BACKGROUND:Integrating end-of-life (EoL) care in cardiac intensive care units (CICUs) is particularly complex because it requires a shift from a purely curative approach to one that emphasizes symptom management, emotional and spiritual support and patient-centered care. Moreover, this transition is challenging due to the need to balance life-sustaining treatments with the goals of comfort and dignity. The concept of EoL care varies across countries and is influenced by cultural, ethical and legal factors. METHODS:This narrative review examines palliative and EoL care in critically ill cardiac patients, including those with advanced heart failure, cardiogenic shock and other acute or chronic cardiac conditions, with a focus on models of care, multidisciplinary team involvement, ethical challenges and barriers to implementation in the CICU setting. RESULTS:Key candidates for palliative care (PC) in heart disease include patients with advanced heart failure, cardiogenic shock and other acute or chronic cardiac conditions; however, its implementation remains limited compared to other disciplines, such as oncology. In EoL care, multidisciplinary teams, including cardiologists, nurses, PC specialists and social workers, play a crucial role in providing holistic care. Effective communication with patients and their families is essential for aligning treatment with individual values and goals. Ethical dilemmas, such as the withdrawal of life-sustaining treatments and the deactivation of implanted cardiac devices, require compassionate and transparent decision-making. Unlike previous reviews, this work specifically highlights the timing of palliative care integration as the main factor influencing patient outcomes and family experience. CONCLUSIONS:Timely integration of palliative care in the CICU remains a major challenge. Significant gaps persist in training, resource allocation and quality indicators for palliative and EoL care. Addressing these shortcomings through enhanced education, standardized protocols and rigorous research is essential to ensure the effective delivery of PC in the CICU setting.

La sostenibilità ambientale rappresenta una priorità emergente per la cardiologia, in virtù dell’intima interconnessione tra salute planetaria e salute umana, con le malattie cardiovascolari quale principale esito clinico. Il settore sanitario globale è responsabile di circa il 4-5% delle emissioni complessive di gas serra e la cardiologia contribuisce in modo rilevante a tale impatto a causa dell’elevato impiego di risorse in ambito diagnostico, procedurale ed energetico. Parallelamente, fattori ambientali quali l’inquinamento atmosferico, le temperature estreme, definite come valori notevolmente superiori o inferiori alla media regionale causate dal cambiamento climatico, e l’esposizione a contaminanti emergenti, inclusi metalli pesanti (piombo, cadmio, arsenico) e micro- e nanoplastiche, si configurano come determinanti di rischio cardiovascolare di crescente importanza. L’esposizione cronica a tali inquinanti è associata a stress ossidativo, infiammazione sistemica e accelerazione dei processi aterosclerotici. Le strategie per una cardiologia sostenibile mirano principalmente alla riduzione delle emissioni correlate al consumo energetico e alla catena di approvvigionamento. Tra le azioni prioritarie figurano l’adozione dei principi dell’economia circolare (riduzione, riuso e riciclo), l’appropriatezza e l’ottimizzazione degli esami diagnostici privilegiando metodiche a minore impronta ambientale, come l’ecocardiografia rispetto a tecniche ad alto impatto di carbonio e l’implementazione della telemedicina per limitare gli spostamenti. Inoltre, la prevenzione cardiovascolare primaria si configura come un’efficace “strategia a doppio beneficio”, capace di ridurre sia il carico di malattia sia la domanda di cure ad elevata intensità emissiva. In questo contesto, i professionisti sanitari e le società scientifiche, tra cui ANMCO, sono chiamati a promuovere un cambiamento culturale, integrando la sostenibilità ambientale come principio etico fondamentale della pratica cardiologica.

BACKGROUND:In adults over 35 years of age, ischemic heart disease (IHD) is the predominant cause of exercise-related acute coronary events and sudden cardiac death. Master athletes, despite high levels of fitness, are not immune to coronary atherosclerosis, which often remains clinically silent until precipitated by exertional stress. Recent data challenge the assumption that long-term endurance training offers protection against coronary artery disease (CAD), revealing a non-negligible prevalence of subclinical atheroma even in asymptomatic athletes. OBJECTIVE:To examine the evolving role of coronary computed tomography angiography (CCTA) in the primary prevention of IHD in master athletes, with a focus on risk stratification, plaque characterization, and integration into sports eligibility assessment. CONTENT:Technological advances have enhanced the diagnostic performance of CCTA, allowing not only the detection of obstructive disease but also the identification of high-risk plaque features, such as low-attenuation fibro-lipid core, positive remodelling, and microcalcifications. In selected older athletes with elevated risk profiles or equivocal stress tests, CCTA provides valuable anatomical information that often eludes functional testing alone. Italian guidelines (COCIS 2023) include CCTA in the evaluation of intermediate-to-high-risk master athletes, emphasizing a risk-adapted approach rather than blanket screening. CONCLUSIONS:CCTA may refine cardiovascular risk assessment in master athletes by detecting subclinical but clinically relevant CAD, potentially improving long-term outcomes and guiding individualized recommendations for sports participation. While broader implementation must consider cost, radiation exposure, and the risk of overdiagnosis, selective use of CCTA appears justified in targeted high-risk populations. Prospective studies are needed to validate this strategy and define its role within comprehensive athlete evaluation frameworks.

Cardiovascular disease is the leading cause of morbidity and mortality globally. Despite effective treatments, poor adherence limits their long-term benefits. Digital health solutions can enhance clinicians’ ability to optimise guideline-based therapies, improving patient outcomes. Digital tools for remote consultations, monitoring, cardiac device interrogation and clinical decision support systems are now widely available. Digital health monitoring improves care quality, providing value to patients, healthcare professionals, hospitals and governments. This transformation is fostering a future where ‘health’ takes precedence over ‘reactive care’, driven by empowered patients and advanced technologies. Success in this transformation requires not only technology, but also new strategic operational models, optimised workflows and workforce redesign. Health systems that form partnerships with other stakeholders, such as peers, payers, start-ups, life sciences organisations, industries, will be better positioned to improve patient experiences and outcomes. This review examines digital solutions that optimise medical therapy prescriptions, promote patient engagement and address therapeutic inertia in AF, heart failure and coronary artery disease.

Environmental sustainability represents an emerging priority for cardiology, owing to the close interconnection between planetary health and human health, with cardiovascular diseases constituting the main clinical outcome. The global healthcare sector accounts for approximately 4-5% of total greenhouse gas emissions, and cardiology contributes substantially to this burden because of its high resource intensity in diagnostic testing, interventional procedures, and energy consumption. At the same time, environmental factors such as air pollution, extreme temperatures, defined as values significantly above or below the regional average caused by climate change, and exposure to emerging contaminants, including heavy metals (lead, cadmium, arsenic) and micro- and nanoplastics are increasingly recognized as major determinants of cardiovascular risk. Chronic exposure to these pollutants is associated with oxidative stress, systemic inflammation, and accelerated progression of atherosclerosis. Strategies for sustainable cardiology primarily aim to reduce emissions related to energy use and supply chains. Priority actions include adopting circular economy principles (reduce, reuse, recycle), improving the appropriateness and optimization of diagnostic testing favoring lower environmental impact modalities, such as echocardiography, over carbon-intensive techniques and implementing telemedicine to reduce patient and provider travel. Furthermore, primary cardiovascular prevention can be considered an effective "double-benefit strategy", capable of simultaneously reducing disease burden and the demand for emission-intensive healthcare. In this context, healthcare professionals and scientific societies, including ANMCO, are called upon to lead a cultural shift by integrating environmental sustainability as a core ethical principle of contemporary cardiology practice.

Chronic coronary syndrome (CCS), encompassing a wide range of phenotypes and clinical scenarios, remains the leading global cause of disability and premature death. Advanced non-invasive imaging modalities, such as coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR), play a pivotal role in enhancing diagnostic accuracy and guiding tailored management strategies for CCS patients. CCTA offers detailed insights into the presence, extent, and severity of coronary atherosclerotic plaques. In addition to detecting coronary stenoses, it enables the characterization of plaque phenotypes and the evaluation of additional prognostic biomarkers, such as perivascular adipose tissue (PVAT) attenuation, allowing for more comprehensive risk stratification. Recent technological advancements have further expanded CCTA's capabilities, enabling the integration of anatomical assessment with hemodynamic evaluation through non-invasive fractional flow reserve computation (FFR-CT) or stress myocardial perfusion analysis. With its superior three-dimensional spatial resolution, CCTA enhances pre-procedural planning for complex coronary revascularization, enabling the selection of optimal interventional strategies and improving patient selection. CMR is considered the gold standard for functional assessment of cardiac function, myocardial viability, quantitative flow evaluation, and tissue characterization, offering excellent soft-tissue contrast. CMR perfusion imaging can accurately assess myocardial ischemia, quantify myocardial blood flow (MBF), and detect microvascular dysfunction, thanks to its high temporal and spatial resolution with the advantage of no radiation exposure. This review highlights the evolving role of CCTA and CMR in managing patients with CCS, focusing on their current applications according to the most recent 2024 ESC guidelines, prognostic value, and recent technological advancements.

Atherosclerotic coronary artery disease remains a leading cause of morbidity and mortality worldwide, despite advances in lipid-lowering and antithrombotic therapies. Increasing evidence highlights the pivotal role of inflammation in all stages of atherosclerosis, from plaque formation to rupture. Colchicine, a well-known anti-inflammatory drug traditionally used in gout and pericarditis, has emerged as a promising agent in the secondary prevention of cardiovascular events. Recent clinical trials have demonstrated significant reductions in cardiovascular outcomes with low-dose colchicine, especially in patients with stable CAD and following myocardial infarction. This review provides an updated overview of the pathophysiological rationale for colchicine use in atherosclerosis, summarizes key clinical trial data, and discusses potential mechanisms, safety considerations, and future directions.

In applied sciences, including medicine, simulation refers to a model of reality that employs a variety of techniques and technologies, along with diverse professional expertise, to facilitate the dynamic analysis and prediction of events or processes based on specific predefined conditions. Simulation is of paramount importance to improve the skills of medical staff, to speed up learning and to optimize clinical practice in different settings, including cardiology. Literature shows that simulation is more effective than other learning strategies, supporting both upgrading of staff's clinical skills and patients' safety, reducing the risk of medical error. Moreover, andragogical principles highlight the need for personalized training programs, in order to meet healthcare professionals' needs, while practicing in a safe environment, improving technical skills, clinical decision making, stress management, cooperation, and teamwork. This review written by the Management and Quality Working Group, by the Young Cardiologists Working Group, and by the Professional Responsibility and Safety of Care Study Group of the the Italian Association of Hospital Cardiologists (ANMCO) highlights the crucial role of simulation in managing high-risk situations commonly encountered in cardiology, emphasizing the importance of continuous high-quality training. It also describes how ANMCO is promoting simulation as a strategy for implementing quality in the field of cardiology.

In applied sciences, including medicine, simulation refers to a model of reality that employs a variety of techniques and technologies, along with diverse professional expertise, to facilitate the dynamic analysis and prediction of events or processes based on specific predefined conditions. Simulation is of paramount importance to improve the skills of medical staff, to speed up learning and to optimize clinical practice in different settings, including cardiology. Literature shows that simulation is more effective than other learning strategies, supporting both upgrading of staff's clinical skills and patients' safety, reducing the risk of medical error. Moreover, andragogical principles highlight the need for personalized training programs, in order to meet healthcare professionals' needs, while practicing in a safe environment, improving technical skills, clinical decision making, stress management, cooperation, and teamwork. This review written by the Management and Quality Working Group, by the Young Cardiologists Working Group, and by the Professional Responsibility and Safety of Care Study Group of the the Italian Association of Hospital Cardiologists (ANMCO) highlights the crucial role of simulation in managing high-risk situations commonly encountered in cardiology, emphasizing the importance of continuous high-quality training. It also describes how AN-MCO is promoting simulation as a strategy for implementing quality in the field of cardiology.

In Brugada syndrome (BrS), syncope is considered a sign of increased risk for sudden cardiac death (SCD) due to ventricular tachycardia/ventricular fibrillation (VT/VF) episodes. However, arrhythmic syncope in BrS is extremely rare, while nonarrhythmic syncope may occur as in the general active population, mostly from reflex events. Symptomatic patients with BrS show a higher risk profile, requiring a watchful risk stratification. In this scenario, a clinical misjudgment could determine to overlook the risk of SCD as well as to pursue inappropriate therapeutic approaches. Therefore, understanding the correct mechanism of the syncope in BrS is mandatory representing a real sign of increased risk only if linked to VT/VF episodes. This review focuses on the BrS population considering the role of the autonomic nervous system, the issue of a correct syncope classification, the potential link between reflex and arrhythmic syncope, and diagnostic work flow in patients with a concomitant reflex mechanism, with a specific focus on the head-up tilt test and implantable loop recorder roles.

BackgroundRisk stratification in drug-induced type-1 Brugada syndrome (BrS) patients is challenging. The role of electrophysiological study (EPS) is debated as the majority of drug-induced type-1 BrS patients would not be studied according to the latest recommendations.MethodsA complete systematic literature search was performed to gauge the EPS role in this population. Three subgroups were defined: positive-EPS group, negative-EPS group, no-EPS group.ResultsAmong 1318 drug-induced type-1 BrS patients, no significant difference in the incidence rate of arrhythmic events was observed between groups (I2 = 45%, P for subgroup difference = 0.10) during a mean follow-up of 5.1 years, also considering symptomatic status.ConclusionIn long-term follow-up of drug-induced type-1 BrS patients, EPS does not seem to aid prognostic stratification.

Based on a wealth of evidence, aspirin is one of the cornerstones of secondary prevention of cardiovascular disease. However, despite several studies showing efficacy also in primary prevention, an unopposed excess risk of bleeding leading to a very thin safety margin is evident in subjects without a clear acute cardiovascular event. Overall, the variability in recommendations from different scientific societies for aspirin use in primary prevention is a classic example of failure of simple risk stratification models based on competing risks (atherothrombosis vs. bleeding), perceived to be opposed but intertwined at the pathophysiological level. Notably, cardiovascular risk is dynamic in nature and cannot be accurately captured by scores, which do not always consider risk enhancers. Furthermore, the widespread use of other potent medications in primary prevention, such as lipid-lowering and anti-hypertensive drugs, might be reducing the benefit of aspirin in recent trials. Some authors, drawing from specific pathophysiological data, have suggested that specific subgroups might benefit more from aspirin. This includes patients with diabetes and those with obesity; sex-based differences are considered as well. Moreover, molecular analysis of platelet reactivity has been proposed. A beneficial effect of aspirin has also been demonstrated for the prevention of cancer, especially colorectal. This review explores evidence and controversies concerning the use of aspirin in primary prevention, considering new perspectives in order to provide a comprehensive individualized approach.

Takotsubo syndrome (TTS), also known as the broken-heart syndrome, is a reversible condition typically observed in female patients presenting for acute coronary syndromes (ACS). Despite its increasing incidence, TTS often remains undiagnosed due to its overlap with ACS. The pathophysiology of TTS is complex and involves factors such as coronary vasospasm, microcirculatory dysfunction, increased catecholamine levels, and overactivity of the sympathetic nervous system. Diagnosing TTS requires a comprehensive approach, starting with clinical suspicion and progressing to both non-invasive and invasive multimodal tests guided by a specific diagnostic algorithm. Management of TTS should be personalized, considering potential complications, the presence or absence of coronary artery disease (CAD), diagnostic test results, and the patient’s clinical course. The current data primarily derive from case series, retrospective analyses, prospective registries, and expert opinions. In recent years, there has been growing recognition of gender differences in the pathophysiology, presentation, and outcomes of TTS. This review provides an updated overview of gender disparities, highlighting the importance of tailored diagnostic and management strategies.

Background: Cardiogenic shock with acute hemodynamic decompensation may be one of the most serious risks in patients affected by ventricular tachycardia (VT). Its proper identification may have important implications in terms of pharmacological management, as might procedural planning in case of patients undergoing catheter ablation. Methods: We describe a case series of patients with provisional strategies for circulatory support in VT ablation, including the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and vascular accesses in the electrophysiology lab but no initial ECMO activation due to an estimated intermediate pre-procedural risk from the case-series population. Results: In total, 10 patients (mean age 70 ± 11 years old, 9 males) with severe cardiomyopathy were admitted for incessant ventricular arrhythmia episodes, further diagnosis, and therapy planning; 1/10 patients (10%), documenting a PAINESD score of 14, underwent VA-ECMO cannulation due to electromechanical dissociation. All 10 patients were discharged alive. Conclusions: A pre-defined strategy before VT ablation is crucial. In our case series, the use of provisional circulatory support with VA-ECMO during incessant ablation of ventricular arrhythmia was a safe and winning alternative to upfront strategies.

Background: The gold standard for the treatment of cardiac implantable electronic devices (CIEDs)-related infection and lead malfunction is transvenous lead extraction (TLE). To date, the risk of mortality directly related to TLE procedures is relatively low, but data on post-procedural and long-term mortality are limited, even more in the aging population. Methods: Consecutive patients with CIEDs who underwent TLE were retrospectively studied. The primary outcome was the endpoint of death, considering independent predictors of long-term clinical outcomes in the TLE aging population comparing patients with and without infection. Results: One hundred nineteen patients (male 77%; median age 76 years) were included in the analysis. Eighty-two patients (69%) documented infection, and thirty-seven (31%) were extracted for a different reason. Infected patients were older (80 vs. 68 years, p-value > 0.001) with more implanted catheters (p-value < 0.001). At the last follow-up (FU) available (median FU 4.1 years), mortality reached 37% of the patient population, showing a statistically significant difference between infected versus non-infected groups. At univariable analysis, age at TLE, atrial fibrillation, and anemia remained significant correlates of mortality; at multivariable analysis, only patients with anemia and atrial fibrillation have a 2.3-fold (HR 2.34; CI 1.16–4.75) and a 2.5-fold (HR 2.46; CI 1.33–4.54) increased rate of death, respectively. Conclusion: Our long-term data showed that aging patients who underwent TLE for CIED-related infection exhibit a high mortality risk during a long-term follow-up, potentially leading to a rapid and effective procedural approach in this patient population.

Echocardiographic evaluation of left ventricular ejection fraction (LVEF) provides important information regarding both myocardial function and prognosis. This parameter presents various limitations and does not allow early detection of myocardial dysfunction. LVEF may be related to hemodynamic load, geometric assumptions, to image quality, and it does not reflect myocardial contractility. It has been hypothesized that speckle tracking echocardiography (STE) may allow overcoming such limits. STE through the measurement of strain and strain rate, which detect myocardial deformation, allows earlier identification of myocardial dysfunction in different settings both in presence of systolic and diastolic dysfunction, helps to predict left ventricular remodeling after acute myocardial infarction (AMI), and helps to decide the timing of surgery in asymptomatic severe valvular heart disease which is still a problematic issue. Increasingly interest regards the role of STE for the assessment of cardiomyopathies, myocarditis, and pulmonary hypertension. STE may be applied to the evaluation of systolic and diastolic dysfunction. STE is useful in all conditions in which cardiac dysfunction is not still overt, but a subclinical involvement is undoubtedly present such as in presence of cardiovascular risk factors and in cardio-oncology at earlier stages. It has been confirmed its role in predicting left ventricular remodeling after AMI which represents an important prognostic datum and in deciding the timing of surgery in asymptomatic valvular diseases. STE is an important tool to detect myocardial impairment even at earlier stages. 3DSTE and layer-specific strain represent promising fields of clinical application of STE.

HomeCirculation: Heart FailureVol. 16, No. 6Outcome and Morphofunctional Changes on Cardiac Magnetic Resonance in Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBOutcome and Morphofunctional Changes on Cardiac Magnetic Resonance in Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination Enrico Ammirati, Laura Lupi, Matteo Palazzini, Michele Ciabatti, Valentina A. Rossi, Piero Gentile, Aitor Uribarri, Chiara R. Vecchio, Daniele Nassiacos, Alberto Cereda, Cristina Conca, Gabriele Tumminello, Nicolas Piriou, Coline Lelarge, Patrizia Pedrotti, Miriam Stucchi, Giovanni Peretto, Michele Galasso, Florent Huang, Umberto Ianni, Antonio Procopio, Gianluigi Saponara, Paolo Cimaglia, Daniela Tomasoni, Francesco Moroni, Annalisa Turco, Simone Sala, Giuseppe Di Tano, Entela Bollano, Claudio Moro, Antonio Abbate, Roberta Della Bona, Italo Porto, Stefano Carugo, Jeness Campodonico, Gianluca Pontone, Aurelia Grosu, Leonardo Bolognese, Jorge Salamanca, Pablo Diez-Villanueva, Krzysztof Ozieranski, Agata Tyminska, Loren Sardo Infirri, Daniel Bromage, Antonio Cannatà, Kimberly N. Hong, Marianna Adamo, Giuseppina Quattrocchi, Alberto Foà, Luciano Potena, Andrea Garascia, Cristina Giannattasio, Eric D. Adler, Gianfranco Sinagra, Frank Ruschitzka, Paolo G. Camici, Marco Metra and Maurizio Pieroni Enrico AmmiratiEnrico Ammirati Correspondence to: Enrico Ammirati, MD, PhD, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy, Email E-mail Address: [email protected] https://orcid.org/0000-0002-1676-5257 Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Search for more papers by this author , Laura LupiLaura Lupi Laura Lupi, MD, Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy, Email E-mail Address: [email protected] https://orcid.org/0000-0003-2633-1695 Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., D.T., M.A., M.M.). Search for more papers by this author , Matteo PalazziniMatteo Palazzini https://orcid.org/0000-0003-1700-7340 Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Department of Medicine and Surgery, Bicocca University, Milano, Italy (M. Palazzini, M.G., C.G.). Search for more papers by this author , Michele CiabattiMichele Ciabatti https://orcid.org/0000-0003-4303-4537 Cardiovascular Department, San Donato Hospital, Arezzo, Italy (M.C., L.B., M. Pieroni). Search for more papers by this author , Valentina A. RossiValentina A. Rossi https://orcid.org/0000-0001-9235-6597 Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Switzerland (V.A.R., F.R.). Search for more papers by this author , Piero GentilePiero Gentile Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Search for more papers by this author , Aitor UribarriAitor Uribarri https://orcid.org/0000-0002-6911-7480 Cardiology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain (A.U.). Vall d’Hebron Institute de Recerca, Barcelona, Spain (A.U.). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain (A.U.). Search for more papers by this author , Chiara R. VecchioChiara R. Vecchio Department of Cardiology, Presidio Ospedaliero di Saronno, Azienda Socio-Sanitaria Territoriale Valle Olona, Saronno, Varese, Italy (C.R.V., D.N.). Search for more papers by this author , Daniele NassiacosDaniele Nassiacos https://orcid.org/0000-0001-5348-7084 Department of Cardiology, Presidio Ospedaliero di Saronno, Azienda Socio-Sanitaria Territoriale Valle Olona, Saronno, Varese, Italy (C.R.V., D.N.). Search for more papers by this author , Alberto CeredaAlberto Cereda Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy (A. Cereda, C.C.). Search for more papers by this author , Cristina ConcaCristina Conca Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy (A. Cereda, C.C.). Search for more papers by this author , Gabriele TumminelloGabriele Tumminello https://orcid.org/0000-0003-3121-8400 Division of Cardiology, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Italy (G.T., S.C.). Search for more papers by this author , Nicolas PiriouNicolas Piriou https://orcid.org/0000-0002-6677-6552 Nantes Université, CHU Nantes, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, l’Institut du Thorax, France (N.P., C.L.). Search for more papers by this author , Coline LelargeColine Lelarge Nantes Université, CHU Nantes, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, l’Institut du Thorax, France (N.P., C.L.). Search for more papers by this author , Patrizia PedrottiPatrizia Pedrotti https://orcid.org/0000-0001-8920-1156 Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Search for more papers by this author , Miriam StucchiMiriam Stucchi Cardiology Unit, Azienda Socio-Sanitaria Territoriale della Brianza (MB), Vimercate Hospital, Italy (M.S.). Search for more papers by this author , Giovanni PerettoGiovanni Peretto https://orcid.org/0000-0003-1815-4000 San Raffaele Hospital and Vita Salute University, Milano, Italy (G. Peretto, S.S., P.G.C.). Search for more papers by this author , Michele GalassoMichele Galasso Department of Medicine and Surgery, Bicocca University, Milano, Italy (M. Palazzini, M.G., C.G.). Search for more papers by this author , Florent HuangFlorent Huang https://orcid.org/0000-0002-3063-1546 Service de Cardiologie, Hôpital Foch, Suresnes, France (F.H.). Search for more papers by this author , Umberto IanniUmberto Ianni https://orcid.org/0000-0003-1129-4203 Cardiology Unit, Madonna del Soccorso Hospital, Azienda Sanitaria Unica Regionale Marche 5, San Benedetto del Tronto, Italy (U.I.). Search for more papers by this author , Antonio ProcopioAntonio Procopio https://orcid.org/0000-0002-0422-7769 Intensive Cardiac Care Unit, “F. Renzetti” Hospital, Lanciano, Chieti, Italy (A.P.). Search for more papers by this author , Gianluigi SaponaraGianluigi Saponara Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy (G.S.). Search for more papers by this author , Paolo CimagliaPaolo Cimaglia https://orcid.org/0000-0002-3326-7663 Maria Cecilia Hospital, GVM Care and Research, Cotignola, Ravenna, Italy (P.C). Search for more papers by this author , Daniela TomasoniDaniela Tomasoni Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., D.T., M.A., M.M.). Search for more papers by this author , Francesco MoroniFrancesco Moroni https://orcid.org/0000-0002-6101-1403 Pauley Heart Center, Virginia Commonwealth University, Richmond (F.M., A.A.). Search for more papers by this author , Annalisa TurcoAnnalisa Turco Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (A. Turco). Search for more papers by this author , Simone SalaSimone Sala https://orcid.org/0000-0003-3303-8892 San Raffaele Hospital and Vita Salute University, Milano, Italy (G. Peretto, S.S., P.G.C.). Search for more papers by this author , Giuseppe Di TanoGiuseppe Di Tano Unità Operativa Cardiologia, Azienda Socio-Sanitaria Territoriale di Cremona, Ospedale OglioPo, Casalmaggiore, Cremona, Italy (G.D.T.). Search for more papers by this author , Entela BollanoEntela Bollano https://orcid.org/0000-0003-3341-2434 Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.B.). Search for more papers by this author , Claudio MoroClaudio Moro Department of Cardiology, Azienda Socio-Sanitaria Territoriale Monza, Desio, Italy (C.M.). Search for more papers by this author , Antonio AbbateAntonio Abbate https://orcid.org/0000-0002-1930-785X Pauley Heart Center, Virginia Commonwealth University, Richmond (F.M., A.A.). Search for more papers by this author , Roberta Della BonaRoberta Della Bona Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS San Martino Hospital, Genoa, Italy (R.D.B., I.P.). Search for more papers by this author , Italo PortoItalo Porto https://orcid.org/0000-0002-9854-5046 Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS San Martino Hospital, Genoa, Italy (R.D.B., I.P.). Department of Internal Medicine and Medical Specialties, University of Genoa, Italy (I.P.). Search for more papers by this author , Stefano CarugoStefano Carugo https://orcid.org/0000-0002-5166-0899 Division of Cardiology, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda Ospedale Maggiore Policlinico, University of Milan, Italy (G.T., S.C.). Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Italy (S.C., J.C.). Search for more papers by this author , Jeness CampodonicoJeness Campodonico Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Italy (S.C., J.C.). Centro Cardiologico Monzino IRCCS, University of Milan, Italy (J.C., G. Pontone). Search for more papers by this author , Gianluca PontoneGianluca Pontone https://orcid.org/0000-0002-1339-6679 Centro Cardiologico Monzino IRCCS, University of Milan, Italy (J.C., G. Pontone). Search for more papers by this author , Aurelia GrosuAurelia Grosu Cardiovascular Department, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy (A. Grosu). Search for more papers by this author , Leonardo BologneseLeonardo Bolognese https://orcid.org/0000-0002-5199-7870 Cardiovascular Department, San Donato Hospital, Arezzo, Italy (M.C., L.B., M. Pieroni). Search for more papers by this author , Jorge SalamancaJorge Salamanca https://orcid.org/0000-0002-5067-5052 Cardiology Department, Hospital Universitario De La Princesa, Madrid, Spain (J.S., P.D.-V.). Search for more papers by this author , Pablo Diez-VillanuevaPablo Diez-Villanueva Cardiology Department, Hospital Universitario De La Princesa, Madrid, Spain (J.S., P.D.-V.). Search for more papers by this author , Krzysztof OzieranskiKrzysztof Ozieranski https://orcid.org/0000-0002-3848-0922 First Department of Cardiology, Medical University of Warsaw, Poland (K.O., A. Tyminska). Search for more papers by this author , Agata TyminskaAgata Tyminska First Department of Cardiology, Medical University of Warsaw, Poland (K.O., A. Tyminska). Search for more papers by this author , Loren Sardo InfirriLoren Sardo Infirri Ospedale di Circolo e fondazione Macchi, Azienda Socio-Sanitaria Territoriale Sette Laghi, Varese, Italy (L.S.I.). Search for more papers by this author , Daniel BromageDaniel Bromage https://orcid.org/0000-0002-4243-5964 School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, King’s College London, United Kingdom (D.B., A. Cannatà). Department of Cardiology, King’s College Hospital London, United Kingdom (D.B., A. Cannatà). Search for more papers by this author , Antonio CannatàAntonio Cannatà https://orcid.org/0000-0001-7609-6297 School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, King’s College London, United Kingdom (D.B., A. Cannatà). Department of Cardiology, King’s College Hospital London, United Kingdom (D.B., A. Cannatà). Search for more papers by this author , Kimberly N. HongKimberly N. Hong Division of Cardiology, Department of Medicine, University of California San Diego (K.N.H., E.D.A.). Search for more papers by this author , Marianna AdamoMarianna Adamo https://orcid.org/0000-0002-3855-1815 Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., D.T., M.A., M.M.). Search for more papers by this author , Giuseppina QuattrocchiGiuseppina Quattrocchi Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Search for more papers by this author , Alberto FoàAlberto Foà Academic Hospital S. Orsola-Malpighi, Bologna, Italy (A.F., L.P.). Search for more papers by this author , Luciano PotenaLuciano Potena https://orcid.org/0000-0001-7388-5012 Academic Hospital S. Orsola-Malpighi, Bologna, Italy (A.F., L.P.). Search for more papers by this author , Andrea GarasciaAndrea Garascia Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Search for more papers by this author , Cristina GiannattasioCristina Giannattasio Department of De Gasperis Cardio Center, Niguarda Hospital, Milano, Italy (E.A., M. Palazzini, P.G., P.P., G.Q., A. Garascia, C.G.). Department of Medicine and Surgery, Bicocca University, Milano, Italy (M. Palazzini, M.G., C.G.). Search for more papers by this author , Eric D. AdlerEric D. Adler https://orcid.org/0000-0002-4765-0188 Division of Cardiology, Department of Medicine, University of California San Diego (K.N.H., E.D.A.). Search for more papers by this author , Gianfranco SinagraGianfranco Sinagra https://orcid.org/0000-0003-2700-8478 Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Italy (G.S.). Search for more papers by this author , Frank RuschitzkaFrank Ruschitzka Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Switzerland (V.A.R., F.R.). Center for Translational and Experimental Cardiology, Department of Cardiology, University Hospital Zurich, University of Zurich, Schlieren, Switzerland (F.R.). Search for more papers by this author , Paolo G. CamiciPaolo G. Camici https://orcid.org/0000-0001-5584-0750 San Raffaele Hospital and Vita Salute University, Milano, Italy (G. Peretto, S.S., P.G.C.). Search for more papers by this author , Marco MetraMarco Metra https://orcid.org/0000-0003-4846-8529 Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (L.L., D.T., M.A., M.M.). Search for more papers by this author and Maurizio PieroniMaurizio Pieroni https://orcid.org/0000-0002-6830-4292 Cardiovascular Department, San Donato Hospital, Arezzo, Italy (M.C., L.B., M. Pieroni). Search for more papers by this author Originally published15 May 2023https://doi.org/10.1161/CIRCHEARTFAILURE.122.010315Circulation: Heart Failure. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 15, 2023: Ahead of Print Messenger RNA (mRNA) COVID-19 vaccination has been associated with a higher-than-expected occurrence of acute myocarditis, although the benefits of the vaccine greatly outweigh the risk of myocarditis. Even if the short-term prognosis of mRNA vaccine–related myocarditis has been reported to be favorable, scarce information is available on midterm prognosis. The current series included 7 to 9 patients with baseline and follow-up cardiac magnetic resonance imaging (CMRI).1,2 Questions on acute myocarditis following mRNA COVID-19 vaccination addressed by this study are the risk of adverse events after discharge and the extent of residual myocardial dysfunction and scar formation.We conducted a retrospective, multicenter study involving 31 hospitals in Europe and the United States. The Niguarda Hospital in Milano, Italy, acted as the coordinating center. The Institutional Review Board in Milano, Italy (Ethics Committee Milano Area 3), approved this study during the session of May 2022 (identifier 395-18052022). Written consent was not necessary due to the nature of the study. The data will not be shared because the current ethics approval does not allow us to share these data. We identified 77 patients with a confirmed diagnosis based on consistent cardiac symptoms, which occurred within 30 days since an mRNA COVID-19 vaccination, significant elevation of troponin levels, and CMRI findings consistent with acute myocarditis according to the 2018 updated Lake Louise criteria. Among patients with available follow-up (n=75; 97.4%), none died or required further hospitalization after a median time of 147 (first to third quartile [Q1–Q3], 74–215) days, and none of these patients experienced myocarditis recurrence. None of these patients received a further vaccination after the episode of myocarditis. Five patients (6.7%) had a subsequent SARS-CoV-2 infection without recurrent myocarditis.In 49 (63.6%) patients, a follow-up CMRI was available (median age, 25 [Q1–Q3, 30–34] years; female sex, 18.4%). There were no significant differences between patients with or without CMRI at follow-up (Table). The follow-up CMRI was performed at a median time of 137 days (Q1–Q3, 93–180) after hospitalization. Compared with the baseline CMRI, there were no changes in the left ventricular (LV) ejection fraction and right ventricular ejection fraction, with a median value of 60% and 57%, respectively. A dilated LV in the follow-up was observed in 5 cases (10.6%), with a median indexed LV end-diastolic volume of 97 (Q1–Q3, 95–112) mL/m2. The proportion of patients with persistent edema at follow-up based on conventional T2-weighted imaging was 20.4% (n=10), a figure significantly lower compared with the presence of edema at baseline (95.9%; n=47; in 2 patients, the presence of edema was based on T2 mapping imaging). LV segments with edema mainly involved the inferior or the inferolateral walls. Thirty-nine patients (79.6%) had a residual scar based on late gadolinium enhancement (LGE) on the follow-up CMRI, while on baseline CMRI, LGE was present in 100% of cases. Similarly, we observed a significant reduction of LGE-positive segments from a median of 4 (Q1–Q3, 3–7) to 2 (Q1–Q3, 1–4; P<0.001) at follow-up. LGE generally spared the anterior wall and the septum (only 3 patients; 6.1% had a residual septal LGE). Finally, pericardial effusion decreased from 16 (32.6%) to 3 (6.1%) patients (Table). No difference was found in the main morphofunctional CMRI parameters at follow-up depending on the type of vaccine administered, that is, BNT162b2 (Pfizer/BioNTech, n=36, 73.5%) or mRNA-1273 (Moderna, n=13, 26.5%). Furthermore, 48 (63.3%) patients had at least 1 echocardiogram after discharge, including 15 (31.2%) without follow-up CMRI, and all had preserved biventricular function without ventricular dilation (Table). When these data were compared with 105 (23.7%) of 443 acute myocarditis patients identified from the Lombardy registry with 2 CMRI scans within 1 year (median age, 32 [Q1–Q3, 23–40] years; women, 19.0%; median interval between the scans of 149 [Q1–Q3, 97–213] days),3 we observed a similar proportion of patients with LV ejection fraction <55% (n=10, 9.5%; P=0.55), residual edema (n=16, 15.2%; P=0.487), and LGE (n=96, 91.4%; P=0.062) on follow-up CMRI compared with acute myocarditis after the mRNA COVID-19 vaccine.Table. Clinical and Diagnostic Characteristics of Patients With mRNA COVID-19 Vaccine MyocarditisBaseline characteristicsChanges in imaging data between baseline and follow-upNo. of patients with available dataAll patientsPatients without follow-up CMRPatients with follow-up CMRP valueBaseline imaging dataFollow-up imaging dataP valueN772849Demographics Age, y7725 (20–35)25 (20–39)25 (30–34)0.771 Women7715 (19)6 (21.4)9 (18.4)1.000 White ethnicity7770 (90.9)26 (92.8)44 (89.8)1.000 History of allergic reaction773 (3.8)1 (3.5)2 (4.1)1.000 Previous myocarditis777 (9.0)2 (7.1)5 (10.2)1.000Prior exposure and vaccination Previous exposure to SARS-CoV2768 (10.5)*1 (3.5)7 (14.6)*0.245 Previous COVID-19 hospitalization762 (2.6)*02 (4.2)*0.528 Type of mRNA vaccine BNT162b2 (Pfizer/BioNTech)7656 (73.7)*20 (74.1)*36 (73.5)*1.000 mRNA-1273 (Moderna)7620 (26.3)*7 (25.9)*13 (25.5)*1.000 Myocarditis after the first vaccine dose7221 (29.2)*6 (24.0)*15 (31.9)*0.591 Myocarditis after the second vaccine dose7236 (50.0)*11 (44.0)*25 (53.2)*0.621 Myocarditis after the third vaccine dose7215 (20.8)*8 (32.0)*7 (14.9)*0.128 Time between the vaccine dose and the onset of symptoms, d723 (2–5)3 (3–5)3 (2–6)0.981 Time between the vaccine dose and hospitalization, d723 (2–6)3 (2–5)3 (2–6)0.771 Presence of IgG anti-Spike protein (after vaccination)2218 (82)*3 (75)*15 (83)*0.582 Positive SARS-CoV-2 RT-PCR on nasopharyngealswab77000Clinical presentation and hospitalization Need for hospitalization77772849 Prodromal symptoms Fever7728 (36.3)5 (17.9)23 (46.9)0.014 Flu-like symptoms7730 (39.0)9 (32.1)21 (42.8)0.467 Other773 (3.9)03 (6.1)0.297 Not reported7724 (31.1)15 (53.6)9 (18.3)0.002† Presenting symptoms Chest pain7773 (94.8)26 (92.8)47 (95.9)0.619 Heart failure774 (5.1)3 (10.7)1 (2.0)0.134 Cardiogenic shock/cardiac arrest773 (3.9)1 (3.6)2 (4.1)1.000 Syncope771 (1.3)01 (2.0)1.000 Other778 (10.4)2 (7.1)6 (12.2)0.703 Systolic blood pressure on admission, mm Hg74120 (110–132)115 (106–135)120 (110–130)0.457 Heart rate on admission, bpm7681 (70–90)80 (70–92)81 (72–90)0.790 Days in hospitals736 (5–8)6 (4–8)7 (5–9)0.220 Days in intensive care unit742 (0–3)2 (0–4)2 (0–3)0.577 Need for inotropes754 (5.3)*2 (7.4)*2 (4.2)*0.606 Need for temporary mechanical circulatory support753 (4.0)*1 (3.7)*2 (4.2)*1.000ECG on admission Normal7514 (18.7)*7 (25.9)*7 (14.6)*0.237 ST-segment elevation7547 (62.7)*14 (51.8)*33 (68.7)*0.214 Other abnormal ST-T segment7513 (17.3)*5 (18.5)*8 (16.7)*1.000 QRS >120 ms741 (1.3)*01 (2.1)*1.000ECG monitoring Nonsustained ventricular tachycardia758 (10.7)*5 (19.2)*3 (6.1)0.117 VT/VF751 (1.3)*1 (3.8)*00.347 Sustained atrial arrhythmias75000Cardiac biomarkers Troponin increase on admission (×fold URL)7780 (27–238)58 (24–171)83 (33–330)0.253 Troponin increase at peak (×fold URL)74108 (50–357)73 (39–243)122 (67–522)0.085 Day of troponin peak after admission181 (0–2)1 (0–2)2 (1–2)0.216 First CK-MB, µg/L3027 (10–45)10 (8–29)31 (14–62)0.078 Peak CK-MB, µg/L3231 (11–54)10 (8–38)34 (13–78)0.122 First NT-proBNP, ng/L46323 (136–610)219 (139–688)356 (125–571)0.961 First BNP945 (17–87)33 (12–81)45 (42–46)0.606Inflammatory biomarkers C-reactive protein increase on admission (×fold URL)738 (2–16)5 (2–11)8 (3–19)0.216 Eosinophilia754 (5.3)*2 (7.7)*2 (4.1)0.606Echocardiography‡Baseline echo (n=48 patients)Follow-up echo (n=48 patients)P value Days after hospitalization144 (59–197) LV EF on first echo, %7456 (50–60)56 (52–62)56 (50–60)0.45355 (84–60)60 (60–64)<0.001† Presence of segmental hypokinesia7436 (48.6)*12 (48.0)*24 (49.0)1.00026 (54.2)3 (6.2)<0.001† Inferior or lateral wall7433 (44.6)*9 (36.0)*24 (49.0)0.331 Anterior wall739 (12.3)*4 (16.0)*5 (10.4)*0.482 Septal wall738 (10.9)*3 (12.0)*5 (10.4)*1.000 LVEDD, mm4448 (45–52)48 (45–50)48 (45–52)0.59948 (46–52)48 (45–50)0.183 Dilated LV736 (8.2)*2 (8.3)*4 (8.2)1.0005 (10.4)00.056 Dilated RV7300000 RV-TAPSE <17 mm732 (2.7)*1 (4.2)*1 (2.0)1.0002 (4.2)00.242 Pericardial effusion7412 (16.2)*3 (12.0)*9 (18.4)0.74011 (22.9)0<0.001† Lowest LV EF value, %7356 (50–60)55 (51–61)56 (50–60)0.780Coronary angiography/CT scan excluding coronary artery disease7735 (45.4)10 (35.7)25 (51.0)0.238Available cardiac MRI‡Baselinecardiac MRI (n=49 patients)Follow-up cardiac MRI (n=49 patients)P value Days after hospitalization774 (2–7)3 (2–9)4 (2–7)0.6974 (2–7)137 (93–180) LV EF, %7659 (55–64)60 (55–64)59 (55–65)0.55659 (55–65)60 (57–64)0.507 LV EF <50%765 (6.6)*2 (3.6)*3 (6.2)*1.0003 (6.2)*00.117 LV EF <55%7614 (18.4)*5 (17.8)*9 (18.7)*1.0009 (18.7)*3 (6.1)0.071 Indexed LVEDV, mL/m26282 (72–88)82 (70–89)82 (73–88)0.96982 (73–88)75 (65–84)0.029† Dilated LV758 (10.6)*3 (10.7)7 (14.6)*1.0007 (14.6)*5 (10.6)*0.759 RV EF, %7357 (52–62)58 (52–62)56 (52–62)0.74056 (52–62)57 (52–61)0.563 Dilated RV752 (2.7)*1 (3.6)*1 (2.1)*1.0001 (2.1)*1 (2.1)*1.000 Edema on T2-w imaging7775 (97.4)28 (100)47 (95.9)0.53147 (95.9)10 (20.4)<0.001† Inferior7737 (48.0)11 (39.2)26 (53.0)0.34326 (53.1)3 (6.1)<0.001† Inferolateral7763 (81.8)21 (75.0)43 (87.7)0.20743 (87.7)4 (8.2)<0.001† Anterolateral7740 (51.9)14 (50.0)26 (53.1)0.81726 (53.1)0<0.001† Anterior7720 (26.0)4 (14.2)16 (32.6)0.10516 (32.6)1 (20.4)<0.001† Septal779 (11.7)3 (10.7)6 (12.2)1.0006 (12.2)2 (4.1)0.159 Presence of LGE7777 (100)28 (100)49 (100)49 (100)39 (79.6)0.001† Inferior7737 (48.0)11 (39.2)26 (53.0)0.34326 (53.1)8 (16.3)<0.001† Inferolateral7745 (58.4)13 (46.4)32 (65.3)0.14932 (65.3)12 (24.5)<0.001† Anterolateral7740 (51.9)14 (50.0)26 (53.1)0.81726 (53.1)8 (16.3)<0.001† Anterior7711 (14.3)2 (7.1)9 (18.4)0.3109 (18.4)00.003† Septal777 (9.1)2 (7.1)5 (10.2)1.0005 (10.2)3 (6.1)0.715 Increased T1 mapping signal3122 (71.0)*9 (75.0)*13 (68.4)*1.00013 (68.4)*4 (13.3)*<0.001† Increased T2 mapping signal4135 (85.3)*14 (87.5)*21 (84.0)*1.00021 (84.0)*3 (10.3)*<0.001† Pericardial effusion7710 (13.0)4 (14.3)16 (32.6)0.10616 (32.6)3 (6.1)0.004†Available histology, n (%)779 (11.7)3 (10.7)6 (12.2)1.000 Active myocarditis96 (66.7)*2 (66.7)*4 (66.7)*0.774Treatments Corticosteroids779 (11.7)3 (10.7)6 (12.2)1.000 Other immunosuppressive agents7711 (14.3)4 (14.3)7 (14.3)1.000 NSAIDs7740 (51.9)11 (39.2)29 (59.2)0.104In-hospital outcome Live7575 (100)*26 (100)*49 (100)* Dead75000 Transplanted/LVAD75000Data are reported as n (%) for categorical variables and as median (interquartile range, 1–3) for continuous variables. The Mann-Whitney U test was used to compare continuous variables of patients with or without follow-up CMR. The Wilcoxon matched-pair signed-rank test was used to analyze paired data of baseline vs follow-up CMR. Categorical variables were compared with the Fisher exact test. BNP indicates brain natriuretic peptide; bpm, beats per minute; CK-MB, creatine kinease-myocardial band isoenzyme; CMR, cardiac magnetic resonance; CMRI, cardiac magnetic resonance imaging; CT, computed tomography; EF, ejection fraction; LGE, late gadolinium enhancement; LV, left ventricle; LVAD, left ventricular assist device; LVEDD, left ventricular end-diastolic diameter; LVEDV, left ventricular end-diastolic volume; MRI, magnetic resonance imaging; NSAID, nonsteroidal anti-inflammatory drug; NT-proBNP, N-terminal pro-B-type natriuretic peptide; RT-PCR, real-time polymerase chain reaction; RV, right ventricle; T2-w, T2 weighted; TAPSE, tricuspid annular plane systolic excursion; URL, upper reference limit; VF, ventricular fibrillation; and VT, ventricular tachycardia.* The proportion of patients was calculated on the number of patients with available data.† P<0.05.‡ Presented CMRI and echocardiographic data are not obtained from a centralized revision of the original exams but are based on the available reports from each institute.In conclusion, we observed that in the midterm follow-up, patients who had acute myocarditis after the mRNA COVID-19 vaccine had preserved biventricular function, while 79.6% of patients had a residual scar and 20.4% had persistent edema. These figures are in line with CMRI finding in patients with other forms of myocarditis: after 6 months, edema based on T2-weighted imaging was present in 16% and LGE in 86% of the patients,4 also in agreement with our data derived from a subanalysis of the Lombardy registry of acute myocarditis. No clinical events were reported in the follow-up, and the few patients with COVID-19 after vaccination did not develop recurrent myocarditis. Longer follow-up is needed, even if published long-term data suggest that patients with preserved biventricular ejection fraction without septal LGE involvement have low rates of adverse clinical events.5 As a study limitation, we underline that the causal link between COVID-19 vaccination and myocarditis remains uncertain, albeit the short median time (3 days) from vaccination to symptom onset suggests causality.The observed CMRI findings at baseline and morphofunctional changes over time align with those of classic viral acute myocarditis with a good prognosis.5 This new information should further reassure patients who experience acute myocarditis after the mRNA COVID-19 vaccination.Article InformationSources of FundingThis work was supported by the Italian Ministry of Health (GR-2019-12368506).Disclosures Dr Ammirati received a grant from the Italian Ministry of Health (GR-2019-12368506; principal investigator of the investigator-driven MYTHS trial [Myocarditis Therapy With Steroids]) and a grant from the Italian Ministry of Health and NextGenerationEU (PNRR-MAD-2022-12376225) and is a consultant for Kiniksa and Cytokinetics. Dr Metra reports personal fees from Actelion, Amgen, AstraZeneca, Abbott, Bayer, Servier, Edwards Therapeutics, Livanova, Vifor pharma, and WindTree Therapeutics, as a member of Trials’ Committees or for speeches at sponsored meetings in the last 3 years. Dr Ruschitzka has not received personal payments by pharmaceutical companies or device manufacturers in the past 3 years (remuneration for the time spent in activities, such as participation as a steering committee member of clinical trials and a member of the Pfizer Research Award selection committee in Switzerland, were made directly to the University of Zurich). The Department of Cardiology (University Hospital of Zurich/University of Zurich) reports research, educational, and/or travel grants from Abbott, Abiomed, Alexion, Amgen, AstraZeneca, At the Limits Ltd, Bayer, Berlin Heart, B. Braun, Biosense Webster, Biosensors Europe AG, Biotronik, Boehringer Ingelheim, Boston Scientific, Bracco, Bristol Myers Squibb, Cardinal Health Switzerland, Concept Medical, Corteria, CSL, Daiichi Sankyo, Diatools AG, Edwards Lifesciences, Guidant Europe NV (BS), Hamilton Health Sciences, IHF, Innosuisse, Johnson/Johnson, Kaneka Corporation, Kantar, Kiniksa, Labormedizinisches Zentrum, MedAlliance, Medical Education Global Solutions, Medtronic, MicroPort, MSD, Mundipharma Medical Company, Novartis, Novo Nordisk, Orion, Pfizer, Quintiles Switzerland Sarl, RecorMedical, Roche Diagnostics, Roche Pharma, Sahajanand IN, Sanofi, Sarstedt AG, Servier, SIS Medical, Sorin CRM SAS, SSS International Clinical Research, Stromal, Terumo Deutschland, Trama Solutions, V-Wave, Vascular Medical, Vifor, Wissens Plus, and ZOLL. These grants do not impact on Dr Ruschitzka’s personal remuneration. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 548.This manuscript was sent to Dr Michael Stanley Kiernan, MD, MS, MBA, Guest Editor, for review by expert referees, editorial decision, and final disposition.Correspondence to: Enrico Ammirati, MD, PhD, Niguarda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy, Email enrico.ammirati@ospedaleniguarda.itLaura Lupi, MD, Institute of Cardiology, Azienda Socio-Sanitaria Territoriale Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy, Email lalli.lupi@gmail.comReferences1. Patel YR, Shah NR, Lombardi K, Agarwal S, Salber G, Patel R, Poppas A, Atalay MK. Follow-up cardiovascular magnetic resonance findings in patients with COVID-19 vaccination-associated acute myocarditis.JACC Cardiovasc Imaging. 2022; 15:2007–2010. doi: 10.1016/j.jcmg.2022.06.009CrossrefMedlineGoogle Scholar2. Pareek M, Steele J, Asnes J, Baldassarre LA, Casale LR, Desai NR, Elder RW, Faherty E, Ferguson I, Fishman RF, et al. Short-term outcomes after myopericarditis related to COVID-19 vaccination.JACC Cardiovasc Imaging. 2022; 15:2002–2005. doi: 10.1016/j.jcmg.2022.03.026CrossrefMedlineGoogle Scholar3. Ammirati E, Cipriani M, Moro C, Raineri C, Pini D, Sormani P, Mantovani R, Varrenti M, Pedrotti P, Conca C, et al; Registro Lombardo delle Miocarditi. Clinical presentation and outcome in a contemporary cohort of patients with acute myocarditis: multicenter lombardy registry.Circulation. 2018; 138:1088–1099. doi: 10.1161/CIRCULATIONAHA.118.035319LinkGoogle Scholar4. Aquaro GD, Ghebru Habtemicael Y, Camastra G, Monti L, Dellegrottaglie S, Moro C, Lanzillo C, Scatteia A, Di Roma M, Pontone G, et al; “Cardiac Magnetic Resonance” Working Group of the Italian Society of Cardiology. Prognostic value of repeating cardiac magnetic resonance in patients with acute myocarditis.J Am Coll Cardiol. 2019; 74:2439–2448. doi: 10.1016/j.jacc.2019.08.1061CrossrefMedlineGoogle Scholar5. Aquaro GD, Perfetti M, Camastra G, Monti L, Dellegrottaglie S, Moro C, Pepe A, Todiere G, Lanzillo C, Scatteia A, et al; Cardiac Magnetic Resonance Working Group of the Italian Society of Cardiology. Cardiac MR with late gadolinium enhancement in acute myocarditis with preserved systolic function: ITAMY study.J Am Coll Cardiol. 2017; 70:1977–1987. doi: 10.1016/j.jacc.2017.08.044CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Brociek E, Tymińska A, Giordani A, Caforio A, Wojnicz R, Grabowski M and Ozierański K (2023) Myocarditis: Etiology, Pathogenesis, and Their Implications in Clinical Practice, Biology, 10.3390/biology12060874, 12:6, (874) June 2023Vol 16, Issue 6 Advertisement Article Information Metrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.122.010315PMID: 37183708 Originally publishedMay 15, 2023 KeywordsCOVID-19COVID-19 vaccinesmagnetic resonance spectroscopymyocarditisvaccinationPDF download Advertisement Subjects Cardiomyopathy Magnetic Resonance Imaging (MRI)

Abstract Background MessengerRNA (mRNA) COVID–19 vaccination has been associated with a higher–than–expected occurrence of acute myocarditis. Scarce information is available on mid–term prognosis and changes in cardiac function, volumes, and tissue characterization on cardiac magnetic resonance (CMR). Methods Retrospective, multicenter study including patients with a definite diagnosis of acute myocarditis within 30 days from mRNA COVID–19 vaccination. The diagnosis is based on endomyocardial biopsy (EMB) or autopsy or by the coexistence of positive biomarkers (troponin >99th upper reference limit or elevated creatine kinase myocardial band [CK–MB]) and cardiac MRI findings consistent with AM according to the 2018 updated Lake Louise Criteria. Results 77 patients (median age 25 years [IQR 20–35], 15% female) were included and followed–up for 147 days [IQR 74–215]. Follow–up CMR was available in n=49 patients and showed no changes in biventricular ejection fraction (EF) as compared to CMR at diagnosis (left ventricular EF: 59%[55–65]vs. 60%[57–64], p=0.507, right ventricular EF: 56%[52–62]vs. 57%[52–61], p=0.563, respectively). Late gadolinium enhancement was present in all patients at diagnosis and persisted in only n=39 (79.6%) at follow–up (p=0.001), generally sparing the anterior wall and the septum. N=10 (20.4%) had a persistent edema based on T2–weighted short tau inversion recovery (STIR) sequences, with predominant involvement of inferior or inferior–lateral walls. The proportion of patients with increased T1 and T2 mapping signals significantly decreased at follow–up (n=13 (68%) vs. n=4 (13%),p<0.001, and n=21 (84%) vs. n=3 (10%),p<0.001, respectively), as well as the presence of pericardial effusion (n=16 (33%) vs. n=3 (6%),p=0.004). No differences in morpho–functional CMR parameters based on the type of vaccine administered were found (BNT162b2 Pfizer/BioNTech®, n=36, 73.5%, m–RNA–1273 Moderna®, n=13, 26.5%). Among patients with available follow–up (N=75, 97.4%), no major adverse cardiovascular events nor myocarditis recurrence or death were reported. Conclusions At mid–term follow–up, patients who experienced an acute myocarditis after a mRNA COVID–19 vaccine had preserved biventricular EF. The rate and localization of residual scar or edema on CMR is in line with classic viral myocarditis with a good prognosis. This new piece of information should further reassure patients who experience acute myocarditis after mRNA COVID–19 vaccination.

AIMS:To describe the proportion of patients with syncope among those affected by hypertrophic cardiomyopathy (HCM) and the relevance of syncope as risk factor for sudden cardiac death and life-threatening arrhythmic events.METHOD AND RESULTS:Systematic review of original articles that assessed syncope in HCM patients. Literature search of PubMed including all English publications from 1973 to 2021.We found 57 articles for a total of 21.791 patients; of these, 14 studies reported on arrhythmic events in the follow-up. Syncope was reported in 15.8% (3.452 of 21.791) patients. It was considered unexplained in 91% of cases. Life-threatening arrhythmic events occurred in 3.6% of non-syncopal patients and in 7.7% of syncopal patients during a mean follow-up of 5.6 years. A relative risk of 1.99 (95%CI 1.39 to 2.86) was estimated for syncope patients by the random effect model using Haldane continuity correction for 0 events.CONCLUSIONS:In the current practice, the cause of syncope remained unexplained in most patients affected by HCM. The management of patients seems mainly driven by risk stratification rather than identification of the aetiology of syncope. There is a need of precise instructions how to apply the recommendations of current guidelines to this disease, which tests are indicated and how to interpret their findings. The protocol was registered in Prospero (ID: 275963).