Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches

Abstract

Purpose To investigate if T1 and T2 mapping is able to differentiate between diseased and healthy myocardium in patients with systemic sarcoidosis, and to compare the standard mapping measurement (measurement within the whole myocardium of the midventricular short axis slice, SAX) to a more standardized method measuring relaxation times within the midventricular septum (ConSept).

Materials and Methods 24 patients with biopsy-proven extracardiac sarcoidosis and 17 healthy control subjects were prospectively enrolled in this study and underwent CMR imaging at 1.5 T including native T1 and T2 mapping. Patients were divided into patients with (LGE+) and without (LGE–) cardiac sarcoidosis. T1 and T2 relaxation times were compared between patients and controls. Furthermore, the SAX and the ConSept approach were compared regarding differentiation between healthy and diseased myocardium.

Results T1 and T2 relaxation times were significantly longer in all patients compared with controls using both the SAX and the ConSept approach (p < 0.05). However, LGE+ and LGE– patients showed no significant differences in T1 and T2 relaxation times regardless of the measurement approach used (ConSept/SAX) (p > 0.05). Direct comparison of ConSept and SAX T1 mapping showed high conformity in the discrimination between healthy and diseased myocardium (Kappa = 0.844).

Conclusion T1 and T2 mapping may not only enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis but may also serve as a marker for early cardiac involvement of the disease allowing for timely treatment. ConSept T1 mapping represents an equivalent method for tissue characterization in this population compared to the SAX approach. Further studies including follow-up examinations are necessary to confirm these preliminary results.

Key Points: 

• Mapping may enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis

• Mapping may serve as a marker for early cardiac involvement in patients with systemic sarcoidosis

• The ConSept approach can be used as an alternative measuring method in sarcoidosis patients

Citation Format

• Dabir D, Luetkens J, Kuetting D et al. Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches. Fortschr Röntgenstr 2021; 193: 68 – 76

Zusammenfassung

Ziel Untersuchung, ob T1- und T2-Mapping bei Patienten mit systemischer Sarkoidose zwischen krankem und gesundem Myokard unterscheidet. Vergleich der herkömmlichen Messmethode (Messung im gesamten mittventrikulären Myokard der kurzen Herzachse, SAX) mit einem standardisierteren Messansatz, bei dem die Relaxationszeiten ausschließlich im mittventrikulären Septum gemessen werden (ConSept).

Material und Methoden 24 Patienten mit bioptisch gesicherter extrakardialer Sarkoidose und 17 gesunde Probanden wurden prospektiv in diese Studie eingeschlossen und an einem 1,5-Tesla-Magneten unter anderem mittels nativem T1- und T2-Mapping untersucht. Patienten wurden im Rahmen der Auswertung unterteilt in Patienten mit (LGE+) und Patienten ohne späte myokardiale Kontrastmittelaufnahme (LGE–). Des Weiteren wurden die SAX- und die ConSept-Messmethode auf ihre Differenzierbarkeit zwischen gesundem und krankem Herzmuskelgewebe untersucht.

Ergebnisse Alle Patienten wiesen unabhängig von der gewählten Messmethode (ConSept bzw. SAX) signifikant längere T1- und T2-Relaxationszeiten im Vergleich zu den gesunden Probanden auf (p < 0,05). Jedoch zeigten sich keine signifikant unterschiedlichen Relaxationszeiten zwischen Patienten mit (LGE+) und ohne späte myokardiale Kontrastmittelaufnahme (LGE–), unabhängig von der gewählten Messmethode (ConSept/Sax) (p > 0,05). Der direkte Vergleich zwischen den Messmethoden ConSept und SAX zeigte beim T1-Mapping eine hohe Übereinstimmung in Bezug auf die Differenzierung zwischen krankem und gesundem Myokard (Kappa = 0,844).

Schlussfolgerung Mittels T1- und T2-Mapping ist es möglich, bei Patienten mit systemischer Sarkoidose zwischen krankem und gesundem Myokard zu unterscheiden. Darüber hinaus stellt das myokardiale Mapping einen möglichen Marker für die Früherkennung einer kardialen Beteiligung dar, was eine zeitgerechte Behandlung begünstigt. ConSept-T1-Mapping stellt einen gleichwertigen Messansatz zur SAX-Methode bei Sarkoidose-Patienten dar. Weitere Studien, inklusive Follow-up-Studien, sind notwendig, um diese vorläufigen Ergebnisse zu bestätigen.

Kernaussagen: 

• Mapping kann zwischen krankem und gesundem Myokard bei Patienten mit systemischer Sarkoidose unterscheiden

• Mapping könnte zur Früherkennung einer kardialen Sarkoidose beitragen

• ConSept-T1-Mapping stellt einen alternativen Messansatz zur SAX-Methode bei Sarkoidose-Patienten dar

Key words

sarcoidosis - CMR - T1 mapping - T2 mapping

Publikationsverlauf

Eingereicht: 05. März 2020

Angenommen: 24. April 2020

Artikel online veröffentlicht:
09. Juni 2020

• References

• 1 Soejima K, Yada H. The work-up and management of patients with apparent or subclinical cardiac sarcoidosis: with emphasis on the associated heart rhythm abnormalities. J Cardiovasc Electrophysiol 2009; 20: 578-583 . doi:10.1111/j.1540-8167.2008.01417.x
• 2 Kandolin R, Lehtonen J, Airaksinen J. et al Cardiac sarcoidosis: epidemiology, characteristics, and outcome over 25 years in a nationwide study. Circulation 2015; 131: 624-632 . doi:10.1161/CIRCULATIONAHA.114.011522
• 3 Nery PB, Beanlands RS, Nair GM. et al Atrioventricular block as the initial manifestation of cardiac sarcoidosis in middle-aged adults. J Cardiovasc Electrophysiol 2014; 25: 875-881 . doi:10.1111/jce.12401
• 4 Birnie DH, Sauer WH, Bogun F. et al HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm 2014; 11: 1305-1323 . doi:10.1016/j.hrthm.2014.03.043
• 5 Smedema JP, Snoep G, van Kroonenburgh MP. et al Evaluation of the accuracy of gadolinium-enhanced cardiovascular magnetic resonance in the diagnosis of cardiac sarcoidosis. J Am Coll Cardiol 2005; 45: 1683-1690 . doi:10.1016/j.jacc.2005.01.047
• 6 Schuster A, Morton G, Chiribiri A. et al Imaging in the management of ischemic cardiomyopathy: special focus on magnetic resonance. J Am Coll Cardiol 2012; 59: 359-370 . doi:10.1016/j.jacc.2011.08.076
• 7 Dabir D, Meyer D, Kuetting D. et al Diagnostic Value of Cardiac Magnetic Resonance Strain Analysis for Detection of Cardiac Sarcoidosis. Rofo 2018; 190: 712-721 . doi:10.1055/a-0598-5099
• 8 Reiter U, Reiter C, Krauter C. et al Quantitative Clinical Cardiac Magnetic Resonance Imaging. Rofo 2020; 192: 246-256 . doi:10.1055/a-0999-5716
• 9 Diao KY, Yang ZG, Xu HY. et al Histologic validation of myocardial fibrosis measured by T1 mapping: a systematic review and meta-analysis. J Cardiovasc Magn Reson 2016; 18: 92 . doi:10.1186/s12968-016-0313-7
• 10 Verhaert D, Thavendiranathan P, Giri S. et al Direct T2 quantification of myocardial edema in acute ischemic injury. JACC Cardiovasc Imaging 2011; 4: 269-278 . doi:10.1016/j.jcmg.2010.09.023
• 11 Rogers T, Dabir D, Mahmoud I. et al Standardization of T1 measurements with MOLLI in differentiation between health and disease – the ConSept study. J Cardiovasc Magn Reson 2013; 15: 78 . doi:10.1186/1532-429X-15-78
• 12 Bonner F, Janzarik N, Jacoby C. et al Myocardial T2 mapping reveals age- and sex-related differences in volunteers. J Cardiovasc Magn Reson 2015; 17: 9 . doi:10.1186/s12968-015-0118-0
• 13 Dabir D, Child N, Kalra A. et al Reference values for healthy human myocardium using a T1 mapping methodology: results from the International T1 Multicenter cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2014; 16: 69 . doi:10.1186/s12968-014-0069-x
• 14 Luetkens JA, Doerner J, Thomas DK. et al Acute myocarditis: multiparametric cardiac MR imaging. Radiology 2014; 273: 383-392 . doi:10.1148/radiol.14132540
• 15 Friedrich MG, Strohm O, Schulz-Menger J. et al Contrast media-enhanced magnetic resonance imaging visualizes myocardial changes in the course of viral myocarditis. Circulation 1998; 97: 1802-1809
• 16 Messroghli DR, Radjenovic A, Kozerke S. et al Modified Look-Locker inversion recovery (MOLLI) for high-resolution T1 mapping of the heart. Magn Reson Med 2004; 52: 141-146 . doi:10.1002/mrm.20110
• 17 Sprinkart AM, Luetkens JA, Traber F. et al Gradient Spin Echo (GraSE) imaging for fast myocardial T2 mapping. J Cardiovasc Magn Reson 2015; 17: 12 . doi:10.1186/s12968-015-0127-z
• 18 Moravsky G, Ofek E, Rakowski H. et al Myocardial fibrosis in hypertrophic cardiomyopathy: accurate reflection of histopathological findings by CMR. JACC Cardiovasc Imaging 2013; 6: 587-596 . doi:10.1016/j.jcmg.2012.09.018
• 19 Luetkens JA, Homsi R, Sprinkart AM. et al Incremental value of quantitative CMR including parametric mapping for the diagnosis of acute myocarditis. Eur Heart J Cardiovasc Imaging 2016; 17: 154-161 . doi:10.1093/ehjci/jev246
• 20 Puntmann VO, Voigt T, Chen Z. et al Native T1 mapping in differentiation of normal myocardium from diffuse disease in hypertrophic and dilated cardiomyopathy. JACC Cardiovasc Imaging 2013; 6: 475-484 . doi:10.1016/j.jcmg.2012.08.019
• 21 Hinojar R, Foote L, Sangle S. et al Native T1 and T2 mapping by CMR in lupus myocarditis: Disease recognition and response to treatment. Int J Cardiol 2016; 222: 717-726 . doi:10.1016/j.ijcard.2016.07.182
• 22 Greulich S, Mayr A, Kitterer D. et al T1 and T2 mapping for evaluation of myocardial involvement in patients with ANCA-associated vasculitides. J Cardiovasc Magn Reson 2017; 19: 6 . doi:10.1186/s12968-016-0315-5
• 23 Puntmann VO, Isted A, Hinojar R. et al T1 and T2 Mapping in Recognition of Early Cardiac Involvement in Systemic Sarcoidosis. Radiology 2017; 285: 63-72 . doi:10.1148/radiol.2017162732
• 24 Greulich S, Kitterer D, Latus J. et al Comprehensive Cardiovascular Magnetic Resonance Assessment in Patients With Sarcoidosis and Preserved Left Ventricular Ejection Fraction. Circ Cardiovasc Imaging 2016; 9 DOI: 10.1161/CIRCIMAGING.116.005022.
• 25 Piechnik SK, Ferreira VM, Dall'Armellina E. et al Shortened Modified Look-Locker Inversion recovery (ShMOLLI) for clinical myocardial T1-mapping at 1.5 and 3 T within a 9 heartbeat breathhold. J Cardiovasc Magn Reson 2010; 12: 69 . doi:10.1186/1532-429X-12-69
• 26 Hinojar R, Foote L, Arroyo Ucar E. et al Myocardial T2 mapping for improved detection of inflammatory myocardial involvement in acure and chronic myocarditis. 17th Annual SCMR Scientific Sessions 2014 New Orleans, LA, USA:
• 27 Hinojar R, Foote L, Cummins C. et al Standardised postprocessing of native T2 in detection and discrimination of myocarditis – comparison with native T1 mapping. 19th Annual SCMR Scientific Sessions 2016 Los Angeles, CA, USA:
• 28 Radunski UK, Lund GK, Stehning C. et al CMR in patients with severe myocarditis: diagnostic value of quantitative tissue markers including extracellular volume imaging. JACC Cardiovasc Imaging 2014; 7: 667-675 . doi:10.1016/j.jcmg.2014.02.005
• 29 Reiter U, Reiter G, Kovacs G. et al Native myocardial T1 mapping in pulmonary hypertension: correlations with cardiac function and hemodynamics. Eur Radiol 2017; 27: 157-166 . doi:10.1007/s00330-016-4360-0