Cardiac Magnetic Resonance Imaging Findings in COVID-19: Experience from a Tertiary Care Center of North India

Abstract

Purpose: Here, we describe cardiac magnetic resonance imaging (CMR) findings in patients with proven COVID-19 infection and presenting with cardiac problems both at presentation and in convalescence from a tertiary care center, in North India. A pertinent review of the literature is also discussed.

Materials and methods: Retrospective analysis of patients with real-time reverse transcriptase-polymerase chain reaction proven COVID-19 infection either at presentation or convalescence referred for CMR at our facility from January 2021 to December 2023 was done. CMR was performed on a 3T system (Ingenia, Philips Healthcare, Best, The Netherlands) and examinations were customized according to the clinical indications.

Results: Retrospective analysis yielded 14 patients (4 at presentation; 10 in convalescence). Patients at presentation 4/14 had clinically presented with chest pain with raised troponins and electrographic abnormalities, while 10/14 patients had presented with clinical features of heart failure with two-dimensional transthoracic echocardiography demonstrating systolic dysfunction with reduced left ventricular ejection fraction. Out of 14, 4 patients at presentation, CMR showed features of acute myocarditis in three patients, while one had inferior wall myocardial infarction (MI) (this patient on catheter angiogram had aneurysmally dilated coronary arteries with thrombus and stenosis in the mid right coronary artery which was successfully stented). Out of 14, 10 patients on CMR had features of dilated cardiomyopathy (DCMP).

Conclusion: Cardiac involvement in COVID-19 can have vivid clinicoradiological presentations with features of myocarditis and MI at presentation or DCMP in convalescence. CMR in such cases is a problem-solving tool where myocarditis is candidly differentiated from MI. Moreover, follow-up CMR demonstrates temporal changes in COVID-19-associated myocarditis and evaluation of cardiac structure and function in patients presenting with DCMP.

Keywords: Acute coronary syndrome; cardiac magnetic resonance imaging; cardiovascular complications of COVID-19; coronary artery aneurysm; myocardial infarction; myocarditis.

Figure 1

P1-A 14-year-old male patient with COVID-19 presented with sudden onset chest pain warranting admission to the emergency department. Electrographic-suggested inferior wall myocardial infarction requiring emergent catheter coronary angiography (CAA). CAA was unremarkable. Troponin levels were 4500 ng/L) a). Cardiac magnetic resonance imaging (CMR)-short-tau-inversion-recovery (STIR) horizontal long axis image shows confluent hyperintensities in LV lateral wall, apex, inferoseptum (arrows), (b-d) late gadolinium enhancement (LGE) horizontal long axis and short axis mid cavity and apex shows patches of mid myocardial enhancement co-localizing to areas of STIR hyperintensities (thick arrows). Note LGE in papillary muscle (thin arrows). Follow-up CMR images (e) STIR and LGE images (f-h) show complete resolution of abnormalities

Figure 2

P4-45-year-old COVID-19-positive male patient presented with acute chest pain with STEMI-like presentation to the emergency department. ECG-was suggestive of inferior wall myocardial infarction requiring urgent catheter coronary angiography (CAA). CAA images show fusiform aneurysms of coronary arteries (a-d). Mid right coronary artery shows thrombotic occlusion with stenotic lesion distally (a). Percutaneous angioplasty with stenting was done (b and c)

Figure 3

P4: Cardiac magnetic resonance imaging late gadolinium enhancement (LGE) images (a-c-short axis base to apex) show transmural LGE in segments 4, 9, 15 (thin arrows). Note sub-endocardial infarction in basal antero-septum (a-thick arrow) short-tau-inversion-recovery images (d and e) show normal signal. Note dilated mid right coronary artery on SFFP image (f)