Cardiac magnetic resonance imaging of myocarditis and pericarditis following COVID-19 vaccination: a multicenter collection of 27 cases

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Abstract

Objectives

To assess clinical and cardiac magnetic resonance (CMR) imaging features of patients with peri-myocarditis following Coronavirus Disease 2019 (COVID-19) vaccination.

Methods

We retrospectively collected a case series of 27 patients who underwent CMR in the clinical suspect of heart inflammation following COVID-19 vaccination, from 16 large tertiary centers. Our patient’s cohort was relatively young (36.6 ± 16.8 years), predominately included males (n = 25/27) with few comorbidities and covered a catchment area of approximately 8 million vaccinated patients.

Results

CMR revealed typical mid-subepicardial non-ischemic late gadolinium enhancement (LGE) in 23 cases and matched positively with CMR T2 criteria of myocarditis. In 7 cases, typical hallmarks of acute pericarditis were present. Short-term follow-up (median = 20 days) from presentation was uneventful for 25/27 patients and unavailable in two cases.

Conclusions

While establishing a causal relationship between peri-myocardial inflammation and vaccine administration can be challenging, our clinical experience suggests that CMR should be performed for diagnosis confirmation and to drive clinical decision-making and follow-up.

Key Points

• Acute onset of dyspnea, palpitations, or acute and persisting chest pain after COVID-19 vaccination should raise the suspicion of possible myocarditis or pericarditis, and patients should seek immediate medical attention and treatment to help recovery and avoid complications.

• In case of elevated troponin levels and/or relevant ECG changes, cardiac magnetic resonance should be considered as the best non-invasive diagnostic option to confirm the diagnosis of myocarditis or pericarditis and to drive clinical decision-making and follow-up.

Related collections

Most cited references 9

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Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Zunyou Wu, Jennifer M. McGoogan (2020)

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Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation

Vanessa M. Ferreira, Jeanette Schulz-Menger, Godtfred Holmvang … (2018)

This JACC Scientific Expert Panel provides consensus recommendations for an update of the cardiovascular magnetic resonance (CMR) diagnostic criteria for myocardial inflammation in patients with suspected acute or active myocardial inflammation (Lake Louise Criteria) that include options to use parametric mapping techniques. While each parameter may indicate myocardial inflammation, the authors propose that CMR provides strong evidence for myocardial inflammation, with increasing specificity, if the CMR scan demonstrates the combination of myocardial edema with other CMR markers of inflammatory myocardial injury. This is based on at least one T2-based criterion (global or regional increase of myocardial T2 relaxation time or an increased signal intensity in T2-weighted CMR images), with at least one T1-based criterion (increased myocardial T1, extracellular volume, or late gadolinium enhancement). While having both a positive T2-based marker and a T1-based marker will increase specificity for diagnosing acute myocardial inflammation, having only one (i.e., T2-based OR T1-based) marker may still support a diagnosis of acute myocardial inflammation in an appropriate clinical scenario, albeit with less specificity. The update is expected to improve the diagnostic accuracy of CMR further in detecting myocardial inflammation.

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Myocarditis after BNT162b2 mRNA Vaccine against Covid-19 in Israel

Dror Mevorach, Emilia Anis, Noa Cedar … (2021)

Background Approximately 5.1 million Israelis had been fully immunized against coronavirus disease 2019 (Covid-19) after receiving two doses of the BNT162b2 messenger RNA vaccine (Pfizer–BioNTech) by May 31, 2021. After early reports of myocarditis during adverse events monitoring, the Israeli Ministry of Health initiated active surveillance. Methods We retrospectively reviewed data obtained from December 20, 2020, to May 31, 2021, regarding all cases of myocarditis and categorized the information using the Brighton Collaboration definition. We analyzed the occurrence of myocarditis by computing the risk difference for the comparison of the incidence after the first and second vaccine doses (21 days apart); by calculating the standardized incidence ratio of the observed-to-expected incidence within 21 days after the first dose and 30 days after the second dose, independent of certainty of diagnosis; and by calculating the rate ratio 30 days after the second dose as compared with unvaccinated persons. Results Among 304 persons with symptoms of myocarditis, 21 had received an alternative diagnosis. Of the remaining 283 cases, 142 occurred after receipt of the BNT162b2 vaccine; of these cases, 136 diagnoses were definitive or probable. The clinical presentation was judged to be mild in 129 recipients (95%); one fulminant case was fatal. The overall risk difference between the first and second doses was 1.76 per 100,000 persons (95% confidence interval [CI], 1.33 to 2.19), with the largest difference among male recipients between the ages of 16 and 19 years (difference, 13.73 per 100,000 persons; 95% CI, 8.11 to 19.46). As compared with the expected incidence based on historical data, the standardized incidence ratio was 5.34 (95% CI, 4.48 to 6.40) and was highest after the second dose in male recipients between the ages of 16 and 19 years (13.60; 95% CI, 9.30 to 19.20). The rate ratio 30 days after the second vaccine dose in fully vaccinated recipients, as compared with unvaccinated persons, was 2.35 (95% CI, 1.10 to 5.02); the rate ratio was again highest in male recipients between the ages of 16 and 19 years (8.96; 95% CI, 4.50 to 17.83), with a ratio of 1 in 6637. Conclusions The incidence of myocarditis, although low, increased after the receipt of the BNT162b2 vaccine, particularly after the second dose among young male recipients. The clinical presentation of myocarditis after vaccination was usually mild.

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Author and article information

Contributors

Marco Francone:

ORCID: http://orcid.org/0000-0002-7906-3420

marco.francone@hunimed.eu

Journal

Journal ID (nlm-ta): Eur Radiol

Journal ID (iso-abbrev): Eur Radiol

Title: European Radiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0938-7994

ISSN (Electronic): 1432-1084

Publication date (Electronic): 1 March 2022

Pages: 1-9

Affiliations

[1 ]GRID grid.452490.e, Department of Biomedical Sciences, , Humanitas University, ; Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy

[2 ]GRID grid.417728.f, ISNI 0000 0004 1756 8807, IRCCS Humanitas Research Hospital, ; via Manzoni 56, 20089 Rozzano, Milan, Italy

[3 ]GRID grid.452599.6, ISNI 0000 0004 1781 8976, Department of Cardiology and Cardiovascular Medicine, , Fondazione Toscana Gabriele Monasterio, ; Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy

[4 ]GRID grid.425213.3, School of Biomedical Engineering and Imaging Sciences, King’s College London, , St Thomas’ Hospital, ; Westminster Bridge Rd, London, SE1 7EH UK

[5 ]GRID grid.412451.7, ISNI 0000 0001 2181 4941, Department of Neuroscience, Imaging and Clinical Sciences, , “G.d’Annunzio” University of Chieti-Pescara, ; Via dei Vestini, 33, 66100 Chieti, CH Italy

[6 ]GRID grid.418230.c, ISNI 0000 0004 1760 1750, Department of Cardiovascular Imaging, , Centro Cardiologico Monzino IRCCS, ; Via Carlo Parea, 4, 20138 Milan, MI Italy

[7 ]Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Corso Bramante, 88, 10126 Turin, TO Italy

[8 ]GRID grid.7605.4, ISNI 0000 0001 2336 6580, Cardiology, Department of Medical Sciences, , University of Turin, ; Turin, Italy

[9 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Department of Biomedical Sciences for Health, , Università Degli Studi Di Milano, ; Via Mangiagalli 31, 20133, Milan, Italy

[10 ]GRID grid.419557.b, ISNI 0000 0004 1766 7370, Unit of Radiology, , IRCCS Policlinico San Donato, ; San Donato Milanese, Italy

[11 ]GRID grid.425670.2, ISNI 0000 0004 1763 7550, Radiology Division, , Ospedale “San Giovanni Calibita” Fatebenefratelli Isola Tiberina, ; Via di Ponte Quattro capi, 39, 00186 Rome, RM Italy

[12 ]Cardiovascular Radiology Unit - Radiology Department, AOU S. Orsola-Malpighi - IRCCS, Via Giuseppe Massarenti, 9, 40138 Bologna, BO Italy

[13 ]U.O.C. Diagnostica per Immagini. Ospedale del Mare - ASL NA1Centro, Via Enrico Russo, 80147 Naples, Italy

[14 ]U.O.C. Cardiologia - UTIC- Emodinamica, Ospedale del Mare - ASL NA1Centro, Via Enrico Russo, 80147 Naples, Italy

[15 ]GRID grid.413643.7, ISNI 0000 0004 1760 8047, U.O.C. di Cardiologia e UTIC, , Ospedale di Vimercate ASST-Brianza, ; Via Santi Cosma e Damiano, 10, 20871 Vimercate, Italy

[16 ]GRID grid.8142.f, ISNI 0000 0001 0941 3192, Department of Radiological and Hematological Sciences, Section of Radiology, , Università Cattolica del Sacro Cuore, ; L.go Francesco Vito 1, 00168 Rome, Italy

[17 ]GRID grid.411075.6, ISNI 0000 0004 1760 4193, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Diagnostic Imaging Area, , Fondazione Policlinico Universitario Agostino Gemelli, ; IRCCS, L.go Agostino Gemelli 8, 00168 Rome, Italy

[18 ]GRID grid.18887.3e, ISNI 0000000417581884, Experimental Imaging Center, , IRCCS Ospedale San Raffaele, ; Via Olgettina, 60, 20132 Milan, Italy

[19 ]GRID grid.15496.3f, ISNI 0000 0001 0439 0892, School of Medicine, , Vita-Salute San Raffaele University, ; Milan, Italy

[20 ]GRID grid.7605.4, ISNI 0000 0001 2336 6580, Radiology Unit, Department of Surgical Sciences, , University of Turin, Città della Salute e della Scienza dì Torino, ; C.so Bramante 88, 10126 Turin, TO Italy

[21 ]GRID grid.7763.5, ISNI 0000 0004 1755 3242, Radiology Unit, Department of Medical Sciences, , University of Cagliari, ; Via Università, 40, 09124 Cagliari, Italy

[22 ]GRID grid.7841.a, Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, , “Sapienza” University of Rome, ; Viale Regina Elena 324, 00161 Rome, Italy

[23 ]GRID grid.7841.a, Department of Experimental Medicine, , “Sapienza” University of Rome, ; Viale del Policlinico 155, 00161 Rome, Italy

Author information

Marco Francone http://orcid.org/0000-0002-7906-3420

Article

Publisher ID: 8566

DOI: 10.1007/s00330-022-08566-0

PMC ID: 8886710

PubMed ID: 35230520

SO-VID: f73ba814-3da8-497a-a7ea-c098f473f2b4

License:

This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

History

Date received : 27 August 2021

Date revision received : 11 December 2021

Date accepted : 4 January 2022

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