Cardiac Sarcoidosis Evaluated by Delayed-Enhanced Magnetic Resonance Imaging
A 56-year-old woman with a history of chronic coughing and occasional wheezing was referred to the gastroenterology clinic with jaundice and weight loss of recent onset. Clinical evaluation showed evidence of chronic liver disease. Chest computed tomography showed an interstitial bilateral lung infiltrate and diaphragmatic lymphadenopathy. A liver biopsy was performed, revealing a noncaseating granulomatous hepatitis (Figure 1). Thorough investigation of granulomatous diseases was performed and the final diagnosis was sarcoidosis. A resting ECG showed premature atrial and ventricular beats and conduction disturbances (right bundle branch block and left anterior fascicular block). The patient was then referred to the Heart Institute (InCor) for cardiac evaluation.
A cine magnetic resonance image (MRI) showed 2 small ventricular aneurysms involving the septum and right ventricular free wall (Figure 2 and Movie I). The left ventricular ejection fraction and end-diastolic and end-systolic volumes were 0.45, 146 mL, and 84 mL, respectively. Contrast (gadolinium; dose 0.2 mmol/kg) delayed-enhanced MR images, using an inversion recovery prepped gradient-echo sequence, revealed areas of hyperenhancement (fibrosis) corresponding precisely to that of the ventricular aneurysms (Figures 2, 3, and 4⇓⇓; Movies I and II). Additionally, several small and focal areas of myocardial fibrosis were observed in other segments (basal antero-septal and antero-lateral; see Figure 3).
This new MR technique has been shown to detect irreversible myocardial injury (necrosis or fibrosis) with great detail and high spatial resolution and has been used to detect new or previous myocardial infarction.
Movies I and II are available as an online-only Data Supplement at http://www.circulationaha.org.
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 Baylor 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.