World Journal of Cardiovascular Diseases, 2013, 3, 118-125 WJCD http://dx.doi.org/10.4236/wjcd.2013.31A018 Published Online March 2013 (http://www.scirp.org/journal/wjcd/ ) Gadolinium enhanced MRI in patients with left ventricular apical ballooning syndrome implicates myocarditis as an etiology Andrew O. Maree 1,2*# , Christian Witzke 1# , Godtfred Holmvang 1 , Gregory D. Lewis 1 , Hani Jneid 1 , Lindsay B. Reardon 1 , Nadeem Afridi 1 , Marc J. Semigran 1 , G. William Dec 1 , Harry C. Lowe 1 , Igor F. Palacios 1 1 Cardiology Section, Department of Medicine, Waterford Regional Hospital, Waterford, Ireland 2 Cardiology Section, Department of Medicine, Massachusetts General Hospital, Boston, USA Email: * andrew.maree@gmail.com Received 2 January 2013; revised 5 February 2013; accepted 15 February 2013 ABSTRACT Aims: Left ventricular apical ballooning syndrome (LVABS) is a clinical condition of unknown etiology, characterized by acute onset of atypical apical wall motion and absence of coronary artery disease. Gado- linium-enhanced cardiac magnetic resonance imaging (Gd-MRI) may be used to identify patients with myo- carditis. Using cardiac MRI, we evaluated whether acute myocarditis may be an etiology that underlies LVABS. Methods and Results: Consecutive patients who presented with LVABS during a three-year pe- riod were included. Demographic data was recorded and echocardiography, coronary angiography, and hemodynamic assessment performed. Gd-MRI was performed in all patients. The study was deemed con- sistent with myocarditis when global myocardial to skeletal muscle enhancement ratio was ≥3.5. Regional Gd-MRI analysis was also performed. Patients (n = 11) were female (100%) and of mean age 72 years (72 ± 11). Preceding febrile illness occurred in 4 (36.3%) and leukocytosis in 6 (54.4%) patients. Initial mean left ventricular ejection fraction (41% ± 12%) im- proved (70.2% ± 8%) upon follow-up (39 ± 43 days). Global MRI analysis was positive in 5/11 (45.5%) (mean relative enhancement ratio 4.8 ± 1.4). Regional MRI analysis was positive in 4/6 further patients (overall: 9/11 (82%)). Conclusions: Gadolinium en- hanced MRI imaging in LVABS implicates myocardi- tis as a possible etiology. Regional MRI analysis adds sensitivity to global cardiac MRI evaluation. Keywords: Left Ventricular Apical Ballooning Syndrome; Gadolinium-Enhanced Cardiac Magnetic Resonance Imaging; Myocarditis; Catecholamine 1. INTRODUCTION Left ventricular apical ballooning syndrome (LVABS) is a clinical condition of unknown etiology that is fre- quently mistaken for ST-elevation myocardial infarction. Characterized by acute onset of chest pain associated with abnormal LV apical wall motion, the diagnosis re- quires documentation of patent epicardial coronary ar- teries by catheterization. Initially described in Japan, isolated cases have been reported in the United States [1-3]. Because this disease typically has an abrupt onset and fast recovery, we hypothesized that acute myocardi- tis may be an underlying etiology [4-6]. To test this hy- pothesis, we used Gadolinium enhanced MRI (Gd-MRI) to evaluate 11 consecutive patients who presented to our tertiary care center with findings consistent with left ven- tricular apical ballooning syndrome. Myocarditis is defined clinically and pathologically as inflammation of the myocardium. Clinical presentation ranges from non-specific systemic symptoms to fulmi- nant hemodynamic collapse [7]. The diagnosis is gener- ally made based on clinical history and examination, electrocardiograph (ECG) changes (ST segment abnor- mality, arrhythmias), serological evidence of myocyte necrosis, echocardiography (ECHO), or cinematographic images demonstrating left ventricular dysfunction. In some cases endomyocardial biopsy is performed and may demonstrate cellular infiltration and myocyte de- generation and/or necrosis. Endomyocardial biopsy was previously regarded as the definitive investigation. How- ever, recent studies have highlighted its low sensitivity and inconsistency in its interpretation in the setting of myocarditis, which has led to its decline [8,9]. Decreased performance of endomyocardial biopsy has coincided with the emergence of non-invasive imaging modalities to make the diagnosis of myocarditis. Cardiac magnetic resonance imaging (CMR) has been prominent * Corresponding author. # These authors contributed equally to the manuscript. Published Online March 2013 in SciRes. http://www.scirp.org/journal/wjcd