Assessment of Myocarditis: Cardiac MR, PET/CT, or PET/MR?

Diagnosis of myocarditis is challenging given its variable clinical manifestations and non-specific laboratory findings. Cardiac magnetic resonance (MR) is currently the preferred imaging modality for the diagnosis of myocarditis. 18F-fluoro-deoxy-glucose (FDG) positron emission tomography/computed tomography (PET/CT), as a functional imaging tool, has a potential role in the assessment of myocarditis by detecting the underlying myocardial inflammatory activity. Data are accumulating that simultaneous cardiac PET/MR may have complementary and incremental values for the evaluation of myocarditis compared to PET/CT or cardiac MR alone. The article aims to summarize the findings in the literature and discuss future directions of cardiac PET/MR for myocarditis. The Lake Louis Criteria (CLL) of cardiac MR is widely used for the diagnosis of myocarditis. It has an overall acceptable sensitivity of 67% and specificity of 91% for acute myocarditis but does not have the same accuracy for chronic myocarditis. FDG PET/CT is capable of assessing myocarditis by providing metabolic information of inflammation as increased myocardial FDG uptake. In addition to reduced radiation exposure, FDG PET performed on a hybrid PET/MR may detect more myocarditis than FDG PET/CT, because of the delayed PET acquisition time on PET/MR. Case-based observations and small clinical studies of FDG PET/MR have shown that FDG PET findings as abnormally increased myocardial uptake correlate well with the cardiac MR biomarkers. FDG PET findings may add complementary and incremental values to cardiac MR by improving the sensitivity of cardiac MR for mild or borderline myocarditis, and increasing specificity for chronic myocarditis. Preliminary data from retrospective and case-based observational studies have suggested the complementary and incremental values of simultaneous cardiac FDG PET/MR for evaluation of myocarditis, compared to PET/CT or MR alone. Well-designed studies are needed to confirm the findings and to assess the value of cardiac PET/MR for clinical management and more importantly patient’s outcome in both acute and chronic myocarditis.