Imaging patterns of cardiac MRI in the diagnosis of

myocarditis.

Poster No.: R-0089

Congress: RANZCR ASM 2013
Type: Educational Exhibit
Authors: A. AGARWAL, C. Murray; Perth/AU
Keywords: Cardiovascular system, MR, Imaging sequences, Inflammation
DOI: 10.1594/ranzcr2013/R-0089

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Learning Objectives

To understand the role of Cardiovascular Magnetic Resonance Imaging in the diagnosis

of myocarditis, including the most useful imaging sequences and characteristic imaging
findings based on histological co-relation.

Background

Myocarditis is an important underlying etiology of various myocardial diseases such as

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dilated and arrhythmogenic right ventricular cardiomyopathies .

Clinical presentation:

Myocarditis usaully presents in young men.

Often the symptomatology is non-specific, for example, fatigue, chest pain, palpitations,
shortness of breath.

The biochemical markers/ECG findings are non-specific-making clinical diagnosis difficult

Hence imaging +/ histological diagnosis is important.

Diagnosis:

•Traditionally Endomyocardial Biopsy (EMB) has been considered the gold standard in
the diagnosis of myocarditis.

•However it is invasive and suffers from 'Sampling error'

i.e. EMB is usually performed at the right or inferior ventricular walls as they are more
accessible and less prone to complications however typical changes of myocarditis are
seen along the LV wall. Hence EMB has low sensitivity due to 'sampling error'. Hence
imaging is crucial

•Cardiovascular Magnetic Resonance Imaging (CMR) is an evolved technique

for the diagnosis and management of various cardiovascular diseases including
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cardiomyopathies .

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•However its validity for the diagnosis of myocarditis has not been fully established. While
in routine clinical use for this purpose in some centres, CMR has not been established
as a valid diagnostic tool for myocarditis to a high degree.

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•Small single centre publications have shown a high positive predictive value .

Imaging Findings OR Procedure Details

Methods:

•The pathology information system of Royal Perth Hospital was mined for the
histopathology results of any patient who had undergone an endomyocardial biopsy
(EMB) between 2004-2012.

•The cardiac MRI features of these patients were reviewed by two subspeciality
radiologists. Studies were retrospectively scored.

•The pattern and distribution of T2 prolongation and delayed myocardial hyper

enhancement(DHE) were regarded as typical or atypical for myocarditis.

•Typical pattern was lateral or inferolateral subepicardial or septal wall delayed

1,2
enhancement .

•Atypical pattern was any other form of enhancement, apart from recognised normal
myocardial DHE such as the fibrous core.

Results:

•55 biopsies had been performed for undifferentiated chest pain.

•There were 15 subjects with a histopathological diagnosis of myocarditis.

•Of these, 7 had undergone a pre-procedural cardiac MRI for the purpose of diagnosis
of myocarditis and guidance for the EMB procedure.

•The typical pattern of delayed hyperenhancement was observed in 70% (5/7) subjects
while 30% (2/7) had atypical pattern

•All demonstrated T2 hyperintensity (oedema)

Images for this section:

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Fig. 1: Short axis view post Gadolinium (Gad) administration, typical subepicardial (SE),
inferolateral wall delayed hyperenhancement (DHE)

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Fig. 2: Four-chamber view post Gad-administration demonstrates nodular Subepicardial
delayed hyperenhancement along the lateral wall

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Fig. 3: Two-chamber view, typical Subepicardial infero-lateral wall DHE

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Fig. 4: Four-chamber view post Gad-administration demonstrates typical nodular
Subepicardial DHE along the lateral and septal walls

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Fig. 5: Two-chamber view in the same patient demonstrating subepicardial DHE.

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Fig. 6: Horizontal four-chamber view demonstrating atypical patchy fine nodular DHE
along the lateral and septal walls.

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Conclusion

•The most typical pattern of acute myocarditis is lateral/inferolateral wall, subepicardial

delayed hyperenhancement, observed in 70% in our study. Atypical DHE is not unusual,
being observed in 30% of subjects.

Personal Information

References

1.Pennell et al. Clinical indications for cardiovascular magnetic resonance (CMR):

Consensus Panel report. Eur Heart J (2004)

2.Friedrich et al. JACC White Paper: CMR in Myocarditis. JACC 2009

3.Cooper L. Myocarditis. N Engl J Med 2009; 360:1526-1538

4.Matthias G et al. Contrast Media-Enhanced Magnetic Resonance Imaging Visualizes

Myocardial Changes in the Course of Viral Myocarditis. Circulation. 1998;97:1802-1809.

5.Baughman KL: Diagnosis of myocarditis: death of Dallas criteria. Circulation

2006;113:593-595.

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