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CLINICAL RESEARCH

Delayed Gadolinium-Enhanced Cardiac Magnetic Resonance in Patients With Chronic Myocarditis Presenting With Heart Failure or Recurrent Arrhythmias

Francesco De Cobelli, MD^_*,_*, Maurizio Pieroni, MD, PhD^,, Antonio Esposito, MD^_*, Cristina Chimenti, MD, PhD^,, Elena Belloni, MD^_*, Renata Mellone, MD^_*, Tamara Canu, RT^_*, Gianluca Perseghin, MD, Carlo Gaudio, MD, Attilio Maseri, MD, Andrea Frustaci, MD and Alessandro Del Maschio, MD^_*

^_* Radiology Department
Cardio-Thoracic and Vascular Department
Internal Medicine Department, San Raffaele Scientific Institute and Università Vita-Salute San Raffaele, Milan, Italy
Department of Heart and Great Vessels "Attilio Reale," La Sapienza University Rome, Rome, Italy

Manuscript received July 5, 2005; revised manuscript received October 19, 2005, accepted November 28, 2005.

^_* Reprint requests and correspondence: Dr. Francesco De Cobelli, Department of Radiology, Vita-Salute University/San Raffaele Scientific Institute, Via Olgettina 60, Milano 20132, Italy (Email: francesco.decobelli{at}hsr.it).

OBJECTIVES: We evaluated the effectiveness of contrast-enhanced cardiac magnetic resonance (CE-CMR) in detecting chronic myocarditis (CM).

BACKGROUND: Chronic myocarditis represents a common evolution of acute myocarditis. Although CE-CMR has been revealed to be effective in identifying areas of myocardial damage in acute myocarditis, its role in the diagnosis of chronic myocardial inflammation has not yet been investigated.

METHODS: Twenty-three patients with CM underwent CE-CMR and endomyocardial biopsy (EMB). Chronic myocarditis was defined by the presence of: 1) chronic (>6 months) heart failure symptoms and/or repetitive ventricular arrhythmias; 2) no history of recent flu-like symptoms or infections; and 3) histologic evidence of active myocarditis (AM) or borderline myocarditis (BM) according to Dallas criteria. Contrast-enhanced cardiac magnetic resonance included black-blood T2-weighted (BBT2w) images without and with fat saturation and delayed three-dimensional T1 turbo field-echo inversion-recovery sequences obtained 15 min after gadolinium injection.

RESULTS: Histology showed AM in 14 patients and BM in 9 patients. FatSat BBT2w revealed the presence of edema in five (36%) patients with AM but not in BM patients. Areas of late enhancement (LE) were observed in 12 (84%) subjects with AM and in 4 (44%) cases with BM. A mid-wall LE pattern was the most frequent finding in both groups while a subepicardial distribution of LE was observed only in patients with AM.

CONCLUSIONS: Contrast-enhanced cardiac magnetic resonance identified areas of myocardial inflammation in up to 70% of patients with biopsy-proven CM. We suggest that CE-CMR may be a useful non-invasive diagnostic tool in patients with CM, and it may indicate and even guide the execution of left ventricular EMB with relevant prognostic and therapeutic implications.

Abbreviations and Acronyms   AM = active myocarditis   BBT2w = black-blood T2-weighted   BM = borderline myocarditis   CE-CMR = contrast-enhanced cardiac magnetic resonance   CM = chronic myocarditis   CMR = cardiac magnetic resonance   EF = ejection fraction   EMB = endomyocardial biopsy   LE = late enhancement   LV = left ventricle/ventricular   PCR = polymerase chain reaction   RV = right ventricle/ventricular

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