Active Cardiac Sarcoidosis
2013; Lippincott Williams & Wilkins; Volume: 127; Issue: 22 Linguagem: Espanhol
10.1161/circulationaha.112.001217
ISSN1524-4539
AutoresJames A. White, Martin Rajchl, John Butler, Robert T. Thompson, Frank S. Prato, Gerald Wisenberg,
Tópico(s)Vasculitis and related conditions
ResumoHomeCirculationVol. 127, No. 22Active Cardiac Sarcoidosis Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBActive Cardiac SarcoidosisFirst Clinical Experience of Simultaneous Positron Emission Tomography–Magnetic Resonance Imaging for the Diagnosis of Cardiac Disease James A. White, MD, Martin Rajchl, MSc, John Butler, MRT(MR), R. Terry Thompson, PhD, Frank S. Prato, PhD and Gerald Wisenberg, MD James A. WhiteJames A. White From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. , Martin RajchlMartin Rajchl From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. , John ButlerJohn Butler From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. , R. Terry ThompsonR. Terry Thompson From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. , Frank S. PratoFrank S. Prato From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. and Gerald WisenbergGerald Wisenberg From the Division of Cardiology, Department of Medicine, University of Western Ontario, London, ON, Canada (J.A.W., G.W.); and Imaging Laboratories, Robarts Research Institute (J.A.W., M.R.), Lawson Health Research Institute (J.A.W., J.B., R.T.T., F.S.P.), and Department of Medical Biophysics (R.T.T., R.S.P., G.W.), Western University, London, ON, Canada. Originally published4 Jun 2013https://doi.org/10.1161/CIRCULATIONAHA.112.001217Circulation. 2013;127:e639–e641IntroductionThe hybridization of positron emission tomography (PET) and magnetic resonance imaging (MRI) within a single imaging bore is a major advance in noninvasive imaging. Intrinsic coregistration of metabolic/molecular probe imaging with morphological, functional, and tissue imaging presents new opportunities for disease characterization.Sarcoidosis is a multisystem inflammatory disease hallmarked by inflammation, noncaseating granuloma formation, and organ dysfunction. Cardiac involvement accounts for up to 25% of disease-related mortality and is conventionally diagnosed with the Japanese Ministry criteria.1 However, studies using cardiac PET and MRI suggest a robust capacity to identify cardiac involvement2,3—PET through identification of active inflammation and MRI through identification of mature fibrosis or scar.In this report, we describe the first clinical use of simultaneous PET-MRI to assist in the diagnosis of cardiac disease: active cardiac sarcoidosis.CaseA 72-year-old woman was referred with a 12-month history of increasing shortness of breath and intermittent chest pain. A coronary angiogram and echocardiogram showed normal coronary arteries but an ejection fraction of 35%. Her history was significant for inflammatory polyarthritis, treated with etanercept and hydroxycholoquine, and biopsy of an enlarged scalene lymph node showing noncaseating granulomas. Her chest x-ray and pulmonary function tests were normal.Cardiac sarcoid was considered, and a hybrid PET-MRI scan was scheduled using a hybrid 3-T MRI-PET scanner (Biograph mMR, Siemens Healthcare, Germany). The patient had 12 hours of fasting followed by a fatty meal and administration of 50 IU/kg unfractionated heparin to suppress normal myocardial glucose uptake. Fifteen minutes later, 5 MBq/kg of 18F-labeled fluro-2-deoxyglucose (FDG) was administered, and a whole-body PET acquisition was initiated. MRI began with standard cine imaging and slice-matched T2-weighted imaging using a triple inversion recovery pulse sequence. A cardiac gated 3-dimensional (3D) coronary magnetic resonance angiography was performed during slow intravenous infusion of Gadovist (0.2 mmol/kg; Bayer Inc, Canada), as previously described.4 Standard 2-dimensional late gadolinium enhancement (LGE) imaging was followed by simultaneous ECG gated cardiac PET (collected in list mode and binned into 8 cardiac phases) and 3D LGE imaging.4 Images were fused and rendered with OsirX (version 4.2; OsirX.com).ResultsCine MRI showed akinesia of the septal wall and severe hypokinesia of the inferoseptal walls (Figure 1). The ejection fraction was 36%. T2-weighted imaging was normal. Coronary magnetic resonance angiography showed no obstructive disease in the proximal or mid segments. Both 2-dimensional and 3D LGE imaging showed subepicardial signal enhancement of the anteroseptal and inferoseptal walls, highly consistent with cardiac sarcoid (Figure 1).Download figureDownload PowerPointFigure 1. Cardiac magnetic resonance images for respective 4-chamber, short-axis, and 2-chamber orientations showing systolic frame cine imaging and corresponding 2-dimensional (2D) late gadolinium enhancement (LGE) and 3-dimensional (3D) LGE scar imaging. White arrows indicate regions of abnormal LGE, consistent with mature scar. Bottom row shows 3D LGE images with fusion of 18F-labeled fluro-2-deoxyglucose (18F-FDG) positron emission tomography signal suggestive of active inflammation surrounding regions of established scar.PET imaging showed a focal increase in 18F-FDG signal within the basal anteroseptal and inferoseptal walls with reduced (ie, suppressed) activity in the mid to distal segments (Figure 1). Fusion of 3D PET and 2-dimensional LGE (Figure 1) or 3D LGE (Figures 1 and 2) imaging showed increased uptake bordering regions of fibrosis. In Figure 2, fused 3D LGE, PET, and coronary magnetic resonance angiography data sets provide clear anatomic registration of the respective findings. Interestingly, regions of high 18F-FDG uptake did not show signal enhancement by T2-weighted MRI (Figure 3).Download figureDownload PowerPointFigure 2. A, Axial multiplanar reconstructions of a fused data set incorporating 3-dimensional (3D) coronary magnetic resonance (background), segmented 3D scar signal (white arrows), and 18F-labeled fluro-2-deoxyglucose (18F-FDG) positron emission tomography (PET) signal (color spectrum). B, Comparison of 3D distribution of 18F -FDG PET signal and 3D scar signal using a 3D maximum-intensity projection of the FDG signal (left) and volume-rendered format of 3D scar (right) showing similarities in geographic distribution.Download figureDownload PowerPointFigure 3. Respective sequential short-axis images from the base to the midventricle for T2-weighted (T2w) cardiac magnetic resonance (CMR) imaging, late gadolinium enhancement (LGE) CMR imaging, and 18F-labeled fluro-2-deoxyglucose (18F-FDG) positron emission tomography (PET) imaging (fused to LGE imaging). White arrows indicate regions of established scar by LGE imaging. Far right, Images at a wider field of view to show splenic nodules with enhancement on both LGE and FDG imaging.Extracardiac examination revealed splenomegaly with hypointense nodules by T2-weighted imaging that enhanced with LGE imaging (Figure 3).DiscussionThis report describes the first clinical experience of simultaneous PET-MRI for the diagnosis of cardiac disease. The unique strengths of PET and MRI were exploited through the use of a hybrid platform to establish a diagnosis of active cardiac sarcoidosis. Intrinsic spatial and temporal registration of these respective data sets provided a unique glimpse into disease pathophysiology, with regions of increased 18F-FDG uptake being trailed in the subepicardial zone by established fibrosis, suggesting inward migration of inflammatory injury. Of importance, T2-weighted imaging was not able to identify active inflammation in this case, suggesting 18F-FDG imaging to be of incremental value.Overall, this sentinel case identifies that cardiac PET-MRI is clinically feasible for the detection of inflammatory cardiac disease. Future study into its role in disease management is warranted.Sources of FundingThis study was done as part of a provincial program supported by the Cardiac Care Network and the PET Steering Committee of Ontario.DisclosuresDr White is a clinician scientist with the Heart and Stroke Foundation of Ontario, Canada. Dr White receives in-kind research support from Bayer, Inc. Canada in the form of MRI contrast agents. This research was supported in part by the Imaging in Cardiovascular Therapeutics grant of the Ontario Research Fund. The other authors report no conflicts.FootnotesCorrespondence to James A. White, MD, PO Box 5015, 100 Perth Dr, London, ON, Canada N6A 5K8. E-mail [email protected]References1. Diagnostic standard and guidelines for sarcoidosis.Jpn J Sarcoidosis Granulomatous Disord. 2007; 27:89–102.Google Scholar2. Patel MR, Cawley PJ, Heitner JF, Klem I, Parker MA, Jaroudi WA, Meine TJ, White JB, Elliott MD, Kim HW, Judd RM, Kim RJ. Detection of myocardial damage in patients with sarcoidosis.Circulation. 2009; 120:1969–1977.LinkGoogle Scholar3. Youssef G, Leung E, Mylonas I, Nery P, Williams K, Wisenberg G, Gulenchyn KY, Dekemp RA, Dasilva J, Birnie D, Wells GA, Beanlands RS. The use of 18F-FDG PET in the diagnosis of cardiac sarcoidosis: a systematic review and metaanalysis including the Ontario experience.J Nucl Med. 2012; 53:241–248.CrossrefMedlineGoogle Scholar4. White JA, Fine N, Gula LJ, Yee R, Al-Admawi M, Zhang Q, Krahn A, Skanes A, MacDonald A, Peters T, Drangova M. Fused whole-heart coronary and myocardial scar imaging using 3-T CMR: implications for planning of cardiac resynchronization therapy and coronary revascularization.JACC Cardiovasc Imaging. 2010; 3:921–930.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Aguilar-Gallardo J, Arreaza J, Omar A, Lasam G and Contreras J (2022) Successful treatment of cardiac sarcoidosis based on clinical suspicion and advanced cardiac imaging: A case report, Medicine, 10.1097/MD.0000000000027814, 101:34, (e30306), Online publication date: 26-Aug-2022. 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