Beyond the Biopsy: Imaging Frontiers in Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) represents an inflammatory infiltrative disease, which creates difficulties during diagnosis and prognosis. The identification and management of CS heavily depend on advanced cardiac imaging techniques. The article examines multimodality imaging in CS by evaluating cardiac magnetic resonance (CMR) imaging, positron emission tomography (PET) with computed tomography (CT), single-photon emission computed tomography (SPECT), echocardiography, CT and hybrid imaging approaches. This review examines each imaging modality with respect to its fundamental principles, diagnostic capabilities, benefits and drawbacks and references key research from the past decade. CMR stands as the primary diagnostic method for detecting myocardial scar and fibrosis in CS patients, providing essential prognostic information. The PET/CT system with 18-fluorodeoxyglucose (FDG) provides an effective method for detecting active inflammation and tracking treatment response. Echocardiography is a readily accessible screening tool that reveals the structural and functional effects of CS, while strain imaging techniques enable the detection of early disease involvement. The use of delayed-enhanced cardiac CT provides an alternative method for detecting myocardial scar. It helps identify patients who are ineligible for CMR and excludes coronary artery disease. Diagnostic confidence and disease activity assessment improve with hybrid imaging, particularly when PET/MR is used. The Discussion section integrates these findings with an evaluation of emerging quantitative imaging markers and novel tracers that show promise for enhancing CS evaluation. The implementation of multimodality imaging techniques has transformed the management of CS by enabling earlier diagnosis, risk assessment and treatment guidance. A personalised imaging approach that combines multiple diagnostic methods yields the best results for diagnosing CS and enhances patient-care outcomes.