Gadolinium enhanced MRI in patients with left ventricular apical ballooning syndrome implicates myocarditis as an etiology

Andrew O. Maree, Christian Witzke, Godtfred Holmvang, Gregory D. Lewis, Hani Jneid, Lindsay B. Reardon, Nadeem Afridi, Marc J. Semigran, G. William Dec, Harry C. Lowe, Igor F. Palacios

Cardiology Section, Department of Medicine, Waterford Regional Hospital, Waterford, Ireland..

DOI: 10.4236/wjcd.2013.31A018                

Abstract

Aims: Left ventricular apical ballooning syndrome (LVABS) is a clinical condition of unknown etiology, characterized by acute onset of atypical apical wall motion and absence of coronary artery disease. Gadolinium-enhanced cardiac magnetic resonance imaging (Gd-MRI) may be used to identify patients with myocarditis. Using cardiac MRI, we evaluated whether acute myocarditis may be an etiology that underlies LVABS. Methods and Results: Consecutive patients who presented with LVABS during a three-year period were included. Demographic data was recorded and echocardiography, coronary angiography, and hemodynamic assessment performed. Gd-MRI was performed in all patients. The study was deemed consistent with myocarditis when global myocardial to skeletal muscle enhancement ratio was ≥3.5. Regional Gd-MRI analysis was also performed. Patients (n = 11) were female (100%) and of mean age 72 years (72 ± 11). Preceding febrile illness occurred in 4 (36.3%) and leukocytosis in 6 (54.4%) patients. Initial mean left ventricular ejection fraction (41% ± 12%) improved (70.2% ± 8%) upon follow-up (39 ± 43 days). Global MRI analysis was positive in 5/11 (45.5%) (mean relative enhancement ratio 4.8 ± 1.4). Regional MRI analysis was positive in 4/6 further patients (overall: 9/11 (82%)). Conclusions: Gadolinium enhanced MRI imaging in LVABS implicates myocarditis as a possible etiology. Regional MRI analysis adds sensitivity to global cardiac MRI evaluation.

Keywords

Left Ventricular Apical Ballooning Syndrome; Gadolinium-Enhanced Cardiac Magnetic Resonance Imaging; Myocarditis; Catecholamine

Conflicts of Interest

The authors declare no conflicts of interest.

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