Original-clinicalRefractory ventricular tachycardia secondary to cardiac sarcoid: Electrophysiologic characteristics, mapping, and ablation
Introduction
Although myocardial involvement occurs in at least 25% of patients with systemic sarcoidosis, it most often involves a small portion of heart and is clinically silent.1 A small fraction of patients develop overt cardiac involvement that can lead to arrhythmic manifestations, including impaired AV conduction, ventricular arrhythmias, and sudden death.2, 3, 4 Although most patients with systemic sarcoid have preserved ejection fraction, advanced cardiac involvement also can lead to reduced systolic function. In patients with cardiac sarcoid, ventricular tachycardia (VT) is associated with significant morbidity and is an independent predictor of mortality.5 Current management for VT might include immunosuppressive therapy, defibrillator implantation, and transplantation, but outcomes are not well defined. This observational study describes the clinical characteristics of a consecutive series of eight patients with recurrent monomorphic VT due to cardiac sarcoidosis and defines the electrophysiologic characteristics of the VT and its electrophysiologic substrate.
Section snippets
Methods
All cases with a diagnosis of nonischemic cardiomyopathy referred to Brigham and Women’s Hospital for catheter ablation of recurrent monomorphic VT from August 1997 to August 2004 were reviewed. Of 98 patients, 8 (8%) were determined to have cardiac sarcoidosis. The diagnosis of sarcoid was based on the pathologic identification of cardiac noncaseating granulomas via either endomyocardial biopsy or examination of the explanted heart in 7 of 8 patients. The remaining patient had a prior
Results
Of 98 patients with sustained monomorphic VT and a diagnosis of cardiomyopathy not due to coronary artery disease, 8 (8%) had cardiac sarcoidosis (Table 1). Mean age was 42 ± 8 years at the time of referral; 7 of 8 patients had recurrent VT despite therapy with multiple antiarrhythmic drugs (mean 2.5 ± 1). All but one patient also had a reduced left ventricular ejection fraction (mean 34% ± 15%). The median time from symptomatic cardiac arrhythmia to ablation was 5 months (range 3–48 months).
Discussion
This series shows that cardiac sarcoid is an important diagnostic consideration in patients with nonischemic heart disease and VT. The differential diagnosis in this population includes other forms of nonischemic dilated cardiomyopathy, arrhythmogenic right ventricular dysplasia, and giant cell myocarditis. Establishing the diagnosis requires a tissue biopsy demonstrating the characteristic noncaseating granulomas. Our patients illustrate several important points. VT can be the presenting event
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