Late Detection of Left Ventricular Dysfunction Using Two-Dimensional and Three-Dimensional Speckle-Tracking Echocardiography in Patients with History of Nonsevere Acute Myocarditis

Abstract

Background: Acute myocarditis (AM) often involves the left ventricular (LV) subepicardium that might be displayed by cardiac magnetic resonance even late after the acute phase. In the absence of global or regional LV dysfunction, conventional transthoracic echocardiography (TTE) does not accurately identify tissue sequelae of AM. We sought to evaluate the diagnostic value of two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography to identify patients with a history of AM with preserved LV ejection fraction (LVEF).

Methods: Fifty patients (group 1: age, 31.4 ± 10.5 years; 76% males) with a history of cardiac magnetic resonance-confirmed diagnosis of AM (according to the Lake Louise criteria) were retrospectively identified and then (21.7 ± 23.4 months later) evaluated by complete echocardiography including 2D and 3D speckle-tracking analysis, as well as 50 age- and gender-matched healthy controls (group 2: age, 31.2 ± 9.5 years: 76% males). Patients with a history of severe clinical presentation of AM (sudden death, ventricular arrhythmia, heart failure, alteration of LVEF) were excluded.

Results: At diagnosis, peak troponin and C-reactive protein were 11.97 (interquartile range, 4.52-25.92) μg/L and 32.3 (interquartile range, 14.85-70.45) mg/L, respectively. Mean delay between acute phase and follow-up study TTE was 21.7 ± 23.4 months. LVEF was not statistically different between groups (62.1% vs 63.5%, P = .099). Two-dimensional global longitudinal strain (GLS) was lower in magnitude in group 1 (-17.8% vs -22.1%, P < .0001) as were 2D layer-specific subepicardial GLS (-15.4% vs -19.7%, P < .0001) and subendocardial GLS (-20.71% vs -25.08%, P < .0001). Three-dimensional global longitudinal, circumferential, area, and radial strains were lower in magnitude in group 1 (-11.80% vs -14.98%, P < .0001; -12.57% vs -15.12%, P < .0001; -22.28% vs -25.87%, P < .0001; 31.47% vs 38.06%, P < .0001, respectively). Receiver operating characteristic curve analysis showed that subepicardial GLS displayed a better diagnostic performance to detect sequelae of AM as compared with GLS (area under the curve = 0.97 vs 0.93, P = .045).

Conclusions: In patients with a history of AM, a subtle LV dysfunction can be detected by 2D and 3D speckle-tracking echocardiography, even though LVEF is conserved, adding incremental information over conventional TTE.

Keywords: Acute myocarditis; Echocardiography; Layer-specific strain; Three-dimensional speckle-tracking; Two-dimensional speckle-tracking.