MRI of cardiac involvement in COVID-19

Abstract

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has led to a diverse pattern of myocardial injuries, including myocarditis, which is linked to adverse outcomes in patients. Research indicates that myocardial injury is associated with higher mortality in hospitalized severe COVID-19 patients (75.8% vs 9.7%). Cardiovascular Magnetic Resonance (CMR) has emerged as a crucial tool in diagnosing both ischaemic and non-ischaemic myocardial injuries, providing detailed insights into the impact of COVID-19 on myocardial tissue and function. This review synthesizes existing studies on the histopathological findings and CMR imaging patterns of myocardial injuries in COVID-19 patients. CMR imaging has revealed a complex pattern of cardiac damage in these patients, including myocardial inflammation, oedema, fibrosis, and ischaemic injury, due to coronary microthrombi. This review also highlights the role of LLC criteria in diagnosis of COVID-related myocarditis and the importance of CMR in detecting cardiac complications of COVID-19 in specific groups, such as children, manifesting multisystem inflammatory syndrome in children (MIS-C) and athletes, as well as myocardial injuries post-COVID-19 infection or following COVID-19 vaccination. By summarizing existing studies on CMR in COVID-19 patients and highlighting ongoing research, this review contributes to a deeper understanding of the cardiac impacts of COVID-19. It emphasizes the effectiveness of CMR in assessing a broad spectrum of myocardial injuries, thereby enhancing the management and prognosis of patients with COVID-19 related cardiac complications.

Keywords: CMR; COVID-19; SARS-CoV-2; myocarditis.

Figure 1.

The LLC. The 2018 LLC diagnostic consensus guideline includes two primary criteria: T1- and T2-based. A positive T1-based criterion is indicated by prolonged native T1 relaxation times, elevated ECV, or non-ischaemic LGE marked by a white arrowhead. The T2-based criterion is considered positive with elevated T2 relaxation times, localized areas of high signal intensity on T2-weighted images identified by white arrows, or an increased overall T2 signal intensity. Of note, in case with very suggestive clinical presentation, even one criterion would support the diagnosis of myocarditis. Abbreviations: SI = signal intensity, T2-W = T2 weighted, LGE = late gadolinium enhancement, ECV = extracellular volume. Ferreira VM, et al. Journal of the American College of Cardiology. 2018 Dec 18;72(24):3158–76. with permission (41).

Figure 2.

Example of classic myocarditis according to LLC during acute COVID-19, patient presented with chest pain and elevated troponin levels. (A) T2-W, Regional increase myocardial signal intensity in the mid inferoseptal, inferior wall consistent with myocardial edema (arrow), (B) T2 map, Regional high T2-times in the inferoseptal segment (blue), (C) T1 map, Regional increase native T1-times in the inferoseptal and inferior segments (red), (D) LGE, Linear subepicardial enhancement in the mid inferoseptal, inferior and inferolateral segments as well as mid-myocardial enhancement involving the septum (arrow).

Figure 3.

Summarized illustration of CMR findings of cardiac involvement in COVID-19.

Figure 4.

CMR findings of myocardial injury in patients with acute severe COVID-19. (A) LGE, Non-ischaemic subepicardial enhancement involving inferior and inferolateral segments (arrow), (B) Four-chamber SSFP, Dilated right ventricle, (C) T1 map, Diffusely increased T1-relaxation times, (D) T2 map, Focal high T2-values in the mid inferolateral wall (blue colour).

Figure 5.

41-year-old woman with COVID infection presented with dyspnoea, palpitation and fatigue and mild perimyocardial involvement. (A) short axis SSFP, small pocket of pericardial fluid as high signal intensity located adjacent to the basal inferior wall of the LV (arrow). (B) T2-weighted, Regional signal increase in the mid anterior, anterolateral segments to suggest myocardial oedema. (C, D) LGE images, Regional subepicardial and adjacent pericardial enhancement of the basal inferior, inferolateral segments, adjacent to a pocket of effusion (white arrows).

Figure 6.

CMR findings in a young male athlete after recovery from COVID-19, clinically presented with persistent fatigue, malaise and shortness of breath. The CMR shows signs of persisting inflammation. (A) LGE-PSIR, Small pockets of pericardial effusion as low signal intensity region (arrow) along the mid-lateral and inferior walls associated with enhancement of the adjacent pericardium, mild subepicardial enhancement of the mid-inferior and inferolateral segments is visible. (B) T1 map, Increase in native T1-times in the anterior, anterolateral, and inferoseptal segments (red colour). (C) T2 map, Globally prolonged T2-relaxtaion times (blue colour). Abbreviation: PSIR = Phase Sensitive Inversion Recovery.

Figure 7.

CMR imaging findings in a 27-year-old man with myocarditis after a second COVID-19 mRNA vaccine dose. (A, B) LGE images, Subepicardial enhancement involving basal to mid inferior, infero and anterolateral segments (white arrow). (C) T2 map, with focal myocardial inflammation manifesting as high T2-values in the mid-lateral wall (blue colour). (D) T1 map, with focal high T1-value in the subepicardial part of the mid lateral wall (red colour).