Multiparametric CMR in Myocarditis: A Comprehensive Review of Diagnostic Advances, Prognostic Value, and the Challenge of Genetic Mimics

Figures

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  Figure 11. Multi-contrast cardiovascular magnetic resonance image panel in patient with immune checkpoint inhibitor myocarditis. (A) T2-weighted SPAIR, (B) T2 mapping, (C) native T1 mapping, (D,E) phase-sensitive inversion recovery late gadolinium enhancement imaging, and (F) cine steady-state free precession. Focal basal myocardial edema (block arrow), focal late gadolinium enhancement (arrowheads), moderate pericardial effusion (*), and mild bilateral pleural effusion (arrows) are demonstrated. Reproduced from: Wintersperger, B.J., et al. (2022) [58]. Licensed under CC BY-NC 4.0 (https://creativecommons.org/licenses/by-nc/4.0/ accessed on 15 December 2025).

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  Figure 12. (a) Cardiac magnetic resonance imaging, apical four-chamber, post-contrast late gadolinium enhancement images showing extensive subendocardial fibrosis (arrow) and left ventricle mural thrombus (star). (b) Cardiac magnetic resonance imaging, apical four-chamber, follow-up post-contrast late gadolinium enhancement images showing significant improvement of subendocardial fibrosis (arrow) and resolution of left ventricle mural thrombus (star). Reproduced from: Taskesen, T., et al. (2022) [62]. Licensed under CC BY-NC 4.0 (https://creativecommons.org/licenses/by-nc/4.0/ accessed on 15 December 2025).

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  Figure 1. Flow chart detailing literature search and selection pathway used in this review.

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  Figure 2. Natural course of myocarditis as seen by cardiovascular magnetic resonance using quantitative techniques and late gadolinium enhancement.

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  Figure 3. Appearance of acute and subacute myocarditis in CMR. (A) Changes are more pronounced in acute myocarditis, as demonstrated by high prevalence and extent of late gadolinium enhancement (LGE) and elevated T2. (B) Subacute myocarditis can show increased LGE as well as elevated T1, ECV, and T2, but in many cases, changes are subtle. Reproduced from: Brendel, J.M., et al. (2022) [6]. Licensed under CC BY 4.0. (https://creativecommons.org/licenses/by/4.0/ accessed on 15 December 2025).

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  Figure 4. Typical CMR findings of chronic healed myocarditis and DCM. T2w and T2 mapping show marked edema in chronic myocarditis contrary to healed myocarditis and DCM. Increased T1 relaxation times and ECV were present in all groups, prominently depicted in the chronic myocarditis and DCM examples. Reproduced from: Krumm, P., et al. (2022) [10]. Licensed under CC BY 4.0. (https://creativecommons.org/licenses/by/4.0/, accessed on 15 December 2025).

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  Figure 5. A 43-year-old male patient with acute chest pain and T-Troponine release (0.05 mcg/L). The EGE ratio (a) was 5.4, with hyperemia of the anterior and infero-septal segments on the mid-ventricular plane (a, red arrows). Edema (b) with a patchy distribution on the antero-lateral and infero-septal segments (b, white arrows) was confirmed by a T2 ratio of 2.4 on the mid-ventricular plane. A non-ischemic LGE (c) was found in the inferior and infero-septal segments (c, yellow arrows) with a subepicardial distribution. Native T1 (d, mean value of 1073 ms), ECV (e, mean value of 29%), and T2 mapping (f, mean value of 51 ms) were all increased, confirming the positivity of both old and new LLC. EGE—early gadolinium enhancement, STIR—short tau inversion recovery, LGE—late gadolinium enhancement, ECV—extracellular volume fraction, and LLC—Lake Louise Criteria. Reproduced from: Cundari, G., et al. (2021). [17]. Licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/ accessed on 15 December 2025).

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  Figure 6. A 65-year-old female with reduced EF (24%), LV dilation (EDV/BSA: 153 ml/mq), and no significant coronary artery disease. No hyperemia (a, EGE ratio < 4), neither edema (b, T2 ratio < 2) nor LGE (c), was found: oLLC were negative for suspected acute myocarditis. Native T1 was severely increased (d), with a mid-ventricular mean value of 1190 ms; ECV (e) mean value was 35%, and T2 mapping was slightly increased (f, mean value: 52 ms). Both T1 and T2 criteria were positive according to nLLC, and the diagnosis of viral myocarditis was confirmed by EMB. EF—ejection fraction, EDV—end-diastolic volume, BSA—body surface area, EGE—early gadolinium enhancement, STIR—short tau inversion recovery, LGE—late gadolinium enhancement, oLLC—old Lake Louise Criteria, ECV—extracellular volume, nLLC—new Lake Louise Criteria, and EMB—endomyocardial biopsy. Reproduced from: Cundari, G., et al. (2021) [17]. Licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/ accessed on 15 December 2025).

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  Figure 7. Management approach for resuming physical activity in an athlete diagnosed with acute myocarditis.

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  Figure 8. CMR frames of a patient with biventricular ACM. Morpho-functional abnormalities of the RV can be appreciated on a 4-chamber view (A) and right ventricular 2-chamber long-axis view (B) of cine images, evidencing RV dilatation (A, double-head arrow) and multiple sacculations of the inferior and RVOT regions (B, arrows). Structural alterations of the LV are showed in a 4-chamber view (C, arrowhead) and short-axis view (D, arrowhead) of T1-weighted images, where fibro-fatty infiltration of the infero-lateral LV walls becomes evident as a hyperintense signal with a typical bite-like pattern. ACM, arrhythmogenic cardiomyopathy; LV, left ventricle; RV, right ventricle; RVOT, right ventricle outflow tract. Reproduced from: Cipriani, A., et al. (2023) [39]. Licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/ accessed on 15 December 2025).

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  Figure 9. LGE-CMR and FDG-PET images for respective short-axis, 4-chamber, and 2-chamber orientations. Top row shows LGE-CMR fibrosis imaging. Arrows indicate areas of abnormal LGE in a patchy distribution pattern reflecting inflammation and/or scar. Bottom row shows fusion FDG-PET/CT showing patchy uptake in regions of scar, suggesting active inflammation. Note the artifact in the RV cavum caused by the ICD lead. LGE: late gadolinium enhancement. FDG: 18-fluordesoxyglucose positron emission tomography. Reproduced from: Korthals,. D, et al. (2024) [12]. Licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/ accessed on 15 December 2025).

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  Figure 10. Late gadolinium enhancement (LGE) characteristics in cardiac sarcoidosis (CS) and giant cell myocarditis (GCM) on cardiac magnetic resonance, showing multifocal, transmural, and subendocardial involvement and the “hook sign.” Reproduced from: Pyhönen, P., et al (2023) [50]. Licensed under CC BY-NC 4.0 (https://creativecommons.org/licenses/by-nc/4.0/ accessed on 15 December 2025).