Cardiac sarcoidosis: diagnostic, prognostic, and therapeutic considerations

Cardiac magnetic resonance imaging in the evaluation of cardiac sarcoidosis: an Australian single-centre experience

BACKGROUND

Cardiac involvement in systemic sarcoidosis is common; however, current diagnostic tools are imprecise. Recognition of cardiac sarcoidosis (CS) is important as it has a relatively poor prognosis. Gadolinium-enhanced cardiac magnetic resonance imaging (Gad-CMR) is emerging as an excellent technique in determining the presence of and extent to which cardiac muscle is affected by sarcoidosis.

METHODS

A retrospective analysis was performed on all patients with biopsy-proven systemic sarcoidosis referred for Gad-CMR scanning to evaluate potential cardiac involvement. All patients also underwent an electrocardiogram, Holter monitor and echocardiography. Gallium-67 radionuclide investigation, positron emission tomography and cardiac biopsy were ordered at the discretion of the treating physician.

RESULTS

Eleven of the 20 patients had Gad-CMR images supportive of the diagnosis of CS. Eight of these 11 patients met the Japanese Ministry of Health and Welfare (JMHW) criteria for the diagnosis of CS; three abnormal Gad-CME scans consistent with diagnosis of CS were seen in patients who did not meet JMHW criteria. No patients with normal Gad-CMR scan met JMHW criteria for CS.

CONCLUSION

These findings suggest that Gad-CMR is potentially superior to the JMHW criteria in the diagnosis of cardiac sarcoidosis.

Fragmented QRS complexes on 12-lead ECG: a marker of cardiac sarcoidosis as detected by gadolinium cardiac magnetic resonance imaging

BACKGROUND

Fragmented QRS complexes (fQRS) on a 12-lead ECG are a marker of myocardial scar in patients with coronary artery disease. Cardiac sarcoidosis is also associated with myocardial granuloma formation and scarring. We evaluated the significance of fQRS on a 12-lead ECG compared to Gadolinium-delayed enhancement images (GDE) in cardiac magnetic resonance imaging (CMR).

METHOD AND RESULTS

The ECGs of patients (n = 17, mean age: 52 +/- 11 years, male: 53%) with established diagnosis of sarcoidosis who underwent a CMR for evaluation of cardiac involvement were studied. ECG abnormalities included bundle branch block, Q wave, and fQRS. fQRS, Q wave, and bundle branch block were present in 9 (53%), 1 (6%), and 4 (24%) patients, respectively. The sensitivity and specificity of fQRS for detecting abnormal GDE were 100% and 80%, respectively. Sensitivity and specificity of Q waves were 11% and 100%, respectively.

CONCLUSIONS

fQRS on a 12-lead ECG in patients with suspected cardiac sarcoidosis are associated with cardiac involvement as detected by GDE on CMR.

Prolonged electrocardiogram QRS duration independently predicts long-term mortality in patients hospitalized for heart failure with preserved systolic function

BACKGROUND

Prolonged electrocardiogram (ECG) QRS duration (>or=120 ms) is a risk factor for death in systolic heart failure, but its effects in heart failure with preserved systolic function (HFPSF) have not been extensively studied. We hypothesized that prolonged ECG QRS duration would independently predict long-term mortality in hospitalized HFPSF patients.

METHODS AND RESULTS

We analyzed 872 HFPSF patients (defined as left ventricular ejection fraction >or=50%) admitted to Michigan community hospitals between 2002 and 2004 and followed for a median of 660 days. We used Cox proportional hazards models to assess mortality hazard for prolonged QRS duration (>or=120 ms) on the last available predischarge ECG, first on a univariable basis and then after multivariable adjustment for other known risk factors. Prolonged QRS duration increased univariable all-cause mortality (HR 1.71; 95% CI 1.33-2.19, P < .001) and after multivariable adjustment (HR 1.31; 95% CI 1.01-1.71, P=.04). The univariable effect size was larger in younger patients. In multivariable models, there was no significant interaction between prolonged QRS and age, hypertension, or coronary artery disease status.

CONCLUSIONS

Prolonged QRS duration (>or=120 ms) on a predischarge ECG is an independent and consistent predictor of long-term mortality in hospitalized HFPSF patients.

Sarcoidosis-induced pericarditis in a patient with portopulmonary hypertension: a case report

Portopulmonary hypertension is a rare and severe complication of patients with cirrhosis. Sarcoidosis, a disease of unknown etiology, is also a cause of pulonary hypertension and right heart dysfunction. We report the case of a 51-year-old male patient, suffering from cirrhosis due to Wilson's disease, portal hypertension and pulmonary hypertension (PH), who developed severe pericarditis. Wilson's disease was diagnosed 8 years before his last admission to our hospital and was being successfully treated with D-penicillamine. PH was recognized 2 years before admission and being treated with bosentan. The patient complained for dyspnea at rest and the 2D echocardiogram revealed a significant amount of pericardial fluid. All other causes of acute pericarditis were excluded and his laboratory, imaging and histopathological investigation showed evidence of sarcoidosis. He underwent a therapy with corticosteroids (methylprednisolone) and his follow-up examination showed remarkable decrease of the levels of mean pulmonary artery pressure and pericardial fluid.

Coronary sarcoidosis presenting as acute coronary syndrome

Sarcoidosis is a systemic disorder of uncertain etiology characterized by noncaseating granulomatous inflammation. The disease often involves the heart on autopsy, but the antemortem diagnosis of cardiac sarcoidosis is frequently missed. Cardiac involvement usually includes granulomatous inflammation or fibrosis of the myocardium, conduction system, or pericardium. We now describe a case of epicardial coronary involvement by sarcoidosis, where the diagnosis was made by surgical biopsy of the coronary artery in an African American man presenting with acute coronary syndrome and recurrent symptomatic restenosis following coronary intervention. The case extends the spectrum of common cardiac syndromes that cardiac sarcoidosis can masquerade as and highlights the importance of maintaining a high index of suspicion for early recognition and instituting specific treatment that might improve prognosis. A review of the literature also suggests the need for improvement in diagnostic approaches and prospective clinical trials to establish the best management strategy for this disease.

Cardiac sarcoidosis

Cardiac sarcoidosis (CS) is a rare but potentially fatal condition that may present with a wide range of clinical manifestations including congestive heart failure, conduction abnormalities, and most notably, sudden death. Recent advances in imaging technology allow easier detection of CS, but the diagnostic guidelines with inclusion of these techniques have yet to be written. It has become clear that minimally symptomatic or asymptomatic cardiac involvement is far more prevalent than previously thought. Because of the potential life-threatening complications and potential benefit of treatment, all patients diagnosed with sarcoidosis should be screened for cardiac involvement. Patients with CS and symptoms such as syncope need an aggressive workup for a potentially life-threatening etiology, and often require implantable cardioverter-defibrillator therapy. CS patients without arrhythmic symptoms are still at risk for sudden death and may warrant an implantable cardioverter-defibrillator for primary prevention reasons. Although corticosteroids are regarded as the first-line drug of choice, therapy for CS is not yet standardized, and it is unclear at this point whether asymptomatic patients require therapy. Randomized clinical trials are clearly warranted to answer these very important patient care questions, and are endorsed fully by the authors.

Enhanced expression of type 1 helper T-cell cytokines in the myocardium of active cardiac sarcoidosis

BACKGROUND

Various cytokines are involved in the pathogenesis of sarcoidosis, but their expression in the myocardium has not been documented for cardiac sarcoidosis.

METHODS AND RESULTS

Myocardial tissue was obtained from 12 patients with cardiac sarcoidosis at the time of left ventriculoplasty, biopsy or autopsy. mRNA expression of various inflammatory cytokines was analyzed using quantitative real-time polymerase chain reaction, as well as by immunohistochemistry. Ten patients with dilated cardiomyopathy (DCM) served as controls. Enhanced expression of interleukin (IL)-1alpha, IL-2, IL-12 p40 and interferon (IFN)-gamma mRNA was limited to the myocardium of cardiac sarcoidosis patients. Expression of IL-1beta, IL-8, IL-10, IL-15 and TNF-alpha occurred in both cardiac sarcoidosis and DCM patients, but IL-4 and IL-5 were not detected in either disease. Immunohistochemistry of the myocardial tissue of sarcoidosis revealed positive staining for IL-12 and IFN-gamma. IL-12 was localized in multinucleated giant cells and macrophages of the sarcoid granulomas, whereas IFN-gamma was detected in lymphocytes and vascular endothelial cells.

CONCLUSIONS

Type 1 helper T-cell cytokines may be involved in the pathogenesis of cardiac sarcoidosis.

MRI of cardiac sarcoidosis: basal and subepicardial localization of myocardial lesions and their effect on left ventricular function

OBJECTIVE

The objective of our study was to use MRI to analyze the topographic localization of myocardial lesions and their relationship to plasma brain natriuretic peptide (BNP) levels and several cardiac function parameters in patients with cardiac sarcoidosis.

MATERIALS AND METHODS

Delayed contrast-enhanced MRI was performed in 40 patients with sarcoidosis (11 cardiac, 29 extracardiac cases). Using a 29-segment model of the left ventricle (LV), the extent of myocardial hyperenhancement was visually scored (0 = no hyperenhancement, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% hyperenhancement) and was compared with plasma BNP level and several parameters of cardiac function.

RESULTS

Ten of the 11 patients with cardiac sarcoidosis showed myocardial hyperenhancement, whereas none of the 29 patients without cardiac sarcoidosis did. In patients with cardiac sarcoidosis, hyperenhancement was significantly more extensive in basal short axis slices than in apical short axis slices (p < 0.0005). Myocardial hyperenhancement was significantly more frequent in subepicardial layers than in subendocardial layers. The global extent of myocardial hyperenhancement was significantly correlated with plasma BNP levels and the LV end-diastolic volume index and was negatively correlated with the LV ejection fraction.

CONCLUSION

In patients with cardiac sarcoidosis, myocardial lesions detected on delayed contrast-enhanced MRI were predominantly localized in the basal and subepicardial myocardium. The extent of myocardial lesions may be related to LV dysfunction and plasma BNP level in patients with cardiac sarcoidosis.

[Extra-thoracic sarcoidosis]

Sarcoidosis is a multisystemic granulomatous disease of unknown aetiology, characterized by the presence of non-caseating epithelioid cell granulomas on tissue biopsy of affected organs. It may involve any organ, presenting in multiple forms to clinicians of different specialties. In its extra-thoracic form it may involve the liver (50-80%), spleen (40-80%), eye (20-50%), extrathoracic lymph nodes (30%), skin (25%), nervous system (10%), heart (5%), kidney, muscle and bone, sometimes without symptoms. The presence of extrathoracic disease may affect the prognosis and treatment options for sarcoidosis. The authors present a review of the major extra-thoracic manifestations of sarcoidosis regarding its clinical presentation, diagnosis, treatment, follow-up and prognosis.

Enhanced expression of myeloid-related protein complex (MRP8/14) in macrophages and multinucleated giant cells in granulomas of patients with active cardiac sarcoidosis

BACKGROUND

The myeloid-related protein complex (MRP8/14) is expressed in activated human macrophages and reported to be involved in the inflammatory process. The expression of MRP8/14 in patients with cardiac sarcoidosis and idiopathic dilated cardiomyopathy (DCM) was investigated.

METHODS AND RESULTS

Serum MRP8/14 levels were measured in 35 patients with sarcoidosis and 23 patients with DCM. Sera from 30 normal volunteers served as controls. Additionally, the expression profiles of MRP8/14 in the myocardium from 12 patients with active cardiac sarcoidosis and 10 DCM patients were examined immunohistochemically. Serum MRP8/14 levels were significantly higher in patients with sarcoidosis than in normal controls [515+/-549 (SD) ng/ml vs 230+/-115 ng/ml, p=0.0019]. In the sarcoidosis group, serum MRP8/14 levels in patients with definite cardiac involvement (n=10) were significantly higher than in those without (n=25) (974+/-878 ng/ml vs 332+/-204 ng/ml, p=0.0227) and they were also higher than in DCM patients (vs 252+/-108 ng/ml, p=0.0026). Immunohistochemically, MRP8/14 was specifically positive in the cytoplasm of macrophages and multinucleated giant cells in the myocardial granulomas.

CONCLUSIONS

MRP8/14 may be involved in the pathogenesis of sarcoid granulomas. The measurement of serum MRP8/14 levels is useful for the diagnosis of sarcoidosis, and their higher levels suggest the cardiac involvement.

Sarcoid heart disease

To this day the aetiology of sarcoidosis continues to elude definition. Partially as a consequence of this, little in the way of new therapies has evolved. The enigma of this condition is that, unusually for a disease with the potential for devastating consequences, many patients show spontaneous resolution and recover. Cardiac involvement can affect individuals of any age, gender or race and has a predilection for the conduction system of the heart. Heart involvement can also cause a dilated cardiomyopathy with consequent progressive heart failure. The most common presentation of this systemic disease is with pulmonary infiltration, but many cases will be asymptomatic and are detected on routine chest radiography revealing lymphadenopathy. Current advances lie in the newer methods of imaging and diagnosing this unusual heart disease. This review describes the pathology and diagnosis of this condition and the newer imaging techniques that have developed for determining cardiac involvement.

Use of tissue Doppler imaging to identify and manage systemic diseases

In systemic diseases such as amyloidosis, sarcoidosis, Friedreich's ataxia, Fabry's disease and muscular dystrophy the clinician has to judge the presence and the amount of cardiac involvement. In most of these patients conventional echocardiographic parameters are not sensitive enough to detect sub-clinical dysfunction. Tissue Doppler imaging and in addition strain rate imaging has proven to be very sensitive for the assessment of myocardial dysfunction. This review explores the impact of these new techniques to identify and to manage cardiac aspects of the different systemic diseases.

Isolated Cardiac Sarcoidosis Associated with the Expression of a Splice Variant Coding for a Truncated BTNL2 Protein

A 33-year-old woman presented with clinical signs of heart failure and previously diagnosed complete atrioventricular block. DNA sequencing revealed a homozygous point mutation in exon 5 of the btnl2 gene coding for a truncated protein which lacks the membrane-anchoring motif. This single nucleotide polymorphism is known to be a risk factor for sarcoidosis. Indeed, endomyocardial biopsy demonstrated multiple nonnecrotizing granulomas composed of epitheloid cells and moderate numbers of multinucleated giant cells. Because no other organs were affected, isolated cardiac sarcoidosis was diagnosed and treated with corticosteroids. Thus, detection of the disease-associated btln2 allele may help to identify patients with sarcoidosis as the underlying cause of heart failure.

Intraoperative Diagnosis of Isolated Cardiac Sarcoid

Cardiac sarcoid is a rare and frequently fatal disease. We report a case of isolated cardiac sarcoid diagnosed during elective cardiac surgery. Although this patient presented with a history that was consistent with sarcoid heart disease, diagnosis is challenging when there is no other organ involvement with sarcoid. The patient was successfully treated with steroids and 8 years later remains clinically free of sarcoidosis.

Potential of the Right Ventricular Endomyocardial Biopsy to Diagnose and Assist in the Management of Congestive Heart Failure: Insights From Recent Clinical Trials

In the United States congestive heart failure is most commonly due to ischemic cardiomyopathy, but nonischemic causes of cardiomyopathy can also result in congestive heart failure. Indeed, nonischemic dilated cardiomyopathy affects approximately 100,000 persons in the United States and is responsible for 45% of heart transplants. Although these patients undergo thorough cardiovascular evaluation, a specific cause is usually not found. Endomyocardial biopsy may yield diagnostic and prognostic information in this setting, and there has been a renewed interest in the use of endomyocardial biopsy in the evaluation of specific subsets of patients with congestive heart failure to identify potentially treatable myocarditides. However, the role of endomyocardial biopsy in the evaluation of patients with nonischemic cardiomyopathy is ill defined. In this review, the authors discuss the latest data on the risks and the utility of endomyocardial biopsy in the management of heart failure in the setting of dilated cardiomyopathy and specific myocarditides. Gaps in present knowledge and the obstacles to research in this area are identified.

Non-Invasive Detection of Latent Cardiac Conduction Abnormalities in Patients With Pulmonary Sarcoidosis Application of Signal Averaged Electrocardiogram

BACKGROUND

Electrocardiographic conduction abnormalities including development of atrioventricular block, bundle branch block or ventricular arrhythmias are characteristic manifestations of cardiac sarcoidosis (CS). The present study seeks to show the minute conduction abnormality by detection of late potentials (LP) on signal averaged electrocardiogram (SAECG).

METHODS AND RESULTS

Ten patients with CS, 52 patients with pulmonary sarcoidosis (PS) but no obvious cardiac manifestations and 52 normal controls were studied. All participants underwent SAECG to detect LP. In patients with CS (the CS group), LP were detected in 8 patients (80%). In 52 patients with PS, LP were detected in 25 patients (46.2%, PS-LP(+) group), comparing only 3 (5.8%) of normal controls (p<0.0001). The remaining 27 patients with PS with negative LP were classified in the PS-LP(-) group. In the CS group, premature ventricular contraction frequency on Holter's monitoring and plasma B-type natriuretic peptide concentrations were significantly higher than those in the PS group. However, no significant difference in these parameters between PS-LP(+) and PS-LP(-) groups were found.

CONCLUSIONS

In the PS patients without obvious cardiac manifestations, LP were detected as high as 46.2%, suggesting latent minute conduction abnormality. The higher incidence of LP in PS might be considered as an expression of latent myocardial fibrosis. Close follow-up is needed in these patients.

Utility of gallium-67 scintigraphy for evaluation of cardiac sarcoidosis with ventricular tachycardia

BACKGROUND

The outcome of cardiac sarcoidosis is sometimes very poor. Ventricular tachycardia (VT) associated with cardiac sarcoidosis is the most common cause of sudden death among most patients. However, there is no established method for potential VT in patients with cardiac sarcoidosis. Thus, we investigated the utility of evaluation of gallium-67 scintigraphy for potential VT in patients with cardiac sarcoidosis.

METHODS AND RESULTS

Cardiac sarcoidosis was diagnosed in 25 patients at ours or collaborating hospitals during the period 1982 through 2004. Twenty-one of these patients were treated with corticosteroid, and these patients were divided into two groups, depending on whether VT was present: a non-VT group (n=7) and a VT group (n=14). Laboratory and gallium-67 scintigraphy findings were examined in both groups. During the follow-up period, initial and maintenance dosages of corticosteroid did not differ significantly between the groups. Accumulation of gallium-67 in the heart at the time of diagnosis was detected more frequently in the VT group than in the non-VT group (14.3 vs. 71.4%, p<0.05). Six of the seven VT patients who underwent follow-up examination showed improvement on the scintigram obtained after treatment. Five of the six showed no VT recurrence in terms of Holter electrocardiogram, electrophysiologic study, or delivery of implantable cardioverter defibrillator shock. Serum angiotensin-converting enzyme and lysozyme concentrations were within normal limits in most patients in both groups.

CONCLUSIONS

Activity of sarcoid granulomas may be associated with the occurrence of VT. Gallium-67 scintigraphy reflects the activity of sarcoid granulomas and thus is useful for evaluation of cardiac sarcoidosis in patients with potential VT.

A retrospective study of cutaneous equine sarcoidosis and its potential infectious aetiological agents

Nine horses from ages 5 to 21 years were diagnosed with cutaneous equine sarcoidosis (ES) over an 18-year period. In addition to skin, the lungs were frequently involved, with other organ systems affected less commonly. A predisposition for thoroughbreds and geldings was noted. Cutaneous lesions and signs included crusts, scales, alopecia and pruritus. These were found at various sites, particularly the legs/thighs/elbows, thorax, neck, face and ventral abdomen. Three horses were euthanized shortly after hospitalization; others survived as long as 12 years. Histopathologic stains, immunohistochemistry and polymerase chain reaction assays on paraffin-embedded cutaneous specimens from eight horses for Mycobacterium spp., Coccidioides immitis, Cryptococcus neoformans, Corynebacterium pseudotuberculosis, and Borrelia burgdorferi were all negative. The aetiology of ES is unlikely microbial and continues to be a diagnosis of exclusion. ES, when limited to the skin, is associated with a good prognosis, with either partial or complete response to glucocorticoid therapy in all the surviving horses.

Sudden death in nondilated cardiomyopathies: pathophysiology and prevention

Sudden cardiac death is a frequent cause of death and has been well studied in the setting of both ischemic and dilated cardiomyopathies. The primary and secondary prevention of sudden cardiac death has not been the focus of randomized clinical trials in the large cohort of patients with nondilated, nonischemic cardiomyopathies, however. Those disorders include hypertrophic cardiomyopathy and its apical variant, arrhythmogenic right ventricular cardiomyopathy, takotsubo cardiomyopathy, left ventricular noncompaction, cardiac amyloidosis, and cardiac sarcoidosis. In these conditions, risk stratification for sudden death is based on observational data.

Transplantation for myocarditis: a controversy revisited

Myocarditis is a major cause of end-stage heart failure and is responsible for up to 10% of cases of idiopathic dilated cardiomyopathy (IDC). Worldwide, approximately 45% of all heart transplants are performed for IDC and up to 8% for myocarditis. Early reports suggested that survival after transplantation for myocarditis was poor and patients had an increased risk of rejection. More recently, larger case series suggest that overall survival after transplantation for myocarditis is similar to survival after transplantation for other causes. However, certain disorders, including cardiac sarcoidosis and giant cell myocarditis (GCM), require heightened surveillance for post-transplantation disease recurrence. We present the case of a 42-year-old man with recurrence of GCM 8 years after transplantation and review the literature on the role of cardiac transplantation for patients with myocarditis.

Demonstration of Cardiac Involvement of Sarcoidosis by Contrast-Enhanced Multislice Computed Tomography and Delayed-Enhanced Magnetic Resonance Imaging

Delayed-enhanced magnetic resonance (MR) imaging has recently been shown to be effective in detecting cardiac sarcoidosis. Two cases in which contrast-enhanced multislice computed tomography imaging clearly identified the localization and extension of cardiac sarcoidosis as delayed-enhanced MR imaging are presented.

Detection of cardiac sarcoidosis using cardiac markers and myocardial integrated backscatter

BACKGROUND

It is not known whether cardiac markers and cyclic variations of integrated backscatter can be used to detect cardiac sarcoidosis.

METHODS

We studied 62 patients with sarcoidosis affecting the lung, eyes, skin, or heart (27 patients with cardiac involvement and 35 patients without). The cyclic variation of integrated backscatter and wall thickening was evaluated in the left ventricular anterior septum and posterior wall. Plasma A-type natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) concentrations and serum cardiac troponin T were also determined.

RESULTS

Plasma natriuretic peptide concentrations were higher in the cardiac involvement group (ANP: 15.5 [interquartile range (IQR) 2.5-34.0] vs. 12.0 [10.0-16.5] pg/ml, P=0.25; BNP: 28.6 [5.9-141] vs. 10.1 [4.8-15.4] pg/ml, P=0.049). However, cardiac troponin T concentration was <0.01 ng/ml in all patients. Receiver-operator characteristic (ROC) analysis showed that both ANP and BNP could identify patients with high-degree atrioventricular block, ventricular tachyarrhythmias, or symptomatic heart failure (the areas under the ROC curve were 0.94 and 0.97, respectively). The cardiac involvement group could be distinguished from the noninvolvement group by combining cutoff values for the magnitude of integrated backscatter cyclic variation (5.5 dB) and wall thickening (30%), albeit only for the posterior wall.

CONCLUSION

Both ANP and BNP are useful markers for identifying patients with sarcoidosis and cardiac complication(s). Moreover, evaluation of integrated backscatter cyclic variation combined with wall thickening may be of help in detecting cardiac involvement in the posterior wall.

Biventricular assist device placement and immunosuppression as therapy for necrotizing eosinophilic myocarditis

BACKGROUND

A previously healthy 47-year-old woman presented reporting nausea, anorexia and light-headedness of 2 weeks' duration, and three episodes of syncope. She also had pleuritic chest pain and rapidly declining cardiac function. The only reported medical history was urinary tract infection and an ankle fracture sustained 5 months before presentation. She was receiving no medication other than estrogen patches for menopause and did not smoke or use illicit drugs.

INVESTIGATIONS

Electrocardiography, chest radiography, echocardiography, measurement of creatinine phosphokinase and troponin T, coronary angiography and endomyocardial biopsy.

DIAGNOSIS

Necrotizing eosinophilic myocarditis.

MANAGEMENT

Biventricular assist device implantation, methylprednisolone, prednisolone and mycophenolate mofetil.

Endomyocardial biopsy for non-transplant-related disorders

Endomyocardial biopsy (EMB) remains the "gold standard" for diagnosing rejection after cardiac transplantation. In addition, it has value in monitoring patients during treatment with doxorubicin. It also is important in the setting of acute-onset heart failure for the diagnosis of myocarditis, particularly giant cell myocarditis because earlier transplantation usually is undertaken in patients with giant cell morphologic features. EMB has a role in the unexplained cardiomyoapthy for excluding specific disease processes that might lead to similar morphofunctional changes but might be reversible or a contraindication for transplantation. This review focuses on the growing number of diseases that can be diagnosed by EMB in adult and pediatric age groups.

Evaluation of the accuracy of gadolinium-enhanced cardiovascular magnetic resonance in the diagnosis of cardiac sarcoidosis

OBJECTIVES

This study analyzed the accuracy of gadolinium-enhanced cardiovascular magnetic resonance (CMR) for the diagnosis of cardiac sarcoidosis (CS).

BACKGROUND

The diagnosis of CS was made according to the guidelines of the Japanese Ministry of Health and Welfare (1993); CMR has not been incorporated into the guidelines, and the diagnostic accuracy of CMR for the diagnosis of CS has not yet been evaluated.

METHODS

We performed an analysis of 12-lead electrocardiograms (ECGs), 24-h ambulatory ECGs, echocardiograms, thallium scintigrams, and gadolinium-enhanced CMR studies in 58 biopsy-proven pulmonary sarcoidosis patients assessed for CS. The diagnostic accuracy of CMR for CS was determined using modified Japanese guidelines as the gold standard.

RESULTS

The diagnosis of CS was made in 12 of 58 patients (21%); CMR revealed late gadolinium enhancement (LGE), mostly involving basal and lateral segments (73%), in 19 patients. In 8 of the 19 patients, scintigraphy was normal, while patchy LGE was present. The sensitivity and specificity of CMR were 100% (95% confidence interval, 78% to 100%) and 78% (95% confidence interval, 64% to 89%), and the positive and negative predictive values were 55% and 100%, respectively, with an overall accuracy of 83%.

CONCLUSIONS

In patients with sarcoidosis, CMR is a useful diagnostic tool to determine cardiac involvement. New diagnostic guidelines should include CMR.

Recurrent pleural and pericardial effusions due to sarcoidosis

A 54-year-old man presented with fever, shortness of breath, and left-sided pleuritic chest pain. His bilateral pleural effusions and pericardial effusion turned out to be due to sarcoidosis

Cardiac sarcoidosis: a retrospective study of 41 cases

This retrospective study concerned 18 female and 23 male patients with cardiac sarcoidosis (CS). The average age at CS diagnosis was 38 years. CS was observed in white (73% of cases) and in black or Caribbean patients (27% of cases). All patients had extracardiac histologic proof of sarcoid tissue. In 63% of cases, the CS arose during the follow-up of systemic sarcoidosis. Systemic sarcoidosis was not specific except for a high frequency of neurosarcoidosis. Revealing cardiac signs were clinical in 63% of cases and electrical in 22%. In most patients these signs were associated with an abnormal echocardiography (77%) and/or a defect on thallium-201 or sestamibi imaging (75%). Thirty-nine patients received steroid therapy (initial dose mostly equal to 1 mg/kg per day), associated in 13 cases with another immunosuppressive treatment. In 26% of cases the immunosuppressive treatment was associated with a specific cardiac treatment. In the long-term follow-up (average follow-up, 58 mo), 87% of the cases showed an improvement, and 54% were cured from a clinical and laboratory point of view (electrocardiogram, 24-hour monitoring, echocardiography, radionuclide imaging). There was no sudden death. Two patients worsened, which can be explained in 1 case by very late treatment and in the other case by lack of treatment, except for a pacemaker. Our experience leads us to treat CS with corticosteroids as soon as possible and to use another immunosuppressive treatment where there is an insufficient therapeutic response or where there are contraindications to corticosteroids.

Sarcoid heart disease: clinical course and treatment

Sarcoidosis is a rare granulomatous disease of unknown etiology that can affect any organ. Cardiac involvement, although uncommon, has a wide spectrum of clinical manifestations and is potentially fatal. Although there is no agreement upon a strategy for the diagnosis (which is difficult to make based on clinical information alone), the introduction of newer technology is promising and may be useful both for the early diagnosis of cardiac involvement and for the evaluation of response to therapy. Early treatment is crucial in improving symptoms and prognosis. ICD implantation and cardiac transplantation may offer improvements in management, as steroid therapy and pacemaker implantation has led to improved outcomes over the past three decades.

Ventricular tachyarrhythmia associated with cardiac sarcoidosis: its mechanisms and outcome

BACKGROUND

Cardiac sarcoidosis is increasingly recognized and is associated with poor prognosis. Ventricular tachycardia (VT) associated with cardiac sarcoidosis is the most likely cause of sudden death in most patients, but the mechanism has not been well established.

HYPOTHESIS

This study investigated the mechanisms and outcome of VT associated with cardiac sarcoidosis.

METHODS

The study included eight consecutive patients (five men, three women, aged 54 +/- 19 years) who had sustained monomorphic VT associated with cardiac sarcoidosis in our hospital.

RESULTS

The average ejection fraction was 43 +/- 11%. Twenty-two VTs were observed in these patients, and mean heart rate during VT was 192 +/- 29 beats/min (range 144-259). The phenomenon of transient entrainment was documented in 10 of 22 (45%) VTs by ventricular pacing (eight in the active phase). Another five (23%) VTs could not be entrained, but could be initiated by programmed stimulation and terminated by rapid pacing, reproducibly. In 3 of the 22 (14%) VTs, cardioversion was required urgently because of the fast rate, while the remaining 4 (18%) could be induced during electrophysiologic study.

CONCLUSIONS

In this study, there was a high possibility that the mechanism of 15 (68%) VTs was reentry. Reentrant substrate is formed not only in association with the healing of cardiac granulomas in the inactive phase of cardiac sarcoidosis but also in the active phase. Ventricular tachycardia with cardiac sarcoidosis, even if this mechanism is reentry, has different inducibility between the active and inactive phases in an electrophysiologic study. This makes the therapy for cardiac sarcoidosis (e.g., corticosteroids, antiarrhythmic agents, and catheter ablation) difficult. The implantable cardioverter-defibrillator is an effective treatment for ventricular tachyarrythmia with cardiac sarcoidosis.

Diagnosis de localisations cardiaques et suivi longitudinal de 24 sarcoïdoses

PURPOSE

Cardiac sarcoidosis is responsible for 50% of deaths which mainly occur by ventricular arrhythmia or conduction disorders. The aim of this study is to determine the value of cardiac explorations for an early diagnosis of these localizations, which are often underestimated and can cause sudden death.

PATIENTS AND METHODS

We prospectively studied 24 consecutive patients, aged 33 +/-10 years, presenting with a sarcoidosis. Nine (38%) were asymptomatic and had no treatment. Fifteen (62%) were symptomatic: two (8%) had only pulmonary lesions and 13 (54%) had a polyvisceral disease. Seven (30%) were treated. Thirteen (54%) had an elevation of the disease activity markers. The patients had a 12-lead ECG, an echocardiography (TTE), a Holter ECG and a Magnetic Resonance Imaging (MRI) at inclusion.

RESULTS

Realization rate was: 100% ECG (24), 83% TTE (20), 75% Holter ECG (18) and 62% MRI (15). Only two patients (8%) had a cardiac involvement. The first one had a polyvisceral sarcoidosis presenting with a hypokinetic cardiomyopathy and a complete AV block and the second one presented with a complete AV block which revealed sarcoidosis. Both patients had a MRI septal hypersignal and disease activity markers. They were treated with cardiac stimulation and corticotherapy: the first patient died suddenly, the second one remains asymptomatic after a 14 months follow-up. The 22 patients (92%) with normal explorations did not present any cardiac involvement during the follow-up (3.7 +/-1.6 years).

CONCLUSIONS

This study confirms the rarity of cardiac involvement in sarcoidosis. An exhaustive cardiac check-up does not seem very productive even for patients presenting with polyvisceral disease or an elevation of disease markers. A systematic 12-lead ECG seems to be the most useful and simple tool for the early diagnosis of cardiac sarcoidosis. The other explorations will be realized according to clinical data. The absence of abnormal findings seems to have a good negative predictive value allowing to rule out a cardiac problem.

Cardiac sarcoidosis: an overview of management for the patient requiring oral and maxillofacial surgery

PURPOSE

The study goal was to present a current definition of sarcoidosis and an overview of cardiac involvement and implications in perioperative management of cardiac sarcoidosis.

MATERIALS AND METHODS

Materials included a retrospective review of 4 patients with cardiac sarcoidosis who underwent minor oral surgery. Laboratory data, medical data, and data obtained through monitoring the patient's general condition related to the surgery were critically analyzed.

RESULTS

Preoperative understanding of cardiac pathophysiology, evaluation of the patient's general condition, laboratory data, medical records, and physician correspondence were important, as was precise treatment planning against cardiac emergencies that could occur in surgical treatments. It was essential to monitor vital signs, any electrocardiographic changes, blood pressure, and heart rate, starting from the pretreatment period and continuing through the oral and maxillofacial surgery into the post-treatment period. Glucocorticosteroid coverage and prevention of endocarditis were also considered during oral and maxillofacial surgery planning.

CONCLUSIONS

Critical issues were identified in the performance of oral and maxillofacial surgery for patients with cardiac sarcoidosis.

A clinical and histopathologic comparison of cardiac sarcoidosis and idiopathic giant cell myocarditis

OBJECTIVES

The goal of this study was to determine the prognostic value of clinical data available at presentation and histology in cardiac sarcoidosis (CS) and idiopathic giant cell myocarditis (IGCM).

BACKGROUND

The prognosis of patients with nonischemic cardiomyopathy is partly dependent on the histologic diagnosis. Survival in IGCM is poor. The prognosis of a histologically related entity, cardiac sarcoidosis (CS), is less well established, and the prognostic value of the distinction between CS and IGCM on endomyocardial biopsy (EMB) is unknown.

METHODS

We identified 115 patients from the Multicenter IGCM Registry with CS (n = 42) and IGCM (n = 73). We compared the clinical data for these two groups using Cox proportional-hazards models to assess the association between histologic diagnosis and survival. In order to determine whether histologic features could reliably differentiate these two entities, two cardiac pathologists semiquantitatively graded the inflammatory infiltrate components and compared the results between groups.

RESULTS

Black race was more frequent in the CS group (31% vs. 4%, p < 0.0001). Syncope and atrioventricular block were also more frequently observed in CS than IGCM (31% vs. 5%, p = 0.0002 and 50% vs. 15%, p < 0.0001, respectively). Left-sided heart failure was more common in IGCM (40% vs. 64%, p = 0.013). In CS patients diagnosed by EMB, the five-year transplant-free survival after diagnosis was 69.8% versus 21.9% for IGCM (p < 0.0001, log-rank test). In multivariate models, presentation with heart failure predicted IGCM, and presentation with heart block or more than nine weeks of symptoms predicted CS. Eosinophils, myocyte damage, and foci of lymphocytic myocarditis were more frequent in IGCM, while granulomas and fibrosis were more frequent in CS.

CONCLUSIONS

Transplant-free survival is better for patients with CS than for IGCM diagnosed by EMB. Presentation with heart failure predicted IGCM, and presentation with heart block or more than nine weeks of symptoms predicted CS.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

Spontaneous development of left ventricular aneurysm in a patient with untreated cardiac sarcoidosis

A young adult patient with untreated sarcoidosis spontaneously developed a left ventricular (LV) aneurysm in the anterolateral free wall. Single-photon emission computed tomography (SPECT) using Gallium-67 clearly demonstrated widespread abnormal uptake, including the LV aneurysm. Thallium-201 SPECT revealed a perfusion defect in the anterolateral wall, and abnormal uptake of technetium-99m pyrophosphate was seen, especially in the borders of the defect lesion.