 Hello everybody. I'm Dr. Tosha Desai. I'm a clinical associate at Asian Heart Institute Mumbai and I'll be presenting a talk on an early insight into the cardiac MRI findings in COVID-19 vaccine associated myocarditis, a systematic review of 95 patients based on modified Lake Lois criteria. Though there has not been a causal relationship established yet, but there have been several reports that have shown a higher than expected rate of myocarditis or pericarditis following COVID vaccination with mRNA based vaccines. And there has been an incidence reported of myocarditis of one case per one lakh shots. So according to AJR, radiologists need to be cognizant of the association between COVID vaccine and myocarditis, as well as of the role of cardiac MRI for assessing suspected myocarditis post vaccination. So we aimed to conduct a systematic review of the limited research material available till date of the recently recognized entity of COVID-19 vaccine associated myocarditis. We wanted to establish the role of multi parametric CEMRI in the diagnosis of myocarditis with focus on demographics, onset, characteristics of myocardial injury and its distribution. We followed a search strategy according to the Prisma guidelines, where an extensive online database search was performed using the keywords like COVID vaccine, myocarditis, CMR, SARS-CoV-2, etc. And the published articles that described CMR findings were included in the review. Duplicates were excluded. Two others independently reviewed the abstracts following which the data was extracted and analyzed using Microsoft Excel. And the CMR data analysis was performed only on those studies that fulfilled modified Lake Louis criteria, since there was a lot of non-uniformity of description of cardiac MRI findings in all the cases. And for most of the studies, EDMA was defined to be present when the ratio of myocardium to skeletal muscle signal intensity was more than two. And LGE was defined as the one that did not correspond to any vascular territory and spared the subendocardium. So from the 21 studies analyzed, 16 studies were included, which included a total of 95 patients. The majority were male, median age was 24 years, the median time of onset from vaccination to the onset of symptoms was 2.5 days. For myocardial EDMA criteria, T2 or stir hyperintensity was reported in majority of the patients. T2 mapping was reported in only 2% of patients. And T2 mapping with T2 stir hyperintensity was reported in 6% of patients. For non-ish chemical myocardial injury criteria, LGE was the most commonly reported finding at a percentage rate of 88.4%. LGE with elevated native global T1 weighted value was demonstrated in 11.5% patients. And other than that, expansion of ECB, wall motion abnormality, reduced LVEF, pericardial effusion and hyperintensity were also reported. The distribution was predominantly subepicardial, followed by midmyocardial, and LGE was most commonly seen in basal inferolateral segment, followed by mid-entrolateral and inferolateral segments. This is our master chart. So as you can see, the distribution is predominantly basal and that too basal inferolateral, followed by basal entrolateral, mid-enferolateral and mid-entrolateral. And the distribution of LGE is typically subepicardial, followed by midmyocardial, and absolutely none of this study is reported an exclusive subendocardial distribution. So a few examples. This is case one. This is just an image of a 15-year-old boy with myocarditis. As you can see in A, it's the star image, short axis view. And we can see star hyperintensity in the basal lateral and inferior wall, which indicates myocardial edema. Correspondingly, LGE is also seen in the image B, which indicates inflammatory myocardial necrosis. C and D are T1 mapping and T2 mapping, and which shows elevated T1 and T2 at the above mentioned side. This case, too, represents cardiac MRI findings in a 27-year-old male who demonstrated late gadolinium enhancement in epicardial to the midwall in left ventricular inferolateral wall, which was consistent with myocarditis. T1 map and ECV map also showed elevated native T1 and ECV values. And the D, E and F images are speckle tracking ecocardography images, which shows a corresponding values of peak systolic longitudinal strain, which were lower as compared to the endocardial layer. Case three is presented to highlight the occurrence of pericarditis associated with myocarditis. The image C shows pericardial enhancement consistent with findings of pericarditis. So where does CMR stand in the diagnosis of myocarditis? As Dr. Evan Herman says that with regard to cardiac MRI, certainly there is hyperemia, edema, necrosis and scar that remains late criteria. They can be helpful. But as you can also see in the CDC working case definition, CMR in these cases is utilized as a second line imaging modality to either support or verify a diagnosis, which is not clearly confirmed by history, lab or imaging. What are the modified Lake Lewis criteria? For that first we need to understand the original LLC, which were any two out of the three, which included T2 weighted imaging with regional high T2 signal intensity or high T2-SI ratio, early gadolinium enhancement and late gadolinium enhancement. Then following the introduction of T1 mapping and T2 mapping, the modified Lake Lewis criteria ever introduced, which had two basic components of T1 based imaging and T2 based imaging. T1 based imaging consisted of increase of native T1 or increase of ECV or positive non ischemic LGE and T2 based imaging consisted of increase of T2 or regional high T2-STER intensity or high T2-SI ratio. Now vaccine induced myocarditis is, the occurrence is infrequent. The cases are underreported and there has been a prevalence of subclinical myocarditis. So we need to implement modified LLC over the original LLC because the sensitivity of modified LLC has found to become considerably higher than the original LLC. So from previous literature, it also appears that myocarditis typically occurs more common in males, incidence is highest among adults and young adults, which is also verified in our systematic review and LGE and myocarditis edema in our patients were predominantly localized to basal and midlateral LV segments, which is also consistent with other case series of adult and pediatric population that has been reported prior to this. This is just an example of how two-dimensional speckle tracking with ecocardiography and feature tracking with CMR can quantitatively measure longitudinal strain and it has shown to detect LV dysfunction before a reduction in LVEF is identified and in cases of acute myocarditis, reduced LV strain has shown to predict adverse outcomes even in patients with preserved LVEF. There are a few limitations for in our study. We had no control group, neither of these studies that were included had a control group. So it was not possible to compare rates of acute myocarditis between those randomly assigned to receive vaccination versus no vaccination. And there could have also been a recall or referral bias after COVID-19 vaccination. The systematic review focused only on cardiac MRI findings based on modified LLC. Hence the interplay between clinical features and cardiac MRIs as well as cases with cardiac MRI findings that were reported in other formats were not taken into account. And lastly we did not have a long-term follow-up data on these patients. So to summarize, this systematic review suggests an association between acute myocarditis and vaccination in young males and highlights a potential pattern in accompanying CMR abnormalities and the findings of CMR in such patients are similar to those observed in other types of viral myocarditis or idiopathic myocarditis. It is recommended that reporting be performed in accordance with the modified Lake Louise criteria to serve as a standard for future reference. And lastly, an early diagnosis and assessment of the extent of involvement of CMR is key to minimize COVID-19 vaccinated adversities and improve the medical management of patients suspected of myocarditis. These are my references. Thank you.