CMR Outcomes in Patients Recovered From COVID-19

Aparna Irodi MD, FRCR reviewing
Valentina O. Puntmann et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol 2020; Jul 27

Study Questions:
What are the cardiovascular magnetic resonance (CMR) findings in unselected patients with recent coronavirus disease 2019 (COVID-19)?

Methodology

  • Conducted on patients from the University of Frankfurt COVID-19 Registry.
  • Inclusion: 2 weeks had elapsed following initial diagnosis, respiratory symptoms had resolved, and an upper respiratory swab was negative for SARS-CoV-2 at the end of the isolation period.
  • Exclusion: Patients referred for clinical CMR were excluded.
  • Comparison: Age and sex-matched healthy controls and risk factor-matched patients, with comorbidities including hypertension, diabetes, and coronary artery disease.
  • Blood: High-sensitivity troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) was assessed.
  • CMR technique:
    Native T1 mapping (to assess for diffuse fibrosis and oedema)
    Native T2 mapping (to assess for oedema)
    Late gadolinium enhancement (LGE) imaging (indicative of inflammation and scar).

Results:

    • 100 patients included.
    • 33% requiring hospitalization, 2% requiring mechanical ventilation, 17% undergoing noninvasive ventilation with positive airway pressure.

During hospitalization, 15% had significantly elevated hsTnT values (≥13.9 pg/ml).

    • Median time between positive upper respiratory swab and CMR was 71 days.
    • Persistent symptoms at the time of CMR included atypical chest pain (17%), palpitations (20%), and shortness of breath and general exhaustion (36%).
    • hsTnT was detectable (3 pg/ml or higher) in 71% and significantly elevated in 5%.
    • Abnormal CMR findings were present in 78% of patients
    • Increased myocardial native T1 (73%)
    • Increased myocardial native T2 (60%)
    • Myocardial LGE (32%, of whom 12/32 had an ischemic LGE pattern)
    • Pericardial enhancement (22%)
    • Native T1 and T2 were correlated with hsTnT.
    • Endomyocardial biopsy was performed in three patients with severe abnormalities (including high nativeT1 and T2, LGE, and left ventricular ejection fraction <50%), revealing active lymphocytic inflammation with no detectable viral genome.
Conclusions: There is a high incidence of CMR abnormality in patients who have recovered from COVID-19, even in patients who had only a mild disease (only 33% of the study population had required admission, but, 78% had CMR abnormality).
CMR abnormalities indicated myocarditis (elevated native T1 and T2, LGE) in the majority and pericarditis in a few.
CMR was abnormal even when hsTnT values were within normal limits.
Perspective:
There is a high prevalence of abnormal CMR findings in patients who have recovered from COVID-19.
Further study will be needed to determine if and how abnormal CMR findings should impact clinical management and follow-up in this patient population.