Myocarditis Following COVID-19 Vaccination: Cardiac Imaging Findings in 118 Studies

Abstract

We reviewed the reported imaging findings of myocarditis in the literature following COVID-19 vaccination on cardiac imaging by a literature search in online databases, including Scopus, Medline (PubMed), Web of Science, Embase (Elsevier), and Google Scholar. In total, 532 cases of myocarditis after COVID-19 vaccination were reported (462, 86.8% men and 70, 13.2% women, age range 12 to 80) with the following distribution: Pfizer-BioNTech: 367 (69%), Moderna: 137 (25.8%), AstraZeneca: 12 (2.3%), Janssen/Johnson & Johnson: 6 (1.1%), COVAXIN: 1 (0.1%), and unknown mRNA vaccine: 9 (1.7%). The distribution of patients receiving vaccine dosage was investigated. On cardiac MR Imaging, late intravenous gadolinium enhancement (LGE) was observed mainly in the epicardial/subepicardial segments (90.8%, 318 of 350 enhancing segments), with the dominance of inferolateral segment and inferior walls. Pericardial effusion was reported in 13.1% of cases. The vast majority of patients (94%, 500 of 532) were discharged from the hospital except for 4 (0.7%) cases. Post-COVID-19 myocarditis was most commonly reported in symptomatic men after the second or third dose, with CMRI findings including LGE in 90.8% of inferior and inferolateral epicardial/subepicardial segments. Most cases were self-limited.

Keywords: Janssen/Johnson & Johnson; Moderna; Pfizer-BioNTech; coronavirus; myocarditis.

Figure 1

Coronary angiography and cardiac MRI. (A) The right coronary artery only had a mild plaque (<30% luminal diameter) in the mid portion, whereas in (B) the left main stem, left anterior descending artery, and circumflex artery had no evidence of coronary plaques. (C) T2-weighted 3-chamber view on cardiac MRI, showing focal areas of edema involving the subepicardial-intramyocardial regions of the basal and apical segments of the inferolateral wall (arrows). (D) Late gadolinium enhancement confirmed the presence of non-ischemic myocardial lesions in the basal and apical segments of the inferolateral wall (arrows) consistent with acute myocarditis. Reprinted/adapted with permission from Ref. [13] 2021, Elsevier.

Figure 2

Cardiac MRI PSIR-LGE views show late gadolinium subepicardial enhancement in basal lateral segments in (a) four-chamber and (b) short-axis views. Reprinted/adapted with permission from Ref. [14]. 2021, Elsevier.

Figure 3

Images of a 15-year-old boy with myocarditis after COVID-19 vaccination. One day after receiving his second vaccination dose, he developed fever, myalgia, and intermittent tachycardia. (A) T2-weighted short inversion time inversion recovery MRI scans at 1.5 T in short-axis view show focal high-signal intensities (arrow) at the basal lateral and inferior wall, indicating myocardial edema. (B) Late gadolinium enhancement image in short-axis view shows corresponding linear subepicardial enhancement (arrow), indicating inflammatory myocardial necrosis. (C) T1 mapping and (D) T2 mapping in the short-axis view show elevated T1 and T2 at the mid-ventricular lateral and inferolateral wall (arrow in (C,D)), indicating acute myocardial injury (focal T1, 1165 ms; focal T2, 70 ms; institution-specific cut-off values for acute myocarditis: T1 global ≥ 1000 ms, T2 global ≥ 55.9 ms). Reprinted/adapted with permission from Ref. [8], 2021, RSNA.

Figure 4

Magnetic Resonance Imaging of Case 2. Post-contrast magnitude inversion recovery (MAG-IR) (A) and phase-sensitive inversion recovery (PSIR) (B) images in short-axis views show subepicardial enhancement in the inferolateral wall at the base (arrowheads). Native T1 map shows corresponding abnormality (arrowheads in (C)) with elevated values (D) in the inferolateral wall compared with the interventricular septum. T2 mapping also showed abnormality in this region (arrows in (E)) with elevated values (F) when compared with the interventricular septum. Reprinted/adapted with permission from Ref. [15] 2021, Elsevier.

Figure 4

Magnetic Resonance Imaging of Case 2. Post-contrast magnitude inversion recovery (MAG-IR) (A) and phase-sensitive inversion recovery (PSIR) (B) images in short-axis views show subepicardial enhancement in the inferolateral wall at the base (arrowheads). Native T1 map shows corresponding abnormality (arrowheads in (C)) with elevated values (D) in the inferolateral wall compared with the interventricular septum. T2 mapping also showed abnormality in this region (arrows in (E)) with elevated values (F) when compared with the interventricular septum. Reprinted/adapted with permission from Ref. [15] 2021, Elsevier.

Figure 5

Flow diagram of the study selection process. Preferred reporting items for systematic reviews and meta-analyses (PRISMA). Adapted from Moher et al.