1. LEARNING OBJECTIVES Consider nonischemic causes of ventricular arrhythmia Add cardiac sarcoid to your differential diagnosis for ventricular arrhythmia Be familiar with the role of cardiac MRI in the diagnosis of cardiac sarcoid New Diagnosis of Sarcoidosis Presenting as Ventricular Tachycardia Amy Silverberg MD and Robert E. Burke MD University of Colorado Anschutz Medical Campus, Denver VA Medical Center INTRODUCTION With ventricular arrhythmias related to coronary artery disease increasingly common in the inpatient setting, physicians should remain alert to the nonischemic causes of ventricular tachycardia and be familiar with the role of cardiac MRI in the diagnosis of myocardial pathology. CT CHEST moderate upper-lobe-predominant centrilobular emphysema mediastinal and hilar adenopathy DISCUSSION Conduction abnormalities and ventricular arrhythmias are commonly seen by the internist, particularly in the hospital setting. In a patient without coronary artery disease, the finding of ventricular tachycardia (VT) mandates methodical investigation to identify other, less common etiologies. Although this patient was asymptomatic with regard to his VT, the finding of hilar lymphadenopathy coupled with his MRI findings was diagnostic of cardiac sarcoidosis (CS). Cardiac MRI is becoming a test of choice for investigating abnormalities of the myocardium that predispose to VT. CS most often involves the left ventricular myocardium and can manifest as electrical dysfunction, including: - high-degree atrioventricular block - bundle-branch block - ventricular tachycardia Endomyocardial biopsy is an insensitive test for CS because of: - patchy involvement of the myocardium by granulomas - usual biopsy site is not the most common site of granuloma formation As a noninvasive diagnostic modality, cardiac MRI has higher specificity than PET scan and higher sensitivity than endomyocardial biopsy. REFERENCES Britton KA, Stevenson WG, Levy BD, Katz JT, Loscalzo J. The beat goes on. N Engl J Med 2010; 362: 1721-26. Kim JS, Judson MA, Donnino R, Gold M, Cooper LT, Prystowsky EN, Prystowsky S. Cardiac sarcoidosis. Am Heart J 2009; 157: 9-21. Doughan AR, Williams BR. Cardiac sarcoidosis. Heart 2006; 92: 282-288. Special thanks to Utpal Sagar, MD and R. Silverberg. CASE DESCRIPTION A 65 year-old man presents with three months of cough and dyspnea on exertion. No: fever, rash, syncope, chest pain, palpitations, orthopnea, lower extremity edema Social History: 50 pack-year history of cigarette use, quit 2 months prior to presentation Physical Exam - normal vital signs - well-appearing - regular rate, every other cardiac cycle softer and not transmitted to radial pulse Transthoracic echocardiogram: Mild biventricular systolic dysfunction. Cardiovascular catheterization: No obstructive coronary disease. CARDIAC MRI Cardiac MRI with gadolinium revealed focal areas of delayed contrast enhancement of the anterior and basal septum as well as the basal lateral wall. RV LV Anteroseptum Inferolateral wall Inferoseptum Noncaseating granuloma EKG/Telemetry right bundle branch block ventricular bigeminy periods of normal sinus rhythm episodes of regular, monomorphic, wide-complex tachycardia Emphysema Lymphadenopathy