TABLE 3.
Cardiac magnetic resonance findings in COVID‐19
| Study, year | Study design | Number of study participants | MRI device | Covid severity | LV | RV | LGE(n) | AHA segments (segment number (n)) | ECV (extracellular volume)%) | T1 mapping | T2 Mapping | Comment |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Wang et al. (2021) | Prospective | 47 Consecutive patients who tested positive for COVID‐19 and discharged were recruited versus 31 healthy controls | 3T CMR scanner (Ingenia CX, Philips Healthcare, Best, Te Netherlands). |
72.7% had moderate disease and 27.3% moderate and critical disease, all patients were hospitalized. Of note all but one patients had normal EKGs |
Only CMR derived 3 D global circumferential strain (GCS) was significantly different between LGE+ve and Controls and LGE ‐ve | RV peak 3D Global longitudinal strain was significantly reduced in LGE +ve as compared to controls and LGE ‐ve | 13 | Most were located inferior and infero‐lateral segments at base and mid‐ segments. | NA | T1 mapping was not significantly different between LGE+ve and LGE ‐ve (p > 0.05) | NA | LGE was most commonly in infero and infero lateral and was subqpicardial. walls and it is irrespective of EKG changes in moderate to severe COVID‐19 after recovery, serum troponin was significantly elevated in LGE +ve patients during hospital stay |
| Clark et al. (2020) | Retrospective | 22 | 1.5 Tesla Siemens Avanto Fit (Siemens Healthcare Sector, Erlangen, Germany) | Asymptomatic (5), Mild (17) | Covid‐19 postive athletes versus Healthy controls versus Tactical athletic controls: LVEF (%, IQR)* 60% [59,63] versus 60 [57, 64] versus 61 [57, 64] p = 0.8, LVEDV (ml) 180 [153,208] versus 166 [143, 211] versus 188 [157, 207] p = 0.83, LVEDVi (ml/m2) 94 [89, 102] versus 95 [79, 100] versus 84 [73, 98] p = 0.02. LV mass (g) 115 [101,151] versus 76 [63, 96] (p < 0.001) versus 140 [120, 155] p = 0.11 . | Covid‐19 postive athletes versus Healthy controls versus Tactical athletic controls: RVEF (%) 52 [IQR: 50, 54] versus 57 [IQR: 55, 60] (p < 0.001) versus 56 [IQR: 51, 59] p = 0.01, RVEDVi (ml/m2) 105 [IQR: 97, 114] versus 95 [IQR: 80, 106] versus 88 [IQR: 76, 106] p = 0.01, RVESVi (ml/m2) 50 [IQR: 46, 55] versus 40 [IQR: 33, 45] (p < 0.001) versus 43 [IQR: 31, 51] p < 0.01 | 2 | Myocardial (2), Pericardial (1), Any (2) | Covid‐19 positive athletes versus healthy controls versus tactial athletic controls (% ± SD) Mid septum 25.3 ± 2.6 versus 24 ± 3 versus 22.5 ± 2.6 p < 0.001, Covid‐19 positive athletes (%) Basal septum 24 (22.7,25.9), Basal lateral 21.6 (20.6,23.8),mid lateral 23.3 (21.4,25). Covid‐19 positive athletes with myocardial pathology versus Covid‐19 positive athletes without myocardial | T1 Covid‐19 positive athletes versus Healthy controls versus Tactical athletic controls (ms)* Basal septum 995(969,1006) versus 986 (971, 999) versus 990 (964, 1024) p = 0.89, Basal lateral 971(951,984) versus 958 (945, 983) versus 975 (962, 1011) p = 0.17, Mid septum 982(973,997) versus 978 (963, 998) versus 989 (963, 1008) p = 0.22, mid lateral 980 (947,988) | T2 Covid‐19 positive athletes versus Healthy controls: Basal septum 44.3(42.3,46.1) versus 42.4 (41.5, 43.3) p = 0.009, Basal lateral 45.4 (43.2,46.6) versus 44.0 (43.0, 44.6) p = 0.034, Mid septum 46.4(45.2,48.2) versus 44.6 (43.2, 45.4) p = 0.004, mid lateral 47.0 (45.2,48.2) versus 44.0 (42.6, 45.4) p = 0.003. T2 Covid‐19 positive athletes | Cardiac inflammation or fibrosis following Covid‐19 infection can be missed by EKG or strain echo alone and CMR may have a role in diagnosing cardiac pathology post Covid‐19 infection |
| pathology (%) 24.3 (22.5, 26) versus 24.0 (22.9, 25.8) p = 0.95. | versus 965 (946, 975) versus 968 (944, 1000) p = 0.93 . T1 in those with Covid‐19 and myocardial pathology versus without myocardial pathology basal septum 997 (988,1007) versus 995 (968,1005) (p = 0.65), T1 Covid‐19 positive athletes with myocardial pathology versus Covid‐19 positive athletes without myocardial pathology (ms): Basal Septum 997 (988, 1007) versus 995 (968, 1005) p = 0.65, | with myocardial pathology versus Covid‐19 positive athletes without myocardial pathology (ms): Basal Septum 44.3 (44,44.6) versus 44.3 (42.3,46.7) p = 0.95 | ||||||||||
| Esposito et al. (2020) | Retrospective | 10 | 1.5‐T in nine patients and 3‐T in one patient | NA | EF > 55%(5), EF 40–55%(3), EF < 40% (2) | NA | 3 | A few thin and shadowed subepicardial striae of LGE were detectable in the lateral wall, accounting for 1%, 3%, and 3% of LV mass respectively | Calculated for wot patients: 30, 36 | Increased myocardial‐to‐skeletal muscle intensity ratio on STIR images increased native‐T1 mapping (at 1.5‐T: median 1,156 ms [IQR: 1,123 to 1,198 ms]; normal value < 1,045 ms; at 3‐T: 1,378 ms; | T2 mapping (ms)*: 62 [IQR: 59 to 67] (normal value < 50), T2‐ratio*: 2.3 [IQR: 2.2 to 2.4] (normal value < 1.9) | This study found that CMR may be more reliable than LGE in detecting myocardial injury in their patient cohort. |
| normal value < 1,240 ms) and increased T2 mapping (median 62 ms [IQR: 59 to 67 ms]; normal value < 50 ms) | ||||||||||||
| Huang et al. (2020) | Restrospective | 26 | 3‐T MR scanner (Skyra, Siemens, Healthineers, Erlangen, Germany) | Moderate (22), Severe (4) | LVEF Patients with positive conventional CMR findings versus negative conventional CMR findings versus Controls (%) 60.7 ± 6.4 versus 64.3 ± 5.8 versus 63.0 ± 8.9 (p = 0.4) | RVEF Patients with positive conventional CMR findings versus negative conventional CMR findings versus Controls (%) 36.5 ± 6.1 versus 41.1 ± 8.6 versus 46.1 ± 12.0 (p = 0.01) | 8 | 2(2), 3(1), 4(3), 5(1), 8(1), 9(1), 10(3), 11(2), fS12(1) | ECV in patients with positive conventional CMR findings versus patients without positive findings versus controls (%) 28.2 [IQR: 24.8 to 36.2] versusversus 24.8 [IQR: 23.1 to 25.4] versusversus 23.7 [IQR: 22.2 to 25.2] p = 0.002 | Global T1: patients with positive conventional CMR findings versus patients without positive findings versus controls (ms, IQR) 1,271 [1,243 to 1,298] versusversus 1,237 [1,216 to 1,262] versusversus 1,224 [1,217 to 1,245], p = 0.002. | Global T2: patients with positive conventional CMR findings versus patients without positive findings versus controls (ms) 42.7 ± 3.1 versusversus 38.1 ± 2.4 versus 39.1 ± 3.1, p < 0.001 | In this cohort of patients who complained of cardiac symptoms after recovering from Covid‐19 infection, 58% had positive CMR findings indicative of cardiac edema, fibrosis, or impaired ventricular function. Those with positive conventional CMR findings were noted to have decreased right ventricular function. |
| Puntmann et al. (2020) | Prospective observational | 100 | 3‐T scanners (Magnetom Skyra; Siemens Healthineers) | Recovered at home (n = 67) asymptomatic (n = 18), minor‐moderate symptoms (n = 49), severe/requiring hospitalization (33), | LVEF (%) Covid 57, Control 60, RF matched control 62 (p < 0.001). LVEDV Index (ml/m2) Covid 86, Control 80, RF matched control 76 (p < 0.001). LV mass index (g/m2) Covid 48, Control 51, RF matched control | RVEF (%): Covid 54, Control 60, RF matched control 59 (p < 0.001) | 74 | Covid versus Controls versus RF matched controls: Myocardial (32 vs 0 vs 9, p < 0.001), Non‐ischemic (20 vs 0 vs 4, | NA | Native T1: Covid versus Controls versus RF matched controls (1125 vs 1082 vs 1111, p < 0.001)*, Abnormal Native T1: Covid versus Controls versus RF matched controls (%) (73 vs 12 vs 58, p < 0.001), | Native T2: Covid versus Controls versus RF matched controls (38.2 vs 35.7 vs 36.4, p < 0.001), Abnormal Native T2: Covid versus Controls versus RF matched controls (%) (60 vs 12 vs 26, p < 0.001), | CMR shows cardiac involvement in a significant number of patients regardless of pre‐existing medical conditions. |
| Mechanical ventilation (2), non‐invasive ventilation (17) | 53 (p = 0.005) | p < 0.001), Epicardial (22 vs 0 vs 8, p < 0.001) | Significantly abnormal native T1: Covid versus Controls vs RF matched controls (%) (40 vs 0 vs 12, p < 0.001) | Significantly abnormal native T2: Covid versus Controls versus RF matched controls (%) (60 vs 12 vs 26, p < 0.001), Significantly abnormal native T2: Covid versus Controls versus RF matched controls (%) (22 versus 0 , p < 0.001) | ||||||||
| Rajpal et al. (2020) | Restrospective | 26 | 1.5‐T scanner (Magnetom Sola; Siemens Healthineers) | Recovered at home none needed hospitalizations | LVEF 57.730% (avg) | RVEF 56.884% (avg) | 12 | 2(1), 3(4), 5(1), 6(1), 8(5), 9(8), 12(3) | 24.7 (avg) | T1‐978.8 (normal range < 999 ms) | T2‐52.4 (normal range < 53 ms) (Average AHA segments 8.4) | CMR allowed observation of myocarditis and previous myocardial injury associated with Covid‐19 infection. |
| Starekova et al. (2021) |
Case series Retrospective single center |
145 | 1.5‐T or 3‐T MRI systems (GE Healthcare) | NA | NA | NA | NA | NA |
Only two out of 145 athletes had CMR evidence of myocarditis Of note patients were not symptomatic, and there was no EKG or biochemical evidence of myocardial injury |
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| Martinez et al. (2021) | Cross‐sectional | 789 screened and 30 athletes referred for further testing | NA |
Viral symptoms 65% Asymptomatic/ pauci symptomatic 34.9% |
NA | NA | NA | NA | NA | NA | NA | Out of 30 patients referred to further testing five athletes (three myocarditis and two pericarditis were restricted from going back to play) |
| Moulsen et al.(2021) | Prospective multi‐center | Of 3018 athletes recovered from covid, 198 underwent CMR for primary screening or because they screened positive on initial cardiac testing | NA | Most patients were asymptomatic or mildly symptomatic. Patients underwent either EKG/ECHO/Troponin or primary CMR screening | NA | NA | NA | NA | NA | NA | NA | Primary screening identified only six patients with probable/ definite cardiac involvement. While 15 had cardiac involvement by CMR which was directed by abnormal initial screening tests. Cardiac symptoms and abnormal initial testing . Adverse outcomes occurred in only one patient. |
*Median.
Abbreviations: CMR, Cardiac Magnetic Resonance; EF, Ejection Fraction; ECV, Extracellular volume; EDV, End diastolic volume; ESV, End systolic volume; IQR, Interquartile range; RF, Risk Factor; LGE, Late Gadolinium enhancement; LV, Left ventricle; RV, Right ventricle.