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MRI imaging in the short axis. Posterior and posterolateral late gadolinium enhancement in the subepicardial region in with acute myopericarditis (Patient 1)
Source publication
Background
Myocardial involvement in young adults has various causes. Acute myopericarditis is one of the myocardial involvements in young adults. It is easy to confuse with acute ST-elevation myocardial infarction because of the electrocardiographic features. This study aims to investigate a number of imaging techniques and clinical features for a...
Contexts in source publication
Context 1
... echocardi- ography device (General Electric, USA) 2.5 MHz transducer and two dimensional images (2-D), M-mode and Doppler. Depth in operation was 20 cm, dynamic range was 6. M- mode and 2-D images of left ventricle were taken based on the criteria of American Society of Echocardiography [10]. Three patients underwent CMR imaging within 72 h (see Fig. 2 for one patient's ...
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Citations
... Due to the overlap in symptoms with other clinical presentations, the diagnosis of myocarditis is often challenging. It is, therefore, important to highlight that a preceding acute febrile illness, symptoms of connective tissue disease, and a viral infection should always lead to suspicion [20][21][22]. Figure 2 provides an overview of the investigations used in the diagnosis of myocarditis and respective fndings [21,23]. ...
Background
In December 2019, the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) led to the COVID-19 pandemic, with millions of deaths worldwide. Vaccine breakthroughs in late 2020 resulted in the authorization of COVID-19 vaccines. While these vaccines have demonstrated efficacy, evidence from vaccine safety monitoring systems around the globe supported a causal association between COVID-19 vaccines, in particular those using mRNA technology, i.e., Moderna's mRNA-1273 and Pfizer-BioNTech's BNT162b2, and myocarditis.
Objective
This paper aims to investigate the epidemiology of mRNA COVID-19 vaccine-induced myocarditis, including age, ethnicity, and gender associations with these vaccines. It also discusses the immunopathophysiological mechanisms of mRNA COVID-19 vaccine-associated myocarditis and outlines principles of diagnosis, clinical presentation, and management.
Methods
A literature review was conducted using PubMed, Embase, and Queen Mary University of London Library Services databases. Search terms included “myocarditis,” “coronavirus disease 2019,” “SARS-CoV-2,” “mRNA Covid-19 vaccines,” “Covid vaccine-associated myocarditis,” “epidemiology,” “potential mechanisms,” “myocarditis diagnosis,” and “myocarditis management.”
Results
While the definite mechanism of mRNA COVID-19 vaccine-associated myocarditis remains ambiguous, potential mechanisms include molecular mimicry of spike proteins and activation of the adaptive immune response with dysregulated cytokine expression. Male predominance in COVID-19 vaccine-induced myocarditis may be attributed to sex hormones, variations in inflammatory reactions, coagulation states based on gender, and female-specific protective factors. Moreover, an analysis of diagnostic and management strategies reveals a lack of consensus on acute patient presentation management.
Conclusion
In contrast to viral infections that stand as the predominant etiological factor for myocarditis with more severe consequences, the mRNA COVID-19 vaccination elicits a mild and self-limiting manifestation of the condition. There is currently insufficient evidence to confirm the definite underlying mechanism of COVID-19 vaccine-associated myocarditis. Further research is needed to develop preventive and therapeutic solutions in this context.
... Although most findings in the setting of myocarditis are not specific, focal echogenicity, particularly in the lateral and inferior wall, and the presence of pericardial effusions have been shown to be sensitive for acute myopericarditis in young adults. 52 Speckle tracking-based myocardial strain is also a potentially sensitive method to identify acute myocarditis with echocardiography. 53 Impaired ventricular function is a predictor of poor outcomes, and echocardiography is also useful in follow-up to ensure recovery of function 54 ...
Myocarditis is an established but rare adverse event following administration of messenger RNA-based coronavirus disease 2019 (COVID-19) vaccines and is most common in male adolescents and young adults. Symptoms typically develop within a few days of vaccine administration. Most patients have mild abnormalities on cardiac imaging with rapid clinical improvement with standard treatment. However, longer term follow-up is needed to determine whether imaging abnormalities persist, to evaluate for adverse outcomes, and to understand the risk associated with subsequent vaccination. The purpose of the review is to evaluate the current literature related to myocarditis following COVID-19 vaccination, including the incidence, risk factors, clinical course, imaging findings, and proposed pathophysiologic mechanisms.
... Ведущей этиологической причиной развития миоперикардитов является вирусная инвазия [41][42][43]. Как и при раздельном поражении миокарда и перикарда, миоперикардит развивается нередко после перенесенной острой респираторно-вирусной инфекции, острого тонзиллита, пневмонии, гастроэнтерита или энтероколита [44,45]. В развивающихся странах существенное значение в развитии миоперикардита играют другие инфекционные агенты, особенно туберкулез [1]. ...
... Необходимым условием постановки верного диагноза является тщательный сбор жалоб и анамнеза, позволяющий выявить характерные для миоперикардита особенности (например, связь с перенесенной инфекцией, лихорадка). ЭхоКГ также позволяет выявить характерные для миоперикардита изменения, такие как изменение листков перикарда и гиперэхогенные очаги в миокарде [45]. Проведение коронароангиографии и МРТ сердца также зачастую являются необходимыми для дифференциальной диагностики с ИМ. ...
Russian Society of Cardiology (RSC)
With the participation of the Eurasian Association of Therapists, the Russian Scientific Medical Society of Therapists (RNMOT), the Russian Society of Pathologists, the Russian Society of Radiologists and Radiologists (RSR)
Approved by the Scientific and Practical Council of the Russian Ministry of Health (30.09.2022)
... Ведущей этиологической причиной развития миоперикардитов является вирусная инвазия [41][42][43]. Как и при раздельном поражении миокарда и перикарда, миоперикардит развивается нередко после перенесенной острой респираторно-вирусной инфекции, острого тонзиллита, пневмонии, гастроэнтерита или энтероколита [44,45]. В развивающихся странах существенное значение в развитии миоперикардита играют другие инфекционные агенты, особенно туберкулез [1]. ...
... Необходимым условием постановки верного диагноза является тщательный сбор жалоб и анамнеза, позволяющий выявить характерные для миоперикардита особенности (например, связь с перенесенной инфекцией, лихорадка). ЭхоКГ также позволяет выявить характерные для миоперикардита изменения, такие как изменение листков перикарда и гиперэхогенные очаги в миокарде [45]. Проведение коронароангиографии и МРТ сердца также зачастую являются необходимыми для дифференциальной диагностики с ИМ. ...
... It is estimated that the incidence of myocarditis fluctuates between 0.02 and 1.5% of the general population with the average age of patients from 20-51 years, mostly men [1,4,5]. Due to the heterogeneity of clinical presentation, which can range from asymptomatic to acute coronary syndrome (ACS) -like and acute heart failure, the diagnosis of acute myocarditis (AM) is still challenging [6][7][8][9]. When myocarditis is presented with chest pain, electrocardiographic changes with ST-segment deviation, raised cardiac troponin levels, differentiation from myocardial infarction (MI) is necessary [9][10][11]. ...
... Echocardiography findings including global ventricular dysfunction, regional wall motion abnormalities or diastolic dysfunction are also non-specific [6,10]. Thus, a coronary angiography has been still performed in patients with inflammatory heart diseases in order to exclude obstructive coronary artery disease (CAD) [8,10]. A final diagnosis of myocarditis is possible only on endomyocardial biopsy (EMB), which is still the diagnostic gold standard but due to its invasive character, low availability and small numbers of multidisciplinary teams with complementary competences in EMB procedure, extremely limited in clinical practice [6,7,10,[12][13][14]. Hence, cardiac magnetic resonance imaging (CMR) has recently emerged as a reference standard for the diagnosis of acute myocarditis due to its ability to identify myocardial oedema and inflammation, as well as scarring associated with MI [15][16][17]. ...
... It seems to be reasonable to first use CMR as a noninvasive tool for the tissue characterization of the myocardium in clinically stable patients presented with chest pain, ST segment elevation in electrocardiogram (ECG) and normal coronary arteries [6,18]. However, CMR is expensive and not always available in many areas worldwide [6,8,10,19]. One of the most commonly used devices in most centres is conventional transthoracic echocardiogram (TTE) but is often not sufficiently sensitive to detect subtle myocardial dysfunction [7,8]. ...
Purpose
Comparing myocarditis with an acute coronary syndrome (ACS)-like presentation and acute myocardial infarction (AMI) poses an important clinical challenge. The purpose of the study was to investigate the diagnostic value of the clinical, laboratory and especially echocardiographic characteristics including speckle tracking echocardiography (STE) of patients with ACS-like myocarditis and AMI.
Methods
We conducted a retrospective analysis comparing 69 symptomatic patients (≤ 45 years old), hospitalized at the Department of Interventional Cardiology (Medical University of Lodz, Poland) between April 2014 and June 2021 with an initial diagnosis of ST-segment elevation myocardial infarction.
Results
37 patients with the cardiac magnetic resonance–confirmed acute myocarditis and 32 patients diagnosed with AMI based on the clinical presentation, electrocardiogram and the presence of a culprit lesion on the coronary angiography were analysed including echocardiography parameters. On STE analysis an average global longitudinal (GLS), radial and circumferential strain including three—layers observation were significantly lower (absolute value) in patients with AMI versus acute myocarditis (p<0.05). There was no significant difference in Endo/Epi ratio (p = 0.144) between the groups. An average GLS < (-17.5) represented the optimal cut-off value for the myocarditis diagnosis.
Conclusion
In patients with AMI a significant reduction of global and three-layers strains compared to patients with myocarditis was detected. Furthermore, our analysis also confirmed the discriminative pattern of myocardial injury between the groups.
... Although most findings in the setting of myocarditis are not specific, focal echogenicity, particularly in the lateral and inferior wall, and the presence of pericardial effusions have been shown to be sensitive for acute myopericarditis in young adults. 52 Speckle tracking-based myocardial strain is also a potentially sensitive method to identify acute myocarditis with echocardiography. 53 Impaired ventricular function is a predictor of poor outcomes, and echocardiography is also useful in follow-up to ensure recovery of function 54 ...
Myocarditis is an established but rare adverse event following administration of messenger RNA-based coronavirus disease 2019 (COVID-19) vaccines and is most common in male adolescents and young adults. Symptoms typically develop within a few days of vaccine administration. Most patients have mild abnormalities on cardiac imaging with rapid clinical improvement with standard treatment. However, longer term follow-up is needed to determine whether imaging abnormalities persist, to evaluate for adverse outcomes, and to understand the risk associated with subsequent vaccination. The purpose of the review is to evaluate the current literature related to myocarditis following COVID-19 vaccination, including the incidence, risk factors, clinical course, imaging findings, and proposed pathophysiologic mechanisms.
... Acute myocarditis, due to its initial infarct-like clinical presentation, including chest pain, increased cardiac biomarkers, ST-segment elevation in the ECG, malignant arrhythmias, and impaired left ventricular ejection fraction (LVEF), constitutes a great challenge for clinicians to distinguish it from ACS [9,10]. The actual and accurate incidence of myocarditis in populations remains unknown, as the endomyocardial biopsy (EMB)-the diagnostic ESC gold standard-is infrequently followed in clinical practise [11,12]. ...
... In young patients presenting ST-segment elevation in the ED coronary angiography, the first exam performed to exclude obstructive CAD. At present, in most cases, this invasive technique is much more available than CTA or CMR imaging [9]. ...
... Based on our study, all of the above-mentioned features, including young age, absence of cardiovascular risk factors, history of fever or any other infection symptoms, atypical troponin release, and an increased CRP level on admission may compose a low-risk MI patient's profile. Until now, there have been few studies sufficiently differentiating myocarditis and MI on the grounds of the non-invasive tests [9,13,17,33]. They have recommended assessment of the MI risk among young patients with ST-segment elevation before the invasive procedures. ...
Myocarditis may mimic myocardial infarction (MI) due to a similar clinical presentation, including chest pain, electrocardiography changes, and laboratory findings. The purpose of the study was to investigate the diagnostic value of clinical, laboratory, and electrocardiography characteristics of patients with acute coronary syndrome - like myocarditis and MI. We analysed 90 patients (≤45 years old) with an initial diagnosis of ST-segment elevation myocardial infarction; 40 patients (44.4%), through the use of cardiac magnetic resonance, were confirmed to have myocarditis, and 50 patients (55.6%) were diagnosed with MI. Patients with myocarditis were younger and had fewer cardiovascular risk factors than those with MI. The cutoff value distinguishing between myocarditis and MI was defined as the age of 36 years. The history of recent infections (82.5% vs. 6%) and C-reactive protein (CRP) levels on admission (Me 45.9 vs. 3.4) was more associated with myocarditis. Further, the QTc interval was inversely correlated with the echocardiographic ejection fraction in both groups but was significantly longer in patients with MI. Non-invasive diagnostics based on clinical features and laboratory findings are basic but still essential tools for differentiation between MI and myocarditis. The three-factor model including the criteria of age, abnormal CRP, and history of recent infections might become a valuable clinical indication.
... 14 Echocardiographic heart involvement was accepted as pericardial effusion, focal perimyocardial echo bright appearance, or/and myocardial wall segment abnormality. 15 ...
Background
During COVID-19 pandemic, several vaccines have been developed such as mRNA vaccines. However, acute pericarditis and myocarditis/myopericarditis cases have been described after mRNA vaccination. The mechanism for the development of cardiac involvement is unknown. Potential mechanism for oxidative stress associated with vaccine-induced heart involvement is unidentified. This study aimed to examine the role of oxidative stress and the heart involvement in young adults vaccinated with COVID-19 mRNA vaccines.
Methods
In this cross-sectional study, a total of 23 participants were included and 10 of these participants were asymptomatic patients (control group). Comparison of the cardiac involvement and control group was made by using troponin I, C-reactive protein (hsCRP), D-dimer levels, and oxidative stress tests including nitric oxide, and imaging techniques (ECG, echocardiography, cardiovascular magnetic resonance).
Results
The median age of acute pericarditis group (10 patients) was 22 years (Q1-Q3: 18.5–31), and the mean age was 24.4±7.5 years. The median age of myopericarditis group (3 patients) was 22 years (Q1–Q3 18.0–25.0), and the mean age was 21.6 ±3.5 years. All the myopericarditis cases were male. The patients with myopericarditis had higher troponin I level, hsCRP, and D-dimer levels (troponin I level; 1600.00 ng/mL; D-dimer; 1.20 μg/mL, hsCRP; 3.0 mg/L, respectively; p < 0.05). Serum nitric oxide levels and OSI (total oxidant status, H2O2/total antioxidant status) were lower in myopericarditis group than the control and acute pericarditis group (p < 0.05). This shows inflammatory and procoagulant state.
Conclusion
Vaccine-induced myopericarditis cases are associated with oxidative stress test abnormality (abnormal NO, OSI levels). However, there is no relationship between NO levels and other oxidative stress tests difference in vaccine-induced acute pericarditis. It is thought that vaccine-induced pericarditis and myopericarditis could have different pathogenesis. This could make it necessary to reassess the second dose of vaccination for vaccine-induced cardiac involvement cases.
... ECG shows repolarization abnormalities leads II, aVF and III.Table 1. Patient's laboratory results at presentation. 500 µL, (normal; 4000 to 11,000 per microliter of blood), lenfo-monocytosis Platelet Count 98,000 (normal; 150,000 to 400,000 per microliter of blood)Anti-EBV capsid antigen IgM (EBV-VCA) positive ventricle with mild impaired systolic function and increased perimyocardial brightness by echocardiography[4].Due to triad of clinical signs, we suspected EBV infection associated with myocarditis and hepatitis. Antibody serology tests showed that the anti-EBV capsid antigen IgM (EBV-VCA) was positive, EBV-VCA) IgG was negative.Other etiologies were excluded by PCRs, serologies, cultures, and viral tests including COVID-19 and hepatitis.The patient not underwent magnetic resonance imaging (CMR), due to technic problems of CMR device. ...
... 14 Echocardiographic involvement was accepted as pericardial effusion or focal perimyocardial echo bright appearance. 15 Cardiac MR Scan (CMR) and Cardiac Positron Emission Tomography (PET) ...
Background
In the post-acute COVID-19 syndrome, many patients suffer from palpitations, effort-associated fatigue, and even sudden death. The mechanism of heart involvement in this syndrome is uncertain. The main purpose of the study was to identify possible cardiac involvement causes in patients with post-acute COVID-19 by using biomarkers such as NT-proBNP and nitric oxide (NO) and cardiac imaging modalities.
Methods
In this cross-sectional study, a total of 105 participants were included according to the existence of symptoms, and 40 of these participants were asymptomatic patients. The ages of the participants ranged from 20 to 50 years. All patients were healthy before COVID-19. The symptoms were defined as palpitations and/or fatigue association with exercise in post-acute COVID-19 term. The comparison of the two groups was made by using biochemical parameters (NT-proBNP, Troponin I, NO) and imaging techniques (echocardiography, cardiovascular magnetic resonance (CMR) and cardiac positron emission tomography (PET)).
Results
The symptomatic patients had higher NT-proBNP levels compared with asymptomatic patients (132.30±35.15; 76.86±16.79, respectively; p < 0.001). Interestingly, the symptomatic patients had lower NO levels than asymptomatic patients (9.20±3.08; 16.15±6.02, respectively; p < 0.001). Echocardiography and CMR were normal. However, we found regional increased 18F-FDG uptake on cardiac PET to be compatible with myocardial fatigue.
Conclusion
We found elevated NT-proNBP levels, low serum NO levels, and increased 18F-FDG uptake on cardiac PET in post-acute COVID syndrome. Cardiac PET could replace or be added to CMR for detecting subtle subacute/chronic myocarditis. The follow-up of patients with post-acute COVID-19 could target the possibility of risk of heart failure.
