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Comparative assessment of diagnostic algorithms of myocardial inflammation by endomyocardial biopsy and tissue mapping by CMR against high-sensitive troponin in viral myocarditis

Session Blockbusters from the Young in myocardial and pericardial disease

Speaker Hafisyatul Aiza Zainal Abidin

Event : ESC Congress 2019

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Myocardial Disease – Diagnostic Methods
  • Session type : Abstract Sessions

Authors : HA Zainal Abidin (Sungai Buloh,MY), K Klingel (Tubingen,DE), A Rolf (Bad Nauheim,DE), T Keller (Bad Nauheim,DE), H Zhou (Changsha,CN), M Vasquez (Liberia,CR), F Escher (Berlin,DE), D Lassner (Berlin,DE), M Vasa-Nicotera (Frankfurt am Main,DE), A Zeiher (Frankfurt am Main,DE), P Schultheiss (Berlin,DE), E Nagel (Frankfurt am Main,DE), V Puntmann (Frankfurt am Main,DE)

HA Zainal Abidin1 , K Klingel2 , A Rolf3 , T Keller3 , H Zhou4 , M Vasquez5 , F Escher6 , D Lassner6 , M Vasa-Nicotera7 , A Zeiher7 , P Schultheiss6 , E Nagel8 , V Puntmann8 , 1Department of Cardiology, Universiti Teknologi MARA (UiTM) - Sungai Buloh - Malaysia , 2Institute for Pathology and Neuropathology, University Hospital Tubingen - Tubingen - Germany , 3Department of Cardiology, Kerckhoff Hospital, University Giessen - Bad Nauheim - Germany , 4Department of Radiology, Xiang Ya Hospital, Central South University - Changsha - China , 5Department of Cardiology, Enrique Baltodano Briceno Hospital - Liberia - Costa Rica , 6Institute of Cardiac Diagnostics and Therapy (IKDT) - Berlin - Germany , 7Department of Cardiology, Goethe University Hospital Frankfurt - Frankfurt am Main - Germany , 8Institute of Experimental and Translational Cardiac Imaging, DZHK Centre for Cardiovascular Imaging, Goethe University Frankfurt - Frankfurt am Main - Germany ,


Background: Myocarditis is defined by inflammatory involvement of the myocardium, either histologically by evidence of myocardial necrosis and cellular infiltration on endomyocardial biopsy (EMB), or non-invasively by presence of myocardial oedema using tissue mapping with cardiovascular magnetic resonance (CMR). Objective: to undertake intra-individual comparisons of EMB vs. CMR diagnostic algorithms of myocardial inflammation, as well as against an independent gold-standard of myocardial injury, high-sensitive troponin (hs-TropT). 

Methods: Prospective multicentre study of consecutive patients (n=109) with clinical diagnosis of myocarditis. EMBs were analysed by 2 reference centres using the ESC diagnostic and their local algorithms. The CMR criteria used sequence-specific cut-offs for native T1 and T2 (standard deviation, SD); myocardial inflammation T1=2SD, T2=2SD and no inflammation: T1 and T2<2SD, with subcategories for acute/high-grade: T1=5SD, T2=2SD; chronic/low-grade: T1=2SD, T2=2SD; healed: T1<2SD, T2<2SD but myocardial impairment and non-inflammatory cardiomyopathy: T1=2SD, T2<2SD. 

Results: The agreement between ESC criteria and CMR criteria (AUC:0.56, p=0.381) was poor. There was a significant agreement between myocardial injury (hs-TropT=13.9 ng/L) and CMR criteria (AUC:0.84, p<0.001), but not ESC algorithm. hs-TropT levels had significant associations with native T1 and T2 (r=0.37 and 0.35, p<0.001), but not with immunohistochemical inflammatory markers. Viral presence was similarly proportioned between inflammatory/non-inflammatory subjects, irrespective of the algorithm. 

Conclusions: Poor agreement between CMR and EMB-based diagnostic algorithms suggests non-overlapping definitions of myocardial inflammatory involvement. Excellent agreement between CMR algorithm and hs-TropT reiterates its high sensitivity for inflammatory myocardial injury.

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