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Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF

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Aldostefano Porcari, Marco Merlo, Chiara Baggio, Giulia Gagno, Marco Cittar, Giulia Barbati, Alessia Paldino, Matteo Castrichini, Giancarlo Vitrella, Lorenzo Pagnan, Antonio Cannatà, Alessandro Andreis, Annagrazia Cecere, Alberto Cipriani, Anne Raafs, Daniel I. Bromage, Stefania Rosmini, Paul Scott, Daniel Sado, Gianluca Di Bella & 5 more Gaetano Nucifora, Martina Perazzolo Marra, Stephane Heymans, Massimo Imazio, Gianfranco Sinagra

Original languageEnglish
Article numbere13815
JournalEuropean Journal of Clinical Investigation
Issue number10
Early online date22 May 2022
Accepted/In press7 May 2022
E-pub ahead of print22 May 2022
PublishedOct 2022

Bibliographical note

Funding Information: We would like to thank Fondazione CRTrieste, Fondazione CariGO, Fincantieri and all the healthcare professionals for the continuous support to the clinical management of patients affected by cardiomyopathies, followed in Heart Failure Outpatient Clinic of Trieste, and their families. Publisher Copyright: © 2022 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.

King's Authors



Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization. Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF.


Data of patients undergoing cardiac magnetic resonance (CMR) for clinically suspected AM in seven European Centres (2013–2020) were retrospectively analysed. Patients with AM confirmed by CMR and LVEF ≥50% were included. LGE was visually characterized: localized versus. non-localized, subepicardial versus midwall. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including cardiac death, life-threatening arrhythmias, development of heart failure or of LVEF <50%.


Of 389 screened patients, 256 (66%) fulfilled inclusion criteria: median age 36 years, 71% males, median LVEF 60%, median LV-GLS -17.3%. CMR was performed at 4 days from hospitalization. At 27 months, 24 (9%) patients experienced ≥1 ACE (71% developed LVEF <50%). Compared to the others, they had lower median LV-GLS values (−13.9% vs. −17.5%, p = .001). At Kaplan–Meier analysis, impaired LV-GLS (both considered as > −20% or quartiles), non-localized and midwall LGE were associated with ACEs. Patients with LV-GLS ≤−20% did not experience ACEs. LV-GLS remained associated with ACEs after adjustment for non-localized and midwall LGE.


In AM presenting with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE characterization, improving risk stratification and representing a rationale for further studies of therapy in this cohort.

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