CTCA vs coronary catheter angiography in the diagnosis of coronary artery sarcoidosis: A pictorial case report

Abstract

Learning Objectives: Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas which may include multisystem involvement. Approximately 27% of patients with sarcoidosis were demonstrated in an autopsy study to have cardiac involvement. 1 However, our case describes a rare presentation of coronary artery sarcoidosis and how best to image it. This pictorial case report aims to highlight the possibility of coronary artery sarcoidosis presenting as an acute coronary syndrome. Background: A 51 year old man presented with palpitations and chest pain with ECG showing non-sustained ventricular tachycardia and troponin elevation to 0.39. This was on a background of paroxysmal atrial fibrillation (AF), catheter ablation 2 years prior and chronic mildly elevated troponins between 0.19 and 0.26. A recent diagnosis of pulmonary and cardiac sarcoid had been made on outpatient cardiac MRI (CMR), CT and PET examinations showing pulmonary nodules, delayed septal midwall myocardial enhancement on MR and increased uptake on PET. Coronary catheter angiography revealed 99% left anterior descending (LAD) stenosis, but otherwise normal coronary arteries, with no cardiovascular risk factors apart from age and sex. Subsequent CT coronary angiogram (CTCA) confirmed short segment severe stenosis at the ostial LAD, with negative remodelling, but without evidence of atherosclerosis. A diagnosis of coronary artery sarcoidosis was therefore made. Imaging Findings: In our case, coronary catheter angiography identified the severe luminal stenosis, however, given the history of known myocardial sarcoidosis with otherwise normal coronary arteries and minimal cardiovascular risk factors, CTCA was performed. This was effective for both intra and extraluminal assessment of the coronaries, and was able to identify a focal, short segment narrowing of the proximal LAD and D1 branch, with no atheroma, adjacent to the previously demonstrated region of sarcoidosis within the myocardium on CMR. These findings supported the diagnosis of coronary artery sarcoidosis and the patient underwent coronary artery bypass surgery, from which he recovered well. Conclusion: Coronary artery sarcoidosis is a rare presentation of sarcoid. To the best of our knowledge, this is the third reported case of sarcoidosis affecting the coronary arteries presenting as an acute coronary syndrome.2,3 Coronary artery stenosis is caused by atherosclerotic disease in the majority of cases. In patients with a history of cardiac sarcoid, the possibility of coronary artery involvement should also be considered, but is difficult to confirm using coronary catheter angiography due to an inability to visualize the vessel wall.L618977026 <br />