Prognostic value of right ventricular late gadolinium enhancement in patients with acute myocarditis
Right ventricular late gadolinium enhancement may independently predict major adverse cardiovascular events and guide risk stratification and management in myocarditis
image: (A) The flowchart of the enrollment of 193 adult patients diagnosed with acute myocarditis.
(B) MACE-free survival curves of patients with acute myocarditis grouped by RV LGE presence. Patients with RV LGE were at higher risk of long-term MACE. MACE included deaths, heart transplantations, re-hospitalization for heart failure, sustained ventricular arrhythmias (>30 s), and recurrent myocarditis.
(C) Multivariate Cox analysis. *P <0.05. ARVC: Arrhythmogenic right ventricular cardiomyopathy; CAD: Coronary artery disease; CI: Confidence interval; CMR: Cardiac magnetic resonance; CRP: C-reactive protein; HR: Hazard ratio; LGE: Late gadolinium enhancement; LVEF: Left ventricular ejection fraction; MACEs: Major adverse cardiovascular events; RV: Right ventricular.
Credit: Dr. Shihua Zhao from Peking Union Medical College, China | Image Link: https://mednexus.org/doi/10.1097/CM9.0000000000004111
Acute myocarditis is an inflammatory myocardial disorder with variable clinical courses and outcomes. Cardiac magnetic resonance (CMR) is recommended in the 2025 ESC guidelines as a key noninvasive tool for diagnosis. Previous studies have identified several independent predictors of poor outcomes, including the presence of late gadolinium enhancement (LGE), septal or midwall LGE, reduced left ventricular ejection fraction (LVEF), and impaired left ventricular global longitudinal strain. However, the predictive value of right ventricular LGE (RV LGE) remains unclear. Existing studies show conflicting results, and data from Asian cohorts remain scarce.
To address this gap, Professor Shihua Zhao from Fuwai Hospital, China, along with a team of cardiologists and imaging experts, conducted a retrospective cohort study to clarify the prognostic role of RV LGE in acute myocarditis, filling an important evidence gap, especially in Asian populations. Their findings were made available online in the Chinese Medical Journal on April 27, 2026.
“LGE reflects myocardial inflammation, necrosis, and fibrosis. There is accumulating evidence that the presence and location of LGE could predict adverse outcomes in acute myocarditis. We hypothesized that RV LGE was related to diffuse myocardial fibrosis and poor outcomes,” explained Professor Shihua Zhao. To test this, the team performed a single-center retrospective study approved by the hospital ethics committee. From June 2010 to December 2021, 193 patients diagnosed with acute myocarditis according to 2013 ESC criteria and updated Lake Louise criteria were enrolled. Patients with significant coronary artery disease, other cardiomyopathies, severe renal insufficiency, or incomplete data were excluded. CMR images were analyzed by experienced radiologists in a blinded manner. These patients were divided into the RV LGE-present group (n = 19) and the RV LGE-absent group (n = 174). Patients were followed up every six months. The primary endpoint was major adverse cardiovascular events (MACE), including all-cause death, heart transplantation, heart failure hospitalization, sustained ventricular arrhythmia, and myocarditis recurrence.
Patients with RV LGE presented with worse cardiac function, more severe LGE extent, and higher rates of fulminant myocarditis. After a follow-up of 3.6 ± 2.5 years, the RV LGE-present group had higher adverse events than the RV LGE-absent group (34.5% vs. 16.3%, P < 0.001). Multivariate cox regression confirmed RV LGE as an independent predictor of MACE (HR = 3.273, 95% CI: 1.188–9.015, P = 0.022), alongside reduced LVEF.
Compared with previous studies that reported inconsistent findings on RV LGE, this study focused on an Asian cohort of myocarditis and directly demonstrated that RV LGE carried stronger prognostic significance than LGE location or pattern alone. The team proposes that RV LGE reflects global inflammation, fibrosis, and impaired cardiac function and increases arrhythmia risk.
Although limited by a small number of events and single-center design, this research supports the clinical value of RV LGE in risk stratification. The team concluded that RV LGE on CMR served as a valuable predictor for risk stratification of acute myocarditis and could help guide individualized therapy for high-risk patients.
Reference
Title of original paper: Prognostic value of right ventricular late gadolinium enhancement in patients with acute myocarditis: Insights from a cohort study in Asia
Journal: Chinese Medical Journal
DOI: https://mednexus.org/doi/10.1097/CM9.0000000000004111
About Dr. Yan Zhao from Peking University
Yan Zhao, MD, graduated from Peking University. Associate chief physician with nearly 20 years of clinical experience, affiliated with the Department of Cardiology, Fuwai Hospital, Beijing, China. Lead one clinical study, participated in multiple national and provincial research projects, and published multiple SCI papers as the first author or co-first author.
About Dr. Jing-Hui Li from Tongji University
Jing-Hui Li, MD, graduated from Tongji University. Associate Chief Physician affiliated with Fuwai Hospital, Beijing, China. Visiting scholar at the Center for Systems Biology, Massachusetts General Hospital, Harvard University. Lead the National Natural Science Foundation of China. Published multiple papers, including those in Radiology as the first author or co-first author.
Funding information
This work was supported by National Natural Science Foundation of China (Grant No. 82302170) and National Key R&D Program of China (Grant Nos. 2021YFF0501400 and 2021YFF0501404).