Multimodality Approach for Surveillance of Cardiac Sarcoidosis After Heart Transplantation Based on a Case Series

Abstract

<h3>Purpose</h3> Cardiac sarcoidosis is an inflammatory, granulomatous disease of a progressive nature, which may clinically present as sudden death, arrhythmias, or heart failure (HF). When advanced, heart transplantation (HT) emerges as a therapeutic option. The post-transplant outcomes of this patients, regarding survival and rejections, seem to be similar to those related to other etiologies. However, the involvement of multiple organs by the disease and its reactivation potential is a concern regarding its recurrence in the transplanted heart, but its diagnosis, screening and immunosuppression strategy in this scenario are still little explored in the literature. <h3>Methods</h3> We retrospectively reviewed the clinical course of 4 patients with cardiac sarcoidosis who underwent HT between 2014 and 2021. <h3>Results</h3> We followed 4 female patients submitted to HT due to sarcoidosis. The first one transplanted in 2014, aged 32 years, and reativated sarcoidosis after 1 year, diagnosed by cardiac magnetic resonance imaging (MRI) compatible with inflammatory cardiomyopathy and died in 2017 of a non-cardiac cause. Second patient transplanted in 2020, aged 55 years, had high troponin levels also after 1 year post HT, with no evidence of rejection - subsequently, underwent cardiac PET/CT with accentuated diffuse uptake, received treatment with increased steroid dose, with an improvement in the marker after. The third, transplanted in 2021 aged 50 years, presented cardiac MRI after 1 month with a non-ischemic late mesoepicardial enhancement and PET/CT with moderate FDG uptake in the corresponding region suggestive of active cardiac sarcoidosis, using corticosteroids in increased dose for a while, showing improvement in the control PET/CT pattern. Finally, fourth patient transplanted in 2015, aged 40, with no evidence of reactivation of the disease so far, but due to sarcoidosis diagnosis previous to HT, she has always received higher doses of steroids. <h3>Conclusion</h3> There are few reports of recurrence of sarcoidosis after heart transplantation, which makes management of these cases challenging. An integrated approach that includes advanced imaging methods, routine serial endomyocardial biopsies, and serum biomarkers may be useful in monitoring this patients after HT, giving early diagnosis and treatment, which may be lifesaving given it´s potential fatal prognosis.