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Xu L, Khoshknab M, Moss J, Berger RD, Chrispin J, Callans D, Marchlinski FE, Zimmerman SL, Han Y, Trayanova N, Desjardins B, Nazarian S. Lipomatous Metaplasia Is Associated With Ventricular Tachycardia Recurrence Following Ablation in Patients With Nonischemic Cardiomyopathy. JACC Clin Electrophysiol 2024; 10:1135-1146. [PMID: 38703163 PMCID: PMC11209768 DOI: 10.1016/j.jacep.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/19/2024] [Accepted: 02/05/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Ventricular tachycardia (VT) recurrence rates remain high following ablation among patients with nonischemic cardiomyopathy (NICM). OBJECTIVES This study sought to define the prevalence of lipomatous metaplasia (LM) in patients with NICM and VT and its association with postablation VT recurrence. METHODS From patients who had ablation of left ventricular VT, we retrospectively identified 113 consecutive NICM patients with preprocedural contrast-enhanced cardiac computed tomography (CECT), from which LM was segmented. Nested within this cohort were 62 patients that prospectively underwent CECT and cardiac magnetic resonance from which myocardial border zone and dense late gadolinium enhancement (LGE) were segmented. A control arm of 30 NICM patients without VT with CECT was identified. RESULTS LM was identified among 57% of control patients without VT vs 83% of patients without VT recurrence and 100% of patients with VT recurrence following ablation. In multivariable analyses, LM extent was the only independent predictor of VT recurrence, with an adjusted HR per 1-g LM increase of 1.1 (P < 0.001). Patients with LM extent ≥2.5 g had 4.9-fold higher hazard of VT recurrence than those with LM <2.5 g (P < 0.001). In the nested cohort with 32 VT recurrences, LM extent was independently associated with VT recurrence after adjustment for border zone and LGE extent (HR per 1 g increase: 1.1; P = 0.036). CONCLUSIONS Myocardial LM is prevalent in patients with NICM of a variety of etiologies, and its extent is associated with postablation VT recurrence independent of the degree of fibrosis.
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Affiliation(s)
- Lingyu Xu
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mirmilad Khoshknab
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juwann Moss
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ronald D Berger
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Chrispin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Callans
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuchi Han
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Vereckei A, Besenyi Z, Nagy V, Radics B, Vágó H, Jenei Z, Katona G, Sepp R. Cardiac Sarcoidosis: A Comprehensive Clinical Review. Rev Cardiovasc Med 2024; 25:37. [PMID: 39077350 PMCID: PMC11263157 DOI: 10.31083/j.rcm2502037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/29/2023] [Accepted: 11/07/2023] [Indexed: 07/31/2024] Open
Abstract
Sarcoidosis is an inflammatory multisystemic disease of unknown etiology characterized by the formation of non-caseating granulomas. Sarcoidosis can affect any organ, predominantly the lungs, lymphatic system, skin and eyes. While > 90% of patients with sarcoidosis have lung involvement, an estimated 5% of patients with sarcoidosis have clinically manifest cardiac sarcoidosis (CS), whereas approximately 25% have asymptomatic, clinically silent cardiac involvement verified by autopsy or imaging studies. CS can present with conduction disturbances, ventricular arrhythmias, heart failure or sudden cardiac death. Approximately 30% of < 60-year-old patients presenting with unexplained high degree atrioventricular (AV) block or ventricular tachycardia are diagnosed with CS, therefore CS should be strongly considered in such patients. CS is the second leading cause of death among patients affected by sarcoidosis after pulmonary sarcoidosis, therefore its early recognition is important, because early treatment may prevent death from cardiovascular involvement. The establishment of isolated CS diagnosis sometimes can be quite difficult, when extracardiac disease cannot be verified. The other reason for the difficulty to diagnose CS is that CS is a chameleon of cardiology and it can mimic (completely or almost completely) different cardiac diseases, such as arrhythmogenic cardiomyopathy, giant cell myocarditis, dilated, restrictive and hypertrophic cardiomyopathies. In this review article we will discuss the current diagnosis and management of CS and delineate the potential difficulties and pitfalls of establishing the diagnosis in atypical cases of isolated CS.
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Affiliation(s)
- András Vereckei
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Zsuzsanna Besenyi
- Department of Nuclear Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Viktória Nagy
- Division of Non-Invasive Cardiology, Department of Medicine, University of
Szeged, 6720 Szeged, Hungary
| | - Bence Radics
- Department of Pathology, University of Szeged, 6720 Szeged, Hungary
| | - Hajnalka Vágó
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary
| | - Zsigmond Jenei
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Gábor Katona
- Department of Medicine and Hematology, Semmelweis University, 1088
Budapest, Hungary
| | - Róbert Sepp
- Division of Non-Invasive Cardiology, Department of Medicine, University of
Szeged, 6720 Szeged, Hungary
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Kim J, Dwivedi G, Boughton BA, Sharma A, Lee S. Advances in cellular and tissue-based imaging techniques for sarcoid granulomas. Am J Physiol Cell Physiol 2024; 326:C10-C26. [PMID: 37955119 DOI: 10.1152/ajpcell.00507.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
Sarcoidosis embodies a complex inflammatory disorder spanning multiple systems, with its origin remaining elusive. It manifests as the infiltration of inflammatory cells that coalesce into distinctive noncaseous granulomas within afflicted organs. Unraveling this disease necessitates the utilization of cellular or tissue-based imaging methods to both visualize and characterize the biochemistry of these sarcoid granulomas. Although hematoxylin and eosin stain, standard in routine use alongside cytological stains have found utility in diagnosis within clinical contexts, special stains such as Masson's trichrome, reticulin, methenamine silver, and Ziehl-Neelsen provide additional varied perspectives of sarcoid granuloma imaging. Immunohistochemistry aids in pinpointing specific proteins and gene expressions further characterizing these granulomas. Finally, recent advances in spatial transcriptomics promise to divulge profound insights into their spatial orientation and three-dimensional (3-D) molecular mapping. This review focuses on a range of preexisting imaging methods employed for visualizing sarcoid granulomas at the cellular level while also exploring the potential of the latest cutting-edge approaches like spatial transcriptomics and matrix-assisted laser desorption ionization mass spectrometry imaging (MALDI-MSI), with the overarching goal of shedding light on the trajectory of sarcoidosis research.
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Affiliation(s)
- Junwoo Kim
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Berin A Boughton
- Australian National Phenome Centre, Murdoch University, Murdoch, Western Australia, Australia
| | - Ankur Sharma
- Onco-Fetal Ecosystem Laboratory, Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Silvia Lee
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
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Shah HH, Zehra SA, Shahrukh A, Waseem R, Hussain T, Hussain MS, Batool F, Jaffer M. Cardiac sarcoidosis: a comprehensive review of risk factors, pathogenesis, diagnosis, clinical manifestations, and treatment strategies. Front Cardiovasc Med 2023; 10:1156474. [PMID: 37273881 PMCID: PMC10235776 DOI: 10.3389/fcvm.2023.1156474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/21/2023] [Indexed: 06/06/2023] Open
Abstract
Cardiac Sarcoidosis (CS) is a deadly consequence of systemic sarcoidosis that inflames all three layers of the heart, especially the myocardium-clinical signs of CS range from asymptomatic disease to abrupt cardiac death. CS generally remains undiagnosed secondary to a lack of definitive diagnostic criteria, a high percentage of false negative results on endomyocardial biopsy, and ill-defining clinical manifestations of the disease. Consequently, there is a lack of evidence-based recommendations for CS, and the present diagnostic and therapeutic management depend on expert opinion. The aetiology, risk factors, clinical symptoms, diagnosis, and therapy of CS will be covered in this review. A particular emphasis will be placed on enhanced cardiovascular imaging and early identification of CS. We review the emerging evidence regarding the use of Electrocardiograms (ECGs), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) imaging of the heart to identify and quantify the extent of myocardial inflammation, as well as to guide the use of immunotherapy and other treatment regimens, such as ablation therapy, device therapy, and heart transplantation, to improve patient outcomes.
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Kato S, Sakai Y, Okabe A, Kawashima Y, Kuwahara K, Shiogama K, Abe M, Ito H, Morimoto S. Histology of Cardiac Sarcoidosis with Novel Considerations Arranged upon a Pathologic Basis. J Clin Med 2022; 11:jcm11010251. [PMID: 35011991 PMCID: PMC8746035 DOI: 10.3390/jcm11010251] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Shu Kato
- Postgraduate Clinical Training Center, Fujita Health University Hospital, Aichi 470-1192, Japan;
| | - Yasuhiro Sakai
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
- Correspondence: ; Tel.: +81-562-93-9934
| | - Asako Okabe
- Department of Diagnostic Pathology, Kansai Medical University Hospital, Osaka 573-1191, Japan;
| | - Yoshiaki Kawashima
- Department of Pathology, Fujita Health University Bantane Hospital, Aichi 454-8509, Japan;
| | - Kazuhiko Kuwahara
- Department of Diagnostic Pathology, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
| | - Kazuya Shiogama
- Department of Morphology and Pathological Diagnosis, Fujita Health University School of Medical Sciences, Aichi 470-1192, Japan; (K.S.); (M.A.)
| | - Masato Abe
- Department of Morphology and Pathological Diagnosis, Fujita Health University School of Medical Sciences, Aichi 470-1192, Japan; (K.S.); (M.A.)
| | - Hiroyasu Ito
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
| | - Shin’ichiro Morimoto
- Department of Cardiology, Fujita Health University School of Medicine, Aichi 470-1192, Japan;
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Alba AC, Gupta S, Kugathasan L, Ha A, Ochoa A, Balter M, Sosa Liprandi A, Sosa Liprandi MI. Cardiac Sarcoidosis: A Clinical Overview. Curr Probl Cardiol 2021; 46:100936. [PMID: 34400001 DOI: 10.1016/j.cpcardiol.2021.100936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/17/2021] [Indexed: 12/26/2022]
Abstract
Cardiac sarcoidosis (CS) with clinical manifestation occurs in about 5-8% of patients with sarcoidosis. CS may be clinically suspected by the presence of ventricular arrhythmia, conduction abnormalities, and heart failure (HF). However, 20%-25% of patients may present with silent CS, having asymptomatic cardiac involvement. The diagnosis of CS is based on findings from nuclear studies, cardiac magnetic resonance, and extra-cardiac tissue biopsy. Due to the inflammatory nature of the disease, immunosuppressive medications are a cornerstone of therapy. The treatment also includes recommended HF medical therapies. Since CS patients are at risk of sudden cardiac death resulting from progression of cardiac dysfunction or the presence of scar originating from fatal arrhythmias, implantable cardioverter-defibrillators should be considered, with special indication beyond accepted recommendations in HF. In CS, the extent of left ventricular dysfunction is the most important mortality predictor. Heart transplant or mechanical circulatory support may represent life saving strategies in selective CS patients.
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Affiliation(s)
- Ana Carolina Alba
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
| | - Shyla Gupta
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Lakshmi Kugathasan
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Andrew Ha
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Alejandro Ochoa
- Echocardiography, Cardioestudio, Clinica Las Vegas, Medellin, Colombia
| | - Meyer Balter
- Division of Respiratory Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Alvaro Sosa Liprandi
- Department of Cardiology and Heart Failure, Sanatorio Güemes, Buenos Aires, Argentina
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Haanschoten DM, Adiyaman A, 't Hart NA, Jager PL, Elvan A. 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. Eur J Clin Invest 2021; 51:e13497. [PMID: 33482016 DOI: 10.1111/eci.13497] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
| | - Ahmet Adiyaman
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Nils A 't Hart
- Department of Pathology, Isala Hospital, Zwolle, the Netherlands
| | - Piet L Jager
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Arif Elvan
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
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Piriou N, Bruneval P. Cardiac sarcoidosis: A multimodal approach to reach the diagnosis. Int J Cardiol 2020; 323:264-266. [PMID: 33096145 DOI: 10.1016/j.ijcard.2020.10.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Nicolas Piriou
- Cardiology department and Nuclear Medicine Department, University Hospital of Nantes, Nantes, France
| | - Patrick Bruneval
- Pathology department, University Hospital Georges Pompidou, University of Paris, Paris, France.
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