Cardiac sarcoidosis with extensive and heterogeneous left ventricular FDG uptake in absence of guidelines indication for an implantable defibrillator: Ventricular tachycardia precipitated by immunosuppressive therapy, should we have done differently?

Abstract

A 40‐year‐old man, newly diagnosed with cardiac sarcoidosis (CS) presented with symptomatic ventricular tachycardia three days after starting steroid‐based immunosuppressive therapy (IT). There was no clear guideline indication for implantable cardioverter‐defibrillator (ICD) before the initiation of IT. Shortly after ICD implantation and the initiation of anti‐arrhythmic drugs, recurring ventricular arrhythmias required titration of the anti‐arrhythmic drug therapy. One‐year follow‐up assessment showed no significant arrhythmias and complete PET scan FDG uptake suppression. This case, along with recent publications, suggests transient pro‐arrhythmic effects of steroids in patients with CS, which are not appropriately addressed in the current guidelines. We believe ICD implantation should be considered in clinically manifest CS before initiating IT, particularly in cases with heterogeneous and/or extensive FDG uptake on PET scans.

Arrhythmias in Cardiac Sarcoidosis: Management and Prognostic Implications

“…FDG-PET is a preferred modality for monitoring treatment response and surveillance for any recurrence [63,67]. Although a significant recovery of systolic function is expected with immunosuppressive therapy in patients demonstrating active inflammation and low or no burden of scarring on MRI imaging, it is difficult to predict the response of different arrhythmias [68]. AV block has been shown to resolve in many CS patients (42%) with steroid therapy [34].…”