Tailored approach for management of ventricular tachycardia in cardiac sarcoidosis

Treating ventricular tachycardia (VT) in patients with cardiac sarcoidosis (CS) is challenging as patients present in different phase of the disease (inflammatory, scar, or sometimes both). A  customized approach to treatment is required for better outcomes. We describe our experience in the management of VT in CS based on the phase of the disease.

Patients were considered to have myocardial inflammation if there was an increased myocardial ¹⁸ fluorodeoxy glucose (FDG) uptake in PET-CT scan of the chest (n = 14). These patients were treated with antiarrhythmic drugs (AADs) and immunosuppression. Patients with scar related VT (without active inflammation) were managed with AADs and underwent radiofrequency ablation (RFA) if unresponsive to drug therapy (n = 4). Patients previously treated for CS who presented with VT and evidence of reactivation (abnormal FDG uptake) after a quiescent period of 6 months were treated with intensified immunosuppression alongside AADs (n = 3/14). Patients with myocardial inflammation responded well to immunosuppression. Patients with drug resistant VT in the scar phase responded well to RFA. Four patients in the inflammatory group had recurrence of VT during follow-up of whom 3 were found to have disease reactivation. Intensified immunosuppression suppressed VT in all 3 patients. In 1 patient, VT recurrence was found to be scar related and required RFA for control.

Tailoring therapy for VT in CS according to the phase of disease results in good clinical outcome and avoids unnecessary immunosuppression.