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Chareonthaitawee P, Gutberlet M. Clinical Utilization of Multimodality Imaging for Myocarditis and Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2023; 16:e014091. [PMID: 36649452 DOI: 10.1161/circimaging.122.014091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Myocarditis is defined as inflammation of the myocardium according to clinical, histological, biochemical, immunohistochemical, or imaging findings. Inflammation can be categorized histologically by cell type or pattern, and many causes have been implicated, including infectious, most commonly viral, systemic autoimmune diseases, vaccine-associated processes, environmental factors, toxins, and hypersensitivity to drugs. Sarcoid myocarditis is increasingly recognized as an important cause of cardiomyopathy and has important diagnostic, prognostic, and therapeutic implications in patients with systemic sarcoidosis. The clinical presentation of myocarditis may include an asymptomatic, subacute, acute, fulminant, or chronic course and may have focal or diffuse involvement of the myocardium depending on the cause and time point of the disease. For most causes of myocarditis except sarcoidosis, myocardial biopsy is the gold standard but is limited due to risk, cost, availability, and variable sensitivity. Diagnostic criteria have been established for both myocarditis and cardiac sarcoidosis and include clinical and imaging findings particularly the use of cardiac magnetic resonance and positron emission tomography. Beyond diagnosis, imaging findings may also provide prognostic value. This case-based review focuses on the current state of multimodality imaging for the diagnosis and management of myocarditis and cardiac sarcoidosis, highlighting multimodality imaging approaches with practical clinical vignettes, with a discussion of knowledge gaps and future directions.
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Elwazir MY, Bois JP, Chareonthaitawee P. Utilization of cardiac imaging in sarcoidosis. Expert Rev Cardiovasc Ther 2022; 20:253-266. [DOI: 10.1080/14779072.2022.2069560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mohamed Y. Elwazir
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - John P. Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Hulten E, Aslam S, Osborne M, Abbasi S, Bittencourt MS, Blankstein R. Cardiac sarcoidosis-state of the art review. Cardiovasc Diagn Ther 2016; 6:50-63. [PMID: 26885492 DOI: 10.3978/j.issn.2223-3652.2015.12.13] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sarcoidosis is a multi-system inflammatory disorder of unknown etiology resulting in formation of non-caseating granulomas. Cardiac involvement-which is associated with worse prognosis-has been detected in approximately 25% of individuals based on autopsy or cardiac imaging studies. Nevertheless, the diagnosis of cardiac sarcoidosis is challenging due to the low yield of endomyocardial biopsy, and the limited accuracy of various clinical criteria. Thus, no gold standard diagnostic criterion exists. This review will summarize the pathophysiology, diagnosis, and treatment of cardiac sarcoidosis with a focus on advanced cardiovascular imaging, We review the evidence to support a role for cardiac magnetic resonance (CMR) imaging in the initial evaluation of selected patients with suspected cardiac sarcoidosis, with cardiac positron emission tomography (PET) as an alternative or complementary initial diagnostic test in a subgroup of patients in whom CMR may be contra-indicated or when CMR is negative with continued clinical concern for myocardial inflammation. In addition to the diagnostic value of these tests, CMR and PET are also useful in identifying patients who have higher risk of adverse events such as ventricular tachycardia or death, in whom preventive therapies such as defibrillators should be more strongly considered. Although no randomized controlled trials for treatment of cardiac sarcoidosis exist, immunosuppressive therapy is often used. We review emerging evidence regarding the use of cardiac PET to identify and quantity the amount of myocardial inflammation as well as to guide the use of immunotherapy. Future studies are needed to determine the benefit of imaging guided therapies aimed at improving patient outcomes.
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Affiliation(s)
- Edward Hulten
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Saira Aslam
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michael Osborne
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Siddique Abbasi
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcio Sommer Bittencourt
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ron Blankstein
- 1 Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA ; 2 Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA ; 3 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ; 4 Center for Clinical and Epidemiological Research, University Hospital and Sao Paulo State Cancer Institute, University of São Paulo, São Paulo, Brazil ; 5 Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Houston BA, Mukherjee M. Cardiac sarcoidosis: clinical manifestations, imaging characteristics, and therapeutic approach. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:31-7. [PMID: 25452702 PMCID: PMC4240214 DOI: 10.4137/cmc.s15713] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/12/2014] [Accepted: 10/21/2014] [Indexed: 12/26/2022]
Abstract
Sarcoidosis is a multi-system disease pathologically characterized by the accumulation of T-lymphocytes and mononuclear phagocytes into the sine qua non pathologic structure of the noncaseating granuloma. Cardiac involvement remains a key source of morbidity and mortality in sarcoidosis. Definitive diagnosis of cardiac sarcoidosis, particularly early enough in the disease course to provide maximal therapeutic impact, has proven a particularly difficult challenge. However, major advancements in imaging techniques have been made in the last decade. Advancements in imaging modalities including echocardiography, nuclear spectroscopy, positron emission tomography, and magnetic resonance imaging all have improved our ability to diagnose cardiac sarcoidosis, and in many cases to provide a more accurate prognosis and thus targeted therapy. Likewise, therapy for cardiac sarcoidosis is beginning to advance past a “steroids-only” approach, as novel immunosuppressant agents provide effective steroid-sparing options. The following focused review will provide a brief discussion of the epidemiology and clinical presentation of cardiac sarcoidosis followed by a discussion of up-to-date imaging modalities employed in its assessment and therapeutic approaches.
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Affiliation(s)
- Brian A Houston
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Ohira H, Tsujino I, Yoshinaga K. ¹⁸F-Fluoro-2-deoxyglucose positron emission tomography in cardiac sarcoidosis. Eur J Nucl Med Mol Imaging 2011; 38:1773-83. [PMID: 21559980 DOI: 10.1007/s00259-011-1832-y] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
Abstract
Cardiac sarcoidosis (CS) is a rare and potentially life-threatening disease that causes conduction disturbance, systolic dysfunction, and most notably sudden cardiac death. Accurate diagnosis of CS is thus mandatory; however, a reliable approach that enables diagnosis of CS with high sensitivity and specificity has yet to be established. Recent studies have demonstrated the promising potential of (18)F-fluoro-2-deoxyglucose positron emission tomography ((18)F-FDG PET) in the diagnosis and assessment of CS. Indeed, (18)F-FDG PET provides a wide variety of advantages over previous imaging modalities; however, there are pitfalls and limitations that should be recognized. In this review article, (1) the rationale for (18)F-FDG PET application in CS, (2) suitable pretest preparations, and (3) evaluation protocols for the (18)F-FDG PET images obtained will be addressed. In particular, sufficient suppression of physiological (18)F-FDG uptake in the heart is essential for accurate assessment of CS. Also, (4) recent studies addressing the diagnostic role of (18)F-FDG PET and (5) the clinically important differences between (18)F-FDG PET and other imaging technologies will be reviewed. For example, active sarcoid lesions and their response to steroid treatment will be better detected by (18)F-FDG PET, whereas fibrotic lesions might be shown more clearly by magnetic resonance imaging or other nuclear myocardial perfusion imaging. In the last decade, (18)F-FDG PET has substantially enhanced detection of CS; however, CS would be better evaluated by a combination of multiple modalities. In the future, advances in (18)F-FDG PET and other emerging imaging modalities are expected to enable better management of patients with sarcoidosis.
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Affiliation(s)
- Hiroshi Ohira
- First Department of Medicine, Hokkaido University School of Medicine, N15, W7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
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