyzed and compared to 39 healthy controls. The CMR protocol included native T1, T2, and extracellular volume fraction (ECV) in addition to standard Lake Louise Criteria (LLC) parameters on a 1.5 T scanner.ResultsMean global values for novel mapping parameters were significantly elevated in patients with clinically suspected acute myocarditis compared to controls, with native T1 1098 ± 77 vs 990 ± 34 ms, T2 52.8 ± 4.6 ms vs 46.7 ± 2.6 ms, and ECV 29.8 ± 5.1% vs 23.3 ± 2.6% (all p-values < 0.001). Ideal cutoff values were generated using corresponding ROC curves and were for global T1 1015 ms (AUC 0.936, sensitivity 91%, specificity 86%), for global T2 48.5 ms (AUC 0.908, sensitivity 91%, specificity 74%); and for ECV 25.9% (AUC 0.918, sensitivity 86%, specificity 89%). While the diagnostic yield of the LLC was 57% (13/23) in our patient cohort, 70% (7/10) of patients missed by the LLC demonstrated abnormalities across all three global mapping parameters (native T1, T2, and ECV) and another 20% (2/10) of patients demonstrated at least one abnormal mapping value.ConclusionsSimilar to findings in adults, pediatric patients with acute myocarditis demonstrate abnormal CMR tissue mapping values compared to controls. Furthermore, we found CMR parametric mapping techniques measurably increased CMR diagnostic yield when compared with conventional LLC alone, providing additional sensitivity and specificity compared to historical references. Routine integration of these techniques into imaging protocols may aid diagnosis in children.
Highlights
Multiple studies in adult patients suggest that tissue mapping performed by cardiovascular magnetic resonance (CMR) has excellent diagnostic accuracy in acute myocarditis, these techniques have not been studied in depth in children
One of these patients exhibited markedly abnormal tissue mapping values, with global T1 1270 ms, global T2 60 ms, segmental max T2 of 66 ms and extracellular volume (ECV) 39.6%, and no perceptible Lake Louise Criteria (LLC) criteria (Fig. 3). In this retrospective study we demonstrated that tissue mapping techniques can improve CMR diagnosis of acute myocarditis in pediatric patients
Through an exploratory framework we generated AUC curves and ideal diagnostic cutoff values to demonstrate that mapping techniques in conjunction with the LLC may increase the sensitivity of CMR for the diagnosis of myocarditis in pediatric patients when compared with LLC alone
Summary
Multiple studies in adult patients suggest that tissue mapping performed by cardiovascular magnetic resonance (CMR) has excellent diagnostic accuracy in acute myocarditis, these techniques have not been studied in depth in children. Adult studies suggest that newer CMR techniques assessing the characteristics of the myocardium, including native T1 mapping, T2 mapping, and calculation of extracellular volume (ECV), are more sensitive for diagnosing myocarditis and may offer additional prognostic value [4, 5, 7,8,9]. Adult studies demonstrate there are cases where CMR mapping is superior to LLC in diagnosing myocarditis [8, 11, 13, 14]. Recent CMR guidelines recommend the use of routine mapping in cases of suspected myocarditis [16]
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