Cardiac MRI in the Diagnosis and Therapeutic Monitoring of Cardiac Sarcoidosis: The Role of Quantitative Mapping.

Presenting Author(s)

• 

  Marina R. Cavallari, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil

Primary Author(s)

• 

  Marina R. Cavallari, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil

Co-Author(s)

• LP

  Luciano G. Possa, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Natassia SSC Gomes, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• 

  Camilla F. Reimberg, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia
  São Paulo , Sao Paulo, Brazil
• GM

  Gustavo R. Modolo, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• EB

  Everton R. Barbosa, MD

  MD
  Instituto Dante Pazzanese de Cardiologia, Brazil
• 

  Amanda Marsiaj Rassi, MD

  Cardiologist
  Instituto Dante Pazzanese de cardiologia
  São Paulo, Sao Paulo, Brazil
• 

  Alice Cunha Darzé, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• MN

  Mariana de Oliveira Nunes, MD

  MD
  Intituto Dante Pazzanese de Cardiologia, Brazil
• JC

  João Marcelo Caneschi, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• Rd

  Rafael de Castro Hendges, MD, PhD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• CP

  Carlos EE Prazeres, MD

  Doctor
  Instituto Dante Pazzanese de Cardiologia, Brazil
• NZ

  Naiana T. Zamin, MD

  Doctor
  Clinica Kozma, Brazil
• CA

  Camila G. Almeida, MD

  Doctor
  Clínica Privada, Brazil
• MN

  Max Novo, MD

  Doctor
  Clinica Cardiomax, British Virgin Islands
• 

  Antonio Tito 3. Paladino Filho, MD, PhD

  Cardiologist
  Hospital Vila Nova Star, Rede D’or São Paulo-SP
  Sao Paulo, Sao Paulo, Brazil
• 

  Paul Salvador Salvador Morales, MD

  Cardiologist
  Instituto Dante Pazzanese de Cardiologia
  São Paulo, Sao Paulo, Brazil
• 

  Tiago Senra, MD, PhD

  Physician
  Dante Pazzanese Institute of Cardiology
  Sao Paulo, Sao Paulo, Brazil
• 

  Ibraim Masciarelli Pinto, MD, PhD

  Director, Non Invasive Cardiology
  Instituto Dante Pazzanese de Cardiologia
  Sao Paulo, Sao Paulo, Brazil

Description of Clinical Presentation: A 46-year-old male presented with a 6-month history of progressive dyspnea. Initial exercise stress test revealed sustained ventricular tachycardia at peak effort. Coronary CTA ruled out atherosclerotic disease but revealed indirect signs of right ventricular overload, prompting a referral for cardiac MRI (CMR).

Diagnostic Techniques and Their Most Important Findings: A 1.5T scanner was used. The protocol included: Cine imaging (TrueFISP) for biventricular function; T2-weighted black-blood sequences for tissue characterization; native T1 and T2 mapping for interstitial fibrosis and edema; and Late Gadolinium Enhancement (LGE) for necrosis/fibrosis.
Findings demonstrated: septal hypertrophy (16mm); increased T2 signal in the septum with elevated T2 maps, suggestive of myocardial edema; and mid-basal septal subepicardial LGE. The findings were highly suggestive of cardiac sarcoidosis (CS), which was confirmed by PET-CT showing cardiac and pulmonary involvement. Treatment with immunosuppressants was initiated. A follow-up CMR 30 days later showed a significant reduction in myocardial edema, evidenced by normalized T2 maps and a decrease in septal thickness (16mm to 14mm), and significative clinical improvement.

Learning Points from this Case:

1. 
   CMR is the cornerstone for non-invasive diagnosis of CS. The cardinal finding is non-ischemic LGE, typically involving the basal septum. Complementary findings include edema on T2-weighted images and parametric maps, ventricular thickening, and dysfunction.
   
   


2. 
   Quantitative mapping (T1, T2, ECV) provides objective measures of active inflammation (elevated T2) and diffuse fibrosis (elevated native T1/ECV), offering superior prognostic stratification beyond LGE alone.
   
   


3. 
   CMR is invaluable for monitoring therapy response. A reduction in myocardial edema (signaled by T2 normalization) is a key marker of treatment success. LGE may be irreversible but can stabilize; its extent in the acute phase may be overestimated due to concomitant edema.
   
   

Cardiac MRI Before and after treatment). A1 and A2 increased T2 signal in the septum, D1 and D2 elevated T2 maps, suggestive of myocardial edema; B1 and B2 septal hypertrophy; C1 and C2 mid-basal septal subepicardial LGE.
Fluorine 18 fluorodeoxyglucose (FDG) PET/CT at diagnosis with cardiac and pulmonary impairment. PET-CT after treatment without cardiac or pulmonary uptake.