Ventricular tachyarrhythmia associated with cardiac sarcoidosis: its mechanisms and outcome

Cardiac sarcoidosis with extensive and heterogeneous left ventricular FDG uptake in absence of guidelines indication for an implantable defibrillator: Ventricular tachycardia precipitated by immunosuppressive therapy, should we have done differently?

A 40-year-old man, newly diagnosed with cardiac sarcoidosis (CS) presented with symptomatic ventricular tachycardia three days after starting steroid-based immunosuppressive therapy (IT). There was no clear guideline indication for implantable cardioverter-defibrillator (ICD) before the initiation of IT. Shortly after ICD implantation and the initiation of anti-arrhythmic drugs, recurring ventricular arrhythmias required titration of the anti-arrhythmic drug therapy. One-year follow-up assessment showed no significant arrhythmias and complete PET scan FDG uptake suppression. This case, along with recent publications, suggests transient pro-arrhythmic effects of steroids in patients with CS, which are not appropriately addressed in the current guidelines. We believe ICD implantation should be considered in clinically manifest CS before initiating IT, particularly in cases with heterogeneous and/or extensive FDG uptake on PET scans.

Cardiac sarcoidosis in a patient with ulcerative colitis: A case report and literature review

RATIONALE

Both ulcerative colitis (UC) and sarcoidosis are chronic inflammatory diseases with unknown etiologies and are rare. However, the odds ratio in UC patients has been reported to range from 1.7 to 2.1, suggesting a potential etiology between sarcoidosis and UC. Furthermore, the underlying etiologies of UC and sarcoidosis remain unidentified. Sharing the experience of a UC patient with cardiac sarcoidosis could provide valuable insights to prevent sudden death in UC patients.

PATIENT CONCERNS

A 71-year-old Japanese woman was diagnosed with UC at 58-year-old and maintained remission on mesalazine treatment. She complained of just palpitation; therefore, she consulted a cardiologist.

DIAGNOSES

The patient received a diagnosis of cardiac sarcoidosis with complicating ulcerative colitis based on the results of N-terminal prohormone of the brain natriuretic peptide (NT-proBNP), imaging examinations, and histology.

INTERVENTION

The patient was treated with prednisolone and methotrexate. The prednisolone was then tapered, and the methotrexate dose was adjusted based on her symptoms, imaging results, and laboratory findings.

OUTCOME

She no longer had any symptoms, and the abnormal FDG uptake had disappeared after 2 years.

LESSON

In UC patients, periodic or additional (in case of symptomatic) electrocardiography and NT-proBNP are recommended for the early detection of cardiac sarcoidosis, a life-threatening complication.

Update on cardiac sarcoidosis

Cardiac sarcoidosis is an inflammatory myocardial disease of unknown etiology. It is characterized by the deposition of non-caseating granulomas that may involve any part of the heart. Cardiac sarcoidosis is often under-diagnosed or recognized partly due to the heterogeneous clinical presentation of the disease. The three most frequent clinical manifestations of cardiac sarcoidosis are atrioventricular block, ventricular arrhythmias, and heart failure. A definitive diagnosis of cardiac sarcoidosis can be made with histology findings from an endomyocardial biopsy. However, the diagnosis in the majority of cases is based on findings from the clinical presentation and advanced imaging due to the low sensitivity of endomyocardial biopsy. The Heart Rhythm Society (HRS) 2014 expert consensus statement and the Japanese Ministry of Health and Welfare criteria are the two most commonly used diagnostic criteria sets. This review article summarizes the available evidence on cardiac sarcoidosis, focusing on the diagnostic criteria and stepwise approach to its management.

Prednisone vs methotrexate in treatment naïve cardiac sarcoidosis

BACKGROUND

Side effects limit the long-term use of glucocorticoids in cardiac sarcoidosis (CS), and methotrexate has gained attention as steroid sparing agent although the supporting evidence is poor. This study compared prednisone monotherapy, methotrexate monotherapy or a combination of both, in the reduction of myocardial Fluorine-18 fluorodeoxyglucose (FDG) uptake and clinical stabilization of CS patients.

METHODS AND RESULTS

In this retrospective cohort study, 61 newly diagnosed and treatment naïve CS patients commenced treatment with prednisone (N = 21), methotrexate (N = 30) or prednisone and methotrexate (N = 10) between January 2010 and December 2017. Primary outcome was metabolic response on FDG PET/CT and secondary outcomes were treatment patterns, major adverse cardiovascular events, left ventricular ejection fraction, biomarkers and side effects. At a median treatment duration of 6.2 [5.7-7.2] months, 71.4% of patients were FDG PET/CT responders, and the overall myocardial maximum standardized uptake value decreased from 6.9 [5.0-10.1] to 3.4 [2.1-4.7] (P < 0.001), with no significant differences between treatment groups. During 24 months of follow-up, 7 patients (33.3%; prednisone), 6 patients (20.0%; methotrexate) and 1 patient (10.0%; combination group) experienced at least one major adverse cardiovascular event (P = 0.292). Left ventricular ejection fraction was preserved in all treatment groups.

CONCLUSIONS

Significant suppression of cardiac FDG uptake occurred in CS patients after 6 months of prednisone, methotrexate or combination therapy. There were no significant differences in clinical outcomes during follow-up. These results warrant further investigation of methotrexate treatment in CS patients.

Characteristics and survival of patients diagnosed with cardiac sarcoidosis: A case series

Background

Sarcoidosis is a multiorgan system granulomatous disease of unknown etiology. It is hypothesized that a combination of environmental, occupational, and/or infectious factors provoke an immunological response in genetically susceptible individuals, resulting in a diversity of manifestations throughout the body. In the United States, cardiac sarcoidosis (CS) is diagnosed in 5% of patients with systemic sarcoidosis, however, autopsy results suggest that cardiac involvement may be present in > 50% of patients. CS is debilitating and significantly decreases quality of life and survival. Currently, there are no gold-standard clinical diagnostic or monitoring criteria for CS.

Methods

We identified patients with a diagnosis of sarcoidosis who were seen at the Simmons Center from 2007 to 2020 who had a positive finding of CS documented with cardiovascular magnetic resonance (CMR) and/or endomyocardial biopsy as found in the electronic health record. Medical records were independently reviewed for interpretation and diagnostic features of CS including late gadolinium enhancement (LGE) patterns, increased signal on T2-weighted imaging, and non-caseating granulomas, respectively. Extracardiac organ involvement, cardiac manifestations, comorbid conditions, treatment history, and vital status were also abstracted.

Results

We identified 44 unique patients with evidence of CS out of 246 CMR reports and 9 endomyocardial biopsy pathology reports. The first eligible case was diagnosed in 2007. The majority of patients (73%) had pulmonary manifestations, followed by hepatic manifestations (23%), cutaneous involvement (23%), and urolithiasis (20%). Heart failure was the most common cardiac manifestation affecting 59% of patients. Of these, 39% had a documented left ventricular ejection fraction of < 50% on CMR. Fifty eight percent of patients had a conduction disease and 44% of patients had documented ventricular arrhythmias. Pharmacotherapy was usually initiated for extracardiac manifestations and 93% of patients had been prescribed prednisone. ICD implantation occurred in 43% of patients. Patients were followed up for a median of 5.4 (IQR: 2.4-8.5) years. The 10-year survival was 70%. In addition to age, cutaneous involvement was associated with an increased risk of death (age-adjusted OR 8.47, 95% CI = 1.11-64.73).

Conclusion

CMR is an important tool in the non-invasive diagnosis of CS. The presence of LGE on CMR in a pattern consistent with CS has been shown to be a predictor of mortality and likely contributed to a high proportion of patients undergoing ICD implantation to decrease risk of sudden cardiac death.

Clinical implications

Additional studies are necessary to develop robust criteria for the diagnosis of CS with CMR, assess the benefit of serial imaging for disease monitoring, and evaluate the effect of immunosuppression on disease progression.

Outcomes of catheter ablation for ventricular tachycardia in patients with sarcoidosis: Insights from the National Inpatient Sample database (2002-2018)

INTRODUCTION

Data on utilization, major complications, and in-hospital mortality of catheter ablation (CA) for sarcoidosis-related ventricular tachycardia (VT) are limited. We sought to determine the outcomes of sarcoidosis-related VT, and incidence and predictors of complications associated with the CA procedure.

METHODS

We queried the 2002-2018 National Inpatient Sample database to identify patients aged ≥18 years with sarcoidosis admitted with VT. A 1:3 propensity score-matched (PSM) analysis was used to compare patient outcomes between CA and medically managed groups. Multivariable regression was performed to determine independent predictors of in-hospital mortality and procedural complications associated with the CA procedure.

RESULTS

Of 3220 sarcoidosis patients with VT, 132 (4.1%) underwent CA. Patients who underwent CA were younger, male predominant, more likely Caucasian, had differences in baseline comorbidities including more likely to have heart failure, less likely to have prior myocardial infarction, COPD, or severe renal disease, had a higher mean household income, and more likely admitted to a larger/urban teaching hospital. After PSM, we examined 106 CA cases and 318 medically managed cases. There was a trend toward a lower in-hospital mortality rate in the CA group when compared to the medically managed group (1.9% vs. 6.6%, p = 0.08). The most common complications were pericardial drainage (5.3%), postoperative hemorrhage (3.8%), accidental puncture periprocedure (3.0%), and cardiac tamponade (2.3%). Independent predictors of in-hospital mortality and procedural complications among the CA group included congestive heart failure (odds ratio [OR], 13.2; 95% confidence interval [CI], 1.7-104.2) and mild to moderate renal disease (OR, 3.9; 95% CI, 1.1-13.3).

CONCLUSIONS

Compared to patients with sarcoidosis-related VT who received medical therapy alone, those who underwent CA have a trend for a lower mortality rate despite procedure-related complications occurring as high as 9.1%. Additional studies are recommended to better evaluate the benefits and risks of VT ablation in this group.

Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis

Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.

The prognostic value of positron emission tomography in the evaluation of suspected cardiac sarcoidosis

OBJECTIVES

To assess the prognostic value of positron emission tomography (PET) imaging in patients undergoing evaluation for known or suspected cardiac sarcoidosis (CS) while not on active immunotherapy.

BACKGROUND

Previous studies have attempted to identify the value of PET imaging to aid in risk stratification of patients with CS, however, most cohorts have included patients currently on immunosuppression, which may confound scan results by suppressing positive findings.

METHODS

We retrospectively analyzed 197 patients not on immunosuppression who underwent 18F-fluorodeoxyglucose (FDG) PET scans for evaluation of known or suspected CS. The primary endpoint of the study was time to ventricular arrhythmia (VT/VF), or death. Candidate predictors were identified by univariable Cox proportional hazards regression. Independent predictors were identified by performing multivariable Cox regression with stepwise forward selection.

RESULTS

Median follow-up time was 531 [IQR 309, 748] days. 41 patients met the primary endpoint. After stepwise forward selection, left ventricular ejection fraction (LVEF) (HR 0.98, 95% CI 0.96-0.99, P = 0.02), history of VT/VF (HR 4.19, 95% CI 2.15-8.17, P < 0.001), and summed rest score (SRS) (HR 1.06, 95% CI 1.02-1.12, P = 0.01) were predictive of the primary endpoint. Quantitative and qualitative measures of FDG uptake on PET were not predictive of clinical events.

CONCLUSIONS

Among untreated patients who underwent PET scans to evaluate known or suspected CS, LVEF, history of VT/VF, and SRS were associated with adverse clinical outcomes.

Meta-Analysis of Catheter Ablation Outcomes in Patients With Cardiac Sarcoidosis Refractory Ventricular Tachycardia

Cardiac sarcoidosis (CS) frequently leads to ventricular tachycardia (VT), which is often refractory to antiarrhythmic and/or immunosuppressive medications and requires catheter ablation. We conducted a systematic review and meta-analysis to evaluate the role of catheter ablation in patients with refractory VT undergoing catheter ablation. We searched PubMed, Embase, and Scopus databases from their inception to December 31, 2021 with search terms "cardiac sarcoidosis" AND "electrophysiological studies OR ablation." Fifteen studies were ultimately included for evaluation. Patient demographics, VT mapping, and acute and long-term procedural outcomes were extracted. A total of 15 studies were included in our meta-analysis, with a total of 401 patients, of whom 66% were male, with ages ranging from 39 to 64 years. A total of 95% of patients were on antiarrhythmics and 79% of patients were on immunosuppressants. Left ventricular ejection fraction ranged from 35% to 49% and procedure duration ranged from 269 to 462 minutes. Ablation was reported using both irrigated and nonirrigated catheter tips. A total of 25% of patients (84/339) underwent repeat ablation. Acute procedural success was achieved in 57% (161/285). Procedure complications occurred in 5.7% (17/297) procedures. VT recurrence after first ablation was 55% (confidence interval 48% to 63%, 213/401); VT recurrence after multiple ablations was 37% (81/220). The composite end point of death, heart transplant, and left ventricular assist device implantation was 21% (confidence interval 14% to 30%, 55/297). In conclusion, catheter ablation is a useful modality in patients with CS with refractory VT. However, patients with CS presenting with refractory VT after undergoing VT ablation carry a poor prognosis.

[Catheter ablation of ventricular tachycardia in patients with structural heart disease]

Ventricular cardiac rhythm disorders are potentially life-threatening arrhythmias. Ventricular tachycardia (VT) in patients with structural heart disease carries an increased risk of sudden cardiac death. Interventional radiofrequency catheter ablation is increasingly becoming the focus of treatment for ventricular arrhythmias. So far, no randomized study has been able to demonstrate a reduction in mortality; however, depending on the existing cardiomyopathy, interventional VT ablation has proven to be more effective for rhythm stabilization than antiarrhythmic therapy and is subsequently associated with improve quality of life through reduced implantable cardioverter defibrillator (ICD) treatment. The aim of this work is to discuss the pathophysiology, mechanism and treatment of VT with structural heart disease in order to define the role of catheter ablation.

Management of ventricular tachycardia in patients with cardiac sarcoidosis

Sarcoidosis is a multisystem granulomatous disease with 2 different phases (inflammation and scar). In the current era of targeted use of implantable cardioverter-defibrillators and modern heart failure therapy, recent data indicate the prognosis of cardiac sarcoidosis (CS) is much improved, and hence more patients are presenting with recurrent ventricular tachycardia (VT). This review highlights our current understanding of the pathophysiology and management of ventricular arrhythmias in CS with the major focus on indications, techniques, and outcomes of ablation. It is likely macroreentry phenomena around areas of fibrosis is the most frequent mechanism of ventricular arrhythmia in CS. It is also possible that inflammation may play a role in initiating reentry with ventricular ectopy in CS patients, or by slowing conduction in diseased tissue. The best available data would suggest annual rates of VT of perhaps 1%-2% and 10%-15% in patients with initially clinically silent and clinically manifest disease, respectively. Current guidelines recommend a stepwise approach to VT management. The first suggested step is treatment with immunosuppression if there is evidence of active inflammation. Antiarrhythmic medications are often started at the same time, with catheter ablation considered if VT cannot be controlled. Activation and entrainment mapping and ablation are favored in the setting of hemodynamically tolerated VT. Substrate ablation targets areas of abnormal electrogram and favorable pace mapping using linear and/or cluster lesion sets with the goal of abolishing critical isthmuses and/or blocking VT exit sites. Epicardial mapping ablation is required in 20%-35% of cases. In general, more morphologies of VT are induced (often 3-4) and subsequent outcomes (recurrence rates 40%-50%) are less favorable than in other forms of nonischemic cardiomyopathy. The prognosis of CS is much improved and, as a result, more patients are developing VT during follow-up. Likely principally related to the complex disease substrate, VT ablation is technically challenging, with moderate outcomes, and much remains to be learned.

Predicting risk of sudden cardiac death in patients with cardiac sarcoidosis using multimodality imaging and personalized heart modeling in a multivariable classifier

Cardiac sarcoidosis (CS), an inflammatory disease characterized by formation of granulomas in the heart, is associated with high risk of sudden cardiac death (SCD) from ventricular arrhythmias. Current "one-size-fits-all" guidelines for SCD risk assessment in CS result in insufficient appropriate primary prevention. Here, we present a two-step precision risk prediction technology for patients with CS. First, a patient's arrhythmogenic propensity arising from heterogeneous CS-induced ventricular remodeling is assessed using a novel personalized magnetic-resonance imaging and positron-emission tomography fusion mechanistic model. The resulting simulations of arrhythmogenesis are fed, together with a set of imaging and clinical biomarkers, into a supervised classifier. In a retrospective study of 45 patients, the technology achieved testing results of 60% sensitivity [95% confidence interval (CI): 57-63%], 72% specificity [95% CI: 70-74%], and 0.754 area under the receiver operating characteristic curve [95% CI: 0.710-0.797]. It outperformed clinical metrics, highlighting its potential to transform CS risk stratification.

Management of Cardiac Sarcoidosis Using Mycophenolate Mofetil as a Steroid-Sparing Agent

BACKGROUND

Cardiac sarcoidosis (CS) is a major cause of morbidity and mortality in patients with systemic sarcoidosis. Steroid-sparing agents are increasingly used, despite a lack of randomized trials or published guidelines to direct treatment.

METHODS AND RESULTS

This retrospective study included 77 patients with CS treated with prednisone monotherapy (n = 32) or a combination with mycophenolate mofetil (n = 45) between 2003 and 2018. Baseline characteristics and clinical outcomes were evaluated. The mean patient age was 53 ± 11 years at CS diagnosis, 66.2% were male, and 35.1% were Black. The total exposure to maximum prednisone dose (initial prednisone dose × days at dose) was lower in the combination therapy group (1440 mg [interquartile range (IQR), 1200-2760 mg] vs 2710 mg [IQR, 1200-5080 mg]; P = .06). On ¹⁸F-fluorodeoxyglucose positron emission tomography scans, both groups demonstrated a significant decrease in the cardiac maximum standardized uptake value after treatment: a median decrease of 3.9 (IQR 2.7-9.0, P = .002) and 2.9 (IQR 0-5.0, P = .001) for prednisone monotherapy and combination therapy, respectively. Most patients experienced improvement or complete resolution in qualitative cardiac ¹⁸F-fluorodeoxyglucose uptake (92.3% and 70.4% for the prednisone and combination therapy groups, respectively). Mycophenolate mofetil was well tolerated.

CONCLUSIONS

Mycophenolate mofetil in combination with prednisone for the treatment of CS may minimize corticosteroid exposure and decrease cardiac inflammation without significant adverse effects.

Ten Questions Cardiologists Should Be Able to Answer About Cardiac Sarcoidosis: Case-Based Approach and Contemporary Review

Sarcoidosis is an inflammatory multisystemic disease of unknown etiology characterized by the formation of noncaseating epithelioid cell granulomas. Cardiac sarcoidosis might be life-threatening and its diagnosis and treatment remain a challenge nowadays. The aim of this review is to provide an updated overview of cardiac sarcoidosis and, through 10 practical clinical questions and real-life challenging case scenarios, summarize the main clinical presentation, diagnostic criteria, imaging findings, and contemporary treatment.

Arrhythmias in Cardiac Sarcoidosis Bench to Bedside: A Case-Based Review

Cardiac sarcoidosis is a component of an often multiorgan granulomatous disease of still uncertain cause. It is being recognized with increasing frequency, mainly as the result of heightened awareness and new diagnostic tests, specifically cardiac magnetic resonance imaging and ¹⁸F-fluorodeoxyglucose positron emission tomography scans. The purpose of this case-based review is to highlight the potentially life-saving importance of making the early diagnosis of cardiac sarcoidosis using these new tools and to provide a framework for the optimal care of patients with this disease. We will review disease mechanisms as currently understood, associated arrhythmias including conduction abnormalities, and atrial and ventricular tachyarrhythmias, guideline-directed diagnostic criteria, screening of patients with extracardiac sarcoidosis, and the use of pacemakers and defibrillators in this setting. Treatment options, including those related to heart failure, and those which may help clarify disease mechanisms are included.

Outflow-tract ventricular tachycardia: Can 12 lead ECG during sinus rhythm identify underlying cardiac sarcoidosis?

Background

Patients with outflow tract ventricular tachycardia (OTVT) with normal echocardiogram are labeled as idiopathic VT (IVT). However, a subset of these patients is subsequently diagnosed with underlying cardiac sarcoidosis (CS). Objective:Whether electrocardiogram (ECG) abnormalities in sinus rhythm (SR) can differentiate underlying CS from IVT.

Methods

We retrospectively analyzed the SR-ECGs of 42 patients with OTVT/premature ventricular complexes (PVC) and normal echocardiography. All underwent advanced imaging with cardiac magnetic resonance (CMR)/¹⁸FDG PET-CT for screening of CS. Twenty-two patients had significant abnormalities in cardiac imaging and subsequently had biopsy-proven CS (Cases). Twenty patients had normal imaging and were categorized as IVT (Controls). SR-ECGs of all patients were analyzed by 2 independent, blinded observers.

Results

Baseline characteristics were comparable. Among the ECG features analyzed – fascicular (FB) or bundle branch block (BBB) was seen in 9/22 Cases vs. 1/20 controls (p = 0.01). Among patients without FB or BBB, fragmented QRS (fQRS) was present in 9/13 cases but in none of the controls (p < 0.001). Low voltage QRS was more often seen among cases as compared to controls (10/22 vs. 3/20 p = 0.03). A stepwise algorithm based on these 3 sets of ECG findings helped to diagnose CS among patients presenting with OTVT/PVC with sensitivity of 91%, specificity of 75%, a PPV of 80%, and a NPV of 88%.

Conclusions

In patients presenting with OTVT/PVC: FB/BBB, fQRS, and low QRS voltage on the baseline ECG were more often observed among patients with underlying CS as compared to true IVT. These findings may help to distinguish underlying CS among Cases presenting with OTVT/PVC.

Cardiac Arrhythmias in Autoimmune Diseases

Autoimmune diseases (ADs) affect approximately 10% of the world's population. Because ADs are frequently systemic disorders, cardiac involvement is common. In this review we focus on typical arrhythmias and their pathogenesis, arrhythmia-associated mortality, and possible treatment options among selected ADs (sarcoidosis, systemic lupus erythematosus, scleroderma, type 1 diabetes, Graves' disease, rheumatoid arthritis, ankylosing spondylitis [AS], psoriasis, celiac disease [CD], and inflammatory bowel disease [IBD]). Rhythm disorders have different underlying pathophysiologies; myocardial inflammation and fibrosis seem to be the most important factors. Inflammatory processes and oxidative stress lead to cardiomyocyte necrosis, with subsequent electrical and structural remodeling. Furthermore, chronic inflammation is the pathophysiological basis linking AD to autonomic dysfunction, including sympathetic overactivation and a decline in parasympathetic function. Autoantibody-mediated inhibitory effects of cellular events (i.e., potassium or L-type calcium currents, M₂muscarinic cholinergic or β₁-adrenergic receptor signaling) can also lead to cardiac arrhythmia. Drug-induced arrhythmias, caused, for example, by corticosteroids, methotrexate, chloroquine, are also observed among AD patients. The most common arrhythmia in most AD presentations is atrial arrhythmia (primarily atrial fibrillation), expect for sarcoidosis and scleroderma, which are characterized by a higher burden of ventricular arrhythmia. Arrhythmia-associated mortality is highest among patients with sarcoidosis and lowest among those with AS; there are scant data related to mortality in patients with psoriasis, CD, and IBD.

A new electrocardiographic parameter associated with sudden cardiac death in pulmonary sarcoidosis

INTRODUCTION

The interval from the peak to the end of the electrocardiographic T wave (T_p-T_e) may correspond to malignant ventricular arrhythmias. In this study we aimed to assess T_p-T_e variability and investigate the transmural dispersion of repolarisation in pulmonary sarcoidosis disease without proofed cardiac involvement.

MATERIAL AND METHODS

This was a retrospective case-control study that included patients who had a pathologic and radiologic diagnosis of sarcoidosis. All data of the patients' demographic features and electrocardiographs were analysed.

RESULTS

We enrolled 78 patients with sarcoidosis and 54 healthy volunteers as controls in our study. Men comprised 36% of the sarcoidosis group and 27% of controls. The mean age in the sarcoidosis and control group was 45.4 ±8.7 years (range: 23-58 years) and 44.6 ±11.9 years (range: 21-73 years), respectively. There was no significant difference between the groups for age or sex (p = 0.654, p = 0.246, respectively). There was a significant increase in T_p-T_e results in all precordial leads in the sarcoidosis group compared with the control group (p < 0.05).

CONCLUSIONS

Pulmonary sarcoidosis is suspected to have cardiac involvement; therefore, we need to develop new approaches. We present strong evidence that T_p-T_e intervals were increased in patients with pulmonary sarcoidosis, which suggests that there may be a link between sarcoidosis and ventricular arrhythmias without proofed cardiac involvement.

Myocarditis Causing Premature Ventricular Contractions: Insights From the MAVERIC Registry

BACKGROUND

Premature ventricular contractions are a common clinical presentation that drives further diagnostic workup. We hypothesize the presence of underlying inflammation is often unrecognized in these patients with a potential for continued disease progression if not diagnosed and treated early in the disease course.

METHODS

This is a single-center, prospective study including 107 patients with frequent symptomatic premature ventricular contractions (>5000/24 h) and no known ischemic heart disease. Patients underwent a combination of laboratory testing, 18F-fluorodeoxyglucose positron emission tomography scan, cardiac magnetic resonance imaging, and biopsy. Patients were diagnosed with myocarditis based on a multidisciplinary approach and treated with immunosuppressive therapy.

RESULTS

The mean age of the cohort was 57±15 years, 41% were males, and left ventricular ejection fraction was 47±11.8%. Positive positron emission tomography scan was seen in 51% (55/107), of which 51% (28/55) had preserved left ventricle function. Based on clinical profile, 18F-fluorodeoxyglucose-positron emission tomography imaging, cardiac magnetic resonance, and histological data 58% patients (32/55) received immunosuppressive therapy alone and 25.4% (14/55) received immunosuppressive therapy and catheter ablation. Optimal response was seen in 67% (31/46) over a mean follow-up of 6±3 months. In patients with left ventricle systolic dysfunction, 37% (10/27) showed an improvement in mean left ventricular ejection fraction of 13±6%.

CONCLUSIONS

Approximately 51% of patients presenting with frequent premature ventricular contractions have underlying myocardial inflammation in this cohort. 18F-fluorodeoxyglucose-positron emission tomography scan can be a useful modality for early diagnosis and treatment with immunosuppressive therapy in selected patients can improve clinical outcomes.

Long-Term Corticosteroid-Sparing Immunosuppression for Cardiac Sarcoidosis

Background

Long‐term corticosteroid therapy is the standard of care for treatment of cardiac sarcoidosis (CS). The efficacy of long‐term corticosteroid‐sparing immunosuppression in CS is unknown. The goal of this study was to assess the efficacy of methotrexate with or without adalimumab for long‐term disease suppression in CS, and to assess recurrence and adverse event rates after immunosuppression discontinuation.

Methods and Results

Retrospective chart review identified treatment‐naive CS patients at a single academic medical center who received corticosteroid‐sparing maintenance therapy. Demographics, cardiac uptake of 18‐fluorodeoxyglucose, and adverse cardiac events were compared before and during treatment and between those with persistent or interrupted immunosuppression. Twenty‐eight CS patients were followed for a mean 4.1 (SD 1.5) years. Twenty‐five patients received 4 to 8 weeks of high‐dose prednisone (>30 mg/day), followed by taper and maintenance therapy with methotrexate±low‐dose prednisone (low‐dose prednisone, <10 mg/day). Adalimumab was added in 19 patients with persistently active CS or in those with intolerance to methotrexate. Methotrexate±low‐dose prednisone resulted in initial reduction (88%) or elimination (60%) of 18‐fluorodeoxyglucose uptake, and patients receiving adalimumab‐containing regimens experienced improved (84%) or resolved (63%) 18‐fluorodeoxyglucose uptake. Radiologic relapse occurred in 8 of 9 patients after immunosuppression cessation, 4 patients on methotrexate‐containing regimens, and in no patients on adalimumab‐containing regimens.

Conclusions

Corticosteroid‐sparing regimens containing methotrexate with or without adalimumab is an effective maintenance therapy in patients after an initial response is confirmed. Disease recurrence in patients on and off immunosuppression support need for ongoing radiologic surveillance regardless of immunosuppression regimen.

Catheter ablation for ventricular tachycardia in patients with cardiac sarcoidosis: a systematic review

Aims

Cardiac sarcoidosis (CS) is associated with a poor prognosis. Important features of CS include heart failure, conduction abnormalities, and ventricular arrhythmias. Ventricular tachycardia (VT) is often refractory to antiarrhythmic drugs (AAD) and immunosuppression. Catheter ablation has emerged as a treatment option for recurrent VT. However, data on the efficacy and outcomes of VT ablation in this context are sparse.

Methods and results

A systematic search was performed on PubMed, EMBASE, and Cochrane database (from inception to September 2016) with included studies providing a minimum of information on CS patients undergoing VT ablation: age, gender, VT cycle length, CS diagnosis criteria, and baseline medications. Five studies reporting on 83 patients were identified. The mean age of patients was 50 ± 8 years, 53/30 (males/females) with a maximum of 56 patients receiving immunosuppressive therapy, mean ejection fraction was 39.1 ± 3.1% and 94% had an implantable cardioverter defibrillator in situ. The median number of VTs was 3 (2.6-4.9)/patient, mean cycle length of 360 ms (326-400 ms). Hundred percent of VTs received endocardial ablation, and 18% required epicardial ablation. The complication rates were 4.7-6.3%. Relapse occurred in 45 (54.2%) patients with an incidence of relapse 0.33 (95% confidence interval 0.108-0.551, P < 0.004). Employing a less stringent endpoint (i.e. freedom from arrhythmia or reduction of ventricular arrhythmia burden), 61 (88.4%) patients improved following ablation.

Conclusions

These data support the utilization of catheter ablation in selected CS cases resistant to medical treatment. However, data are derived from observational non-controlled case series, with low-methodological quality. Therefore, future well-designed, randomized controlled trials, or large-scale registries are required.

Viewpoints in the diagnosis and treatment of cardiac sarcoidosis: Proposed modification of current guidelines

Isolated cardiac sarcoidosis is a generally accepted disease condition, and the low yield of endomyocardial biopsy because of patchy involvement is also well known. However, current guidelines still require histologic confirmation of granuloma for the diagnosis of cardiac sarcoidosis, either in myocardial or extra-cardiac tissues. Therefore, only a presumptive diagnosis of chronic multifocal myocarditis of unknown origin can be made in a large number of patients in whom the only considerable diagnosis is cardiac sarcoidosis based on current knowledge. Even if these patients are treated with the same treatment scheme as that for cardiac sarcoidosis, which may not cause harm in the absence of a definite diagnosis, the true spectrum of cardiac sarcoidosis could not be determined for deciding the optimal treatment strategy. In addition, the current recommendations for dose, duration of initial steroid therapy, and treatment in patients who did not respond to initial steroid therapy are not easy to follow in real-world practice. We would like to propose a scoring system for the diagnosis of cardiac sarcoidosis and suggest our adoption or modification of the diverse current recommendations.

Cardiac sarcoidosis - an expert review for the chest physician

Introduction: Sarcoidosis is a multisystem granulomatous disease predominantly affecting the lungs, with increased risk of cardiovascular disease, pulmonary hypertension and cardiac sarcoidosis (CS), the latter due to direct granuloma infiltration. Sarcoidosis is often managed by chest physicians who need to understand the diagnostic pathways and initial management plans for patients with cardiac involvement. Areas covered: The most serious consequence of CS is sudden cardiac death due to ventricular tachyarrhythmias or complete atrioventricular block. Additional complications include atrial arrhythmias and congestive cardiac failure. There are no internationally accepted screening pathways, but a combination of history, clinical examination and ECG detects up to 85% of cases. Newer modalities including signal-averaged ECG and speckle-tracking echocardiography increase identification of patients who require a definitive diagnosis. Early immunosuppression reduces the risk of conduction abnormalities and incidence of supraventricular arrhythmias. Management of ventricular arrhythmias requires antiarrhythmic medications followed by possible catheter ablation and device (ICD) implantation. Expert commentary: Prospective trials are underway to identify the optimum methods for screening, which will guide future international statements on indications for and methods of screening in CS.

Decompensated Heart Failure With Ventricular Arrhythmia: How Useful Is VT Ablation?

PURPOSE OF REVIEW

Ventricular arrhythmias are common in patients with heart failure. Their management especially in the context of decompensated heart failure poses a clinical challenge to modern cardiologists. In this review article, we aim to summarise the current evidence on the epidemiology, pathophysiology, and management of ventricular tachycardia in heart failure, focusing primarily on the use of catheter ablation.

RECENT FINDINGS

The evolution of electro-anatomical mapping techniques and ablation catheter technology in the recent years has paved the path for the successful application of catheter ablation in the treatment of ventricular arrhythmias. The efficacy of catheter ablation in the management of ventricular tachycardia in patients with chronic heart failure has recently been the epicentre of a number of randomised controlled trials, demonstrating promising results with regard to arrhythmia suppression and all-cause mortality. The usefulness of catheter ablation in decompensated heart failure has been explored to a lesser degree, primarily in the setting of an electrical storm. Implantable cardiac defibrillators play the most important role in improving prognosis and preventing sudden cardiac death in patients with heart failure. Catheter ablation for the treatment of recurrent VT in patients with chronic heart failure is an efficacious strategy that can be applied adjunctively to or in instead of antiarrhythmic therapy, and it is highly successful at preventing recurrent ventricular tachycardia, ICD shocks. Its efficacy in the context of decompensated heart failure requires further research, with current evidence rendering its use promising.

A complete heart block in a young male: a case report and review of literature of cardiac sarcoidosis

Cardiac sarcoidosis is one of the uncommon causes of heart failure. Generally, it presents in the form of varying clinical manifestations ranging from asymptomatic to fatal arrhythmias such as ventricular tachycardia and complete heart block. It is difficult to make a diagnosis strictly based on clinical grounds. However, in the setting of extracardiac sarcoidosis and patients presenting with advanced heart block or ventricular arrhythmia, direct cardiac involvement should be suspected. The definitive diagnosis of cardiac sarcoidosis can be made from endomyocardial biopsy, but it is falling out of favor due to patchy myocardial involvement, considerable procedure-related risks, and advancement in additional imaging modalities. Once cardiac sarcoidosis has been diagnosed, management of the disease remains challenging. Steroids are considered the mainstay of therapy, and implantable cardioverter defibrillator therapy can be considered in a selected group of patients at greater risk for malignant ventricular arrhythmias.

Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Indications, Strategies, and Outcomes-Part II

In contrast to ventricular tachycardia (VT) that occurs in the setting of a structurally normal heart, VT that occurs in patients with structural heart disease carries an elevated risk for sudden cardiac death (SCD), and implantable cardioverter-defibrillators (ICDs) are the mainstay of therapy. In these individuals, catheter ablation may be used as adjunctive therapy to treat or prevent repetitive ICD therapies when antiarrhythmic drugs are ineffective or not desired. However, certain patients with frequent premature ventricular contractions (PVCs) or VT and tachycardiomyopathy should be considered for ablation before ICD implantation because left ventricular function may improve, consequently decreasing the risk of SCD and obviating the need for an ICD. The goal of this paper is to review the pathophysiology, mechanism, and management of VT in the setting of structural heart disease and discuss the evolving role of catheter ablation in decreasing ventricular arrhythmia recurrence.

Cardiac Sarcoidosis: A Review of Contemporary Challenges in Diagnosis and Treatment

Sarcoidosis is a systemic disease characterized by noncaseating granulomas and is often a diagnosis of exclusion. The actual prevalence of cardiac sarcoidosis (CS) is unknown, as studies have demonstrated mixed data. CS may be asymptomatic and is likely more frequently encountered than previously thought. Sudden death may often be the presenting feature of CS. Most deaths attributed to CS are caused by arrhythmias or conduction system disease, and congestive heart failure may occur. Current expert consensus on diagnosis of CS continues to rely on endomyocardial biopsy, in the absence of which, histologic proof of extracardiac sarcoid involvement is necessitated. Emergence of newer noninvasive imaging modalities such as cardiac magnetic resonance imaging and positron emission tomography, have become increasingly popular tools utilized in patients with both clinical and asymptomatic CS, and have demonstrated good diagnostic capability. The main therapeutic approaches in patients with CS can be broadly divided into the following 2 categories: pharmacological management and invasive or device oriented. However, much remains unknown about the optimal screening protocols of asymptomatic patients with extracardiac sarcoidosis and treatment of biopsy-proven CS. Our knowledge about CS has amplified significantly over the last 30 years and the growing realization that this process is often asymptomatic is paving the way for better screening protocols and earlier detection of this serious condition.

Isolated cardiac sarcoidosis masquerading as right ventricular outflow tract ventricular tachycardia

A 67-year-old man with coronary artery disease (CAD) and left anterior descending artery (LAD) stent presented with symptomatic monomorphic ventricular tachycardia (VT) at a rate of 190 bpm requiring cardioversion. ECG showed left bundle branch block pattern and inferior axis, suggestive of a right ventricular outflow tract (RVOT) focus rather than left ventricular scar due to LAD territory myocardial infarction (MI). Echocardiography showed normal wall motion. Angiography revealed a patent mid-LAD stent. Cardiac MRI with delayed postcontrast sequence revealed several regions of hyperenhancement abnormality within the basal portion of the interventricular septum. Increased metabolic activity on positron emission tomography confirmed active inflammatory sarcoidosis.Although VTs in patients with prior CAD are likely to be related to either scar or ischaemia, alternative diagnoses (eg, infiltrative disorders, RVOT-VT, arrhythmogenic right ventricular cardiomyopathy) should be considered in patients with an apparent right ventricular focus on ECG.

Long-Term Outcomes of Catheter Ablation of Ventricular Tachycardia in Patients With Cardiac Sarcoidosis

BACKGROUND

Catheter ablation (CA) of ventricular tachycardia (VT) in patients with cardiac sarcoidosis can be challenging because of the complex underlying substrate. We sought to determine the long-term outcome of CA of VT in patients with cardiac sarcoidosis.

METHODS AND RESULTS

We enrolled 31 patients (age, 55±10 years) with diagnosis of cardiac sarcoidosis based on Heart Rhythm Society criteria and VT who underwent CA. In 23 (74%) patients, preprocedure cardiac magnetic resonance imaging and positron emission tomographic (PET) evaluation were performed. Preprocedure magnetic resonance imaging was positive for late gadolinium enhancement in 21 of 23 (91%) patients, whereas abnormal 18-fluorodeoxyglucose uptake was found in 15 of 23 (65%) cases. In 14 of 15 patients with positive PET at baseline, PET was repeated after 6.1±3.7-month follow-up. After a median follow-up of 2.5 (range, 0-10.5) years, 1 (3%) patient died and 4 (13%) underwent heart transplant. Overall VT-free survival was 55% at 2-year follow-up. Among the 16 (52%) patients with VT recurrences, CA resulted in a significant reduction of VT burden, with 8 (50%) having only isolated (1-3) VT episodes and only 1 patient with recurrent VT storm. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET at baseline, and lack of PET improvement over follow-up were associated with increased risk of recurrent VT.

CONCLUSIONS

In patients with cardiac sarcoidosis and VT, CA is effective in achieving long-term freedom from VT or improvement in VT burden in the majority of patients. The presence of late gadolinium enhancement at magnetic resonance imaging, a positive PET scan at baseline, or lack of improvement at repeat PET over follow-up predict worse arrhythmia-free survival.

Risk assessment of patients with clinical manifestations of cardiac sarcoidosis with positron emission tomography and magnetic resonance imaging

BACKGROUND

Prior studies have shown that late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and fluorodeoxyglucose (FDG) positron emission tomography (PET) confer incremental risk assessment in patients with cardiac sarcoidosis (CS). However, the incremental prognostic value of the combined use of LGE and FDG compared to either test alone has not been investigated, and this is the aim of the present study.

METHODS

Retrospective observational study of 56 symptomatic patients with high clinical suspicion for CS who underwent LGE-CMR and FDG-PET and were followed for the occurrence of death and/or malignant ventricular arrhythmias (VA).

RESULTS

The combination of PET and CMR yielded the following groups: 1) LGE-negative/normal-PET (n=20), 2) LGE-positive/abnormal-FDG (n=20), and 3) LGE-positive/normal FDG (n=16). After a median follow-up of 2.6years (IQR 1.2-4.1), 16 patients had events (7 deaths, 10 VA). All, but 1, events occurred in patients with LGE. LGE-positive/abnormal-FDG (7 events, HR 10.1 [95% CI 1.2-84]; P=0.03) and LGE-positive/normal-FDG (8 events, HR 13.3 [1.7-107]; P=0.015) patients had comparable risk of events compared to the reference LGE-negative/normal-PET group. In adjusted Cox-regression analysis, presence of LGE (HR 18.1 [1.8-178]; P=0.013) was the only independent predictor of events.

CONCLUSION

CS patients with LGE alone or in association with FDG were at similar risk of future events, which suggests that outcomes may be driven by the presence of LGE (myocardial fibrosis) and not FDG (inflammation).

Diurnal characteristics of heart rate variability in patients with sarcoidosis

BACKGROUND

The aim of this study was to evaluate autonomic nervous system function by measuring heart rate variability (HRV) in patients with sarcoidosis without known cardiac manifestations.

PATIENTS AND METHODS

The study comprised 61 participants, including 31 patients with sarcoidosis without known cardiac manifestations and 30 healthy volunteers. All participants underwent echocardiographic examination, 12-channel electrocardiography (ECG), and 24-h Holter monitoring. HRV parameters were determined and compared between the groups.

RESULTS

There were no differences between groups with regard to age, body mass index, systolic and diastolic blood pressure, or heart rate at the time of admission. In the time domain analyses, the 24-h, daytime, and night-time standard deviations of all normal-to-normal R‑R interval (SDNN) values were significantly lower in patients with sarcoidosis than those in the controls. The frequency domain analyses showed that 24-h and daytime low-frequency (LF) values, 24-h, daytime, and night-time high-frequency (HF) values were significantly lower in the patient group compared with the control group, whereas the night-time LF/HF ratio was significantly higher.

CONCLUSION

Although Holter ECG is not a diagnostic tool for cardiac sarcoidosis, the HRV parameters, especially the night-time LF/HF values, may demonstrate increased sympathetic activation in patients with sarcoidosis.

Medical therapy to prevent recurrence of ventricular arrhythmia in normal and structural heart disease patients

INTRODUCTION

Recurrent ventricular arrhythmias (VA) are a source of significant morbidity in patients without structural heart disease (SHD) and also mortality in patients with SHD. The treatment goals for these two patient populations differ greatly. Areas covered: The secondary prevention of recurrent VA in patients without and with SHD will be reviewed, focusing on clinical data (especially randomized, controlled trials) in the literature as determined through searches in PubMed and ClinicalTrials.gov. This will include β blockers, non-dihydropyridine calcium channel blockers and antiarrhythmic drugs in both subgroups and non-antiarrhythmic medications in SHD. Expert commentary: The available options for medical therapy for VA in both normal hearts and SHD are insufficient, due to substandard efficacy and toxicities. While non-pharmacologic therapies may provide an excellent option, further drug development and randomized trials are needed, as is a reappraisal of the current mode of utilization.

An oxidative stress biomarker, urinary 8-hydroxy-2'-deoxyguanosine, predicts cardiovascular-related death after steroid therapy for patients with active cardiac sarcoidosis

BACKGROUND

We investigated whether urinary 8-hydroxy-2'-deoxyguanosine (U-8-OHdG), a marker of oxidative DNA damage, is a prognosticator of cardiovascular-related death in patients with cardiac sarcoidosis (CS).

METHODS AND RESULTS

In this prospective study, 30 consecutive patients were divided into the active CS (n=20) and non-active CS (n=10) groups, based on abnormal isotope accumulation in the heart on (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography ((18)F-FDG PET/CT) imaging. Nineteen patients in the active CS group underwent corticosteroid therapy. Before corticosteroid therapy initiation, U-8-OHdG, brain natriuretic peptide (BNP), other biomarkers, and indices of cardiac function were measured. Patients were followed-up for a median of 48months. The primary endpoint was the incidence of cardiovascular-related death. During the follow-up period, in the corticosteroid-treated active CS group, 7 of 19 patients experienced cardiovascular-related death. By contrast, in the non-active CS group, 1 of 10 patients died from cardiovascular-related causes. Univariate and multivariate analyses showed that U-8-OHdG and BNP were independent predictors for cardiovascular-related death. The cut-off values for predicting cardiovascular death in corticosteroid-treated patients with active CS were 19.1ng/mg·Cr and 209pg/mL for U-8-OHdG and BNP, respectively. Patients with a U-8-OHdG concentration ≥19.1ng/mg·Cr or a BNP concentration ≥209pg/mL had a significantly higher cardiovascular-related death risk, but U-8-OHdG had better predictive value compared with BNP.

CONCLUSION

These findings suggested that U-8-OHdG was a powerful predictor of cardiovascular-related death in patients with CS, suggesting that active CS patients with elevated U-8-OHdG levels might be resistant to corticosteroid therapy.