Detection of Myocardial Damage in Patients With Sarcoidosis

Abstract

Background-In patients with sarcoidosis, sudden death is a leading cause of mortality, which may represent unrecognized cardiac involvement. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) can detect minute amounts of myocardial damage. We sought to compare DE-CMR with standard clinical evaluation for the identification of cardiac involvement. Methods and Results-Eighty-one consecutive patients with biopsy-proven extracardiac sarcoidosis were prospectively recruited for a parallel and masked comparison of cardiac involvement between (1) DE-CMR and (2) standard clinical evaluation with the use of consensus criteria (modified Japanese Ministry of Health [JMH] guidelines). Standard evaluation included 12-lead ECG and at least 1 dedicated non-CMR cardiac study (echocardiography, radionuclide scintigraphy, or cardiac catheterization). Patients were followed for 21Ϯ8 months for major adverse events (death, defibrillator shock, or pacemaker requirement). Patients were predominantly middle-aged (46Ϯ11 years), female (62%), and black (73%) and had chronic sarcoidosis (median, 7 years) and preserved left ventricular ejection fraction (median, 56%). DE-CMR identified cardiac involvement in 21 patients (26%) and JMH criteria in 10 (12%, 8 overlapping), a Ͼ2-fold higher rate for DE-CMR (Pϭ0.005). All patients with myocardial damage on DE-CMR had coronary disease excluded by x-ray angiography. Pathology evaluation in 15 patients (19%) identified 4 with cardiac sarcoidosis; all 4 were positive by DE-CMR, whereas 2 were JMH positive. On follow-up, 8 had adverse events, including 5 cardiac deaths. Patients with myocardial damage on DE-CMR had a 9-fold higher rate of adverse events and an 11.5-fold higher rate of cardiac death than patients without damage. Conclusions-In patients with sarcoidosis, DE-CMR is more than twice as sensitive for cardiac involvement as current consensus criteria. Myocardial damage detected by DE-CMR appears to be associated with future adverse events including cardiac death, but events were few, and this needs confirmation in a larger

Magnetic Resonance Imaging as a Predictor of Survival Free of Life‐Threatening Arrhythmias and Transplantation in Cardiac Sarcoidosis

“…Most of the comparable previous work11, 12, 19, 24, 25, 27 relied mainly on the Japanese diagnostic criteria,22, 23 which suffer from problems with sensitivity and specificity3, 4, 8, 10, 29 and are no longer endorsed by experts in the field 3. The generic limitations of retrospective studies apply to our work, as they do to all other outcome data in CS because of the lack of prospective research.…”

“…The general signs of poor cardiac prognosis, such as spontaneous ventricular tachyarrhythmias and impaired left ventricular (LV) function, are also applicable to CS,3 but additional risk markers more specific to CS are clearly needed. Myocardial late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) has been reported to predict serious cardiac events in patients with extracardiac sarcoidosis,4, 5, 6, 7 although not consistently 8, 9, 10. Whether CMRI has prognostic value in established CS is much less studied 11, 12.…”

Hospitalization Rates, Prevalence of Cardiovascular Manifestations, and Outcomes Associated With Sarcoidosis in the United States

“…The availability of these guidelines has also been complemented with rapid and landmark advances in myocardial imaging modalities. The development of the guidelines and imaging techniques has undoubtedly served to enhance the early detection of sarcoidosis, thus increasing the incidence of this disease 10, 11, 26, 27…”

Myocardial Scar Delineation Using Diffusion Tensor Magnetic Resonance Tractography

“…In ischemic cardiomyopathy, delineation of the extent of infarction and the area of viable myocardium plays an important role in patient management and the assessment of long‐term prognosis 1, 2, 3, 4. Myocardial tissue characterization is also of value in the diagnosis and assessment of a number of nonischemic cardiomyopathies 5, 6, 7. In addition, scar‐imaging techniques are increasingly used in the preprocedural assessment of the underlying arrhythmic substrate for patients undergoing catheter ablation for ventricular arrhythmias,8 for which intraprocedural scar definition is performed using endocardial or epicardial voltage mapping 8, 9…”

“…A variety of imaging modalities and approaches have been used to assess myocardial injury, infiltration, and viability, most notably late gadolinium enhancement (LGE),1, 2, 3, 5, 6, 7 and positron emission tomography 10, 11, 12. LGE has emerged as a leading technique for tissue characterization of the myocardium; however, several issues complicate its use.…”