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Subendocardial Involvement as an Underrecognized Cardiac MRI Phenotype in Myocarditis
Jing-Hui Li1, Xi-Qi Xu1, Yong-Jian Zhu1
1From the Departments of Magnetic Resonance Imaging (J.H.L., M.J.L., S.H.Z.) and Pathology (H.Y.W.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Rd, Beijing 100037, China; Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases (X.Q.X., Y.J.Z., Z.C.J.), and Department of Radiology (Y.N.W.), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padova, Italy (C.Y.C.).
Subendocardial late gadolinium enhancement (LGE) in myocarditis on cardiac MRI indicates more severe disease. Patients with subendocardial LGE had worse outcomes, including higher rates of cardiac death or transplant and major adverse cardiovascular events (MACE).
Area of Science:
- Cardiovascular Imaging
- Pathology
- Medical Diagnostics
Background:
- Subendocardial late gadolinium enhancement (LGE) on cardiac MRI in myocarditis presents a diagnostic challenge, mimicking myocardial ischemia.
- Understanding the implications of subendocardial involvement in myocarditis is crucial for accurate diagnosis and prognosis.
Purpose of the Study:
- To compare histopathologic features, clinical characteristics, and outcomes of myocarditis patients with and without subendocardial involvement on cardiac MRI.
- To elucidate the prognostic significance of subendocardial LGE in the context of myocarditis.
Main Methods:
- Retrospective analysis of 39 pathologically proven myocarditis patients (2015-2020), divided into subendocardial involvement (n=18) and no subendocardial involvement (n=21) groups based on cardiac MRI.
- Histopathologic data (lymphocytic vs. giant cell myocarditis) and clinical outcomes (cardiac death, transplant, MACE) were analyzed.
- Statistical methods included Student t test, Mann-Whitney U test, and univariable Cox regression with a median follow-up of 784 days.
Main Results:
- Subendocardial involvement was associated with a higher frequency of giant cell myocarditis (33% vs 4.8%) and more severe lymphocytic myocarditis.
- Patients with subendocardial LGE exhibited lower left ventricular ejection fraction (27% vs 41%), larger LGE extent (13% vs 5%), and significantly higher rates of cardiac death/transplant (44% vs 4.8%).
- Major adverse cardiovascular events (MACE) were more frequent in the subendocardial involvement group (83% vs 33%), even in subgroups with comparable LGE extent and ejection fraction.
Conclusions:
- Subendocardial involvement detected by cardiac MRI in myocarditis signifies more severe clinical features and a poorer prognosis.
- This finding highlights the importance of identifying subendocardial LGE for risk stratification and management of myocarditis patients.
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