Reply: Acute Myocarditis With Ventricular Noncompaction in a COVID-19 Patient.

We appreciate the interest in our work (1) and are pleased to address the aroused considerations. The recent report from Bonnet et al. (2) presented a special case of underlying isolated ventricular noncompaction in a coronavirus disease-2019 (COVID-19) patient with acute heart failure. The patient underwent cardiac magnetic resonance (CMR) and echocardiography, which confirmed isolated ventricular noncompaction diagnosis. In addition, the CMR imaging depicted subepicardial late gadolinium enhancement (LGE). The authors determined that the patient was accompanied with acute myocarditis. However, for patients with suspected myocarditis, the Lake Louise Criteria 2009 (3) recommends 2 of 3 signs (edema, early gadolinium enhancement, and LGE) for positivity. Previous studies showed that positive LGE can be present even 2 years after myocarditis onset. Therefore, caution should be taken when diagnosing myocarditis on the “acute” phase of the case based on only LGE-positive CMR.

Growing evidence suggests cardiac involvement as a complication of SARS-CoV-2 infection. The autopsy findings identified direct viral-induced injury of multiple organs, including the heart (4). A recent report from Inciardi et al. (5) presented a case of a 53-year-old woman with SARS-CoV-2 infection and acute heart failure. The CMR was presented with diffuse biventricular edema and LGE, indicating acute myocarditis. These findings revealed that SARS-CoV-2 can cause direct injury to hearts and lead to acute myocarditis.

Patients with underlying cardiovascular disease and high troponin levels are more prone to experience severe outcomes of COVID-19. CMR, as a powerful imaging technique for a broad range of cardiac pathologies, has also become the most promising noninvasive imaging tool for patients with acute myocarditis. In viral myocarditis, LGE presence maintained a significant positive association with major adverse cardiac events (6). Therefore, the application of CMR, especially the presence and the extent of LGE, may add another aspect of outcome prediction for COVID-19 with cardiovascular diseases.