The Many Faces of Cardiac Sarcoidosis

Cardiac sarcoidosis in patients with recurrent ventricular arrhythmias refractory to endocardial ablation

INTRODUCTION

The clinical presentation of cardiac sarcoidosis is diverse. Detection of granuloma in histopathological evaluation proves the diagnosis, but endomyocardial biopsy (EMB) is associated with a high sampling error. However, prompt immunosuppressive therapy may significantly affect patient's prognosis. By analyzing our single center cohort of patients with recurrent ventricular arrhythmias (VA) and nonischemic cardiomyopathy after failure of endocardial ablation, we looked for additional markers supporting the diagnosis of cardiac sarcoidosis.

METHOD

In the last 4 years, 135 patients (mean age 49 y, 63% male) were hospitalized for epicardial ventricular arrhythmia (VA) ablation after failure of endocardial ablation. Nineteen patients had either previously received a diagnosis of cardiac sarcoidosis or were newly diagnosed. The mean follow-up time was 4.3 years. The ECG criteria, primary manifestation, histological findings in EMB, history of VT ablation, distribution of scars on MRI, electroanatomical mapping (EAM), PET CT findings, presence of atrial tachycardias, valve disease and comorbidities were analyzed.

RESULTS

Six of 19 (32%) patients showed right bundle block; 6 of 19 (32%) had AV nodal disease, including 4 patients with AV-block III; and 14 patients (73%) primarily presented with ventricular arrhythmias (including 3 with cardiac arrest). In all 19 patients cardiac EMB revealed elevated CD68 macrophages and CD3 T lymphocytes, and 7 of 19 were positive for granuloma (36,8%). Six of 6 patients (100%) undergoing PET CT showed acute inflammation. By analyzing the scar distribution, the most common locations were basal anteroseptal, basal inferoseptal, mid inferoseptal, mid inferior and the septal RV/RVOT. (septal substrate in 100%). There was a high correlation between the findings on the MRIs and low voltage in the electroanatomical mapping EAM). All patients received an immunosuppressive therapy. No patient died during follow-up, 1 patient had a high urgent heart transplant after withdrawal of steroid therapy.

CONCLUSION

Chronic untreated inflammation may be the underlying pathophysiology for patients with unspecific cardiomyopathy and recurrent VA refractory to endocardial and epicardial ablation. Septal substrate in the EAM/MRI, elevated CD3 lymphocytes in the EBM and inflammation in the PET CT may indicate the possible diagnosis of cardiac sarcoidosis. Initializing immunosuppressive therapy in patients with this dedicated constellation with should be taken into consideration.

High-Risk Sarcoidosis: A Focus on Pulmonary, Cardiac, Hepatic and Renal Advanced Diseases, as Well as on Calcium Metabolism Abnormalities

Although sarcoidosis is generally regarded as a benign condition, approximately 20-30% of patients will develop a chronic and progressive disease. Advanced pulmonary fibrotic sarcoidosis and cardiac involvement are the main contributors to sarcoidosis morbidity and mortality, with failure of the liver and/or kidneys representing additional life-threatening situations. In this review, we discuss diagnosis and treatment of each of these complications and highlight how the integration of clinical, pathological and radiological features may help predict the development of such high-risk situations in sarcoid patients.

Recurrent Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, manifesting with bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint or eye lesions. Heerfordt-Waldenström Syndrome - a constellation of facial palsy, fever, uveitis and parotitis - is a rare presentation of this disorder. A 47-year-old Chinese woman presented with unintentional weight loss, lethargy with mediastinal and hilar lymphadenopathy. Biopsy of the right paratracheal lymph node via mediastinoscopy showed mycobacterial granulomatous lymphadenitis consistent with tuberculosis with several acid-fast bacilli identified. Lymphoproliferative disorder was ruled out. She was started on treatment for tuberculosis. Eleven weeks into treatment, she developed a right facial palsy accompanied with fever, uveitis and occipital headache. At this juncture, further history revealed a background of recurrent alternating facial palsy and parotid gland enlargement which was treated for Bell's palsy by three different doctors. New nodules appeared in the left lobe of the thyroid gland. Biopsy of a palpable thyroid nodule and a right supraclavicular lymph nodule showed histological features suggestive of sarcoidosis. Fungal and mycobacterial infections were ruled out. In addition, examination of her cerebral spinal fluid showed lymphocytic inflammation. The serum ACE level was not raised. A diagnosis of sarcoidosis with incomplete features of Heerfordt-Waldenström Syndrome along with thyroid and meningeal involvement was made. The patient was commenced on prednisolone and azathioprine and her symptoms responded shortly after. We present a rare case of Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman.

Re-evaluating serum angiotensin-converting enzyme in sarcoidosis

Sarcoidosis is a systemic inflammatory disease of unknown etiology, which mainly affects the lungs and lymph nodes, as well as extrapulmonary organs. Its incidence, and prevalence rate, and disease course largely vary with regions and populations globally. The clinical manifestations of sarcoidosis depend on the affected organs and the degree of severity, and the diagnosis is mainly based on serum biomarkers, radiographic, magnetic resonance, or positron emission tomography imaging, and pathological biopsy. Noncaseating granulomas composing T cells, macrophages, epithelioid cells, and giant cells, were observed in a pathological biopsy, which was the characteristic pathological manifestation of sarcoidosis. Angiotensin-converting enzyme (ACE) was first found in the renin-angiotensin-aldosterone system. Its main function is to convert angiotensin I (Ang I) into Ang II, which plays an important role in regulating blood pressure. Also, an ACE insertion/deletion polymorphism exists in the human genome, which is involved in the occurrence and development of many diseases, including hypertension, heart failure, and sarcoidosis. The serum ACE level, most commonly used as a biomarker in diagnosing sarcoidosis, in patients with sarcoidosis increases. because of epithelioid cells and giant cells of sarcoid granuloma expressing ACE. Thus, it serves as the most commonly used biomarker in the diagnosis of sarcoidosis and also aids in analyzing its therapeutic effect and prognosis in patients with sarcoidosis.

Challenges of cardiac sarcoidosis

Sarcoidosis is a multisystem granulomatosis of unknown origin, which can involve almost any organ. Most frequently the disease involves the lungs and mediastinal lymph nodes, but it can affect the skin, the eyes, nervous system, the heart, kidneys, joints, muscles, calcium metabolism, and probably any other anecdotical organ involvement. Cardiac sarcoidosis is one of the most challenging involvements, as it can lead to cardiac mortality and morbidity, and also because the diagnosis may be difficult. With no specific symptoms, cardiac sarcoidosis may be difficult to suspect in a patient with no previous extra-cardiac sarcoidosis diagnosis. This manuscript reviews the current knowledge of the diagnosis and decision to treat cardiac sarcoidosis, and illustrates the information with a case presentation of a young adult with no risk factors, no previous diagnosis of sarcoidosis, and with cardiac symptoms impairing his quality of life.

Sarcoidosis

Sarcoidosis is a disease of unknown cause characterized by granulomatous inflammation. Although the lung is almost universally involved, any organ can be affected. Complex pathogenesis and protean clinical manifestations are additional features of the disease. The diagnosis is one of exclusion, although the presence of noncaseating granulomas at disease sites is a prerequisite in most cases. The management of sarcoidosis requires a multidisciplinary approach, particularly when the heart, the brain, or the eyes are involved. The paucity of effective therapies and the lack of reliable predictors of disease behavior greatly contribute to making sarcoidosis a challenging disease to manage.

Pleural and pericardial effusions with cardiac conduction system and myocardial involvement: A rare presentation of sarcoidosis

Sarcoidosis is a granulomatous immune disorder that can infiltrate many organ systems. When the cardiac system is involved, the myocardium and conduction system are frequently affected. We report the case of a patient presenting with complete heart block following cardioversion from atrial flutter accompanied by pleural and pericardial involvement whose diagnosis of sarcoidosis was subsequently made on pathological examination. Pericardial effusion and pleural effusion are rare manifestations of sarcoid, and the both of them happening simultaneously (less than 10 case reports) in conjunction with cardiac conduction system and myocardial involvement are almost nonexistent in the literature (one case report). As cardiac involvement in sarcoid can drastically increase the mortality, it is important to be vigilant for the diverse manifestations of cardiac involvement in all patients for which there is clinical suspicion of sarcoid.

Histology of Cardiac Sarcoidosis with Novel Considerations Arranged upon a Pathologic Basis

Sarcoidosis is a rare disease of isolated or diffuse granulomatous inflammation. Although any organs can be affected by sarcoidosis, cardiac sarcoidosis is a fatal disorder, and it is crucial to accurately diagnose it to prevent sudden death due to dysrhythmia. Although endomyocardial biopsy is invasive and has limited sensitivity for identifying granulomas, it is the only modality that yields a definitive diagnosis of cardiac sarcoidosis. It is imperative to develop novel pathological approaches for the precise diagnosis of cardiac sarcoidosis. Here, we aimed to discuss commonly used diagnostic criteria for cardiac sarcoidosis and to summarize useful and novel histopathologic criteria of cardiac sarcoidosis. While classical histologic observations including noncaseating granulomas and multinucleated giant cells (typically Langhans type) are the most important findings, others such as microgranulomas, CD68⁺ CD163^- pro-inflammatory (M1) macrophage accumulation, CD4/CD8 T-cell ratio, Cutibacterium acnes components, lymphangiogenesis, confluent fibrosis, and fatty infiltration may help to improve the sensitivity of endomyocardial biopsy for detecting cardiac sarcoidosis. These novel histologic findings are based on the pathology of cardiac sarcoidosis. We also discussed the principal histologic differential diagnoses of cardiac sarcoidosis, such as tuberculosis myocarditis, fungal myocarditis, giant cell myocarditis, and dilated cardiomyopathy.

Kardiale Beteiligungen bei rheumatologischen Erkrankungen – eine Übersicht

Rheumatische Erkrankungen gehen mit einem erhöhten kardiovaskulären Risiko einher, können darüber hinaus jedoch im Bereich aller kardialen Strukturen zu spezifischen entzündlichen Veränderungen führen. Symptome wie Dyspnoe, Tachykardie und Leistungsminderung stehen patientenseitig im Vordergrund, wenngleich kardiale Beteiligungen nicht selten asymptomatisch verlaufen. Diagnostisch werden neben der klinischen Untersuchung und laborchemischen Verfahren apparative Diagnostiken wie Echokardiografie und Kardio-MRT aber auch invasive Verfahren wie die Herzkatheteruntersuchung und Myokardbiopsie angewendet. Die Therapie richtet sich nach der Grunderkrankung, den betroffenen kardialen Strukturen und reicht von einer medikamentösen Therapie bis zu interventionell-operativem Vorgehen.

Atrial tachyarrhythmia as a presenting symptom leading to the diagnosis of pulmonary sarcoidosis treated with catheter-based ablation

A 55-year-old woman was referred for recurrent palpitations. A 48-hour ambulatory cardiac monitor revealed an atrial tachycardia rate up to 170 beats per minute. A subsequent electrophysiology study revealed atrial fibrillation and both typical and atypical atrial flutter. Computed tomography revealed multiple pulmonary nodules, and an endobronchial ultrasound-guided fine-needle aspiration confirmed the diagnosis of pulmonary sarcoidosis. The patient underwent radiofrequency ablation of the cavotricuspid isthmus and left common, right superior, and right inferior pulmonary vein isolation via cryoablation, without recurrent symptoms.

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.

Value of 3D mapping-guided endomyocardial biopsy in cardiac sarcoidosis: Case series and narrative review on the value of electro-anatomic mapping-guided endomyocardial biopsies

AIM

Integration of endomyocardial biopsy (EMB) in the diagnostic workup of cardiac sarcoidosis (CS) is under-recognized in current clinical practice, since capturing focal granulomas is challenging. Our aim was to describe our experience with electro-anatomic mapping (EAM)-guided EMB and provide a comprehensive review of the literature.

METHODS AND RESULTS

Five patients (age 49.4 ± 11.4) with suspected CS underwent EAM-guided EMB in Isala Heart Center (Zwolle, the Netherlands) between 2017 and 2019. In all patients, a 3D bipolar voltage map (<0.5-1.5 mV) and unipolar voltage map (LV < 8.3 mV, RV < 5.5 mV) was created using a high-density mapping catheter. The bioptome was connected to the mapping system to guide targeted EMB. Biopsy samples (2-9 samples) were taken from both LV and RV sites, guided by EAM and areas with abnormal electrograms, without complications. CS diagnosis was based on EMB in 2/5 patients. A granuloma was captured in one patient at the LV basal septum with normal bipolar and abnormal unipolar voltage. All patients with delayed enhancement on cardiac magnetic resonance, revealed fibrosis in the biopsy sample. In one patient with suspected isolated cardiac sarcoidosis, diagnosis could not be confirmed by histopathology analysis, while unipolar voltage mapping was abnormal and diastolic potentials were present. Literature search revealed 7 reports (18 patients) describing EAM-guided EMB in CS patients, with 100% of the EMB taken form the RV.

CONCLUSION

Unipolar voltage mapping may be superior to target active inflamed tissue and should be evaluated in future research regarding EAM-guided EMB in CS.

Dilated Cardiomyopathy Compatible With Sarcoidosis Presenting with Syncope Due to Torsades de Pointes: a Case Report

Sarcoidosis is a multisystemic noncaseating granulomatous disease of unknown etiology. Cardiac sarcoidosis clinical presentation is diverse, and syncope is one of the possible primary events. Due to its variable natural history and initial presentation associated with lacking sensitive and specific diagnostic tests, it still represents a challenging diagnosis. This article presents the case of a 51-year-old female patient with intermittent syncope events associated with torsades de pointes and dilated cardiomyopathy compatible with sarcoidosis.

Pathological entities that may affect the lungs and the myocardium. Evaluation with chest CT and cardiac MR

Certain entities may simultaneously involve the lungs and the myocardium. Knowing their cardiac and thoracic manifestations enhances the understanding of those conditions and increases awareness and suspicion for possible concurrent cardiothoracic involvement. Entities that can present with pulmonary and myocardial involvement include infiltrative diseases like sarcoidosis and amyloidosis, eosinophil-associated conditions including eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome (HES), connective tissue diseases such as systemic sclerosis (SSc) and lupus erythematosus and genetic disorders like Fabry disease (FD). Lung involvement in sarcoidosis is almost universal. While cardiac involvement is less common, concurrent cardiothoracic involvement can often be seen. Pulmonary amyloidosis is more often a localized process and generally occurs separately from cardiac involvement, except for diffuse alveolar-septal amyloidosis. EGPA and HES can present with consolidative or ground glass opacities, cardiac inflammation and endomyocardial fibrosis. Manifestations of SSc include interstitial lung disease, pulmonary hypertension and cardiomyopathy. Lupus can present with serositis, pneumonitis and cardiac inflammation. FD causes left ventricular thickening and fibrosis, and small airways disease. This article aims to review the clinicopathological features of chest and cardiac involvement of these entities and describe their main findings on chest CT and cardiac MR.

Anesthetic management of laparoscopy-assisted total proctocolectomy in a cardiac sarcoidosis patient with a cardiac resynchronization therapy-defibrillator: a case report

Background

Cardiac sarcoidosis (CS) causes severe conduction abnormalities and arrhythmias. CS patients are increasingly being treated with cardiac resynchronization therapy-defibrillators (CRT-Ds). For the first time, we report the anesthetic management of a CS patient with a CRT-D.

Case presentation

A 65-year-old male with an implanted CRT-D due to CS was scheduled for a laparoscopy-assisted total proctocolectomy for his transverse colon cancer. His left ventricular ejection fraction was 32.0%, and his physical status was a New York Heart Association class III. General and epidural anesthesia were performed while using standard monitors and a FloTrac^TM system. The dual-chamber pacing (DDD) modality of the CRT-D was unchanged, and its defibrillation function was deactivated before surgery. The surgery was successfully performed, and the patient was discharged without worsening of his cardiac condition.

Conclusions

A detailed understanding of this patient’s condition, as well as sarcoidosis, helped to facilitate successful anesthetic management of this patient.

Idiopathic giant cell myocarditis or cardiac sarcoidosis? A retrospective audit of a nationwide case series

Aims

Cardiac sarcoidosis (CS) and giant cell myocarditis (GCM) are inflammatory cardiomyopathies sharing histopathological and clinical features. Their differentiation is difficult and susceptible of confusion and apparent mistakes. The possibility that they represent different phenotypes of a single disease has been debated.

Methods and results

We made a retrospective audit of 73 cases of GCM diagnosed in Finland since the late 1980s. All available histological material was reanalyzed as were other examinations pertinent to the distinction between GCM and CS. Finding granulomas in or outside the heart was considered diagnostic of CS and exclusive of GCM. Altogether 45 of the 73 cases of GCM (62%) were reclassified as CS. In all except one case, this was based on finding sarcoid granulomas that either had been originally missed (n = 29) or misinterpreted (n = 11) or were found in additional posttransplant myocardial specimens (n = 3) or samples of extracardiac tissue (n = 1) accrued over the disease course. Supporting the reclassification, patients relocated to the CS group had less heart failure at presentation (prevalence 20% vs. 46%, P = 0.017) and better 1 year transplant‐free survival (82% vs. 45%, P = 0.011) than patients considered to represent true GCM.

Conclusions

Recognizing granulomas in or outside the heart remains a challenge for the pathologist. Given that CS and GCM are considered distinct diseases and granulomas exclusive of GCM, many cases of GCM, if thoroughly scrutinized, may need reclassification as CS. However, whether CS and GCM are truly different entities or parts of a one‐disease continuum has not yet been conclusively settled.