The prognostic role of PET myocardial perfusion imaging in patients with cardiac sarcoidosis: a systematic review

Abstract Funding Acknowledgements Type of funding sources: None. Background Sarcoidosis is a multi-systemic inflammatory disease of unknown etiology. Cardiac Sarcoidosis (CS) has been reported in as much as 25% of patients with systemic involvement. 18Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) has a high diagnostic sensitivity/specificity in the diagnosis of CS. Purpose The aim of this review is to summarize evidence on the prognostic role of FDG PET. Methods Studies were identified by searching MEDLINE from inception to October 2020. Medical Subject Headings (MeSH) terms for sarcoidosis; cardiac and FDG PET imaging were used. Studies of any design assessing the prognostic role of FDG PET in patients with either suspected or confirmed cardiac sarcoidosis imaging done at baseline were included. Abnormal PET was defined as abnormal metabolism (presence of focal or focal-on-diffuse uptake of FDG) OR abnormal metabolism and a perfusion defect. Studies reporting any outcome measure were included. Pooled risk ratio for the composite outcome of MACE was done. Results A total of 6 studies were selected for final inclusion (515 patients, 53.4% women, 19.8% racial minorities.) Studies were institution based, retrospective in design and enrolled consecutive patients. All were observational in nature and published in English. All studies used a qualitative assessment of PET scans (abnormal FDG uptake with or without abnormal perfusion). Two studies assessed quantitative metrics (summed stress score in segments with abnormal FDG uptake, standardized uptake value and cardiac metabolic activity.) All studies reported Major Adverse Cardiovascular Events (MACE) as a composite outcome. After a mean follow up ranging from 1.4 to 4.1 years, there were a total of 105 MACE. All studies included death (either all-cause death or sudden cardiac death) and ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) as a component of MACE. Four of the six studies adjusted for several characteristics in their analysis. All four studies used Left Ventricular Ejection Fraction (LVEF). However, other adjustment variables were not consistent across studies. Five studies found a positive prognostic association with the primary outcome, two of which assessing right ventricular uptake. Conclusion Although available evidence indicates FDG PET can be used in the risk stratification of patients with CS, our findings show further studies are needed to quantify the effect in this patient group.

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Combined simultaneous FDG-PET/MRI with T1 and T2 mapping as an imaging biomarker for the diagnosis and prognosis of suspected cardiac sarcoidosis

European Journal of Hybrid Imaging ◽

10.1186/s41824-021-00119-w ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Edward Cheung ◽

Sarah Ahmad ◽

Matthew Aitken ◽

Rosanna Chan ◽

Robert M. Iwanochko ◽

...

Keyword(s):

Fdg Pet ◽

Cardiac Sarcoidosis ◽

T2 Mapping ◽

Ventricular Tachyarrhythmia ◽

Prognostic Significance ◽

Final Diagnosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Fdg Uptake

Abstract Purpose To evaluate the diagnostic and prognostic significance of combined cardiac 18F-fluorodeoxyglucose (FDG) PET/MRI with T1/T2 mapping in the evaluation of suspected cardiac sarcoidosis. Methods Patients with suspected cardiac sarcoidosis were prospectively enrolled for cardiac 18F-FDG PET/MRI, including late gadolinium enhancement (LGE) and T1/T2 mapping with calculation of extracellular volume (ECV). The final diagnosis of cardiac sarcoidosis was established using modified JMHW guidelines. Major adverse cardiac events (MACE) were assessed as a composite of cardiovascular death, ventricular tachyarrhythmia, bradyarrhythmia, cardiac transplantation or heart failure. Statistical analysis included Cox proportional hazard models. Results Forty-two patients (53 ± 13 years, 67% male) were evaluated, 13 (31%) with a final diagnosis of cardiac sarcoidosis. Among patients with cardiac sarcoidosis, 100% of patients had at least one abnormality on PET/MRI: FDG uptake in 69%, LGE in 100%, elevated T1 and ECV in 100%, and elevated T2 in 46%. FDG uptake co-localized with LGE in 69% of patients with cardiac sarcoidosis compared to 24% of those without, p = 0.014. Diagnostic specificity for cardiac sarcoidosis was highest for FDG uptake (69%), elevated T2 (79%), and FDG uptake co-localizing with LGE (76%). Diagnostic sensitivity was highest for LGE, elevated T1 and ECV (100%). After median follow-up duration of 634 days, 13 patients experienced MACE. All patients who experienced MACE had LGE, elevated T1 and elevated ECV. FDG uptake (HR 14.7, p = 0.002), elevated T2 (HR 9.0, p = 0.002) and native T1 (HR 1.1 per 10 ms increase, p = 0.044) were significant predictors of MACE even after adjusting for left ventricular ejection fraction and immune suppression treatment. The presence of FDG uptake co-localizing with LGE had the highest diagnostic performance overall (AUC 0.73) and was the best predictor of MACE based on model goodness of fit (HR 14.9, p = 0.001). Conclusions Combined cardiac FDG-PET/MRI with T1/T2 mapping provides complementary diagnostic information and predicts MACE in patients with suspected cardiac sarcoidosis.

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49 Predictors and prognostic role of left ventricular ejection fraction recovery after st elevation myocardial infarction

10.1136/heartjnl-2019-ics.49 ◽

2019 ◽

Author(s):

A Kearney ◽

M Alkhalil ◽

J Jones ◽

M Donnelly ◽

D MacElhatton ◽

...

Keyword(s):

Myocardial Infarction ◽

Left Ventricular Ejection Fraction ◽

Ejection Fraction ◽

Left Ventricular ◽

St Elevation Myocardial Infarction ◽

Left Ventricular Ejection ◽

Prognostic Role ◽

Ventricular Ejection Fraction ◽

St Elevation

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State of the art paper Prognostic role of troponin and natriuretic peptides as biomarkers for deterioration of left ventricular ejection fraction after chemotherapy

Archives of Medical Science ◽

10.5114/aoms.2013.34987 ◽

2014 ◽

Vol 5 ◽

pp. 1007-1018 ◽

Cited By ~ 3

Author(s):

Paweł Stachowiak ◽

Zdzisława Kornacewicz-Jach ◽

Krzysztof Safranow

Keyword(s):

Left Ventricular Ejection Fraction ◽

Ejection Fraction ◽

Natriuretic Peptides ◽

State Of The Art ◽

Left Ventricular ◽

Ventricular Ejection ◽

Left Ventricular Ejection ◽

Prognostic Role ◽

Ventricular Ejection Fraction

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Cardiac sarcoidosis: A review on the work-up and management

Open Medicine ◽

10.2478/s11536-012-0095-8 ◽

2013 ◽

Vol 8 (1) ◽

pp. 107-116

Author(s):

Boris Solun ◽

Dana Marcoviciu ◽

Yulia Belnik ◽

Tamar Azran ◽

Dror Dicker ◽

...

Keyword(s):

Sudden Death ◽

Cardiac Sarcoidosis ◽

Ventricular Tachyarrhythmia ◽

Clinical Manifestations ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Diagnostic Tools ◽

Unknown Etiology ◽

Ventricular Ejection Fraction ◽

Electrocardiographic Monitoring

AbstractSarcoidosis is a multisystem granulomatous disease of unknown etiology and with variable presentation. Skin, lymph nodes, lungs, eyes and the central nervous system are mostly involved. Cardiac sarcoidosis (CS) is a rare condition with clinical manifestations in about 5% of patients. Since it increases the risk of acute cardiac failure, ventricular arrhythmia, conduction disturbances and even sudden death, it aggravates markedly the prognosis. The early diagnosis of CS is difficult, requiring the use of diagnostic tools such as electrocardiographic monitoring, two-dimensional echocardiography, radionuclide scan, cardiac magnetic resonance imaging, positron emission tomography and endomyocardial biopsy. Once the diagnosis of CS is established, there is a need for early corticosteroids treatment, with or without immunosuppressive therapy, to prevent deterioration of cardiac function. In patients with refractory ventricular tachyarrhythmia, markedly reduced left ventricular ejection fraction and high risk of sudden death, prophylactic insertion of a pacemaker or implantable defibrillator is recommended. We had the opportunity to treat a patient with CS and to review the currently accepted diagnostic and treatment approach.

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Cardiac Tuberculosis on 18F-FDG PET Imaging—A Great Masquerader of Cardiac Sarcoidosis

Indian Journal of Radiology and Imaging ◽

10.1055/s-0041-1739379 ◽

2021 ◽

Author(s):

Sumati Sundaraiya ◽

Abubacker Sulaiman ◽

Adhithyan Rajendran

Keyword(s):

Pet Imaging ◽

Fdg Pet ◽

Cardiac Sarcoidosis ◽

Granulomatous Inflammation ◽

Ventricular Myocardium ◽

Left Ventricular ◽

Whole Body ◽

Left Ventricular Myocardium ◽

Fdg Uptake ◽

18F Fdg

AbstractA young gentleman with suspected cardiac sarcoidosis and LV dysfunction whose CMR revealed multifocal subepicardial to mid myocardial linear enhancement in the left ventricular myocardium underwent cardiac 18F-FDG PET imaging. The images revealed patchy regions of increased FDG uptake involving the apical to mid anterolateral, mid to basal anteroseptal/ right ventricular and mildly increased FDG uptake in apical inferior segments of the LV myocardium concordant with CMR findings. Whole body PET CT imaging showed multiple hypermetabolic supra and infra diaphragmatic lymphadenopathy, with no pulmonary lesion identified. Biopsy from the left para aortic lymph node revealed necrotizing granulomatous inflammation consistent with tuberculosis. Based on the histopathological findings of the lymph nodes, diagnosis of cardiac tuberculosis was made, given the similar imaging appearances in both sarcoidosis and TB. This case highlights that cardiac TB although rare, should be included in the differential diagnosis in patients with suspected infiltrative cardiomyopathy, particularly in TB endemic regions.

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Imaging in Suspected Cardiac Sarcoidosis: A Diagnostic Challenge

Current Cardiology Reviews ◽

10.2174/1573403x15666190725121246 ◽

2020 ◽

Vol 16 (2) ◽

pp. 90-97 ◽

Cited By ~ 1

Author(s):

Francis J. Ha ◽

Sharad Agarwal ◽

Katharine Tweed ◽

Sonny C. Palmer ◽

Heath S. Adams ◽

...

Keyword(s):

Cardiac Imaging ◽

Fdg Pet ◽

Cardiac Sarcoidosis ◽

Imaging Techniques ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Imaging Modalities ◽

Cardiac Imaging Techniques ◽

Diagnostic Dilemma

Cardiac Sarcoidosis (CS) represents a unique diagnostic dilemma. Guidelines have been recently revised to reflect the established role of sophisticated imaging techniques. Trans-thoracic Echocardiography (TTE) is widely adopted for initial screening of CS. Contemporary TTE techniques could enhance detection of subclinical Left Ventricular (LV) dysfunction, particularly LV global longitudinal strain assessment which predicts event-free survival (meta-analysis of 5 studies, hazard ratio 1.28, 95% confidence interval 1.18-1.37, p < 0.0001). However, despite the wide availability of TTE, it has limited sensitivity and specificity for CS diagnosis. Cardiac Magnetic resonance Imaging (CMR) is a crucial diagnostic modality for suspected CS. Presence of late gadolinium enhancement signifies myocardial scar and enables risk stratification. Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) coupled with myocardial perfusion imaging can identify active CS and guide immunosuppressant therapy. Gallium scintigraphy may be considered although FDG-PET is often preferred. While CMR and FDG-PET provide complementary information in CS evaluation, current guidelines do not recommend which imaging modalities are essential in suspected CS and if so, which modality should be performed first. The utility of hybrid imaging combining both advanced imaging modalities in a single scan is currently being explored, although not yet widely available. In view of recent, significant advances in cardiac imaging techniques, this review aims to discuss changes in guidelines for CS diagnosis, the role of various cardiac imaging modalities and the future direction in CS.

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Ventricular tachycardia in cardiac sarcoidosis -prognosis, characterization of ventricular substrates and outcomes of treatment-

European Heart Journal ◽

10.1093/ehjci/ehaa946.2141 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Tonegawa ◽

K Miyamoto ◽

N Ueda ◽

K Nakajima ◽

M Wada ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Cardiac Sarcoidosis ◽

Tertiary Care ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Pharmacologic Therapy ◽

Ventricular Ejection Fraction ◽

Fdg Uptake ◽

The Relationship

Abstract Background The prognosis, the underlying substrate and clinical outcomes of treatment are unclear in patients with cardiac sarcoidosis (CS)-related ventricular tachycardia (VT). Objective This study investigated the prognosis and the relationship between electroanatomical mapping (EAM) and imaging findings in patients with CS-related VT. Methods A total of 203 CS patients (Age 68.1±11.6 years, 87 males) were enrolled at two tertiary care medical centers between 2000 and 2018. All met the 2016 Japanese Circulation Society guidelines for diagnosis of CS. They were followed for a composite of major adverse cardiac events (MACE) including cardiac death, heart transplantation, unscheduled hospitalization for heart failure, and life-threatening ventricular arrhythmias. Distribution of late gadolinium enhancement (LGE) on cardiac MRI (CMR) and/or an abnormal myocardial 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography at diagnosis were examined. The relationship between EAM and the image findings were also analyzed in patients with radiofrequency ablation (RFA) for VT. Results During a median follow-up of 53 months, 87 of the 203 patients (43%) experienced a MACE. Baseline factors associated with MACE were presence of sustained VT (HR, 2.43, 95% CI 1.54–3.85, P<0.001), left ventricular ejection fraction below 50% (HR, 1.95 95% CI 1.07–3.56, P=0.029), and abnormal myocardial FDG uptake (HR, 2.42 95% CI 1.04–5.61, P=0.039). Overall, 69 of the 203 patients (34%) experienced sustained VT. Abnormal myocardial FDG uptake was significantly more prevalent in patients with VT than in those without (92.7% vs. 78.5%, P=0.02). A total of 25 patients (9.9%) required RFA for CS-related VT (Age 64.0±8.7 years, 12 males, 1.32±0.56 RFAs per patient). Abnormal electrocardiograms (EGM) were observed in 22 of the 25 patients (88%). LGE was more frequent than abnormal FDG uptake in areas with an abnormal EGM (77% vs. 41%; P=0.002). Over a mean follow-up period of 67-months, 13 of the 25 patients with RFA (52%) remained free of VT episodes (Figure). VT recurred in nine of the 12 patients with RFA and in 17 of the 47 patients without RFA, but was suppressed by intensive pharmacologic therapy such as the combined use of amiodarone and sotalol. In patients with CS-related VT, survival without experiencing a MACE did not differ in participants with or without RFA. Conclusions In our 203 CS patients, sustained VT and abnormal FDG uptake were associated with worse cardiac outcomes. The prevalence of abnormal FDG uptake was significantly higher in patients with CS-related VT, LGE on CMR was more frequent within localized areas of an abnormal EGM, suggesting that both scar itself and the associated inflammation were involved in the pathogenesis of CS-related VT. Successful RFA of CS-related VT is still challenging, and recurrence is common. Preprocedural CMR can be useful in detecting abnormal EGMs that are potential targets for substrate ablation. Funding Acknowledgement Type of funding source: None

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P1806Diagnosis of isolated cardiac sarcoidosis using FDG-PET/CT on the basis of new guidelines

European Heart Journal ◽

10.1093/eurheartj/ehz748.0558 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

H Kawai ◽

M Sarai ◽

Y Kato ◽

H Naruse ◽

J Ishii ◽

...

Keyword(s):

Predictive Value ◽

Fdg Pet ◽

Cardiac Sarcoidosis ◽

Left Ventricular ◽

Diagnosis And Treatment ◽

Fdg Uptake ◽

Pet Ct ◽

18F Fdg ◽

New Guidelines ◽

Fdg Pet Ct

Abstract Introduction Sarcoidosis is a systemic inflammatory disease which can involve any organs. The reported prevalence of isolated cardiac sarcoidosis (CS) varies widely because of the lack of an agreed definition of isolated CS (iCS). ICS was newly defined in the new guidelines for CS by Japanese Circulation Society. Purpose We aimed to examine the diagnostic accuracy of 18F-FDG PET/CT and the ratio of iCS in the whole CS by reviewing the patients with suspected CS undergoing the whole-body and cardiac FDG PET/CT scans. Methods We retrospectively reviewed 74 consecutive patients undergoing 18F-FDG PET/CT from 2013 to 2018 (mean age 60±14 years, 37 male) without the initiation of corticosteroid. Myocardial FDG uptake in CS was defined as a “focal” or “focal on diffuse” pattern. Systemic sarcoidosis (sCS) and iCS were diagnosed according to guidelines for the diagnosis and treatment of CS by Japanese Circulation Society. In short, iCS was diagnosed clinically when no clinical findings of sarcoidosis in any other organs and FDG uptake in heart were shown in addition to the following three of four criteria: high-grade atrioventricular block or fatal ventricular arrhythmia, structural abnormality, left ventricular contractile dysfunction, and delayed Gadolinium enhancement of myocardium on MRI. Results Of 31 patients with extra-cardiac sarcoidosis, 10 already met the diagnostic criteria of sCS before undergoing 18F-FDG PET/CT and 11 was newly diagnosed as sCS after FDG PET/CT. Of the remaining 43 without extra-cardiac sarcoidosis, 18 had FDG uptake in heart. Of 18 with FDG uptake in heart, iCS was diagnosed in 7, and sCS in 3 with extra-cardiac uptake of FDG as well as myocardium. Finally, 24 and 7 patients met the criteria of sCS and iCS based on the guideline, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG PET/CT for CS including sCS and iCS were 90, 87, 88, 85, and 92%, respectively. Conclusion The ratio of iCS on the basis of new guidelines for diagnosis and treatment of CS was 22% of the whole CS.

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