Cardiovascular magnetic resonance for evaluation of cardiac involvement in COVID-19: recommendations by the Society for Cardiovascular Magnetic Resonance

Abstract

Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that has affected nearly 600 million people to date across the world. While COVID-19 is primarily a respiratory illness, cardiac injury is also known to occur. Cardiovascular magnetic resonance (CMR) imaging is uniquely capable of characterizing myocardial tissue properties in-vivo, enabling insights into the pattern and degree of cardiac injury. The reported prevalence of myocardial involvement identified by CMR in the context of COVID-19 infection among previously hospitalized patients ranges from 26 to 60%. Variations in the reported prevalence of myocardial involvement may result from differing patient populations (e.g. differences in severity of illness) and the varying intervals between acute infection and CMR evaluation. Standardized methodologies in image acquisition, analysis, interpretation, and reporting of CMR abnormalities across would likely improve concordance between studies. This consensus document by the Society for Cardiovascular Magnetic Resonance (SCMR) provides recommendations on CMR imaging and reporting metrics towards the goal of improved standardization and uniform data acquisition and analytic approaches when performing CMR in patients with COVID-19 infection.

Keywords: COVID-19; Cardiac complications; Cardiovascular magnetic resonance; Diagnostic criteria; Microinfarctions; Multisystem inflammatory syndrome; Myocardial infarction; Myocarditis; SARS-CoV-2; Thrombotic complications.

Fig. 1

Cardiovascular manifestations of COVID-19 on cardiovascular magnetic resonance (CMR). Clockwise from the top: (1) A patient diagnosed with acute myocarditis, found to have midmyocardial late gadolinium enhancement (LGE) in the inferior and inferoseptal walls, with increased T2 relaxation times in the inferior wall (white arrows). (2) A patient with subendocardial LGE in the mid to distal septum and apex, found to have an occlusion in the mid left anterior descending artery on coronary angiography (red arrows). (3) Globally increased native T1 and T2 relaxation times in a patient with multisystem inflammatory syndrome. (4) A patient diagnosed with stress cardiomyopathy, with thickening of the basal segments (white arrows) and akinesis of apex (asterisk) seen on cine imaging. (5) A patient diagnosed with acute pericarditis, found to have diffuse LGE in the pericardium (red arrows) and a pericardial effusion (asterisk)

Fig. 2

Recommendations for the use of CMR in COVID-19. As shown, CMR may be considered among patients with severe COVID-19 infection and clinical evidence of myocardial injury. Among convalescent patients with COVID-19 infection, CMR is of highest utility among patients with abnormal echocardiogram, electrocardiogram (ECG), and biomarkers as well as ongoing cardiopulmonary symptoms. MIS-C multisystem inflammatory syndrome in children

Fig. 3

Microinfarction in COVID-19 infection. Patterns of LGE (in brackets the features of each): (A) Infarct (bright, subendocardial, territorial); B Non-ischemic (mid myocardial, less bright, more diffuse); C Dual pathology (both a and b); D Microinfarcts (bright spots—e.g. a gram or so- of LGE often but not exclusively subendocardial and potentially in more than one territory); E Chronic, likely pre-existent disease (only 4 cases total) and non-specific (E1: Dilated cardiomyopathy, E2: amyloidosis, E3) Non-specific (unequivocal LGE that both cannot be considered normal and has insufficient volume to assign with certainty to any other category). F Nonspecific (unequivocal LGE that cannot be considered normal and has insufficient volume to assign with certainty to any other category). G Nonsignificant LGE (minor right ventricle insertion point LGE alone; trabecular LGE alone; or septal perforator LGE alone, which can be considered normal variant) [as originally published in the COVID-HEART Study by Artico et al. [68]

Fig. 4

Revised Lake Louise Criteria for the diagnosis of nonischemic myocardial inflammation in patients with COVID-19. The specificity of a diagnosis of nonischemic myocardial inflammation is increased in patients meeting at least one T1-based criterion and one T2-based criterion. Supportive criteria include (1) global or regional ventricular systolic dysfunction and (2) pericardial inflammation. Red arrows indicate pericardial LGE, and the asterisk indicates the pericardial effusion