Cardiac Involvement in Patients Recovered From COVID-19 Using CMR

Quick Takes

  • Among patients with cardiac symptoms following COVID-19 recovery, CMR findings include abnormal T2 imaging suggestive of myocardial edema, late gadolinium enhancement (LGE), and RV systolic dysfunction.
  • Given the overlap between abnormal T2 STIR findings and LGE in this study cohort, it is likely that at least some of the patients had LGE due to patchy myocardial edema, which would likely improve over time.

Study Questions:

What are the cardiovascular magnetic resonance (CMR) findings in patients with cardiac symptoms following recovery from coronavirus disease 2019 (COVID-19)?

Methods:

This retrospective study was performed at a single academic medical center in Wuhan, China, beginning in March 2020. Consecutive patients who recovered from COVID-19 and were clinically referred for CMR due to cardiac symptoms after hospitalization were included. Notable exclusion criteria were known coronary artery disease and prior myocarditis. A healthy control population with a similar age and gender distribution was created retrospectively.

Results:

A total of 26 patients (mean age 38 years, 38% male, 8% with chronic hypertension) and 20 controls were included. Most patients (81%) required supplemental oxygen while hospitalized. High-sensitivity troponin I was measured in 50% of patients during hospitalization (median peak value 2.2 pg/ml), and in all patients at the time of CMR (median value 2.0 pg/ml, with all values in the normal range). The most common cardiac symptom prompting CMR referral was palpitations (88%). CMR exams were performed a median 47 days following onset of cardiac symptoms.

CMR evidence of myocardial edema on T2-weighted short tau inversion recovery (STIR) imaging was present in 14/26 patients (54%), involving 33% of myocardial segments. Late gadolinium enhancement (LGE) was present in 8/26 patients (31%), in patchy mid-wall and focal linear subepicardial distributions, involving 4% of myocardial segments. The most common sites of LGE were the basal and mid-inferior and inferolateral segments. Altogether, 15/26 patients (58%) had abnormal T2 STIR imaging, LGE, or both; only one patient with LGE had normal T2 STIR imaging. Only one patient had left ventricular ejection fraction <50%. Patients with abnormal T2 STIR imaging or LGE had a lower mean right ventricular (RV) ejection fraction (36.5%) as compared with healthy controls (46.1%, p = 0.01). Quantitative CMR analyses showed that global T1, T2, and extracellular volume values were significantly higher among patients with abnormal STIR and LGE findings as compared with controls.

Conclusions:

Among patients with cardiac symptoms following COVID-19 recovery, CMR findings include abnormal T2 imaging suggestive of myocardial edema, LGE, and RV systolic dysfunction.

Perspective:

While this study suggests that myocardial edema and LGE are common in COVID-19 convalescents, it is important to note that a number of patients with cardiac symptoms did not have abnormal myocardial tissue characteristics or cardiac structural abnormalities. It is likely that residual pulmonary disease was a driver of symptoms for these patients. LGE occurs due to localized increase in extracellular volume and may be indicative of fibrosis or scar, but it can also represent localized edema or inflammation. Given the overlap between abnormal T2 STIR findings and LGE in this study cohort, it is likely that at least some of the patients had LGE due to patchy myocardial edema, which would likely improve over time. Only half of the patients in this study had troponin measurements during hospitalization, possibly a reflection of the fact that the study was performed relatively early in the pandemic, and the prognostic significance of troponin elevation was not yet fully appreciated. This study’s limitations include small sample size and lack of long-term clinical follow-up. Further research is needed to determine how patients with abnormal CMR findings should be followed after COVID recovery.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Acute Heart Failure, Chronic Heart Failure, Magnetic Resonance Imaging, Hypertension

Keywords: Contrast Media, Coronavirus, COVID-19, Diagnostic Imaging, Edema, Cardiac, Gadolinium, Heart Failure, Hypertension, Magnetic Resonance Imaging, Respiration, Artificial, Secondary Prevention, Stroke Volume, Troponin I, Ventricular Dysfunction, Right


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