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Comment & Response
October 28, 2020

Cardiac Involvement After Recovering From COVID-19

Author Affiliations
  • 1Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
JAMA Cardiol. 2021;6(2):243. doi:10.1001/jamacardio.2020.5276

To the Editor I read with interest the article by Puntmann et al1 regarding the cardiac magnetic resonance (CMR) imaging findings in a group of 100 patients with asymptomatic to a severe course of coronavirus disease 2019 (COVID-19) after a median of 2 to 3 months from diagnosis. I was surprised by the high frequency of cardiac involvement still present in that group, including signs of fibrosis in 78% of patients and ongoing inflammation in 60% of them. The study drew large media attention around the world and brings serious clinical concerns regarding the potential need for in-depth cardiologic screening in all patients after recovering from COVID-19.

The recent study by my coauthors and me2 on persistent subclinical changes in CMR imaging after a median of 7 months from myocarditis in children revealed ongoing active inflammation in 28% of patients and healed myocarditis with persistent scars in 44% of patients. Therefore, a 2-fold lower frequency of persistent myocardial changes, detected later from the onset of the disease, was observed in our group of adolescents with confirmed myocarditis. We did not use T1 and T2 mapping techniques, which are able to detect a subtler myocardial injury or ongoing myocardial inflammation,3 but the difference was still remarkably large, especially considering asymptomatic or mildly affected patients composed a significant amount of the post–COVID-19 group.2

Therefore, I would like to raise some comments regarding the study by Puntmann et al,1 which might explain the high frequency of cardiac involvement detected. First, the application of the modified Lake Louise criteria,4 requiring the presence of both T1 and T2 relaxation time elevation to diagnose an ongoing inflammation, was not reported in the article, and although T1 and T2 usually rise in parallel, on that occasion, the frequency of ongoing myocarditis, at least theoretically, could range from 38% to 60%. Second, Puntmann et al1 used reference criteria for cutoff values of elevated T1 and T2 from studies performed on a 3-T Philips scanner, while their study was done on a 3-T Siemens scanner. In my opinion, these values are not interchangeable. The reference ranges reported for a 3-T Philips scanner are much lower than reference values for a 3-T Siemens scanner, which have been summarized in our report2 and are higher by approximately 100 milliseconds for T1 and 10 milliseconds for T2.5 Therefore, a cutoff point could have been set too low, leading to many false-positive findings. However, only 3 patients with the most severe course had a myocardial biopsy to verify that hypothesis.

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Article Information

Corresponding Author: Łukasz A. Małek, MD, PhD, Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Niemodlińska str 33, 04-635 Warsaw, Poland (lmalek@ikard.pl).

Published Online: October 28, 2020. doi:10.1001/jamacardio.2020.5276

Conflict of Interest Disclosures: None reported.

Puntmann  VO, Carerj  ML, Wieters  I,  et al.  Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19).   JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557PubMedGoogle Scholar
Małek  ŁA, Kamińska  H, Barczuk-Falęcka  M,  et al.  Children With acute myocarditis often have persistent subclinical changes as revealed by cardiac magnetic resonance.   J Magn Reson Imaging. 2020;52(2):488-496. doi:10.1002/jmri.27036PubMedGoogle ScholarCrossref
Bohnen  S, Radunski  UK, Lund  GK,  et al.  Tissue characterization by T1 and T2 mapping cardiovascular magnetic resonance imaging to monitor myocardial inflammation in healing myocarditis.   Eur Heart J Cardiovasc Imaging. 2017;18(7):744-751. doi:10.1093/ehjci/jex007PubMedGoogle ScholarCrossref
Ferreira  VM, Schulz-Menger  J, Holmvang  G,  et al.  Cardiovascular magnetic resonance in nonischemic myocardial inflammation: expert recommendations.   J Am Coll Cardiol. 2018;72(24):3158-3176. doi:10.1016/j.jacc.2018.09.072PubMedGoogle ScholarCrossref
Barczuk-Falęcka  M, Małek  ŁA, Werys  K, Roik  D, Adamus  K, Brzewski  M.  Normal values of native T1 and T2 relaxation times on 3T cardiac MR in a healthy pediatric population aged 9-18 years.   J Magn Reson Imaging. 2020;51(3):912-918. doi:10.1002/jmri.26886PubMedGoogle ScholarCrossref