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Abstract

We appreciate the correspondence from Dr Alter and colleagues on our article in CHEST.1Nagai T Kohsaka S Okuda S Anzai T Asano K Fukuda K Incidence and prognostic significance of myocardial late gadolinium enhancement in patients with sarcoidosis without cardiac manifestation.Chest. 2014; 146: 1064-1072Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Whether left ventricular (LV) volumetric and functional determinants, measured by cardiovascular MRI (CMR), could influence the long-term prognosis of patients with systemic sarcoidosis is a topic of interest, and we analyzed volumetric and functional CMR variables in our study.1Nagai T Kohsaka S Okuda S Anzai T Asano K Fukuda K Incidence and prognostic significance of myocardial late gadolinium enhancement in patients with sarcoidosis without cardiac manifestation.Chest. 2014; 146: 1064-1072Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar These variables, including LV ejection fraction, LV end-systolic volume, and LV end-diastolic volume, were comparable between patients who experienced adverse events and those who did not, with the exception of LV mass (121.3 ± 32.2 g vs 82.3 ± 18.2 g, respectively, for patients who experienced events and those who did not;P < .001). In addition, there were no significant differences in these variables between the late gadolinium enhancement (LGE)-positive and LGE-negative groups. These findings suggest that, in our study, CMR-measured LV volume and systolic function were not directly associated with LGE and adverse events. However, it should be noted that adverse events occurred in only four patients. Previous studies showed that > 20% of patients with systemic sarcoidosis had positive LGE, cardiac events occurred in > 10% of patients, and LGE was hypothesized to predict future cardiac events, even in patients with preserved LV systolic function.2Greulich S Deluigi CC Gloekler S et al.CMR imaging predicts death and other adverse events in suspected cardiac sarcoidosis.JACC Cardiovasc Imaging. 2013; 6: 501-511Crossref PubMed Scopus (307) Google Scholar, 3Patel MR Cawley PJ Heitner JF et al.Detection of myocardial damage in patients with sarcoidosis.Circulation. 2009; 120: 1969-1977Crossref PubMed Scopus (467) Google Scholar, 4Patel AR Klein MR Chandra S et al.Myocardial damage in patients with sarcoidosis and preserved left ventricular systolic function: an observational study.Eur J Heart Fail. 2011; 13: 1231-1237Crossref PubMed Scopus (75) Google Scholar Contrary to these findings, our rates of positive LGE and cardiac events were lower, and, importantly, LGE did not predict adverse events.1Nagai T Kohsaka S Okuda S Anzai T Asano K Fukuda K Incidence and prognostic significance of myocardial late gadolinium enhancement in patients with sarcoidosis without cardiac manifestation.Chest. 2014; 146: 1064-1072Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar These differences can be explained by disease severity, including the extent of LGE. Patients in our study had lower frequencies of receiving immunosuppressants and having ECG abnormalities, no cardiac symptoms or impaired LV systolic function, and smaller extent of LGE compared with those in a previous study.3Patel MR Cawley PJ Heitner JF et al.Detection of myocardial damage in patients with sarcoidosis.Circulation. 2009; 120: 1969-1977Crossref PubMed Scopus (467) Google Scholar Ise et al5Ise T Hasegawa T Morita Y et al.Extensive late gadolinium enhancement on cardiovascular magnetic resonance predicts adverse outcomes and lack of improvement in LV function after steroid therapy in cardiac sarcoidosis.Heart. 2014; 100: 1165-1172Crossref PubMed Scopus (88) Google Scholar previously reported that smaller extent of LGE (% LGE mass < 20%) could predict a lower rate of cardiac events. Taking these findings together, the clinical implication of adding LV wall stress analysis would be limited in our population with latent and less severity and preserved LV systolic function. We believe that a larger cohort with a higher event rate (eg, greater disease severity, impaired LV function, and larger extent of LGE) is needed to investigate the association between LV volume and functional variables and long-term prognosis in patients with systemic sarcoidosis.