Introduction Sarcoidosis is a chronic, multisystem disorder. Although clinical evidence of myocardial involvement is present in only 5% of patients with sarcoidosis, subclinical cardiac involvement as proven by autopsy is present in 20 to 30% of cases. Myocardial involvement of sarcoidosis has been proven to occur much more commonly in patients presenting with cardiac symptoms compared with those who do not have cardiac symptomatology (84 vs 4%).
Case Report A 72-year-old man presented with three episodes of syncope lasting 2 minutes each with spontaneous recovery each time. There was no history of chest pain, shortness of breath, palpitations, diaphoresis, or weakness in any part of the body. Cardiac rhythm revealed complete heart block. Past medical history was significant for sarcoidosis involving lung and skin. Initial electrocardiogram showed sinus rhythm with normal axis with a ventricular rate of 53 beats per minute showing a high-degree AV block. Echocardiogram revealed concentric left ventricular hypertrophy with left ventricular ejection fraction 60%, without any structural evidence of cardiac sarcoidosis. Patient was transferred to coronary recovery unit and a temporary transvenous pacemaker was inserted via right internal jugular approach. Once the patient stabilized a permanent DDD pacemaker was implanted.
Discussion Cardiac sarcoidosis should be suspected by astute clinicians when an otherwise healthy young or middle-aged person develops cardiac symptoms or in a patient with known sarcoidosis who develops arrhythmias. Cardiac sarcoidosis has been found to be manifested in the form of supraventricular and more commonly ventricular arrhythmia, conduction abnormalities such as first-degree heart block progressing to complete heart block, valvular dysfunction such as mitral incompetence, cor pulmonale with advanced fibrotic pulmonary sarcoidosis, pericarditis, or heart failure. Progressive heart failure has accounted for about 25 to 75% deaths in sarcoidosis. The prognosis of symptomatic cardiac sarcoidosis is not well defined. An early autopsy series of 113 patients concluded that survival in most patients is limited to approximately 2 years after development of cardiac symptoms. Sudden cardiac death due to ventricular tachyarrhythmia or conduction block accounts for 30 to 65% of the deaths. There is a high incidence of recurrence of arrhythmias and sudden death even when on antiarrhythmic medications. ICD therapy may be considered for primary prevention in patients with an ejection fraction > 35%, inducible ventricular tachycardia in a symptomatic patient on EP testing, and/or nonsustained ventricular arrhythmia. Surgery has a role in mitral valve disease or resection of ventricular aneurysm. Cardiac transplantation has been performed in younger patients with irreversible heart failure.
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