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. 2022 Mar 1;7(3):298-308.
doi: 10.1001/jamacardio.2021.5505.

Combined Cardiac Fluorodeoxyglucose-Positron Emission Tomography/Magnetic Resonance Imaging Assessment of Myocardial Injury in Patients Who Recently Recovered From COVID-19

Kate Hanneman  1 , Christian Houbois  1   2 , Alice Schoffel  3 , Dakota Gustafson  4 , Robert M Iwanochko  3 , Bernd J Wintersperger  1 , Rosanna Chan  1 , Jason E Fish  4 , Kathryn L Howe  5 , Paaladinesh Thavendiranathan  1   3
Affiliations

Combined Cardiac Fluorodeoxyglucose-Positron Emission Tomography/Magnetic Resonance Imaging Assessment of Myocardial Injury in Patients Who Recently Recovered From COVID-19

Kate Hanneman et al. JAMA Cardiol. .

Abstract

Importance: Although myocardial injury can occur with acute COVID-19, there is limited understanding of changes with myocardial metabolism in recovered patients.

Objective: To examine myocardial metabolic changes early after recovery from COVID-19 using fluorodeoxyglucose-positron emission tomography (PET) and associate these changes to abnormalities in cardiac magnetic resonance imaging (MRI)-based function and tissue characterization measures and inflammatory blood markers.

Design, setting, and participants: This prospective cohort study took place at a single-center tertiary referral hospital system. A volunteer sample of adult patients within 3 months of a diagnosis of COVID-19 who responded to a mail invitation were recruited for cardiac PET/MRI and blood biomarker evaluation between November 2020 and June 2021.

Exposures: Myocardial inflammation as determined by focal fluorodeoxyglucose (FDG) uptake on PET.

Main outcomes and measures: Demographic characteristics, cardiac and inflammatory blood markers, and fasting combined cardiac 18F-FDG PET/MRI imaging were obtained. All patients with focal FDG uptake at baseline returned for repeated PET/MRI and blood marker assessment 2 months later.

Results: Of 47 included patients, 24 (51%) were female, and the mean (SD) age was 43 (13) years. The mean (SD) interval between COVID-19 diagnosis and PET/MRI was 67 (16) days. Most patients recovered at home during the acute infection (40 [85%]). Eight patients (17%) had focal FDG uptake on PET consistent with myocardial inflammation. Compared with those without FDG uptake, patients with focal FDG uptake had higher regional T2, T1, and extracellular volume (colocalizing with focal FDG uptake), higher prevalence of late gadolinium enhancement (6 of 8 [75%] vs 9 of 39 [23%], P = .009), lower left ventricular ejection fraction (mean [SD], 55% [4%] vs 62% [5%], P < .001), worse global longitudinal and circumferential strain (mean [SD], -16% [2%] vs -17% [2%], P = .02 and -18% [2%] vs -20% [2%], P = .047, respectively), and higher systemic inflammatory blood markers including interleukin 6, interleukin 8, and high-sensitivity C-reactive protein. Among patients with focal FDG uptake, PET/MRI, and inflammatory blood markers resolved or improved at follow-up performed a mean (SD) of 52 (17) days after baseline PET/MRI.

Conclusions and relevance: In this study of patients recently recovered from COVID-19, myocardial inflammation was identified on PET in a small proportion of patients, was associated with cardiac MRI abnormalities and elevated inflammatory blood markers at baseline, and improved at follow-up.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hanneman reported personal fees from Sanofi Genzyme, Amicus, and Medscape outside the submitted work. Dr Wintersperger reported personal fees from Siemens Healthineers, nonfinancial research support from Siemens Healthineers, and personal fees from Bayer AG outside the submitted work; had a patent for IG fitting method for T1 mapping (US10314548B2) issued (owned by the University Health Network); and University Health Network has a master research agreement with Siemens Healthineers. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cardiac PET/Magnetic Resonance Imaging Finding in Patients Recently Recovered From COVID-19
A representative patient with focal fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) is shown in panel A (PET positive) and a representative patient without FDG uptake on PET is shown in panel B (PET negative). Magnetic resonance imaging findings are shown in short-axis, including late gadolinium enhancement (LGE; pink arrowhead), T2, and native T1. In the PET-positive patient, T1 and T2 values were higher in the region of focal FDG uptake (yellow contours, values shown in orange boxes) compared with remote myocardium at the interventricular septum on the midventricular slice (blue contours, values shown in white boxes). In the patient who was PET negative, T2 and T1 values at the interventricular septum were normal (blue contours, values shown in white boxes). CMV indicates cardiac metabolic volume.
Figure 2.
Figure 2.. Comparison of Cardiac Magnetic Resonance Imaging Tissue Characterization and Functional Measures and Blood Biomarkers Between Patients With Focal Fluorodeoxyglucose Uptake (PET+) and Those Without (PET−)
Graphs for magnetic resonance imaging parameters depict individual patient data points with error bars displayed as mean (SD). Graphs for blood biomarkers depict mean values and individual patient data points containing 3 technical replicates with error bars displayed as mean (SD). ECV indicates extracellular volume; hsCRP, high-sensitivity C-reactive protein; IL, interleukin; LVEF, left ventricular ejection fraction; MPO, myeloperoxidase; PET, positron emission tomography.
Figure 3.
Figure 3.. Change Between Baseline and Follow-up in Magnetic Resonance Imaging and Blood Biomarker Parameters
All patients with focal fluorodeoxyglucose (FDG) uptake on baseline evaluation returned for follow-up 2 months later with interval improvement in positron emission tomography/magnetic resonance imaging and blood inflammatory marker parameters. ECV indicates extracellular volume; hsCRP, high-sensitivity C-reactive protein; IL, interleukin; LVEF, left ventricular ejection fraction; MPO, myeloperoxidase.
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