Non-ischemic Cardiomyopathies - Cases

1352864 - Serial cardiac MRI demonstrating improvement of immune checkpoint inhibitor-induced myocarditis after steroid treatment

Friday, January 27, 2023

7:00 AM – 7:50 AM

Location: Pacific Jewel

Presenting Author(s)

XW

Xin Wei, MD

Fellow in training
MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia, Maryland, United States

Primary Author(s)

XW

Xin Wei, MD

Fellow in training
MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia, Maryland, United States

Co-Author(s)

PB

Patrick T. Bering, MD

Physician
MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia
Laurel, Maryland, United States

Description of Clinical Presentation: A 77-year-old male with atrial fibrillation on apixaban was recently administered capecitabine/oxaliplatin/nivolumab 08/17/2022 for metastatic distal esophageal adenocarcinoma diagnosed 12/2021. He presented with dyspnea on exertion and diffuse ST-segment elevation on EKG (Fig 1) with significant troponin. Coronary angiography showed minimal coronary artery disease. Echocardiography showed severely reduced left ventricular ejection fraction (LVEF) of 25%-30%, decreased from his baseline of normal LVEF in 05/2022. He underwent cardiac MRI examination which demonstrated diffuse inflammation by native T1 and T2 mapping, leading to the diagnosis of grade 4 immune checkpoint inhibitor (ICI)-induced myocarditis. He received p</span>ulse-dose steroid methylprednisolone 1-g daily for 3 days followed by 1-mg/kg daily of oral prednisone. After 1 week of steroid therapy, a repeat cardiac MRI demonstrated significant improvement in LVEF as well as reduction in inflammation by native T1 and T2 mapping, accompanied with significant symptomatic improvement. The patient was discharged with a 4-6 weeks steroid taper.

Diagnostic Techniques and Their Most Important Findings:

Our patient underwent two cardiac MRI examinations 09/14/2022 and 09/21/2022 on the same clinical MRI system (Siemens 1.5 T). The techniques performed included cine imaging in cardiac orientations, post contrast imaging with inversion recovery sequences, pre- and post-contrast T1 mapping using MOLLI technique, and native T2 mapping. Gadobutrol was utilized for contrast enhanced imaging.

First study: Severely reduced LVEF of 32% and RVEF of 30%. P</span>rolonged native myocardial T1 relaxation time of 1098 ms and native myocardial T2 of 59 ms, globally. Calculated myocardial ECV of 40%. Myocardial late gadolinium enhancement (LGE) in the basal inferoseptal, inferior and inferolateral walls (Fig 2).

Second study: Improvement of LVEF to 50% and RVEF to 44%. Decreased native myocardial T1 and T2 values with global measurements of 1017 ms and 54 ms , respectively (Fig 3). Calculated ECV of 36%. The myocardial LGE pattern was similar.

Learning Points from this Case: ICI-induced cardiotoxicity is a rare adverse event with an incidence of 0.04-1.14%, characterized by a high mortality of 25-50%. Cardiac MRI, especially with parametric mapping, plays a pivotal role in the appropriate diagnosis and treatment of patients with suspected ICI cardiotoxicity per the 2018 Modified Lake Louise Criteria (mLLC) for the cardiac MRI diagnosis of myocarditis. The treatment of ICI-induced myocarditis has largely been based on the use of glucocorticoids. Our case demonstrates near complete functional recovery and improvement in parametric myocardial evaluation after one week of steroid treatment. The application of mLLC with T1/T2 mapping appears useful in the CMR diagnosis of acute ICI myocarditis since the LGE pattern can be normal or minimal even in the setting of significant cardiac involvement; furthermore, given its quick response to therapy, there could be a role in identifying treatment response.