Immune checkpoint inhibitor-related myocarditis: an illustrative case series of applying the updated Cardiovascular Magnetic Resonance Lake Louise Criteria

Figures

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  Figure 1. Initial multi-contrast cardiovascular magnetic resonance image panel in patient with immune checkpoint inhibitor myocarditis (high-sensitivity troponin I at time of cardiovascular magnetic resonance: 5 ng/L). (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 oedema (block arrow), focal late gadolinium enhancement (arrowheads), moderate pericardial effusion (*), and mild bilateral pleural effusion (arrows) are demonstrated.

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  Figure 2. Repeat cardiovascular magnetic resonance of same patient as displayed in Figure 1 after 6 months of steroid treatment demonstrating (A) T2 mapping, (B) native T1 mapping, and (C, D) phase sensitive inversion recovery late gadolinium enhancement imaging. Pericardial effusion has resolved, residual focal late gadolinium enhancement demonstrated (arrowhead).

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  Figure 3. Myocarditis from anti-PD-L1 treatment with a very high-sensitivity troponin I level (12 122 ng/L at time of cardiovascular magnetic resonance). (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 mid-ventricular inferior/inferoseptal myocardial oedema (block arrows), high signal intensity focal subepicardial late gadolinium enhancement (arrowheads), and mild pericardial effusion (*) are demonstrated.

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  Figure 4. Follow-up cardiovascular magnetic resonance of same patient as displayed in Figure 3, 8.5 months after initial presentation and steroid treatment demonstrating (A, B) phase sensitive inversion recovery late gadolinium enhancement, (C) native T1 mapping, and (D) T2 mapping. Small pericardial effusion has resolved, and focal late gadolinium enhancement has improved (arrowheads). Segmental and global T1 and T2 values are within local normal ranges (Note: Follow-up performed at 3 T).

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  Figure 5. Anti-PD-L1 antibody-induced myocarditis and pericarditis with moderate to high elevations in high-sensitivity troponin I. (855 ng/L at time of cardiovascular magnetic resonance). (A) T2-weighted SPAIR, (B) T2 mapping, (C) native T1 mapping, (D) phase sensitive inversion recovery late gadolinium enhancement imaging, and (E, F) cine steady state free precession. Very subtle subepicardial late gadolinium enhancement with additional pericardial enhancement (arrowheads), mild pericardial effusion (*), and mild pleural effusions are demonstrated.

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  Figure 6. Anti-PD-L1 therapy-mediated myocarditis with moderate increase in high-sensitivity troponin I (4717 ng/L at time of cardiovascular magnetic resonance). (A) T2-weighted SPAIR, (B, C) T2 mapping, (D, E) native T1 mapping, and (F) phase sensitive inversion recovery late gadolinium enhancement imaging. Diffuse septal oedema (block arrows) and only subtle focal septal late gadolinium enhancement (arrowhead) visualized.

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