Treatment of cardiac sarcoidosis

The role of imaging in the selection of patients for HFpEF therapy

Heart failure with preserved ejection fraction (HFpEF) traditionally has been characterized as a form of heart failure without therapeutic options, in particular with a lack of response to the established therapies of heart failure with reduced ejection fraction (HFrEF). However, this is no longer true. Besides physical exercise, risk factor modification, aldosterone blocking agents, and sodium-glucose cotransporter 2 inhibitors, specific therapies are emerging for specific HFpEF etiologies, such as hypertrophic cardiomyopathy or cardiac amyloidosis. This development justifies increased efforts to arrive at specific diagnoses within the umbrella of HFpEF. Cardiac imaging plays by far the largest role in this effort and is discussed in the following review.

Cardiac Sarcoidosis-Induced Heart Failure

Sarcoidosis is a common disease with the incidence of cardiac involvement varying. Cardiac sarcoidosis should be kept on the differential when young patients present with acute heart failure, conduction abnormalities or new arrhythmia. Cardiac involvement in sarcoidosis must be diagnosed early and treated aggressively. Here we present a patient who presented with shortness of breath and was found to have significant heart failure with reduced ejection fraction caused by sarcoidosis with cardiac involvement. She was treated with optimization of medical therapy for heart failure and eventually required implantable cardioverter defibrillator (ICD) placement.

Sarcoidosis and Aortic Stenosis: A Role for Transcatheter Aortic Valve Replacement?

Sarcoidosis is an infiltrative disease known to affect multiple layers of the heart.¹ Although rare, aortic valve involvement has been seen.^17,18 The role of transcatheter aortic valve replacement (TAVR) has been described in amyloidosis,⁴ a well-known infiltrative disease, but not in sarcoidosis. As the awareness of cardiac sarcoidosis grows,¹⁷ as in amyloidosis, its impact on the aortic valve will grow too. Our review highlights the epidemiology, pathophysiology, and treatment of cardiac sarcoidosis with a discussion for TAVR in patients affected by aortic valve insult.

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.

Effectiveness and safety of infliximab in cardiac Sarcoidosis

BACKGROUND

Immunosuppressive therapy in active cardiac sarcoidosis (CS) might prevent potential life-threatening complications. Infliximab (IFX) is a tumor necrosis factor alpha monoclonal antibody proven to be effective in refractory extracardiac sarcoidosis. It is sparsely used in CS, because of its association with worsening heart failure in prior studies. The goal of this study is to assess the effectiveness and safety of IFX in CS.

METHODS AND RESULTS

A retrospective, single center cohort study was performed in sarcoidosis patients treated with IFX based on a cardiac indication between January 2016 and March 2019. Patients received IFX intravenously at a dose of 5 mg/kg at week 0, 2, and subsequently every 4 weeks. After every six months, treatment response was evaluated within the multidisciplinary team using FDG-PET/CT, transthoracic echocardiography, biomarkers and device interrogation reports. Responder analysis definitions were based on; dosage of immunosuppressive drugs, improvement in functional class, left ventricular ejection fraction (LVEF) and SUVmax. Twenty-two patients were included (mean age 51.0 SD10.0 years, male 68.2%) with a mean follow-up of 18.9 months (6 to 44 months) of whom 18 (82%) were classified as responders. Median SUVmax on FDG-PET/CT decreased from SUVmax 5.2 [3.7-8.4] to 2.3 [1.4-2.3], p = 0.015. The target-to-background ratio decreased from 3.2 [2.1-5.1] to 1.0 [0.7-2.4], p = 0.002. The median left ventricular (LV) ejection fraction increased from 45.0% [34.0-60.0] to 55.0% [41.0-60.0], p = 0.02. The majority of patients (73%) experienced no side effects and no patients had worsening of heart failure.

CONCLUSION

In this pilot study, patients with refractory CS treated with infliximab, on top of standard of care, had a reduction in inflammation on FDG-PET/CT and an improvement in LV function, without serious adverse events.