Possible Association Between COVID-19 Vaccine and Myocarditis: Clinical and CMR Findings

U.S, September 2021, Shaw et al, JACC: Cardiovascular Imaging

Summary

We present cardiac magnetic resonance (CMR) imaging findings in 4 cases of acute myocarditis that were temporally related to the receipt of COVID-19 vaccine.

Cardiac Magnetic Resonance Imaging Demonstrating Acute Myocarditis in a 24-Year-Old Man
A 24-year-old man with no previous cardiac history developed chest pain 4 days following his second dose of the Pfizer coronavirus disease 2019 (COVID-19) vaccine. He had never had a prior COVID-19 infection. He presented to the emergency department where his COVID-19 antigen testing was negative, and his troponin I was elevated to 4.963 ng/mL (normal <0.034 ng/mL). An ischemic evaluation was negative. CMR demonstrated normal systolic function (left ventricular ejection fraction = 56%) with no regional wall motion abnormalities, pericardial effusion, thickening, or enhancement. On T2 mapping (A and B) there was regional epicardial edema (median 69 ms-77 ms, normal <55 ms) and nonischemic myocardial injury on native T1 (C) (1,111 ms, normal 950 ms-1,050 ms) localized to the basal inferolateral segment. This was confirmed as marked epicardial fibrosis on late gadolinium enhancement imaging (D and E), and regional interstitial expansion (F) seen on extracellular volume fraction mapping (52%, normal <28%) in the basal inferolateral segment. All of these findings support acute myocarditis according to the 2018 updated Lake Louise criteria.

Cardiac Magnetic Resonance Imaging Demonstrating Acute Myocarditis in a 31-Year-Old Woman
A 31-year-old woman with no previous cardiac history developed chest pressure 25 days after her first dose of the Moderna COVID-19 vaccine. She had a laboratory confirmed COVID-19 infection 7 months before. She presented to the emergency department where her COVID-19 antigen testing was negative, and her troponin I was elevated to 7.961 ng/mL (normal <0.034 ng/mL). An ischemic evaluation was negative. CMR demonstrated normal systolic function (LVEF = 57%) with no regional wall motion abnormalities, pericardial effusion, thickening, or enhancement. On T2 mapping (A to C), there were skip areas of epicardial edema involving the basal inferior, basal, mid, and apical lateral segments (59 ms-66 ms, normal <55 ms) and nonischemic myocardial injury on native T1 mapping (D) (1,117 ms-1,137 ms, normal 950 ms-1,050 ms). These areas matched those where epicardial fibrosis was observed on late gadolinium enhancement imaging (E to G) and interstitial expansion by extracellular volume fraction mapping (H) (40%-44%, normal <28%). All of these findings support acute myocarditis according to the 2018 updated Lake Louise criteria. Abbreviations as in Figure 1.

Cardiac Magnetic Resonance Imaging Demonstrating Acute Myocarditis in a 16-Year-Old Man
A 16-year-old man with no previous cardiac history developed chest pain 4 d following his first dose of the Pfizer COVID-19 vaccine. He had a laboratory-confirmed COVID-19 infection 5 mo before. He presented to the emergency department where his COVID-19 antigen testing was negative, and his troponin I was elevated to 4.35 ng/mL (normal <0.034 ng/mL). CMR demonstrated normal systolic function (left ventricular ejection fraction = 64%) with no regional wall motion abnormalities, pericardial effusion, thickening, or enhancement. On T2 mapping (A), there were skip areas of epicardial edema involving the basal and mid inferior, inferolateral, and anterolateral segments (56 ms-74 ms, normal <55 ms) and nonischemic myocardial injury on native T1 mapping (B) (1,122 ms-1,128 ms, normal 950 ms-1,050 ms). These areas matched those where epicardial fibrosis was observed on late gadolinium enhancement imaging (C to E) and interstitial expansion by extracellular volume fraction mapping (F) (38%-42%, normal <28%). All of these findings support acute myocarditis according to the 2018 updated Lake Louise criteria. Abbreviations as in Figure 1.

Figure 5. Cardiac Magnetic Resonance Imaging Demonstrating Acute Myocarditis In A 17-Year-Old Woman
A 17-year-old women with no previous cardiac history developed chest pain 2 d following her second dose of the Pfizer COVID-19 vaccine. She did not have a known prior COVID-19 infection. She presented to the emergency department where her COVID-19 antigen testing was negative, and her troponin I was elevated to 5.41 ng/mL (normal <0.034 ng/mL). Her electrocardiogram demonstrated subtle ST-segment elevation of the anterior limb leads. CMR demonstrated mildly decreased systolic function (left ventricular ejection fraction = 54%) with extensive skip areas of epicardial and midwall edema on T2 mapping involving the inferolateral and anterolateral segments (58 ms-68 ms, normal <55 ms) (A to C). There was corresponding nonischemic myocardial injury on T1 mapping (D) (1,172 ms, normal 950 ms-1,050 ms) as well as on late gadolinium enhancement imaging (E to G) in a noncoronary distribution pattern, along interstitial expansion by extracellular volume fraction mapping (H) (41%, normal <28%). All of these findings support acute myocarditis according to the 2018 updated Lake Louise criteria.

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