Myocardial T1 and T2 Mapping by Magnetic Resonance in Patients With Immune Checkpoint Inhibitor–Associated Myocarditis

Paaladinesh Thavendiranathan, Lili Zhang, Amna Zafar, Zsofia D. Drobni, Syed S. Mahmood, Marcella Cabral, Magid Awadalla, Anju Nohria, Daniel A. Zlotoff, Franck Thuny, Lucie M. Heinzerling, Ana Barac, Ryan J. Sullivan, Carol L. Chen, Dipti Gupta, Michael C. Kirchberger, Sarah E. Hartmann, Jonathan W. Weinsaft, Hannah K. Gilman, Muhammad A. RizviBojan Kovacina, Caroline Michel, Gagan Sahni, Ana González-Mansilla, Antonio Calles, Francisco Fernández-Avilés, Michael Mahmoudi, Kerry L. Reynolds, Sarju Ganatra, Juan José Gavira, Nahikari Salterain González, Manuel García de Yébenes Castro, Raymond Y. Kwong, Michael Jerosch-Herold, Otavio R. Coelho-Filho, Jonathan Afilalo, Eduardo Zataraín-Nicolás, A. John Baksi, Bernd J. Wintersperger, Oscar Calvillo-Arguelles, Stephane Ederhy, Eric H. Yang, Alexander R. Lyon, Michael G. Fradley, Tomas G. Neilan

Research output: Contribution to journalArticlepeer-review

88 Scopus citations


Background: Myocarditis is a potentially fatal complication of immune checkpoint inhibitor (ICI) therapy. Data on the utility of cardiovascular magnetic resonance (CMR) T1 and T2 mapping in ICI myocarditis are limited. Objectives: This study sought to assess the value of CMR T1 and T2 mapping in patients with ICI myocarditis. Methods: In this retrospective study from an international registry of patients with ICI myocarditis, clinical and CMR findings (including T1 and T2 maps) were collected. Abnormal T1 and T2 were defined as 2 SD above site (vendor/field strength specific) reference values and a z-score was calculated for each patient. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. Results: Of 136 patients with ICI myocarditis with a CMR, 86 (63%) had T1 maps and 79 (58%) also had T2 maps. Among the 86 patients (66.3 ± 13.1 years of age), 36 (41.9%) had a left ventricular ejection fraction <55%. Across all patients, mean z-scores for T1 and T2 values were 2.9 ± 1.9 (p < 0.001) and 2.2 ± 2.1 (p < 0.001), respectively. On Siemens 1.5-T scanner (n = 67), native T1 (1,079.0 ± 55.5 ms vs. 1,000.3 ± 22.1 ms; p < 0.001) and T2 (56.2 ± 4.9 ms vs. 49.8 ± 2.2 ms; p < 0.001) values were elevated compared with reference values. Abnormal T1 and T2 values were seen in 78% and 43% of the patients, respectively. Applying the modified Lake Louise Criteria, 95% met the nonischemic myocardial injury criteria and 53% met the myocardial edema criteria. Native T1 values had excellent discriminatory value for subsequent MACE, with an area under the curve of 0.91 (95% confidence interval: 0.84 to 0.98). Native T1 values (for every 1-unit increase in z-score, hazard ratio: 1.44; 95% confidence interval: 1.12 to 1.84; p = 0.004) but not T2 values were independently associated with subsequent MACE. Conclusions: The use of T1 mapping and application of the modified Lake Louise Criteria provides important diagnostic value, and T1 mapping provides prognostic value in patients with ICI myocarditis.

Original languageEnglish
Pages (from-to)1503-1516
Number of pages14
JournalJournal of the American College of Cardiology
Issue number12
StatePublished - 30 Mar 2021


  • Lake Louise Criteria
  • T1 mapping
  • T2 mapping
  • cardiovascular magnetic resonance
  • immune checkpoint inhibitor
  • major adverse cardiovascular event
  • myocarditis


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