Abstract
Sarcoidosis is a multi-system inflammatory disease characterized by the development of inflammation and noncaseating granulomas that can involve nearly every organ system, with a predilection for the pulmonary system. Cardiac involvement of sarcoidosis (CS) occurs in up to 70% of cases, and accounts for a significant share of sarcoid-related mortality. The clinical presentation of CS can range from absence of symptoms to conduction abnormalities, heart failure, arrhythmias, valvular disease, and sudden cardiac death. Given the significant morbidity and mortality associated with CS, timely diagnosis is important. Traditional imaging modalities and histologic evaluation by endomyocardial biopsy often provide a low diagnostic yield. Cardiac positron emission tomography (PET) has emerged as a leading advanced imaging modality for the diagnosis and management of CS. This review article will summarize several aspects of the current use of PET in CS, including indications for use, patient preparation, image acquisition and interpretation, diagnostic and prognostic performance, and evaluation of treatment response. Additionally, this review will discuss novel PET radiotracers currently under study or of potential interest in CS.
Highlights
In a study of 23 patients undergoing treatment with Cardiac involvement of sarcoidosis (CS), Osborne and colleagues found that a reduction of myocardial inflammation, as measured by standard uptake value (SUV), on serial 18 F-FDG positron emission tomography (PET)/CT scans was associated with an improvement in left ventricular ejection fraction [54]
18 F-FDG positronemission emissiontomography/computed tomography/computed tomography (PET/CT) has emerged as the leading imaging modality for use in CS, there remain several disadvantages to its use, including issues related to physiologic myocardial 18 F-FDG uptake which can lead to inconclusive studies
Despite the use of dietary preparation protocols to minimize these issues, there remains a need for the development of new radiopharmaceutical PET tracers that lack physiologic myocardial uptake and do not require extensive patient preparation
Summary
PET/CTstudy studyfor forCS, CS, a thorough examinaof the patient’s medical record should be performed, including review of pertinent history, tion of the patient’s medical record should be performed, including review of pertinent as well as diagnostic studiesstudies and therapeutic interventions with an emphasis history, asprevious well as previous diagnostic and therapeutic interventions with an emon identifying non-sarcoid causescauses of myocardial perfusion and FDG abnormalities that phasis on identifying non-sarcoid of myocardial perfusion and FDG abnormalities may image interpretation. Interpretation of images begins etary preparation prior to the PET study should be confirmed. Up to 40% of cardiac PET/CT scans were found to show falseperfusion abnormalities due to misregistration, with overwith half over of thehalf false-positive defects positive perfusion abnormalities due to misregistration, of the false-posiquantified moderateastomoderate severe, highlighting the importance of properofalignment and tive defectsasquantified to severe, highlighting the importance proper aligncoregistration of images of [44]. CS will show normal resting myocardial perfusion in addition to absence of myocardialFFDG uptake, indicating the the absence of active inflammation and complete suppression. 18F-FDG uptake, indicating absence of active inflammation and complete suppressionof physiologic myocardial uptake Inadequate suppression of of physiologic F-FDG myocardial uptake (Figure 2). A pattern of focal areas of 18F18 of or without anatomically corresponding perfusion defects, is FDGF-FDG uptake,uptake, with or with without anatomically corresponding perfusion defects, is suggestive suggestive of active inflammation in the appropriate clinical setting.
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