Korean Circ J.  2021 Jul;51(7):561-578. 10.4070/kcj.2021.0104.

The Role of Multimodality Imaging in Cardiac Sarcoidosis

• Oyama-Manabe N
• Manabe O
• Aikawa T
• Tsuneta S

• KMID: 2517486
• DOI: http://doi.org/10.4070/kcj.2021.0104

Abstract

The etiology and the progression of sarcoidosis remain unknown. However, cardiac sarcoidosis (CS) is significantly associated with a poor prognosis due to the associated congestive heart failure, arrhythmias (such as an advanced atrioventricular block), and ventricular tachyarrhythmia. Novel imaging modalities are now available to detect CS lesions secondary to active inflammation, granuloma formation, and fibrotic changes. 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) and cardiac magnetic resonance imaging (CMR) play essential roles in diagnosing and monitoring patients with confirmed or suspected CS. The following focused review will highlight the emerging role of non-invasive cardiac imaging techniques, including FDG PET/ CT and CMR.

Keyword

Cardiac sarcoidosis; ¹⁸ F-FDG PET; Cardiac magnetic resonance imaging

Figure

• 

  Figure 1 A representative case of various physiological myocardial uptake patterns during follow-up in one patient.A patient with malignant lymphoma underwent serial 18F-fluorodeoxyglucose positron emission tomography/computed tomography scans for follow-up after chemotherapy. Focus on the left ventricular uptake, no uptake (A), diffuse strong uptake with left ventricular uptake (B), predominant regional uptake in the base of the myocardium (C), and diffuse uptake (D) is pointed out.

• 

  Figure 2 A representative case of a woman in her 60s with complete right bundle branch block before and after steroid therapy. Cardiac magnetic resonance shows subepicardial gadolinium enhancement at the basal septum and lateral wall (A). Focal myocardial fluorodeoxyglucose uptake at the septum and multiple uptake at the mediastinal lymph nodes are consistent with cardiac sarcoidosis (B). After administration of steroid therapy, myocardial and mediastinal uptake are diminished (C).

• 

  Figure 3 A woman in her 60s was admitted to the hospital with acute heart failure. Cardiac magnetic resonance imaging shows abnormal gadolinium enhancement with transmural and epicardium distribution of left ventricle (A, arrows). Through T2 mapping, the diffuse prolongation of T2 values is observed, suggesting myocardial edema or inflammation due to active cardiac sarcoidosis (B, normal range was under 54 ms). 18F-fluorodeoxyglucose positron emission tomography/computed tomography reveals correlated focal uptake, confirming active cardiac sarcoidosis (C, arrows).

• 

  Figure 4 A man in his 40s was diagnosed as systemic sarcoidosis by transbronchial lung biopsy.Due to complete right bundle branch block and diffuse left ventricular dysfunction, he was referred for CMR. Left ventricular 2-chamber view of the late gadolinium enhanced CMR shows hyperenhancement at the inferior wall (A, yellow arrows). After a long fast with a low-carbohydrate diet, the 18F-FDG positron emission tomography/computed tomography reveals abnormal FDG uptake at the inferior wall, indicating active cardiac sarcoidosis (B). (C and D) Feature-tracking using cine magnetic resonance imaging for longitudinal strain clearly depicts regional wall motion abnormality with aneurysmal deformation of the mid-inferior wall (green strain curve).CMR = cardiac magnetic resonance imaging; FDG = fluorodeoxyglucose.

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  Figure 5 Arrhythmia was detected in a woman in her 50s. Abnormal enhancement and uptake are shown in the left ventricular lateral wall with late gadolinium enhancement of CMR and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (A and B, arrows). DE-CT also highlights the abnormal enhancement in the lateral wall, seen in the CMR (C, arrows). The patient was diagnosed with active cardiac sarcoidosis and was implanted with an ICD to prevent ventricular tachycardia. DE-CT after ICD implantation reveals abnormal enhancement in the lateral wall, as seen previously (D, arrows). Although there were metal artifacts mainly at the septum due to the ICD leads, we were able to compare the 2 images and confirm that the lesion was not worsening over time.CMR = cardiac magnetic resonance imaging; DE-CT = delayed iodine contrast-enhanced computed tomography; ICD = implantable cardioverter-defibrillator.

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