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(Circulation. 2002;105:1144.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Positron Emission Tomography Predicted Recovery of Complete A-V Nodal Dysfunction in a Patient With Cardiac Sarcoidosis

N. Takeda, MD; I. Yokoyama, MD, PhD; Y. Hiroi, MD, PhD; M. Sakata, MD; T. Harada, MD; F. Nakamura, MD, PhD; Y. Murakawa, MD, PhD; R. Nagai, MD, PhD

From the Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, Tokyo, Japan.

Correspondence to Norihiko Takeda, MD, Dept of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail ntakeda-tky{at}umin.ac.jp

A 36-year-old man was admitted to our hospital because of exertional dyspnea and syncope. The ECG showed complete A-V block (Figure 1A), and a pacemaker was implanted. Although his chest X-ray did not detect bilateral hilar lymph node enlargement, his acute clinical course with complete A-V block suggested cardiac sarcoidosis. Thus, we performed thoracic computed tomography, which revealed multiple enlarged paratracheal lymph nodes. Pathological examination of one lymph node showed noncaseating granulomas, consistent with sarcoidosis (Figure 2). Radionucleotide scintigram of myocardium showed decreased uptake of thallium in the basal septal segment. Cardiac fluorine-18-deoxyglucose (18FDG)/nitrogen-13-ammonia (13NH3) positron emission tomography (PET) also showed strongly enhanced 18FDG uptake in the basal septal segment, which is a site of the A-V nodal pathway, and reduced 13NH3 uptake in the same region (Figures 3A and 3B). Ga-citrate whole-body scintiscan revealed increased activity in the inferoposterior myocardial segment but not in the basal septal segment. Given these results, we diagnosed cardiac sarcoidosis and administered prednisolone acetate (40 mg daily). Thirty days after the initiation of steroid therapy, we performed a second cardiac PET scan. Surprisingly, the elevated 18FDG uptake in the basal anteroseptal segment had clearly disappeared and the reduced 13NH3 uptake in this region normalized, indicating that steroid therapy had improved the flow metabolism mismatch (Figures 3C and 3D). However, the 201-thallium scintiscan on nearly the same day of the second PET scan showed no definitive change. Ga-citrate scintiscan revealed that the increased uptake in the inferoposterior myocardium disappeared at the time of the second PET scan; however, abnormal Ga uptake or changes in Ga uptake pattern were seen in the basal septal segment, which is the site of the A-V nodal pathway. Complete A-V block did not change at the time of the second cardiac PET scan, but surprisingly, it had improved to a first degree A-V block 20 days after the second PET scan (Figures 1B and 1C). This case strongly suggests that 18FDG/13N-ammonia PET is a useful tool, not only for the diagnosis of cardiac sarcoidosis, but also for the predication of improvement of A-V nodal dysfunction, which is sometimes associated with this disease along with left ventricular dysfunction.

View larger version (15K): [in this window] [in a new window]   Figure 1. A, ECG at the attack of syncope showed complete AV-block. The longest RR interval reached up to 12 seconds. B, ECG obtained at the time of second PET scan showed no change of complete AV-block but showed left-bundle-branch block due to the effect of his pacemaker. C, ECG, 50 days after the steroid therapy, improved to first-degree A-V block.

View larger version (121K): [in this window] [in a new window]   Figure 2. Biopsy specimen of one thoracic lymph node revealed many noncaseating granulomas.

View larger version (145K): [in this window] [in a new window]   Figure 3. Cardiac PET images before steroid therapy revealed markedly elevated 18FDG uptake in basal septum (A) and reduced 13NH3 uptake in basal septum (arrows) and posterior wall (B). Cardiac PET images after steroid therapy showed normalized 18FDG uptake in basal septum (C) and improved 13NH3 uptake in basal septum segment (D).

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Bayer College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030

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