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The aim of this study was to provide insights into myocardial adaptation over time in myocyte injury caused by acute myocarditis with preserved ejection fraction. The effect of myocardial injury, as defined by the presence of late gadolinium enhancement (LGE), on the change of left ventricular (LV) segmental strain parameters was evaluated in a longitudinal analysis. Patients with a first episode of acute myocarditis were enrolled retrospectively. Peak radial (PRS), longitudinal (PLS) and circumferential (PCS) LV segmental strain values at baseline and at follow-up were computed using feature tracking cine cardiac magnetic resonance imaging. The change of segmental strain values in LGE positive (LGE+) and LGE negative (LGE-) segments was compared over a course of 89 ± 20 days. In 24 patients, 100 LGE+ segments and 284 LGE- segments were analysed. Between LGE+ and LGE- segments, significant differences were found for the change of segmental PCS (p < 0.001) and segmental PRS (p = 0.006). LGE + segments showed an increase in contractility, indicating recovery, and LGE- segments showed a decrease in contractility, indicating normalisation after a hypercontractile state or impairment of an initially normal contracting segment. No significant difference between LGE+ and LGE- segments was found for the change in segmental PLS. In the course of acute myocarditis with preserved ejection fraction, regional myocardial function adapts inversely in segments with and without LGE. As these effects seem to counterbalance each other, global functional parameters might be of limited use in monitoring functional recovery of these patients., (© 2022. The Author(s).)

We compared a fast, single breath-hold three dimensional LGE sequence (3D LGE) with an established two dimensional multi breath-hold sequence (2D LGE) and evaluated image quality and the amount of myocardial fibrosis in patients with acute and chronic myocarditis. 3D LGE and 2D LGE (both spatial resolution 1.5 × 1.5 mm 2 , slice-thickness 8 mm, field of view 350 × 350 mm 2 ) were acquired in 25 patients with acute myocarditis (mean age 40 ± 18 years, 7 female) and 27 patients with chronic myocarditis (mean age 44 ± 22 years, 9 female) on a 1.5 T MR system. Image quality was evaluated by two independent, blinded readers using a 5-point Likert scale. Total myocardial mass, fibrotic mass and total fibrotic tissue percentage were quantified for both sequences in both groups. There was no significant difference in image quality between 3D und 2D acquisitions in patients with acute (p = 0.8) and chronic (p = 0.5) myocarditis. No significant differences between 3D and 2D acquisitions could be shown for myocardial mass (acute p = 0.2; chronic p = 0.3), fibrous tissue mass (acute p = 0.7; chronic p = 0.1) and total fibrous percentage (acute p = 0.4 and chronic p = 0.2). Inter-observer agreement was substantial to almost perfect. Acquisition time was significantly shorter for 3D LGE (24 ± 5 s) as compared to 2D LGE (350 ± 58 s, p < 0.001). In patients with acute and chronic myocarditis 3D LGE imaging shows equal diagnostic quality compared to standard 2D LGE imaging but with significantly reduced acquisition time.

BackgroundThe establishment of a timely and correct diagnosis in heart failure-like myocarditis remains one of the most challenging in clinical cardiology.PurposeTo assess the diagnostic potential of texture analysis in heart failure-like myocarditis with comparison to endomyocardial biopsy (EMB) as the reference standard.Materials and MethodsSeventy-one study participants from the Magnetic Resonance Imaging in Myocarditis (MyoRacer) trial (ClinicalTrials.gov registration no. NCT02177630) with clinical suspicion for myocarditis and symptoms of heart failure were prospectively included (from August 2012 to May 2015) in the study. Participants underwent biventricular EMB and cardiac MRI at 1.5 T, including native T1 and T2 mapping and standard Lake Louise criteria. Texture analysis was applied on T1 and T2 maps by using an open-source software. Stepwise dimension reduction was performed for selecting features enabling the diagnosis of myocarditis. Diagnostic performance was assessed from the area under the curve (AUC) from receiver operating characteristic analyses with 10-fold cross validation.ResultsIn participants with acute heart failure-like myocarditis ( n = 31; mean age, 47 years ± 17; 10 women), the texture feature GrayLevelNonUniformity from T2 maps (T2&#95;GLNU) showed diagnostic performance similar to that of mean myocardial T2 time (AUC, 0.69 for both). The combination of mean T2 time and T2&#95;GLNU had the highest AUC (0.76; 95% confidence interval [CI]: 0.43, 0.95), with sensitivity of 81% (25 of 31) and specificity of 71% (22 of 31). In patients with chronic heart failure-like myocarditis ( n = 40; mean age, 48 years ± 13; 12 women), the histogram feature T2&#95;kurtosis demonstrated superior diagnostic performance compared to that of all other single parameters (AUC, 0.81; 95% CI: 0.66, 0.96). The combination of the two texture features, T2&#95;kurtosis and the GrayLevelNonUniformity from T1, had the highest diagnostic performance (AUC, 0.85; 95% CI: 0.57, 0.90; sensitivity, 90% [36 of 40]; and specificity, 72% [29 of 40]).ConclusionIn this proof-of-concept study, texture analysis applied on cardiac MRI T1 and T2 mapping delivers quantitative imaging parameters for the diagnosis of acute or chronic heart failure-like myocarditis and might be superior to Lake Louise criteria or averaged myocardial T1 or T2 values.© RSNA, 2019 Online supplemental material is available for this article. See also the editorial by de Roos in this issue.

Purpose To assess the diagnostic potential of texture analysis applied to T1 and T2 maps obtained with cardiac MRI for the diagnosis of acute infarctlike myocarditis. Materials and Methods This prospective study from August 2012 to May 2015 included 39 participants (overall mean age ± standard deviation, 34.7 years ± 12.2 [range, 18-63 years]; mean age of women, 46.1 years ± 10.8 [range, 24-63 years]; mean age of men, 29.8 years ± 9.2 [range, 18-56 years]) from the Magnetic Resonance Imaging in Myocarditis (MyoRacer) trial with clinical suspicion of acute myocarditis and infarctlike presentation. Participants underwent biventricular endomyocardial biopsy, cardiac catheterization, and cardiac MRI at 1.5 T, in which native T1 and T2 mapping as well as Lake Louise criteria (LLC) were assessed. Texture analysis was applied on T1 and T2 maps by using a freely available software package. Stepwise dimension reduction and texture feature selection was performed for selecting features enabling the diagnosis of myocarditis by using endomyocardial biopsy as the reference standard. Results Endomyocardial biopsy confirmed the diagnosis of acute myocarditis in 26 patients, whereas 13 participants had no signs of acute inflammation. Mean T1 and T2 values and LLC showed a low diagnostic performance, with area under the curve in receiver operating curve analyses as follows: 0.65 (95% confidence interval [CI]: 0.45, 0.85) for T1, 0.67 (95% CI: 0.49, 0.85) for T2, and 0.62 (95% CI: 0.42, 0.79) for LLC. Combining the texture features T2 run-length nonuniformity and gray-level nonuniformity resulted in higher diagnostic performance with an area under the curve of 0.88 (95% CI: 0.73, 1.00) (P < .001) and a sensitivity and specificity of 89% [95% CI: 81%, 93%] and 92% [95% CI: 77%, 93%], respectively. Conclusion Texture analysis of T2 maps shows high sensitivity and specificity for the diagnosis of acute infarctlike myocarditis. © RSNA, 2018 Online supplemental material is available for this article.

Purpose/introduction: This study aims to evaluate the incremental diagnostic value of cardiac magnetic resonance (CMR) feature tracking (FT) derived atrial and ventricular strain-analysis in patients with acute myocarditis (myocarditis) as an additional tool to established Lake-Louise criteria (LLC)., Material and Methods: A total of 86 patients with clinically proven myocarditis and 30 healthy controls underwent a comprehensive CMR protocol. In addition to established LLC, FT derived strain parameters from the left (LA) and right atrium (RA) as well as the left (LV) and right ventricle (RV) were assessed. Receiver operating characteristics analysis was performed to compare diagnostic performance., Results: Patients with myocarditis showed significantly reduced LA passive strain (LA ε e : 26.3 ± 14.5 vs. 33.5 ± 10.1%, p = .007), LA peak early negative strain rate (LA SRe: -1.94 ± 0.59 1/s vs. -1.46 ± 0.62 1/s, p < .001), LV global longitudinal strain (LV GLS: -17.2 ± 4.9% vs. -13.3 ± 6.2%, p < .001), LV midventricular circumferential strain (LV mid CS: -25.9 ± 4.7% vs. -22.0 ± 6.5%, p < .001), and an increased RV basal circumferential SR (RV basal CSR: -0.70 ± 028 vs. -0.58 ± 0.34 1/s, p = .096) compared to healthy controls. In a subgroup analysis of patients with myocarditis and preserved LV function, RV basal CSR was also significantly increased compared to healthy controls (-0.74 ± 0.27 vs. -0.57 ± 0.26 1/s; p = .035) whereas LA SRe (-1.49 ± 0.59 vs. -1.32 ± 0.74%; p = .005) was significantly reduced. In multinominal logistic regression analysis, LA SRe and RV basal CSR proved to be the best independent predictors of myocarditis with preserved LV function. Combined with LLC, strain parameters enhanced the diagnostic performance in such patients (Areas under the curve (AUC): LLC: 0.78, LLC + LV GLS + LA SRe: 0.86), whereas LA SRe was the best performing single parameter (AUC: 0.72)., Conclusion: Combining quantitative CMR derived atrial and ventricular strain parameters with established LLC parameters can improve the diagnostic performance in patients with suspected myocarditis, including those with preserved LV function. Further investigations should focus on LA function, which appears to be more sensitive to early functional changes than LV function., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To re-evaluate a recently suggested approach of quantifying myocardial oedema and increased tissue inhomogeneity in myocarditis by T2-mapping., Methods: Cardiac magnetic resonance data of 99 patients with myocarditis were retrospectively analysed. Thirthy healthy volunteers served as controls. T2-mapping data were acquired at 1.5 T using a gradient-spin-echo T2-mapping sequence. T2-maps were segmented according to the 16-segments AHA-model. Segmental T2-values, segmental pixel-standard deviation (SD) and the derived parameters maxT2, maxSD and madSD were analysed and compared to the established Lake Louise criteria (LLC)., Results: A re-estimation of logistic regression models revealed that all models containing an SD-parameter were superior to any model containing global myocardial T2. Using a combined cut-off of 1.8 ms for madSD + 68 ms for maxT2 resulted in a diagnostic sensitivity of 75% and specificity of 80% and showed a similar diagnostic performance compared to LLC in receiver-operating-curve analyses. Combining madSD, maxT2 and late gadolinium enhancement (LGE) in a model resulted in a superior diagnostic performance compared to LLC (sensitivity 93%, specificity 83%)., Conclusions: The results show that the novel T2-mapping-derived parameters exhibit an additional diagnostic value over LGE with the inherent potential to overcome the current limitations of T2-mapping., Key Points: • A novel quantitative approach to myocardial oedema imaging in myocarditis was re-evaluated. • The T2-mapping-derived parameters maxT2 and madSD were compared to traditional Lake-Louise criteria. • Using maxT2 and madSD with dedicated cut-offs performs similarly to Lake-Louise criteria. • Adding maxT2 and madSD to LGE results in further increased diagnostic performance. • This novel approach has the potential to overcome the limitations of T2-mapping.

Background: The aim of this study was to evaluate the diagnostic potential of a novel cardiovascular magnetic resonance (CMR) based multiparametric imaging approach in suspected myocarditis and to compare it to traditional Lake Louise criteria (LLC)., Methods: CMR data from 67 patients with suspected acute myocarditis were retrospectively analyzed. Seventeen age- and gender-matched healthy subjects served as control. T2-mapping data were acquired using a Gradient-Spin-Echo T2-mapping sequence in short-axis orientation. T2-maps were segmented according to the 16-segments AHA-model and segmental T2 values and pixel-standard deviation (SD) were recorded. Afterwards, the parameters maxT2 (the highest segmental T2 value) and madSD (the mean absolute deviation (MAD) of the pixel-SDs) were calculated for each subject. Cine sequences in three long axes and a stack of short-axis views covering the left and right ventricle were analyzed using a dedicated feature tracking algorithm., Results: A multiparametric imaging model containing madSD and LV global circumferential strain (GCS LV ) resulted in the highest diagnostic performance in receiver operating curve analyses (area under the curve [AUC] 0.84) when compared to any model containing a single imaging parameter or to LLC (AUC 0.79). Adding late gadolinium enhancement (LGE) to the model resulted in a further increased diagnostic performance (AUC 0.93) and yielded the highest diagnostic sensitivity of 97% and specificity of 77%., Conclusions: A multiparametric CMR imaging model including the novel T2-mapping derived parameter madSD, the feature tracking derived strain parameter GCS LV and LGE yields superior diagnostic sensitivity in suspected acute myocarditis when compared to any imaging parameter alone and to LLC.

Purpose: The present study aims at evaluating the feasibility and reproducibility of cardiac magnetic resonance (CMR) feature tracking (FT) derived strain and strain rate (SR) parameters of the left and right atrium (LA, RA) in patients with acute myocarditis as well as their potential to detect diastolic dysfunction. In addition, the diagnostic value of LA and RA strain parameters in the setting of acute myocarditis is investigated., Methods: CMR cine data of 30 patients with CMR-positive acute myocarditis were retrospectively analyzed. 25 age- and gender-matched healthy individuals served as a control. Analysis of longitudinal strain and SR of both atria was performed in two long-axis views using a dedicated FT-software. LA and RA deformation was analyzed including reservoir function (total strain [ε s ], peak positive SR [SR s ]), conduit function (passive strain [ε e ], peak early negative SR [SR e ]) and booster pump function (active strain [ε a ], peak late negative SR [SR a ]). Intra- and inter-observer reproducibility was assessed for all strain and SR parameters using Bland-Altman analyses, intra-class correlation coefficients (ICCs) and coefficients of variation (CV)., Results: FT analyses of both atria were feasible in all patients and controls. Reproducibility was good for reservoir and conduit function parameters and moderate for booster pump function parameters. Myocarditis patients demonstrated an impaired LA reservoir and conduit function when compared to healthy controls (LA ε s : 32±17 vs. 46±13, p=0.019; LA SR s : 1.5±0.5 vs. 1.8±0.5, p=0.117; LA SR e : -1.3±0.5 vs. -1.9±0.5, p<0.001), while LA booster pump function was preserved. In logistic regression and ROC-analyses, LA SR e proved to be the best independent predictor of acute myocarditis (AUC 0.80), and using LA SR e with a cut-off of -1.6s -1 resulted in a diagnostic sensitivity of 83% and a specificity of 80%. Changes in RA phasic function parameters showed a tendency to parallel those of the LA and showed no additional effect with respect to the diagnostic potential in acute myocarditis., Conclusions: Myocarditis patients exhibit an impaired atrial reservoir and conduit function, what might be indicative of ventricular diastolic dysfunction. LA SR e was the best predictor for the presence of acute myocarditis in our study, pointing towards the discriminative power of atrial strain analysis in the CMR-based diagnosis of acute myocarditis., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: To investigate the reproducibility of regional and global strain and strain rate (SR) parameters of both ventricles and to determine sample sizes for all investigated strain and SR parameters in order to generate a practical reference for future studies., Materials and Methods: The study population consisted of 20 healthy individuals and 20 patients with acute myocarditis. Cine sequences in three horizontal long axis views and a stack of short axis views covering the entire left and right ventricle (LV, RV) were retrospectively analysed using a dedicated feature tracking (FT) software algorithm (TOMTEC). For intra-observer analysis, one observer analysed CMR images of all patients and volunteers twice. For inter-observer analysis, three additional blinded observers analysed the same datasets once. Intra- and inter-observer reproducibility were tested in all patients and controls using Bland-Altman analyses, intra-class correlation coefficients (ICCs) and coefficients of variation., Results: Intra-observer reproducibility of global LV strain and SR parameters was excellent (range of ICCs: 0.81-1.00), the only exception being global radial SR with a poor reproducibility (ICC 0.23). On a regional level, basal and midventricular strain and SR parameters were more reproducible when compared to apical parameters. Inter-observer reproducibility of all LV parameters was slightly lower than intra-observer reproducibility, yet still good to excellent for all global and regional longitudinal and circumferential strain and SR parameters (range of ICCs: 0.66-0.93). Similar to the LV, all global RV longitudinal and circumferential strain and SR parameters showed an excellent reproducibility, (range of ICCs: 0.75-0.97). Radial strain and SR parameters were less reproducible in the LV as well as in the RV when compared to circumferential or longitudinal parameters., Conclusion: CMR FT using the TOMTEC algorithm is highly reproducible in health and disease in both, the LV and RV on a global and regional level. The only exceptions are radial strain and SR parameters, which should be used with caution within clinical studies. The sample sizes estimated on the basis of the present study might serve as a reference during the planning of future FT studies., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Unlabelled: Myocarditis is known as the chameleon of cardiac diseases. The symptoms and the course of disease vary greatly so that it is often challenging to establish a diagnosis. Early and accurate diagnosis is of utmost importance, since myocarditis is one of the leading causes of sudden cardiac death in young adults and represents an important precursor to dilated cardiomyopathy. Due to the constraints of the routinely used diagnostic approach, including clinical history and examination, laboratory testing, and electrocardiogram, different imaging modalities have emerged over the last decades as contributors to the noninvasive diagnosis of myocarditis. With this interdisciplinary review we would like to present the current state-of-the-art imaging of myocarditis across all available imaging modalities (i. e., echocardiography, cardiac magnetic resonance, cardiac computed tomography, and nuclear medicine). Furthermore, we present novel imaging techniques that might become useful in the near future for easier and more accurate diagnosis of this highly relevant disease., Key Points: • Different imaging modalities are increasingly used in the diagnostic workup of myocarditis. • Several emerging imaging techniques are currently on the way to becoming part of the clinical routine. • This review summarizes the diagnostic value of echocardiography, CMR, CT, and nuclear medicine imaging. • There is special focus on the possibilities and challenges of novel imaging tools within the different modalities., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The present study aims to evaluate the diagnostic value of cardiac magnetic resonance (CMR) feature tracking (FT) derived strain-analysis of both ventricles in patients with acute myocarditis (ACM) in order to improve its currently still challenging non-invasive diagnosis., Methods: CMR cine data of 31 patients with clinically suspected ACM and confirmation of diagnosis by CMR according to the Lake Louise criteria as well as 14 patients with clinically diagnosed ACM but inconspicuous CMR were retrospectively analyzed. 20 healthy volunteers (HV) served as a control. Analysis of global longitudinal, circumferential and radial strain and strain rate of both ventricles was performed in one long-axis and three short-axis slices using a dedicated FT-software (TomTec Imaging Systems)., Results: Patients with ACM showed significantly reduced LV longitudinal strain (-12.7 ± 6.5 vs. -16.8 ± 5.9%, p=0.021) and LV circumferential strain (LVCirStrain; -22.9 ± 5.7 vs. -27.8 ± 4.4 %, p<0.001) compared to HV. Conversely, they showed improved basal RV circumferential strain rate (BasalRVCirSR; -0.70 ± 0.23 vs. -0.47 ± 0.31s(-1), p=0.009). In ACM patients with preserved EF, BasalRVCirSR was significantly increased compared to HV while LV strain was not significantly different between both groups. In multinominal logistic regression analysis, LVCirStrain and BasalRVCirSR proved to be the best independent predictors of ACM with preserved EF. A combined cut-off of -0.53s(-1) for BasalRVCirSR and of -29.0% for LVCirStrain allowed a classification of ACM patients with preserved EF with a sensitivity of 89% and a specificity of 80%. Also patients with clinical ACM but inconspicuous CMR showed a significantly improved BasalRVCirSR and a cut-off of -0.77s(-1) allowed a classification of ACM patients with a sensitivity of 70% and a specificity of 90%, while all other CMR parameters were normal., Conclusions: The defined cut-offs for LVCirStrain and BasalRVCirSR allow a prediction of ACM with high sensitivity and specificity, even in patients with preserved EF and in patients with otherwise completely inconspicuous CMR. Our results point to a discriminative power especially of RV strain analysis in the CMR-based diagnosis of ACM., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: The purpose of the present study was to investigate the diagnostic value of T2-mapping in acute myocarditis (ACM) and to define cut-off values for edema detection., Methods: Cardiovascular magnetic resonance (CMR) data of 31 patients with ACM were retrospectively analyzed. 30 healthy volunteers (HV) served as a control. Additionally to the routine CMR protocol, T2-mapping data were acquired at 1.5 T using a breathhold Gradient-Spin-Echo T2-mapping sequence in six short axis slices. T2-maps were segmented according to the 16-segments AHA-model and segmental T2 values as well as the segmental pixel-standard deviation (SD) were analyzed., Results: Mean differences of global myocardial T2 or pixel-SD between HV and ACM patients were only small, lying in the normal range of HV. In contrast, variation of segmental T2 values and pixel-SD was much larger in ACM patients compared to HV. In random forests and multiple logistic regression analyses, the combination of the highest segmental T2 value within each patient (maxT2) and the mean absolute deviation (MAD) of log-transformed pixel-SD (madSD) over all 16 segments within each patient proved to be the best discriminators between HV and ACM patients with an AUC of 0.85 in ROC-analysis. In classification trees, a combined cut-off of 0.22 for madSD and of 68 ms for maxT2 resulted in 83% specificity and 81% sensitivity for detection of ACM., Conclusions: The proposed cut-off values for maxT2 and madSD in the setting of ACM allow edema detection with high sensitivity and specificity and therefore have the potential to overcome the hurdles of T2-mapping for its integration into clinical routine.