The two extremes of cardiac sarcoidosis and the effect of Prednisone therapy

Cardiac Sarcoidosis: Pathophysiology, Diagnosis, and Management

Sarcoidosis is a chronic multi-system disorder with an unknown etiology that can affect the cardiac tissue, resulting in Cardiac Sarcoidosis (CS). The majority of these CS cases are clinically silent, and when there are symptoms, the symptoms are vague and can have a lot in common with other common cardiac diseases. These symptoms can range from arrhythmias to heart failure. If CS goes undetected, it can lead to detrimental outcomes for patients. Diagnosis depends on timely utilization of imaging modalities and non-invasive testing, while in some cases, it does necessitate biopsy. Early diagnosis and treatment with immunosuppressive agents are crucial, and it is essential that follow-up testing be performed to ensure resolution and remission. This manuscript provides an in-depth review of CS and the current literature regarding CS diagnosis and treatment.

The Many Faces of Cardiac Sarcoidosis

OBJECTIVES

The objective of this study was to review and illustrate the sometimes diagnostically challenging features of cardiac sarcoidosis. We emphasize variable phenotypes presented at explant and biopsy evaluation and review literature regarding ancillary clinical and pathologic studies to enhance diagnostic accuracy.

METHODS

A literature review was performed and two cardiac sarcoidosis cases were illustrated.

RESULTS

Our cases and literature review demonstrate the pathologic spectrum of cardiac sarcoidosis. Irregular left ventricular free wall involvement is most common, followed by the interventricular septum and right ventricle. Although granulomas are often composed of tight epithelioid macrophage aggregates, early granulomas comprise loosely associated macrophages with lymphocyte predominance. Chronic disease leads to fibrosis and end-stage heart failure. Sampling errors and variable histology cause low endomyocardial biopsy sensitivity.

CONCLUSIONS

Current guidelines use clinical, radiologic, and immunohistologic criteria for diagnosing cardiac sarcoidosis. Knowledge of these guidelines will assist pathologists in making accurate diagnosis of this disease.

Comparison of Clinical and Morphologic Findings in Patients With Cardiac Sarcoidosis Severe Enough to Warrant Heart Transplantation in Those With -vs- Those Without Non-Caseating Granulomas in the Explanted Heart (Burnt-Out Sarcoid)

Can cardiac sarcoidosis with heart failure severe enough to warrant orthotopic heart transplantation (OHT) be present without non-caseating granulomas in the explanted heart? The objective is to compare clinical and morphological features in patients with cardiac sarcoidosis severe enough to warrant OHT with -vs-without non-caseating granulomas in the explanted heart. The study was conducted at Baylor University Medical Center in Dallas, Texas. From a total of 671 explanted hearts examined from 1993 to 2018, twenty-five (4%) had gross morphologic features characteristic of cardiac sarcoidosis. At the time of OHT, the patients ranged in age from 50 to 69 years [mean 57]. Cardiac sarcoidosis was diagnosed before OHT in 3 (12%) patients, by percutaneous biopsy of the heart in 2 patients and by histologic examination of the "left ventricular core" in 1 patient who had a left ventricular assist device inserted, and, by examination of the native heart after OHT in the remaining 22 (88%) patients. Of the 25 patients, 16 (64%) had typical sarcoid non-caseating granulomas in the explanted heart, and 9 (36%) had no granulomas in the explanted heart. Comparison of certain clinical and morphologic features in the group with -vs- the group without cardiac granulomas showed no significant differences. In conclusion, of patients with cardiac sarcoidosis severe enough to warrant OHT, some have typical non-caseating granulomas in the explanted heart and some do not. The clinical and gross morphologic features of those with and those without cardiac granulomas are similar.

Myocardial Involvement in Patients With Histologically Diagnosed Cardiac Sarcoidosis: A Systematic Review and Meta-Analysis of Gross Pathological Images From Autopsy or Cardiac Transplantation Cases

Background In patients with suspected cardiac sarcoidosis, late gadolinium enhancement on cardiovascular magnetic resonance imaging and/or 18F-fluorodeoxyglucose uptake on positron emission tomography are often used to reach a clinical diagnosis of cardiac sarcoidosis. On the basis of data from the imaging literature of clinical cardiac sarcoidosis, no specific features of myocardial involvement are regarded as pathognomonic for cardiac sarcoidosis. Thus, a diagnosis of cardiac sarcoidosis is challenging to make. There has been no systematic analysis of histologically diagnosed cardiac sarcoidosis for patterns of myocardial involvement. We hypothesized that certain patterns of myocardial involvement are more frequent in histologically diagnosed cardiac sarcoidosis. Methods and Results We performed a systematic review and meta-analysis of gross pathological images from the published literature of patients with histologically diagnosed cardiac sarcoidosis who underwent autopsy or cardiac transplantation. Thirty-three eligible articles provided images of 49 unique hearts. Analysis of these hearts revealed certain features of myocardial involvement in >90% of cases: left ventricular (LV) subepicardial, LV multifocal, septal, and right ventricular free wall involvement. In contrast, other patterns were seen in 0% to 6% of cases: absence of gross LV myocardial involvement, isolated LV midmyocardial involvement, isolated LV subendocardial involvement, isolated LV transmural involvement, absence of septal involvement, or isolated involvement of only one LV level. Conclusions In this systematic review and meta-analysis of histologically diagnosed cardiac sarcoidosis, we identified certain features of myocardial involvement that occurred frequently and others that occurred rarely or never. These patterns could aid the interpretation of cardiovascular magnetic resonance imaging and positron emission tomography imaging and improve the diagnosis and the prognostication of patients with suspected cardiac sarcoidosis.