Inflammatory Cardiomyopathy Bern Registry (FlamBer)

Inflammatory cardiomyopathies are associated with inflammation and impaired function of the heart muscle and encompass myo- and pericarditis and cardiac sarcoidosis. Due to the heterogeneity of the clinical manifestations, establishing the diagnosis and prediction of outcome is challenging. Specifically for myocarditis, it is associated with acute and chronic heart failure and sudden cardiac death.

Cardiac magnetic resonance imaging (CMR) allows imaging of tissue characteristics (i.e. edema and fibrosis). CMR is the primary diagnostic tool in myocarditis and can also be used for differentiating other inflammatory diseases. Beside the presence of edema, also hyperemia/capillary leak, fibrosis and myocardial function can be assessed and quantified.

Previous studies demonstrated the prognostic role of CMR features beyond traditional markers of LV function, but are limited to smaller cohorts and single-center studies. Furthermore, CMR is a rapidly developing modality and as new features of the modality become available, additional research is needed to identify which combination of parameters optimize risk stratification of this heterogenous inflammatory cardiomyopathy.

Hence, the goal of the registry is to investigate the diagnostic and prognostic role of clinical techniques in inflammatory cardiomyopathies, particularly CMR, and which combination of features provide the highest potential. This analysis will include new advanced CMR techniques but will also assess the role of other techniques that may be more cost-efficient and more widely available, which could be used as a precursor to CMR imaging exams.

Study Overview

• Status: Enrolling by invitation
• Conditions: Myocarditis; Pericarditis; Cardiac Sarcoidosis

Detailed Description

Inflammatory cardiomyopathies, like myocarditis and cardiac sarcoidosis are associated with inflammation of the heart muscle and or pericardium, which is the likely cause of impaired function of the myocardium. Clinical presentation of these diseases present high variability - from asymptomatic cases to patients with cardiac arrest or severe heart failure. Due to the heterogeneity of the clinical manifestations, establishing the diagnosis and prognosis remains challenging.

Due to its high spatial resolution and excellent tissue characterization (i.e. the identification of edema and fibrosis), cardiac magnetic resonance imaging (CMR) is the cornerstone in the workup of acute myocarditis and can also be used for differentiating other inflammatory diseases. One of the main criteria for the non-invasive diagnosis of myocarditis has been the Lake Louise Criteria (LLC), where specifically the inclusion of edema and fibrosis as assessed by CMR are necessary to make the diagnosis of myocarditis. The first recommendations released in 2009 indicated 2 of 3 of the following criteria were needed; presence of edema, hyperemia/capillary leak and/or fibrosis. More recently, 2018 updated guidelines are broadened to non-ischemic inflammation to include sarcoidosis, systemic lupus erythematosus and a variety of types of myocarditis. These criteria now include a 2 of 2 criteria with at least one T2-based (edema) and one T1-based (necrosis/fibrosis mostly) criterion, which can be supported by pericardial effusion or systolic LV wall motion abnormalities.

Further, CMR has been reported to be a very strong prognosticator. Traditional markers such as late gadolinium enhancement (LGE) and left ventricular ejection fraction (LVEF), assessed in CMR are outcome predictors for future adverse cardiac events in myocarditis patients. Similar findings have been shown in sarcoidosis as well. However, CMR is a rapidly developing modality and as new features of the modality frequently become available, additional research is needed to identify the best combination of parameters for risk stratification in patients with inflammatory.

CMR feature tracking (CMR-FT) is a developing contrast-free quantitative method that uses cine images in routinely acquired CMR scanning and it is able to quantify systolic and diastolic myocardial deformation in different orientations. CMR-FT has recently been shown to have diagnostic and prognostic value beyond ejection fraction in patients with coronary artery disease or dilated cardiomyopathy. Recently, the investigators could show in collaboration with the Brigham and Women's Hospital at Harvard Medical School that myocardial strain using CMR-FT provides independent and incremental prognostic value over clinical features, ejection fraction and scar (LGE) in patients with myocarditis. CMR-FT may serve as a novel marker to improve risk stratification in myocarditis. Yet this has not yet been investigated yet with parametric mapping techniques, nor with other inflammatory cardiomyopathies.

The goal of the registry is to investigate the diagnostic and prognostic role of clinical techniques in inflammatory cardiomyopathies, particularly CMR, and which combination of features provide the highest potential. This analysis will include new advanced CMR techniques like feature tracking and T1- and T2 mapping but will also assess the role of other techniques that may be more cost-efficient and more widely available, which could be used as a precursor to CMR imaging exams. Further, other imaging modalities such as echocardiography and nuclear imaging (I.e. Positron Emission Tomography) and computed tomography (CT) findings will be assessed and associated with biomarkers and outcome.

• Study Type: Observational
• Enrollment (Estimated): 1125

Contacts and Locations

Study Locations

• Switzerland
  • Bern, Switzerland, 3010
    • Department of Cardiology, University Hospital Bern, Inselspital, Bern

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Patients referred to CMR for suspected/known inflammatory cardiomyopathy and/or diagnosed inflammatory cardiomyopathy from CMR findings

Description

Inclusion Criteria:

• Referral to CMR for suspected/known inflammatory cardiomyopathy and/or diagnosed inflammatory cardiomyopathy from CMR findings
• Ability to provide informed consent (knowledge of project languages),
• Age >18 years

Exclusions:

• Inability to give consent or existence of a written or documented oral refusal.
• Evidence of coronary artery disease (CAD) by either previous documented medical history, any imaging findings of CAD, or significant epicardial coronary stenosis by invasive coronary angiography;
• Evidence of hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, cardiac amyloidosis, Takotsubo cardiomyopathy, Loeffler endocarditis, ventricular noncompaction, cardiac tumor, pulmonary embolism, or persistent severe valve disease.
• Recent cardiovascular surgery or intervention (<90 days prior to CMR)
• Heart transplant

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Only
• Time Perspectives: Prospective

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort
Patients with inflammatory cardiomyopathy; Patients referred to CMR for suspected/known inflammatory cardiomyopathy and/or diagnosed inflammatory cardiomyopathy from CMR findings

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
LV (left ventricle) and RV (right ventricle) function as assessed by CMR feature tracking as predictor for MACE (major adverse cardiac Event)	Global and regional longitudinal (%), circumferential (%) and radial (%) strain measurements are used to quantify LV and RV function. MACE is defined as a composite of sustained ventricular tachycardia, recurrent myocarditis, hospitalization for heart failure and all-cause death all-cause death.	5 years
LV and RV tissue characterization as assessed by T1 and T2 mapping as predictor for MACE	Global and regional tissue characteristics are assessed by repetitive T1 and T2 mapping (global and regional T1 and T2 time (ms)). MACE is defined as a composite of major cardiovascular endpoints listed above.	5 years
Presence of myocardial fibrosis and scar as predictor for MACE	Global and regional myocardial tissue is characterized by gadolinium contrast agent application. The presence and extent (% and total mass (g)) of late gadolinium enhancement is evaluated as a predictor for MACE.	5 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prognostic impact of sports cessation in acute myocarditis	Sports behaviour is assessed by repetitive self-evaluating questionnaires before and after diagnosis of acute myocarditis. Sports cessation (total vs. partial vs. no cessation) is evaluated as a predictor of MACE.	Repetitive questionnaire at baseline, after 6 and 12 months as well as after 5 years
Prognostic impact of fragmented QRS in acute myocarditis	Presence and persistence of fragmented QRS as measured by repetitive electrocardiogram is evaluated as a predictor for MACE.	5 years

Collaborators and Investigators

• Sponsor: Insel Gruppe AG, University Hospital Bern
• Investigators: Principal Investigator: Christoph Gräni, MD, PhD, Inselspital, Bern University Hospital

Publications and helpful links

General Publications

• Grani C, Eichhorn C, Biere L, Murthy VL, Agarwal V, Kaneko K, Cuddy S, Aghayev A, Steigner M, Blankstein R, Jerosch-Herold M, Kwong RY. Prognostic Value of Cardiac Magnetic Resonance Tissue Characterization in Risk Stratifying Patients With Suspected Myocarditis. J Am Coll Cardiol. 2017 Oct 17;70(16):1964-1976. doi: 10.1016/j.jacc.2017.08.050. Erratum In: J Am Coll Cardiol. 2017 Nov 28;70(21):2736.
• Fischer K, Obrist SJ, Erne SA, Stark AW, Marggraf M, Kaneko K, Guensch DP, Huber AT, Greulich S, Aghayev A, Steigner M, Blankstein R, Kwong RY, Grani C. Feature Tracking Myocardial Strain Incrementally Improves Prognostication in Myocarditis Beyond Traditional CMR Imaging Features. JACC Cardiovasc Imaging. 2020 Sep;13(9):1891-1901. doi: 10.1016/j.jcmg.2020.04.025. Epub 2020 Jul 15.
• Fischer K, Marggraf M, Stark AW, Kaneko K, Aghayev A, Guensch DP, Huber AT, Steigner M, Blankstein R, Reichlin T, Windecker S, Kwong RY, Grani C. Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging. PLoS One. 2020 Jan 10;15(1):e0227134. doi: 10.1371/journal.pone.0227134. eCollection 2020.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2005
• Primary Completion (Estimated): December 1, 2025
• Study Completion (Estimated): December 31, 2026

Study Registration Dates

• First Submitted: February 18, 2021
• First Submitted That Met QC Criteria: February 24, 2021
• First Posted (Actual): March 1, 2021

Study Record Updates

• Last Update Posted (Actual): July 20, 2023
• Last Update Submitted That Met QC Criteria: July 19, 2023
• Last Verified: July 1, 2023

More Information

Terms related to this study

• Keywords: Outcomes; Pericarditis; MACE; CMR feature tracking; Myocarditis; Strain; Cardiac sarcoidosis; T1 and T2 Mapping; LGE
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Immune System Diseases; Lymphoproliferative Disorders; Lymphatic Diseases; Hypersensitivity; Hypersensitivity, Delayed; Myocarditis; Cardiomyopathies; Pericarditis; Sarcoidosis
• Other Study ID Numbers: 2020-01100 (Other Identifier: Ethics Comitee)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No