key: cord-0719945-68eaqhqp authors: Erdol, Mehmet Akif; Ozbay, Mustafa Bilal; Yayla, Cagri; Arslan, Halil; Isiksalan Ozbulbul, Nilgün; Ozcan Cetin, Elif Hande; Karanfil, Mustafa; Erdoğan, Mehmet; Demirtas, Koray 1; Ertem, Ahmet Göktuğ; Akcay, Adnan Burak title: Cardiac involvement in MRI in young population after COVID‐19: A single tertiary center experience date: 2021-07-19 journal: Echocardiography DOI: 10.1111/echo.15160 sha: b58f7ee491ff95546b91f9c2ad7476759b06fd26 doc_id: 719945 cord_uid: 68eaqhqp BACKGROUND: Coronavirus 2019 (COVID‐19) causes morbidity and mortality in an increasing number of people worldwide. Although it mainly affects the respiratory system, it influences all organs, including the heart. It is associated with a broad spectrum of widespread cardiovascular problems ranging from mild myocardial injury to fulminant myocarditis. We aimed to evaluate the presence and prevalence of cardiac involvement in asymptomatic or symptomatic patients after they recovered from COVID 19 infection. METHODS: A total of 100 consecutive patients with COVID‐19 proven by reverse transcription polymerase chain reaction (RT‐PCR), under 40 years of age and without any known additional chronic diseases were analyzed retrospectively for cardiac magnetic resonance (CMR) results and symptoms. RESULTS: Cardiac involvement was detected in 49 out of 100 patients on CMR imaging. In the cardiac involvement group, the number of patients with chest pain and/or dyspnea was 41 (84%), which was statistically significant (p = 0.001). Twenty‐four patients (47%) in the without cardiac involvement group were asymptomatic and this was also statistically significant (p = 0.001). LV ejection fraction was statistically significantly lower in the group with cardiac involvement (61% vs 66%, p = 0.001). LV stroke volume and tricuspid annular plane systolic excursion (TAPSE) were statistically significantly lower in patients with cardiac involvement (p = 0.028 and p = 0.019, respectively). CONCLUSION: Based on single center experience, myocardial involvement is common in symptomatic patients after COVID‐19. More studies are needed for long‐term side effects and clinical results in these patients. myocardial injury in COVID-19 are direct viral injury leading to myocarditis via ACE-2 receptors on target host cells, inflammatory plaque rupture unmasking the underlying subtle atherosclerotic disease, cardiac stress secondary to high cardiac output and respiratory failure, stress-induced cardiomyopathy, systemic inflammatory response due to massive cytokine release and combination of all these factors. [5] [6] [7] [8] [9] Cardiac magnetic resonance (CMR) imaging is the preferred imaging modality for non-invasive identification and exclusion of myocardial involvement in myocarditis due to its unique ability to detect cardiac edema, fibrosis, and scar. 10, 11 This imaging modality also allows physicians to evaluate heart volume and functions quantitatively. 11, 12 Huang et al. who studied cardiac symptoms in an MR study, reported cardiac involvement in 58% of patients who had recovered from COVID- 19. 13 In another study by Puntmann et al., cardiac involvement was reported in 78% of patients with no cardiac symptoms. 14 In the present study, we had the goal to assess the presence and prevalence of cardiac involvement in patients with no symptoms or mild symptoms recovering from COVID-19. In this single-center study, a total of 100 consecutive patients diag- After at least 14 days of the quarantine period, patients admitted to the cardiology clinic were included in the study. The cardiac symptom was described as the presence of at least one of the symptoms of dyspnea or chest pain that were not present prior to Two-dimensional (2D) and Doppler echocardiographic examinations The CMR was performed with a 16 channel 1.5 T MR scanner (Signa Explorer, General Electric, Milwaukee, USA) and a 16-channel body coil. All images were acquired with ECG triggering during repeated expiration breath-holds. For each subject, localizing scans were obtained to define the long (two-chamber) axis of the left ventricle. A midventricular short-axis view was prescribed and used to plan a four-chamber view. The short axis orientation was then defined accurately, perpendicular to both the two-and four-chamber views. The Left ventricular end-diastolic volume, end-systolic volume, stroke volume, ejection fraction, myocardial thickness, end-diastolic myocardial mass, and end-diastolic mass were assessed at the short-axis steady-state free precession images by applying Simpson's method. RV functions were assessed using the same method with the left ventricle. On the cine short-axis stack, LV and RV endocardial contours were manually traced in end-diastole and end-systole according to the guidelines of Society for Cardiovascular Magnetic Resonance on CMR image post-processing. Atrial width, pericardial thickness, and effusion were evaluated as well. All of the measured parameters were indexed to body surface area when necessary. In T2-W images, the signal ratio was measured from the region of interest covering the left ventricular myocardium as well as within a skeletal muscle in the same slice. For PC velocity analysis, the aorta and pulmonary artery were manually delineated in at least one cardiac phase. Automatic border detection was used for the other cardiac phases. These contours were reviewed and adapted accordingly for each cardiac phase. Moreover, mitral valve flow was evaluated especially for the diastolic dysfunction. In perfusion images, we evaluated perfusion delay or defect visually in the subendocardial area. If there were any suspicious conditions, we drew endo-contour and epi-contour of the left myocardium, and obtained perfusion graphics for perfusion delay or defect. In T1-W early enhancement which reflects hyperemia and capillary leak as a marker of inflammation, the early myocardial enhancement was measured from the region of interest covering the left ventricular myocardium as well as within a skeletal muscle in the same slice. For the LGE analysis, the reader first identified the presence or absence of scar based on visual assessment. To assess the contrast-enhanced images (LGE), all short-axis slices from base to apex were evaluated for areas of normal (completely nulled) myocardium (Figures 1 and 2 ). Scar distribution patterns were then evaluated according to the transmural, focal, and diffuse involvement. All image analyses were performed by one of the two radiologists. The study was considered as positive for myocarditis, according to Lake Louise criteria. 12 In the end, the parenchymal area was evaluated for any kind of lung, mediastinal, or pleural pathologies. Statistical analyses were carried out using IBM SPSS Statistics for Macintosh, Version 24.0 (IBM Corp., Armonk, New York, USA). Kolmogorov-Smirnov test was used in order to examine the distribution of numerical variables. Chi-square or Fisher's exact test were applied for categorical variables and presented as percentages. Student's t-test was applied to the numerical data which conforms to the normal distribution and the results were entered as mean and standard deviation. Conversely, Mann-Whitney-U test was performed for the anormal distributed variables and the results were given as median with inter-quartile range. A two-sided p value of less than 0.05 was determined to be statistically significant. A total of 100 patients who were shown to be infected with COVID- Interventricular septum diameter (mm) 9 (9-10) 10 (9-10) 9 (9-10) 0.559 Posterior wall diameter (mm) 9 (9-10) 9 (9-10) 9 (9-10) 0 Table 2 . Except for systolic pulmonary artery pressure (SPAP), there was no significant difference between the two groups in terms of 2-D echocardiographic findings and doppler echocardiographic findings. SPAP is statistically significantly higher in the group with cardiac involvement (p < 0.001). The CMR imaging parameters of patients with or without cardiac involvement are shown in Table 2 . LV ejection fraction was statistically significantly lower in the group with cardiac involvement (61% vs 66%, In a systematic echocardiographic study, the most common pathology was detected as RV dilation and dysfunction followed by LV diastolic and systolic dysfunction. 18 Nonetheless, myocardial edema with no fibrosis or scar has not been proven to be an independent prognosticator in patients with suspected myocarditis. 24, 25 A study performed on competitive athletes indicated a low yield of the utility of CMR in athletes who recovered from COVID-19, and had normal cardiac markers and ECG. 26 Our study have some limitations. First of all, this is a single center study with a relatively small sample size. Second, it is a retrospective study, and the results need to be further verified by prospective studies. Third, the patients could not be correlated with detailed echocardiography and strain image evaluation. Fourth, the lack of T1-T2 mapping software has limited detailed cardiac evaluation. This is a cross-sectional cohort study without any long-term follow-up data. Long-term follow-up of asymptomatic and mild cases will reveal the clinical importance of CMR findings indicating myocarditis. With the growing number of COVID-19 cases, we will likely understand the impacts of cardiac involvement in asymptomatic or mildly symptomatic patients in the upcoming years. 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None declared. All authors have substantial contributions to conception and design, or acquisition of data, analysis, and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published. The authors received no financial support for the research, authorship, and/or publication of this article.