Role of cardiac magnetic resonance imaging in the diagnosis and management of COVID-19 related myocarditis: Clinical and imaging considerations

Table 1 Summary of existing data surrounding the use of cardiac magnetic resonance imaging use in coronavirus disease 2019 patients

Ref.	Study design	Sample size	CMRI findings	Other diagnostic findings
Kariyanna et al[24],2020	Systematic review of 9 case reports and 2 retrospective studies	11 COVID-19 patients with reported myocardial inflammation or myocarditis	LGE highlighted in 100% of the patients	Elevated cardiac markers (Troponin, CK-MB, BNP) in 9 cases. Bilateral ground glass opacities seen in all patients with CT (6 cases). ECG abnormalities (ST-elevation and T-wave inversion) in 7 cases, and decreased LVEF in 6 cases. Active inflammation reported in the all biopsies performed (2 cases) and cardiomegaly reported in 7 cases
Puntmann et al[25], 2020	Prospective observational cohort study	100 recovered COVID-19 patients	Raised T1 in 73% of patients, raised T2 in 60%, LGE findings in 32%, and pericardial enhancement in 22%	Elevated troponin in 71% of patients, and significantly elevated Troponin in 5%. Endomyocardial biopsy revealed active lymphocytic inflammation. Lower LVEF and RVEF noted
Huang et al[26], 2020	Retrospective study	26 recovered COVID-19 patients who reported cardiac symptoms and underwent CMRI	Elevated T2 and/or LGE in 58% (15 patients) with 14 patients having myocardial edema and 8 LGE +. Global T1, T2, and extracellular volume were elevated in patients with abnormal CMRIs	Decreased RVEF, cardiac index, and stroke volume found in patients with positive CMRI findings
Clark et al[27], 2020	Retrospective cohort analysis	22 collegiate athletes with prior COVID-19 infection	LGE found in 9% (2 athletes)	All patients had normal Troponin, normal ECG, normal LVEF. LV mass was higher and RVEF was lower in athletes compared to control group
Li et al[28], 2021	Prospective observational cohort study	40 COVID-19 patients with moderate to severe pneumonia and no cardiovascular medical history	LGE findings in 3% (1 patient), elevated extracellular volume values in 60% (24 patients)	Normal LV and RV size and function. 70% (24 patients) had lower LV 2D-global longitudinal strain with subclinical changes of myocardial dysfunction

CMRI: Cardiac magnetic resonance imaging; COVID-19: Coronavirus disease 2019; LGE: Late gadolinium enhancement; CK-MB: Creatine kinase-MB; BNP: B-type natriuretic peptide; CT: Computed tomography; ECG: Electrocardiogram; LVEF: Left ventricular ejection fraction; RVEF: Right ventricular ejection fraction LV: Left ventricular; RV: Right ventricular.

Table 2 Proposed indications for cardiac magnetic resonance imaging in coronavirus disease 2019 patients

CMRI is indicated	CMRI not indicated
High risk patients with 2 or more of the following criteria	Low risk patients with all of the following criteria
Symptomatic	Asymptomatic
Elevated troponin	Negative troponin
Abnormal echocardiogram	Normal echocardiogram
Abnormal EKG
High risk for ventricular arrhythmia or sudden death
Myocardial infarction
Clinical suspicion for myocardial injury

CMRI: Cardiac magnetic resonance imaging; EKG: Echocardiogram.