Sarcoidosis diagnosed on granulomas in the explanted heart after transplantation: Results of a French nationwide study

Heart transplantation in end-stage heart failure secondary to cardiac sarcoidosis: an updated systematic review

The prevalence of cardiac sarcoidosis is increasing with improved cardiac imaging and may lead to severe heart failure, cardiomyopathy, and arrhythmias that warrant heart transplant consideration. This study aimed to evaluate the outcomes of heart transplantation in sarcoidosis. We systematically searched PubMed/MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. We identified 15 articles that examined patients with cardiac sarcoidosis. The study aimed to evaluate the outcomes of heart transplantation in cardiac sarcoidosis. We systematically searched EMBASE, PubMed/MEDLINE, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We identified 15 studies that examined 1075 patients with cardiac sarcoidosis who underwent heart transplantation. A total of five studies reported individual patient data. Forty-two patients have been pooled for further analysis. There were 22 male patients, 14 female patients, and 7 patients whose gender was not reported. Among these patients, 10 patients had concomitant pulmonary sarcoidosis at the time of diagnosis. The mean survival was reported for all 42 patients. The mean survival in months was 71.4 months, with a range of 2 days to 288 months. Three patients died of graft failure, 2 patients from septic shock, 2 patients from pneumonia, 1 patient from cervical cancer, and 1 patient from sudden cardiac death. One patient developed a malignant arrythmia in the setting of CMV myocarditis post-heart transplant. Sarcoidosis recurrence after heart transplant was reported in 3 of 30 patients..Patients with cardiac sarcoidosis have shown to have favorable outcomes after heart transplant. Despite these outcomes, some centers still hesitate to pursue heart transplant for CS patients. Carefully selected patients with advanced-stage heart failure due to cardiac sarcoidosis have encouraging outcomes after transplantation. Further studies will be needed to evaluate the outcomes of heart transplantation in sarcoidosis.

How to Tackle the Diagnosis and Treatment in the Diverse Scenarios of Extrapulmonary Sarcoidosis

Extrapulmonary sarcoidosis occurs in 30–50% of cases of sarcoidosis, most often in association with pulmonary involvement, and virtually any organ can be involved. Its incidence depends according to the organs considered, clinical phenotype, and history of sarcoidosis, but also on epidemiological factors like age, sex, geographic ancestry, and socio-professional factors. The presentation, symptomatology, organ dysfunction, severity, and lethal risk vary from and to patient even at the level of the same organ. The presentation may be specific or not, and its occurrence is at variable times in the history of sarcoidosis from initial to delayed. There are schematically two types of presentation, one when pulmonary sarcoidosis is first discovered, the problem is then to detect extrapulmonary localizations and to assess their link with sarcoidosis, while the other presentation is when extrapulmonary manifestations are indicative of the disease with the need to promptly make the diagnosis of sarcoidosis. To improve diagnosis accuracy, extrapulmonary manifestations need to be known and a medical strategy is warranted to avoid both under- and over-diagnosis. An accurate estimation of impairment and risk linked to extrapulmonary sarcoidosis is essential to offer the best treatment. Most frequent extrapulmonary localizations are skin lesions, arthritis, uveitis, peripheral lymphadenopathy, and hepatic involvement. Potentially severe involvement may stem from the heart, nervous system, kidney, eye and larynx. There is a lack of randomized trials to support recommendations which are often derived from what is known for lung sarcoidosis and from the natural history of the disease at the level of the respective organ. The treatment needs to be holistic and personalized, taking into account not only extrapulmonary localizations but also lung involvement, parasarcoidosis syndrome if any, symptoms, quality of life, medical history, drugs contra-indications, and potential adverse events and patient preferences. The treatment is based on the use of anti-sarcoidosis drugs, on treatments related to organ dysfunction and supportive treatments. Multidisciplinary discussions and referral to sarcoidosis centers of excellence may be helpful for difficult diagnosis and treatment decisions.