Sarcoid heart disease: clinical course and treatment

Heart Failure Preserved Ejection Fraction in Women: Insights Learned from Imaging

While the prevalence of heart failure, in general, is similar in men and women, women experience a higher rate of HFpEF compared to HFrEF. Cardiovascular risk factors, parity, estrogen levels, cardiac physiology, and altered response to the immune system may be at the root of this difference. Studies have found that in response to increasing age and hypertension, women experience more concentric left ventricle remodeling, more ventricular and arterial stiffness, and less ventricular dilation compared to men, which predisposes women to developing more diastolic dysfunction. A multi-modality imaging approach is recommended to identify patients with HFpEF. Particularly, appreciation of sex-based differences as described in this review is important in optimizing the evaluation and care of women with HFpEF.

Ventricular Tachycardia in Granulomatous Myocarditis: Role of Catheter Ablation

Granulomatous myocarditis is an inflammatory disease of the myocardium, characterized by lymphocytic infiltration with characteristic granuloma formation. Although a host of disease processes can elicit myocardial granulomas, two common entities are cardiac sarcoidosis and cardiac tuberculosis. Cardiac arrhythmias in this condition are frequent and management of ventricular arrhythmias can be challenging, especially in those with drug-refractory ventricular tachycardia and electrical storm. In this review, we highlight the role of catheter ablation for ventricular tachycardia and optimal patient selection for catheter ablation, based on cardiac imaging.

Underdiagnosis of cardiac sarcoidosis by ECG and echocardiography in cases of extracardiac sarcoidosis

Background

Although screening with 12-lead electrocardiography and transthoracic echocardiography for cardiac involvement has been recommended for patients with biopsy-proven extracardiac sarcoidosis, cardiac sarcoidosis has been reported even in patients with normal electrocardiography and echocardiography findings. We investigated the prevalence and characteristics of these patient cohorts.

Methods

We studied 112 consecutive patients (age, 55±17 years, 64% females) with biopsy-proven extracardiac sarcoidosis who had undergone ¹⁸F-fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance imaging for cardiac sarcoidosis evaluation. The patients were categorised as those showing normal findings both in electrocardiography and transthoracic echocardiography (normal group) and those showing abnormal findings in one or both examinations (abnormal group).

Results

33 (29%) and 79 (71%) patients were categorised into the normal and abnormal groups, respectively, of which 6 (18%) and 43 (54%) patients, respectively, were diagnosed with cardiac sarcoidosis (p<0.01). Of these six patients in the normal group, two with multiple-organ sarcoidosis showed clinical deterioration of cardiac involvement and required steroid therapy; three with small cardiac involvement showed natural remission over follow-up assessments; and one underwent steroid therapy and showed an improvement in the left ventricular ejection fraction to within normal limits.

Conclusions

The prevalence of cardiac sarcoidosis in patients with biopsy-proven extracardiac sarcoidosis and normal electrocardiography and transthoracic echocardiography findings was ∼20%. Electrocardiography and transthoracic echocardiography may not detect cardiac sarcoidosis in patients without conduction and morphological abnormalities. However, some of these patients may subsequently show clinically manifested cardiac sarcoidosis. Physicians should be mindful of this population.

ECG and transthoracic echocardiography may not detect cardiac sarcoidosis in patients without conduction and morphological abnormalities. Some of these patients may subsequently develop clinically manifested cardiac sarcoidosis.https://bit.ly/3qeQuff

PET Cardiac Imaging (Perfusion, Viability, Sarcoidosis, and Infection)

Cardiovascular disease is the leading cause of death worldwide. Given the increased availability of radiopharmaceuticals, improved positron emission tomography (PET) camera systems and proven higher diagnostic accuracy, PET is increasingly utilized in the management of various cardiovascular diseases. PET has high temporal and spatial resolution, when compared to Single Photon Emission Computed Tomography. In clinical practice, hybrid imaging with sequential PET and Computed Tomography acquisitions (PET/CT) or concurrent PET and Magnetic Resonance Imaging are standard. This article will review applications of cardiovascular PET/CT including myocardial perfusion, viability, cardiac sarcoidosis/inflammation, and infection.

Diagnosis of cardiac sarcoidosis: a primer for non-imagers

Sarcoidosis is a multisystem granulomatous disorder that can potentially involve any organ. Cardiac involvement in sarcoidosis has been reported in up to 25% of patients based on autopsy and imaging studies. The gold standard for diagnosing cardiac sarcoidosis is endomyocardial biopsy demonstrating non-caseating granulomas; however, this technique lacks sensitivity due to the patchy nature of myocardial involvement. This, along with the non-specific clinical presentation, renders the diagnosis of cardiac sarcoidosis extremely challenging. Difficulties in obtaining histopathologic diagnosis and the advances in imaging modalities have led to a paradigm shift toward non-invasive imaging in the diagnosis of cardiac sarcoidosis. Advances in cardiac imaging modalities have also allowed unprecedented insights into the prevalence and natural history of cardiac sarcoidosis. This review discusses the role of non-invasive imaging for diagnosis, risk stratification, and monitoring the response to therapies in cardiac sarcoidosis. Echocardiography remains the first-line modality due to widespread availability and affordability. Cardiac magnetic resonance imaging (CMR) can be used to study cardiac structure, function, and most importantly tissue characterization to detect inflammation and fibrosis. Fluoro-deoxy glucose positron emission tomography (FDG PET) is the gold standard for non-invasive detection of cardiac inflammation, and it offers the unique ability to assess response to therapeutic interventions. Hybrid imaging is a promising technique that allows us to combine the unique strengths of CMR and FDG PET. Understanding the advantages and disadvantages of each of these imaging modalities is crucial in order to tailor the diagnostic algorithm and utilize the most appropriate modality for each patient.

Ventricular tachycardia based on cardiac sarcoidosis with a narrow QRS complex, ablated on the left ventricle free-wall

A septuagenarian female with cardiac sarcoidosis suffered from drug refractory ventricular tachycardia (VT) requiring multiple implantable cardioverter-defibrillator shocks. The QRS complex during the VT was very similar to that during sinus rhythm although the QRS width during the VT (142 ms) was relatively wider than that during sinus rhythm (107 ms). The VT exit was located on the ventricular septum close to the His-bundle recording region. However, the critical pathway of this VT was detected on the anterior free wall of the left ventricle (LV), and a radiofrequency application at that site could terminate the VT. No Purkinje potentials were recorded there during the VT or sinus rhythm. According to the electrophysiological study, 3-D mapping, and the response to the ablation, the critical circuit of the VT was surrounded by a protected area of scar associated with cardiac sarcoidosis. As a result, the VT circuit was connected to the basal septal area close to the His-Purkinje system as an outer loop of the VT circuit. This unique trajectory of the VT might have caused a similar QRS morphology to that of sinus rhythm, and the relatively narrow QRS complex despite the critical isthmus was located on the anterior free wall of the LV.

Critical Care of Patients With Cardiopulmonary Complications of Sarcoidosis

Sarcoidosis is a systemic inflammatory disease defined by the presence of aberrant granulomas affecting various organs. Due to its multisystem involvement, care of patients with established sarcoidosis becomes challenging, especially in the intensive care setting. While the lungs are typically involved, extrapulmonary manifestations also occur either concurrently or exclusively within a significant proportion of patients, complicating diagnostic and management decisions. The scope of this review is to focus on what considerations are necessary in the evaluation and management of patients with known sarcoidosis and their associated complications within a cardiopulmonary and critical care perspective.

The Multi-modality Cardiac Imaging Approach to Cardiac Sarcoidosis

BACKGROUND

Sarcoidosis is a multisystem granulomatous disease with a neglected but high prevalence of life-threatening cardiac involvement.

DISCUSSION

The clinical presentation of Cardiac Sarcoidosis (CS) depends upon the location and extent of the granulomatous inflammation, with left ventricular free wall the most common location followed by interventricular septum. The lack of a diagnostic gold standard and the unpredictable risk of sudden cardiac death pose serious challenges for the validation of accurate and effective screening test and the management of the disease. In the last few years advanced cardiac imaging modalities such as Cardiac Magnetic Resonance (CMR) and Positron Emission Tomography (PET) have significantly improved our knowledge and understanding of CS, and have also contributed in risk stratification, assessment of inflammatory activity and therapeutic monitoring of the disease.

CONCLUSION

In this review, we will discuss the state of the art in the diagnosis of CS focusing on the role and importance of multi-modality cardiac imaging.

Treatment options in myocarditis and inflammatory cardiomyopathy : Focus on i. v. immunoglobulins

For myocarditis and inflammatory cardiomyopathy, an etiologically driven treatment is today the best option beyond heart failure therapy. Prerequisites for this are noninvasive and invasive biomarkers including endomyocardial biopsy and polymerase chain reaction on cardiotropic agents. Imaging by Doppler echocardiography and cardiac magnetic resonance imaging as well as cardiac biomarkers such as C‑reactive protein, N‑terminal pro-B-type natriuretic peptide , and troponins can contribute to the clinical work-up of the syndrome but not toward elucidating the underlying cause or pathogenetic process. This review summarizes the phases and clinical features of myocarditis and gives an up-to-date short overview of the current treatment options starting with heart failure and antiarrhythmic therapy. Although inflammation in myocardial disease can resolve spontaneously, often specific treatment directed against the causative agent is required. For fulminant, acute, and chronic autoreactive myocarditis, immunosuppressive treatment has proven to be beneficial in the TIMIC and ESETCID trials; for viral cardiomyopathy and myocarditis, intravenous immunoglobulin IgG subtype and polyvalent intravenous immunoglobulins IgG, IgA, and IgM can frequently resolve inflammation. However, despite the elimination of inflammation, the eradication of parvovirus B19 and human herpesvirus-6 is still a challenge, for which ivIg treatment can become a future key player.

Cardio-Immunology of Myocarditis: Focus on Immune Mechanisms and Treatment Options

Myocarditis and inflammatory cardiomyopathy are syndromes, not aetiological disease entities. From animal models of cardiac inflammation we have detailed insight of the strain specific immune reactions based on the genetic background of the animal and the infectiosity of the virus. Innate and adaptive immunity also react in man. An aetiological diagnosis of a viral vs. a non-viral cause is possible by endomyocardial biopsy with histology, immunohistology and PCR for microbial agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy on the basis of the genetic background and the predisposition for inflammation. It analyses the epidemiologic shift in cardiotropic viral agents in the last 30 years. Based on the understanding of the interaction between infection and the players of the innate and adaptive immune system it summarizes pathogenetic phases and clinical faces of myocarditis. It gives an up-to-date information on specific treatment options beyond symptomatic heart failure and antiarrhythmic therapy. Although inflammation can resolve spontaneously, specific treatment directed to the causative etiology is often required. For fulminant, acute, and chronic autoreactive myocarditis without viral persistence immunosuppressive treatment can be life-saving, for viral inflammatory cardiomyopathy ivIg treatment can resolve inflammation and often eradicate the virus.

Echocardiography in Sarcoidosis

PURPOSE OF REVIEW

Cardiac sarcoidosis (CS) is associated with significant morbidity and mortality. The diagnosis of CS is challenging and typically one that is only entertained after many other conditions have been ruled out. A high index of suspicion is necessary in order to correctly determine appropriate testing for the disease. Transthoracic echocardiography is the most readily available imaging modality available to help establish a diagnosis in a potential patient. However, no one echocardiographic feature is pathognomonic.

RECENT FINDINGS

On echocardiography, unusual wall motion abnormalities, which do not fit a classic coronary distribution, along with diastolic dysfunction may alert one to the presence of cardiac sarcoid, particularly in the right clinical context. Myocardial strain imaging on echocardiography may increase the sensitivity of identifying cardiac sarcoidosis. Alternative imaging with cardiac magnetic resonance imaging or positron emission tomography have become more frequently utilized to establish a diagnosis of CS. Cardiac sarcoidosis remains a difficult condition to diagnose. However early diagnosis is critical to decrease the associated high mortality. Endomyocardial biopsy is highly specific but lacks sensitivity due to the patchy nature of the granulomatous deposition. Thus, imaging plays a role in diagnosis as well as for follow-up. Echocardiography remains an hallmark during the workup for CS. Decreased sensitivity of echocardiography has facilitated the use of other techniques to establish the presence of CS.

Multimodality Imaging in Cardiac Sarcoidosis: Is There a Winner?

Sarcoidosis is a multisystem granulomatous disease of unknown cause that can affect the heart. Cardiac sarcoidosis may be present in as many as 25% of patients with systemic sarcoidosis, and it is frequently underdiagnosed. The early and accurate diagnosis of myocardial involvement is challenging. Advanced imaging techniques play important roles in the diagnosis and management of patients with cardiac sarcoidosis.

Cardiac Sarcoidosis: Is it More Common in Men?

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease which predominantly affects the lungs, although granulomas can also involve all other organs, including the heart. Cardiac sarcoidosis (CS) may occur at any stage of the disease and may be the cause of sudden cardiac death, even in a previously asymptomatic patient. The aim of this study was to evaluate the incidence of CS in a large group of patients diagnosed or followed up due to sarcoidosis.

METHODS

We performed a retrospective analysis of patients at our institution discharged with the final diagnosis "sarcoidosis" (ICD-10: D86) from January 2008 to October 2012. Only those with biopsy (from respiratory tract or lymph nodes) confirmed diagnosis of sarcoidosis were included. We then selected the subset of patients with cardiac involvement due to sarcoidosis confirmed by positive magnetic resonance imaging.

RESULTS

The study covered 1375 consecutive sarcoidosis patients (51 % men), who were hospitalized during 5 years. Multiorgan disease was detected in 160 cases (11.7 %), and cardiac involvement was found in 64 patients (4.7 % of all), 70.3 % of whom were men. Twelve of those with CS were in stage I, 48 in stage II, and four in stage III. The odds ratio for having cardiac involvement in men compared to women was 2.3 (95 % CI 1.36-4.0, p = 0.002).

CONCLUSIONS

Cardiac involvement in sarcoidosis was diagnosed in the similar percentage as in previously published data but was significantly more frequently in men.

What's wrong with this artery? A medical disease discovered by a surgeon

A 50-year-old man presenting with chest pain had positive stress echocardiography; and angiogram showed single artery coronary stenosis, presumed to be atherosclerotic. He was started on optimal medical therapy with good compliance. Four months later, he had a myocardial infarction (MI) and cardiac catheterisation surprisingly showed interval development of severe three-vessel stenosis. He underwent coronary artery bypass grafting (CABG), during which the cardiothoracic surgeon noticed severely inflamed coronary arteries, concerning for vasculitis. Following CABG, the patient continued to have chest pain and was admitted again for MI within 4 months of surgery. Subsequent autoimmune workup was consistent with sarcoidosis. He was started on immunosuppressive therapy for presumed sarcoid-related coronary vasculitis, and 23 months later, the patient has not developed further ischaemic events. This is a rare case and extends the clinical spectrum of cardiac sarcoidosis, presenting with rapidly progressive coronary stenosis most likely due to vasculitis, mimicking atherosclerotic coronary artery disease.

Systematic treatment approach to ventricular tachycardia in cardiac sarcoidosis

BACKGROUND

Fatal arrhythmia is commonly observed in cardiac sarcoidosis, but clinical effects of a systematic treatment approach are still uncertain. This study sought to describe both clinical and electrophysiological characteristics and outcomes of systematic treatment approach to ventricular tachycardia (VT) associated with cardiac sarcoidosis.

METHODS AND RESULTS

We enrolled 37 consecutive patients (11 men; age, 56±11 years) with a diagnosis of sustained VT associated with cardiac sarcoidosis. Clinical effects of a systematic treatment approach including medical therapy (both steroid and antiarrhythmic agents), in association with radiofrequency catheter ablation, were evaluated. All patients received antiarrhythmic agents, and 34 received steroid therapy. During a 39-month follow-up, 23 (62%) patients were free from any VT episodes with medical therapy. Multivariable Cox regression analyses revealed that the absence of gallium-67 myocardial uptake was an independent predictor for VT recurrence (hazard ratio, 7.51; 95% confidence interval, 1.65-34.26; P<0.01). Fourteen patients who experienced VT recurrences even while on drug therapy underwent radiofrequency catheter ablation. Electrophysiological study revealed that the mechanisms of VTs could be classified into 2 subgroups: Purkinje-related or scar-related VT. The QRS duration of VT was narrower in Purkinje-related than in scar-related VTs (157±23 versus 183±22 ms; P<0.05). After a 33-month follow-up subsequent to the radiofrequency catheter ablation, 6 of 14 patients experienced VT recurrence. The number of VTs sustained during electrophysiological study was higher in the patients with VT recurrence than in those without (3.7±1.4 versus 1.9±0.8; P<0.01).

CONCLUSIONS

A systematic treatment approach to cardiac sarcoidosis with VT successfully suppressed VT recurrences in the majority of patients studied.

Myocardial performance index for detection of subclinical abnormalities in patients with sarcoidosis

AIM

The aim of this study was to evaluate ventricular functions in patients with sarcoidosis without an obvious heart disease by using tissue Doppler-derived left and right ventricular myocardial performance index (MPI).

METHODS

The study population included 45 patient with sarcoidosis (29 men, 16 women; mean age, 44±10 years, mean disease duration, 4.2±2.7 years) and 45 healthy control subjects (31 men, 14 women; mean age, 41±8 years). Cardiac functions were determined using echocardiography, consisting of standard two-dimensional and conventional Doppler and tissue Doppler imaging (TDI). Myocardial tissue Doppler velocities [peak systolic (Sa), early diastolic (Ea), and late diastolic velocities (Aa)] were recorded using spectral pulsed Doppler from the LV free wall, septum, and RV free wall from the apical four chamber view. MPI was also calculated by TDI.

RESULTS

The conventional echocardiographic parameters and tissue Doppler measurements were similar between the patients and controls. Left ventricular MPI (0.490±0.092 vs. 0.396±0.088, P=0.010) and right ventricular MPI (0.482±0.132 vs. 0.368±0.090, P=0.006) were significantly higher in patients with sarcoidosis than the control subjects. There was a correlation between the disease duration and right and left ventricular MPI (r=0.418, P=0.005; r=0.366, P=0.013, respectively). There was also a correlation between the systolic pulmonary arterial pressure and right ventricular MPI but not left ventricular MPI (r=0.370, P=0.012; r=0.248, P=0.109, respectively). In receiver operating characteristics curve analysis, the cutoff value of left ventricular MPI >0.46 had 92% sensitivity and 64% specificity in predicting left ventricular diastolic dysfunction.

CONCLUSIONS

We have demonstrated that tissue Doppler-derived myocardial left and right ventricular MPI were impaired in sarcoidosis patients, although systolic function parameters were comparable in the patients and controls, showed a subclinic impaired ventricular functions in patients with sarcoidosis.

Ventricular tachycardia - an atypical initial presentation of sarcoidosis: a case report

Introduction

Symptomatic cardiac involvement is seen in less than 5% of all cases of sarcoidosis. Although clinically apparent cardiac sarcoidosis is an uncommon entity, ventricular tachyarrhythmias as the first presenting symptom are very rare.

Case presentation

We discuss the case of a 41-year-old Asian woman who presented to our hospital with intermittent palpitation and on evaluation was diagnosed to have systemic sarcoidosis with cardiac involvement. She was started on multiple antiarrhythmic drugs and corticosteroids without any satisfactory response.

Conclusions

Our case report indicates that sarcoidosis can manifest as ventricular tachycardia without any detectable systemic findings. This makes sarcoidosis an important diagnostic consideration in patients with ventricular tachycardia of unknown origin given the high mortality associated with ventricular tachyarrhythmias.

Current treatment options in (peri)myocarditis and inflammatory cardiomyopathy

In inflammatory dilated cardiomyopathy and myocarditis there is--apart from heart failure and antiarrhythmic therapies--no alternative to an aetiologically driven specific treatment. Prerequisite are noninvasive and invasive biomarkers including endomyocardial biopsy and PCR on cardiotropic agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy including the genetic background, the predisposition for heart failure and inflammation. It analyses the epidemiologic shift in pathogenetic agents in the last 20 years, the role of innate and aquired immunity including the T- and B-cell driven immune responses. The phases and clinical faces of myocarditis are summarized. Up-to-date information on current treatment options starting with heart failure and antiarrhythmic therapy are provided. Although inflammation can resolve spontaneously, specific treatment directed to the causative aetiology is often required. For fulminant, acute and chronic autoreactive myocarditis immunosuppressive treatment is beneficial, while for viral cardiomyopathy and myocarditis ivIg can resolve inflammation and is as successful as interferon therapy in enteroviral and adenoviral myocarditis. For Parvo B19 and HHV6 myocarditis eradication of the virus is still a problem by any of these treatment options. Finally, the potential of stem cell therapy has to be tested in future trials. In virus-negative, autoreactive perimyocardial disease a locoregional approach with intrapericardial instillation of high local doses of triamcinolone acetate has been shown to be highly efficient and with few systemic side-effects.

Temporal changes in echocardiographic findings in cardiac and non-cardiac sarcoidosis patients

OBJECTIVE

Echocardiography is used for the detection of cardiac sarcoid involvement in patients with non-cardiac sarcoidosis. Little information is available regarding temporal changes in left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension (LVDd) in non-cardiac sarcoidosis patients.

METHODS AND RESULTS

Fifty-four sarcoidosis patients who received periodic follow-up with echocardiography at our institute were enrolled in this study. At the time of initial ultrasonography, 13 patients were diagnosed with cardiac sarcoid involvement. All of the remaining 41 patients with extra-cardiac sarcoidosis only had a LVEF of >50%. During the median follow-up period of 39 months, two (4.9%) of the non-cardiac sarcoidosis patients were diagnosed with cardiac sarcoid involvement; one patient showed a progressive decline in the LVEF over a short period of time. It was also found that two of 41 non-cardiac sarcoidosis patients showed declines in the LVEF of >10% per year; however, they were not diagnosed with cardiac sarcoidosis during the follow-up period.

CONCLUSION

Rapid deterioration of left ventricular function may increase the suspicion of sarcoid involvement of the heart in non-cardiac sarcoidosis patients; however, we must be aware that a certain subfraction of patients may not demonstrate significant abnormalities in LVEF or LVDd on periodic echocardiographic follow-up.

Sarcoidosis manifesting as cardiac sarcoidosis and massive splenomegaly

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. We report an unusual case of sarcoidosis in a woman presenting with cardiac sarcoidosis and massive splenomegaly with a familial history of cardiac sarcoidosis. Cardiac sarcoidosis was diagnosed based on electrocardiogram, echocardiogram, 18F-fluoro-2-deoxyglucose positron emission tomography (18F-FDG-PET) and skin histological findings. We performed splenectomy to rule out malignant lymphoma, and histological findings confirmed sarcoidosis. After splenectomy, we initiated prednisolone therapy. After 20 months of diagnosis, she was symptom free. Echocardiography and 18F-FDG-PET may be a key diagnostic tool and prednisolone therapy may be safe, effective, and feasible for cardiac sarcoidosis.

Cardiac MRI in infiltrative disorders: a concise review

Cardiac MR imaging is an effective method for noninvasive imaging of the heart. The technology has been limited in the past because of imaging difficulties associated with cardiac motion. In recent years, however, cardiac MR imaging has broadened its spectrum of applications in cardiovascular disease with impressive advances in spatial and temporal resolution and increased imaging speeds. This review presents the current clinical applications of cardiac MR imaging for evaluation of cardiac disease in infiltrative disorders such as amyloidosis, hemochromatosis, and sarcoidosis.

Prevalence of echocardiographic features suggesting cardiac sarcoidosis in patients with pacemaker or implantable cardiac defibrillator

BACKGROUND AND OBJECTIVES

Basal septal thinning or localized aneurysmal dilatation without coronary artery disease has been described as a characteristic finding suggestive of cardiac sarcoidosis. We sought to assess the prevalence of this characteristic echocardiographic finding in patients with pacemaker (PM) or implantable cardiac defibrillator (ICD).

SUBJECTS AND METHODS

Echocardiography of patients who received PM or ICD were retrospectively analyzed. Patients with marked thinning and akinesia confined to the basal septum (type 1), or posterolateral wall resulting in localized aneurysmal outward bulging (type 2) without history of myocardial infarction or significant coronary stenosis were included for analysis.

RESULTS

Among 1,357 consecutive patients, 21 exhibited suggestive echocardiographic findings (type 1/2=15/6) with a mean ejection fraction of 37±11%. The prevalence was 1.2% in the PM group and 4.0% in the ICD group. Only 3 patients showed histologically confirmable sarcoidosis in lymph nodes, lung and heart, respectively. Endomyocardial biopsy was attempted in 6 patients, but failed to demonstrate sarcoidosis. The 1-, 2-, 4- and 6-year clinical events (death, cardiac transplantation and hospital admission)-free survival rates were 100%, 85.7±7.6%, 75.0±9.7% and 48.6±12.4%, respectively. During follow-up, two patients with PM underwent ICD implantation, and another underwent heart transplantation.

CONCLUSION

Prevalence of echocardiographic features suggesting prevalence of cardiac sarcoidosis is low in patients who underwent device implantation. However, considering the very low yield of endomyocardial biopsy and the rare extracardiac manifestations in cardiac sarcoidosis, characteristic echocardiographic findings could be an adjunctive diagnostic criterion in these patients.

Arrhythmias in a patient with sarcoidosis

Arrhythmias in a Patient With Sarcoidosis. Sarcoidosis is a multisystemic granulomatous disease of unknown etiology; up to 27% of cases entail cardiac involvement. Conduction abnormalities and ventricular tachycardia are the most common arrhythmias and can cause sudden death. We describe a patient who developed cardiac sarcoidosis 9 years after undergoing surgery for neurosarcoidosis. He presented with 2:1 second-degree atrioventricular block. Ventricular tachycardia with 3 morphologies was induced by exercise stress test. A DDD pacer/implantable cardioverter defibrillator (ICD) was implanted, which prevented exercise-induced ventricular tachycardia in a follow-up stress test. Treatment with steroids was initiated. The AVB disappeared, and no further arrhythmias were documented at the 1-year follow-up. 

Ventricular tachycardia in cardiac sarcoidosis controlled by radiofrequency catheter ablation

We report a case of a 78-year-old woman with cardiac sarcoidosis with a history of syncope and palpitation. Further assessment with echocardiography, gadolinium-enhanced cardiovascular magnetic resonance (CMR) and histology led to a diagnosis of cardiac sarcoidosis. As the patient suffered from ventricular tachycardia (VT) despite active corticosteroid therapy, an implantable cardioverter-defibrillator (ICD) was positioned. She was also administered a beta blocker, but an electrical storm appeared every several days requiring ICD therapy. The drug-refractory VT was finally controlled with a catheter ablation session, during which we could detect the VT focus in the right ventricular outflow tract next to the aneurysm by using an electroanatomic mapping system (CARTO). Referring to echocardiographic and CMR images proved very useful in detecting the aneurysm using the CARTO system.

Effectiveness of prolonged fasting 18f-FDG PET-CT in the detection of cardiac sarcoidosis

BACKGROUND

The Japanese Ministry of Health and Welfare guidelines (JMHWG) are currently the standard used to diagnose cardiac sarcoidosis. JMHWG incorporate (67)Gallium scintigraphy as a minor criterion, while fasting (18)fluorine-2-fluoro-2-deoxy-D-glucose (FDG) PET is not included. As there is no published data comparing the accuracy of prolonged fasting FDG PET-CT (PF-PET) and Gallium scintigraphy for detecting active cardiac sarcoidosis, we sought to compare these two modalities.

METHODS AND RESULTS

We retrospectively reviewed medical records and nuclear images of 76 patients with suspected cardiac sarcoid who had either PF-PET or Gallium scintigraphy between January 2004 and August 2008. Eleven patients were excluded due to inadequate fasting for PF-PET, incomplete records or diagnosis other than sarcoid. Cardiac catheterizations, electrocardiogram interpretations, echocardiography reports, pathology reports, therapeutic interventions, and follow-up findings were correlated to PF-PET and Gallium scintigraphy results. Nuclear images of all patients including controls were reviewed independently by two experienced nuclear physicians blinded to results. Using JMHWG as reference standard, sensitivity, specificity, and accuracy of PF-PET were 85%, 90%, and 86.7% and for Gallium scintigraphy were 15%, 80%, and 42.8%.

CONCLUSIONS

Relative to Gallium scintigraphy, PF-PET appears to provide greater accuracy for detecting cardiac sarcoidosis. Our findings also highlight the importance of revising JMHWG to incorporate PF-PET and the importance of adequate prolonged fasting prior to FDG PET imaging.