Overview of COVID-19 and myocardial inflammation
Imaging of cardiac involvement
Role of CMR in the evaluation of suspected acute myocarditis
Overview of T1 and T2 mapping in acute myocarditis
CMR to diagnose COVID-19 myocardial involvement in athletes
Summary of published studies describing CMR in the recovered athlete
Publication | # post-Covid Athletes | # post-Covid Athletes with CMR findings | # non-Covid Athletes | # non-Covid Athletes with CMR findings | # Other non-Covid controls | # Other non-Covid controls with CMR findings |
---|---|---|---|---|---|---|
Hwang et al. [48] | 8 | 2 | NA | NA | NA | NA |
Brito et al. [51] | 54 | 48 | NA | NA | NA | NA |
Rajpal et al. [52] | 26 | 4 | NA | NA | NA | NA |
Starekova et al. [53] | 145 | 2 | NA | NA | NA | NA |
Clark et al. [54] | 59 | 2 (1 met Lake Louis criteria) | 60 | 0 | 27 | 0 |
Fikenzer, et al. [55] | 8 | 8 | 4 | 0 | NA | NA |
Malek et al. [57] | 26 | 5 | NA | NA | NA | NA |
Vago et al. [58] | 12 | 0 | 15 | 0 | 15 | 0 |
Hendrickson et al. [59] | 137 | 5 | NA | NA | NA | NA |
Moulson et al. [60] | 317; 198 (screening); 119 (clinically indicated) | 21; 6 (screening); 15 (clinically indicated) | NA | NA | NA | NA |
Szabo, et al. [61] | 147 | 7 | 59 | 0 | 56 | 0 |
Petek et al. [62] | 44 | 5 | NA | NA | NA | NA |
Martinez et al. [65] | 27 | 5 | NA | NA | NA | NA |
Daniels et al. [66] | 1597 | 37 | NA | NA | NA | NA |
Application of triad testing in the RTP assessment
12-Lead ECG*† |
ST-segment depression (\(\ge\) 1 mm in depth in 2 or more contiguous leads, excluding aVR, III, V1) |
ST-segment elevation with convex ST morphology (to differentiate from early repolarization) |
QRS prolongation |
• Right bundle branch block (QRS duration > 140 ms) |
• Left bundle branch block (QRS duration > 120 ms) |
• Inter-ventricular conduction delay (QRS duration > 120) |
Multiple premature ventricular extrasystoles (\(\ge\) 2 PVE per 10 s ECG capture) |
Pathologic Q-waves (Q/R ratio \(\ge\) 0.25 or \(\ge 40\) ms duration in 2 or more leads excluding III and aVR) |
Myocardial necrosis biomarkers* |
Conventional or high sensitivity troponin level > ULN acquired > 24 h after exercise |
Transthoracic echocardiography*‡ |
Global systolic LV dysfunction (LVEF < 50% / LVEF < 45% endurance athlete) with or without LV dilation |
Regional/focal LV systolic dysfunction |
Increased wall thickness (> 13 mm) with or without chamber dilation |
Small or greater pericardial effusion |
Intracavitary thrombus |
Lack of standardization in CMR techniques resulting in variability in findings
Technical considerations regarding heterogeneity in LGE and mapping techniques
When to consider CMR testing in the RTP assessment
What should constitute a positive CMR for myocarditis
Use of CMR in follow-up imaging
Research priorities and unanswered questions
Outcomes |
Imaging—Follow-up CMR imaging in those with possible or probable myocarditis by baseline imaging |
Clinical—Arrhythmia and adverse clinical outcomes in those possible or probable myocarditis by baseline imaging |
Technical |
Standardization of pulse sequences, inter-observer variability, and quantification schemes |
Large, normative datasets of CMR in the healthy athlete by activity (power vs endurance, for example) and age |
Cost effectiveness |
Downstream costs of application in different utilization scenarios |
Resource utilization and impact on CMR availability |