Myocardial Inflammation on FDG PET/MRI and Clinical Outcomes in Symptomatic and Asymptomatic Participants after COVID-19 Vaccination

Constantin Arndt Marschner, Paaladinesh Thavendiranathan, Dakota Gustafson, Kathryn L Howe, Jason E Fish, Robert M Iwanochko, Rachel M Wald, Husam Abdel-Qadir, Slava Epelman, Angela M Cheung, Rachel Hong, Kate Hanneman, Constantin Arndt Marschner, Paaladinesh Thavendiranathan, Dakota Gustafson, Kathryn L Howe, Jason E Fish, Robert M Iwanochko, Rachel M Wald, Husam Abdel-Qadir, Slava Epelman, Angela M Cheung, Rachel Hong, Kate Hanneman

Abstract

Purpose: To evaluate potential cardiac sequelae of COVID-19 vaccination at 2-month follow-up and relate cardiac symptoms to myocardial tissue changes on fluorodeoxyglucose (FDG) PET/MRI, blood biomarkers, health-related quality of life, and adverse outcomes.

Materials and methods: In this prospective study (ClinicalTrials.gov: NCT04967807), a convenience sample of individuals aged ≥17 years were enrolled after COVID-19 vaccination and were categorized as symptomatic myocarditis (new cardiac symptoms within 14 days of vaccination and met diagnostic criteria for acute myocarditis), symptomatic no myocarditis (new cardiac symptoms but did not meet criteria for myocarditis), and asymptomatic (no new cardiac symptoms). Standardized evaluation was performed 2 months after vaccination, including cardiac fluorine 18 FDG PET/MRI, blood biomarkers, and health-related quality of life. Statistical analysis included Kruskal-Wallis and Fisher exact tests.

Results: Fifty-four participants were evaluated a median of 72 days (IQR: 42, 91) after COVID-19 vaccination, 17 symptomatic with myocarditis (36±[SD]15 years, 13 males), 17 symptomatic without myocarditis (42±12 years, 7 males), and 20 asymptomatic (45±14 years, 9 males). No participants in the symptomatic without myocarditis or asymptomatic groups had focal FDG-uptake, myocardial edema or impaired ventricular function. Two participants with symptomatic myocarditis had focal FDG-uptake, and three had high T2 on MRI. Health-related quality of life was lower in the symptomatic myocarditis group than the asymptomatic group. There were no adverse cardiac events beyond myocarditis in any participant.

Conclusions: At two-month follow-up, FDG PET/MRI showed evidence of myocardial inflammation in 2/17 participants diagnosed with acute myocarditis early after COVID-19 vaccination, but not in symptomatic and asymptomatic participants without acute myocarditis.Keywords: Myocarditis, Vaccination, COVID-19, PET/MRI, Cardiac MRI, FDG-PET.

Keywords: COVID-19; Cardiac MRI; FDG-PET; Myocarditis; PET/MRI; Vaccination.

Conflict of interest statement

Disclosures: Dr. Hanneman has received speaker's honorarium from Sanofi-Genzyme, Amicus and Medscape. Dr. Hanneman is an associate editor for Radiology: Cardiothoracic Imaging. Dr. Thavendiranathan has received speaker's honorarium from Amgen, BI, and Takeda. Dr. Cheung receiving donation of drugs from MediciNova for the RECLAIM trial and consulting fees from Amgen and Ipsen. Dr. Abdel-Qadir received payment or honoraria for lecture from AstraZeneca and Jazz Pharmaceuticals.

© 2023 by the Radiological Society of North America, Inc.

Figures

Graphical abstract
Graphical abstract
Figure 1:
Figure 1:
Flowchart details participant selection.
Figure 2:
Figure 2:
Quality of life at short-term follow-up by participant group. Scatterplots for (A) EQ-5D-3L index and (B)EQ-5D-3L visual analog scale (VAS) depict individual patient data points with error bars displayed as medians and IQRs. P values are for comparisons between groups as indicated. EQ-5D-3L = EuroQol five-dimension, three-level version questionnaire.
Figure 3:
Figure 3:
Cardiac PET/MRI findings at follow-up by participant group. Scatterplots for continuous PET/MRI parameters of (A) left ventricular ejection fraction [LVEF], (B) native T1 mapping, and(C) native T2 mapping depict individual patient data points with error bars displayed as means and SDs. Pvalues are for comparisons between groups as indicated.
Figure 4:
Figure 4:
Images from combined cardiac fluorine 18 fluorodeoxyglucose (FDG) PET/MRI in a symptomatic female participant between 41 and 50 years of age, 2 months after a diagnosis of myocarditis following COVID-19 vaccination. Short-axis midventricular native (A) T1 and(B) T2 maps demonstrate high T1 and T2 values in the subepicardial inferior and inferolateral walls (white and green arrows, respectively). (C) Short-axis late gadolinium enhancement (LGE) image demonstrates corresponding subepicardial LGE (red arrows).(D) Fused LGE and FDG PET image demonstrates corresponding focal FDG uptake (blue arrows), in keeping with myocardial inflammation.

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