Cardiovascular magnetic resonance in immune checkpoint inhibitor-Associated myocarditis

Lili Zhang, Magid Awadalla, Syed S. Mahmood, Anju Nohria, Malek Z.O. Hassan, Franck Thuny, Daniel A. Zlotoff, Sean P. Murphy, James R. Stone, Doll Lauren Alexandra Golden, Raza M. Alvi, Adam Rokicki, Maeve Jones-O'Connor, Justine V. Cohen, Lucie M. Heinzerling, Connor Mulligan, Merna Armanious, Ana Barac, Brian J. Forrestal, Ryan J. SullivanRaymond Y. Kwong, Eric H. Yang, Rongras Damrongwatanasuk, Carol L. Chen, Dipti Gupta, Michael C. Kirchberger, Javid J. Moslehi, Otavio R. Coelho-Filho, Sarju Ganatra, Muhammad A. Rizvi, Gagan Sahni, Carlo G. Tocchetti, Valentina Mercurio, Michael Mahmoudi, Donald P. Lawrence, Kerry L. Reynolds, Jonathan W. Weinsaft, A. John Baksi, Stephane Ederhy, John D. Groarke, Alexander R. Lyon, Michael G. Fradley, Paaladinesh Thavendiranathan, Tomas G. Neilan

Research output: Contribution to journalArticlepeer-review

162 Scopus citations


Aims: Myocarditis is a potentially fatal complication of immune checkpoint inhibitors (ICI). Sparse data exist on the use of cardiovascular magnetic resonance (CMR) in ICI-Associated myocarditis. In this study, the CMR characteristics and the association between CMR features and cardiovascular events among patients with ICI-Associated myocarditis are presented. Methods and results: From an international registry of patients with ICI-Associated myocarditis, clinical, CMR, and histopathological findings were collected. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. In 103 patients diagnosed with ICI-Associated myocarditis who had a CMR, the mean left ventricular ejection fraction (LVEF) was 50%, and 61% of patients had an LVEF ≥50%. Late gadolinium enhancement (LGE) was present in 48% overall, 55% of the reduced EF, and 43% of the preserved EF cohort. Elevated T2-weighted short tau inversion recovery (STIR) was present in 28% overall, 30% of the reduced EF, and 26% of the preserved EF cohort. The presence of LGE increased from 21.6%, when CMR was performed within 4 days of admission to 72.0% when CMR was performed on Day 4 of admission or later. Fifty-six patients had cardiac pathology. Late gadolinium enhancement was present in 35% of patients with pathological fibrosis and elevated T2-weighted STIR signal was present in 26% with a lymphocytic infiltration. Forty-one patients (40%) had MACE over a follow-up time of 5 months. The presence of LGE, LGE pattern, or elevated T2-weighted STIR were not associated with MACE. Conclusion: These data suggest caution in reliance on LGE or a qualitative T2-STIR-only approach for the exclusion of ICI-Associated myocarditis.

Original languageEnglish (US)
Pages (from-to)1733-1743
Number of pages11
JournalEuropean heart journal
Issue number18
StatePublished - May 7 2020
Externally publishedYes


  • Cardiovascular magnetic resonance
  • Immune checkpoint inhibitor
  • Myocarditis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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