Korean J Radiol.  2017 ;18(4):643-654. 10.3348/kjr.2017.18.4.643.

Predictive Value of Cardiac Magnetic Resonance Imaging-Derived Myocardial Strain for Poor Outcomes in Patients with Acute Myocarditis

Affiliations
  • 1Department of Radiology, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan 49241, Korea.
  • 2Department of Cardiology, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan 49241, Korea.
  • 3Pusan National University School of Medicine and Medical Research Institute, Pusan National University Yangsan Hospital, Yangsan 50612, Korea.
  • 4Department of Radiology, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Yangsan Hospital, Yangsan 50612, Korea. kschoo0618@naver.com

Abstract


OBJECTIVE
To evaluate the utility of cardiovascular magnetic resonance (CMR)-derived myocardial strain measurement for the prediction of poor outcomes in patients with acute myocarditis.
MATERIALS AND METHODS
We retrospectively analyzed data from 37 patients with acute myocarditis who underwent CMR. Left ventricular (LV) size, LV mass index, ejection fraction and presence of myocardial late gadolinium enhancement (LGE) were analyzed. LV circumferential strain (Ecc(SAX)), radial strain (Err(SAX)) from mid-ventricular level short-axis cine views and LV longitudinal strain (Ell(LV)), radial strain (Err(Lax)) measurements from 2-chamber long-axis views were obtained. In total, 31 of 37 patients (83.8%) underwent follow-up echocardiography. The primary outcome was major adverse cardiovascular event (MACE). Incomplete LV functional recovery was a secondary outcome.
RESULTS
During an average follow-up of 41 months, 11 of 37 patients (29.7%) experienced MACE. Multivariable Cox proportional hazard regression analysis, which included LV mass index, LV ejection fraction, the presence of LGE, Ecc(SAX), Err(SAX), Ell(LV), and Err(Lax) values, indicated that the presence of LGE (hazard ratio, 42.88; p = 0.014), together with ErrLax (hazard ratio, 0.77 per 1%, p = 0.004), was a significant predictor of MACE. Kaplan-Meier analysis demonstrated worse outcomes in patient with LGE and an Err(Lax) value ≤ 9.48%. Multivariable backward regression analysis revealed that Err(Lax) values were the only significant predictors of LV functional recovery (hazard ratio, 0.54 per 1%; p = 0.042).
CONCLUSION
CMR-derived Err(Lax) values can predict poor outcomes, both MACE and incomplete LV functional recovery, in patients with acute myocarditis, while LGE is only a predictor of MACE.

Keyword

Myocarditis; Magnetic resonance imaging; Major adverse cardiovascular events; Ventricular dysfunction; Left ventricle; Strain

MeSH Terms

Acute Disease
Adult
Aged
Area Under Curve
Disease Progression
Echocardiography
Female
Gadolinium/chemistry
Heart Ventricles/diagnostic imaging
Humans
Kaplan-Meier Estimate
*Magnetic Resonance Imaging, Cine
Male
Middle Aged
Myocarditis/*diagnostic imaging/mortality/pathology
Predictive Value of Tests
Prognosis
Proportional Hazards Models
ROC Curve
Retrospective Studies
Ventricular Function, Left
Gadolinium

Figure

  • Fig. 1 Myocardial strain measurement by feature tracking method in 43-year-old female patient with acute myocarditis.After endocardial and epicardial borders of LV were traced semi-automatically, software (CVI42) automatically tracked endocardial and epicardial borders across frames during cardiac cycle. EccSAX and ErrSAX measurements (A) were obtained using mid-ventricular level short-axis cine views. EllLV and ErrLax measurements (B) were obtained from 2-chamber long-axis view. EccSAX = LV circumferential strain measured from short-axis cine views, EllLV = LV longitudinal strain measured from long-axis cine views, ErrLax = LV radial strain measured from long-axis cine views, ErrSAX = LV radial strain measured from short-axis cine views, LV = left ventricular

  • Fig. 2 Receiver operating characteristic curve for prediction of MACE.MACE was defined in terms of cardiac death, heart transplantation, implantable cardioverter defibrillator or pacemaker, rehospitalization following cardiac event, or embolic stroke. AUC = area under the curve, ErrLax = LV radial strain measured from long-axis cine views, LV = left ventricle, MACE = major adverse cardiovascular events

  • Fig. 3 MACE according to ErrLax or presence of LGE.A. Survivial in patients with ErrLax ≤ 9.48% vs. those with ErrLax > 9.48%. Note that only one patient without LGE experienced MACE dring follow-up. B. Survivial in patients with LGE vs. those without LGE. C. Survivial in patients with ErrLax ≤ 9.48% and presence of LGE vs. those with ErrLax ≤ 9.48% and presence of LGE vs. those without LGE. Patients with LGE and decreased ErrLax (≤ 9.48%) had worse outcome, compared to patients with LGE only. CMR = cardiovascular magnetic resonance, ErrLax = LV radial strain measured from long-axis cine views, LGE = late gadolinium enhancement, LV = left ventricle, MACE = major adverse cardiovascular events

  • Fig. 4 Receiver operating characteristic curve for prediction of incomplete left ventricular functional recovery.AUC = area under the curve, ErrLax = LV radial strain measured from long-axis cine views, LV = left ventricle


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