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Cardiac MRI gives fresh light on myocarditis caused by vaccines

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On short-axis 1.5T MRI scans of a 19-year-old male who presented with chest pain three days after the second dose of an mRNA vaccine, COVID-19 vaccine associated myocarditis was seen. COVID-19 is a vaccination that protects against the virus COVID-19. Cardiac MRI two days after symptom start shows late gadolinium enhancement (LGE) along the basal to mid inferior lateral wall with adjacent pericardial enhancement (red arrows) and concomitant hyperintensity on T2-weighted imaging (orange arrows). He was admitted and discharged two days later after his symptoms had completely resolved. The RSNA provided this image. On cardiac magnetic resonance imaging (MRI), COVID-19 vaccine-associated myocarditis has a damage pattern comparable to other forms of myocarditis, but the abnormalities are less severe. According to a new study published in the journal Radiology, this is the case. [1]

Inflammation of the heart muscle is common after a viral infection, such as COVID-19. It can cause arrhythmias and impair the heart's ability to pump blood, as well as long-term damage in the form of myocardial scarring. Myocarditis has also been reported as an uncommon side effect of COVID-19 vaccinations based on messenger RNA (mRNA). Cardiac MRI plays a significant role in the diagnosis of acute myocarditis because of its unrivalled capacity to characterise cardiac tissue noninvasively. Understanding the pattern and amount of myocardial injury, as well as its consequences, may allow for better patient care and may help to overcome vaccine hesitancy.

“We know the risk of myocarditis after COVID-19 vaccine is extremely minimal. In comparison to other causes of myocarditis, however, there is relatively limited evidence on the extent of heart harm,” Hanneman explained in a statement. “MRI allows us to perform thorough tissue characterization of the heart, such as determining how much fluid, or edoema, is present in the heart and determining whether or not there is active inflammation. It also tells us about previous damage, such as fibrosis and scarring.”

This retrospective analysis looked at data from 92 adult patients who had myocarditis and abnormalities on cardiac MRI between 2019 and 2021 at a tertiary referral hospital. Myocarditis following COVID-19 vaccine, myocarditis following COVID-19 illness, and myocarditis not connected with COVID-19 immunisation or illness were the three groups of patients studied. Following COVID-19 vaccination, 21 (22%) of the 92 individuals developed myocarditis (mean age 31 years). Following COVID-19 infection, ten individuals (11%) developed myocarditis (mean age 51 years), while 61 (66%) had other myocarditis (mean age 44 years). In comparison to the other groups, those who developed myocarditis after vaccination were younger and more likely to be male.

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All 21 individuals with vaccine-associated myocarditis experienced chest discomfort. One to seven days after immunisation, the pain began and lasted one to six days. Fourteen of the patients (67 percent) were admitted to the hospital, with a three-day median stay. The intensive care unit did not receive any patients.
Troponin levels were found to be increased in all patients hospitalised to the hospital, but they had significantly dropped by the time they were discharged.
Late gadolinium enhancement was seen in 17 (81%) of vaccine-associated myocarditis MRIs, and left ventricular dysfunction was seen in six (29 percent ). Patients with vaccine-associated myocarditis had less functional impairment and less severe myocardial abnormalities than patients with other types of myocarditis, according to cardiac MRI. Patients with COVID-19 infection and other myocarditis showed a higher prevalence of interventricular septum anomalies and worse myocardial damage as determined by T1 mapping. All patients with vaccine-associated myocarditis were asymptomatic and had no adverse outcomes after a short period of follow-up (median 22 days).

Myocarditis produced by the COVID vaccination is quite modest : 

“Because we're a high-volume centre, we've employed MRI to check for myocarditis in this patient population,” Hanneman added, “but the number of individuals we discover with myocardial edoema and injury has been fairly low.” “These findings suggest that myocarditis caused by COVID-19 immunisation is usually moderate and heals fast.” Matteo Fronza, MD, first author and cardiac imaging fellow, remarked that the absence of adverse events and remission of all symptoms during follow-up were comforting. Longer-term follow-up is, however, required.

COVID will cause more heart damage than the vaccination : 

COVID-19 infection can cause cardiac damage, which has been linked to poor outcomes in hospitalised patients, according to the researchers, and this risk should be evaluated against the low risk of vaccine-related problems. In individuals with moderate to severe COVI infection, myocarditis and pericarditis are prevalent.

“Not only is myocarditis after COVID-19 immunisation uncommon, but it also seems to be milder than myocarditis after SARS-CoV2 infection,” Hanneman added.

She noted that her hospital has called back some patients with vaccine-caused myocarditis, and they discovered a significant reduction in edoema in these patients, indicating that there is no longer a cardiac impact.

Paaladinesh Thavendiranathan, MD, SM, a co-investigator and cardiologist, agrees. “Patients who are afraid of myocarditis should not avoid COVID-19 vaccination,” he stated. “After COVID-19 infection, the risk of myocarditis appears to be substantially higher.” Patients should seek medical assistance if they develop symptoms, particularly chest pain, soon after receiving COVID-19 vaccine.”

Hangman added that, as with many things regarding COVID, additional research data is needed to definitively say there is no long-term impairment in these people. “There's a lot we don't know,” she added, adding that “we need to keep studying this.”

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