By:Jenna Schauer, MD Sujatha Buddhe, MD, MS Avanti Gulhane, MD, DNB, FSCMR Sathish Mallenahalli Chikkabyrappa, MD Yuk Law, MD Michael A. Portman, MD et al for The Journal of Pediatrics
Abbreviations:
Late gadolinium enhancement (LGE), Coronavirus disease of 2019 (COVID-19), Nonsteroidal anti-inflammatory drugs (NSAIDs), Intravenous immunoglobulin (IVIG), Left ventricle (LV), Left ventricular ejection fraction (LVEF), Global Longitudinal Strain (GLS)
Myopericarditis, , has emerged as an important adverse event following COVID-19 mRNA vaccination, particularly in adolescents [1]
Patients typically exhibit chest pain and an elevated serum troponin level in the days following the COVID-19 mRNA vaccine. They usually are hemodynamically stable, and symptoms and cardiac biomarkers normalize within a few days[2] cardiac magnetic resonance studies, when performed early, frequently demonstrate abnormalities such as edema and late gadolinium enhancement (LGE), meeting Lake Louise Criteria for diagnosing myocarditis noninvasively [2],[3]
In classical myocarditis LGE can be predictive of a poor outcome [5]
Little is known about the prognostic value or expected evolution of these CMR abnormalities associated with post-COVID-19 mRNA vaccine myopericarditis. In this case series we report the evolution of CMR imaging compared with initial, acute phase, CMR in our cohort of patients with myopericarditis post COVID-19 mRNA vaccine.
Methods
Results
The initial CMRs were performed within 1 week of presentation (median 2, range 0-7 days). All were abnormal; all showed evidence of edema by T2 imaging and 15/16 had LGE in a patchy subepicardial to transmural pattern with predilection for the inferior LV free wall. Distribution of LGE can be seen in Figure 1. LV regional wall motion abnormalities were noted in 2 patients. CMR median LVEF% was 54%, range 46-63%. CMR LVEF was mildly decreased in 7 patients. CMR global longitudinal strain (GLS%) measurements were abnormal in 12 patients (median -16.1%, range -13.2% to -18.1%, normal <-18%).
All patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs): 75% (n=12) received scheduled dosing (mostly, 10 mg/kg ibuprofen every 8 hours) with the remaining 4 receiving NSAIDs as needed for pain. The median time from vaccination to NSAID initiation was 2.5 days (range 0-4 days) and from symptom onset to NSAID initiation was 1 day (range 0-4 days). The two patients who presented with echocardiographic LV dysfunction were treated with intravenous immunoglobulin (IVIG) plus a corticosteroid per our institutional pathway for treatment of myocarditis [2]
One additional patient received IVIG without corticosteroids. Median hospital length of stay was 2 days (range 1-4 days) with no ICU admission and no significant morbidity or mortality. All patients had resolution of chest pain and down-trending serum troponin level prior to discharge.
All patients underwent follow up CMR at 3-8 months after their initial study (median 3.7 months, range 2.8-8.1 months). The results are compared in Table I. Follow up CMR LVEF (57.7 ±2.8%) was significantly improved from initial (54.5 ± 5.5%, p < 0.05), and none of the patients had regional wall motion abnormalities. LVEF by echocardiogram was normal for all patients at the time of follow up. Eleven patients (68.8%) had persistent LGE, although there was a significant decrease in the quantifiable LGE% (8.16± 5.74%) from the initial study (13.77± 8.53%, p <0.05). Cardiac edema resolved in all but one patient. GLS% remained abnormal in most patients (75%, mean -16.4 ± 2.1%) at follow up without significant change from the initial study (-16.0 ± 1.7, p = 0.6). Examples of initial and follow up CMR images are shown in Figure 2. The patient who received IVIG alone and one patient who received IVIG plus corticosteroid had resolution of LGE, and the other had persistence of LGE.
Initial (Mean±SD) | Follow up (Mean±SD) | P value | |
---|---|---|---|
Echocardiographic LVEF % | 59.4±6.0 | 62.6±2.8 | <0.05 |
Electrocardiogram Abnormal Normal | 10 (62.5%) 6 (37.5%) | ||
Peak Serum Troponin (ng/mL) | 9.0± 5.2 | ||
CMR LVEF % | 54.5 ± 5.5 | 57.7 ±2.7 | <0.05 |
CMR LGE % (n=15*) | 13.5± 8.3 | 7.7 ± 5.7 | <0.001 |
CMR global longitudinal strain % (n=15*) | -16.0 ± 1.7 | -16.4 ± 2.1 | 0.5 |
DISCUSSION
We have since established a clinical protocol for serial CMR performance in these patients consistent with the 2021 American Heart Association (AHA) statement that stressed the risk of sudden cardiac death, particularly with exercise, while active inflammation is present. [6]
The CDC notes that even though the absolute risk for myopericarditis following mRNA COVID-19 vaccine is small, the relative risk is higher for particular groups, including males 12-39 years of age.
Some studies have suggested that increasing the interval between the first and second dose may reduce the incidence of myopericarditis in this population [11]
Uncited reference
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Footnotes
No funding was received for this research
The authors declare no conflicts of interest.
Abstract
We describe the evolution of Cardiac MRI (CMR) findings in 16 patients, 12-17 years of age, with myopericarditis after the second dose of the Pfizer mRNA COVID-19 vaccine. Although all patients showed rapid clinical improvement, many had persistent CMR findings at 3-8 month follow up.
Figures
- [12]Figure 1Distribution of Late Gadolinium Enhancement (LGE) in American Heart Association Myocardial Segments
. Figure shows segment with number of patients and percent of cohort.
- Figure 2CMR images from 3 days after admission