[Heart transplantation in myocardial sarcoidosis. Studies on the explanted heart].

HISTORY AND CLINICAL FINDINGS: A 40-year-old man with histologically proven sarcoidosis, known for 15 years, which had involved the myocardium was hospitalized because of intractable heart failure (NYHA class IV). An implantation of an intracardiac defibrillator for ventricular arrhythmias (Lown type IVa) had preceded. On physical examination severe dyspnea at rest cough and fever were noted.

INVESTIGATIONS: The erythrocyte sedimentation rate (88/104 mm), C-reactive protein (250 mg/l) and white cell count (20/nl) were markedly increased. Serum sodium (113 mmol/l), potassium (3.0 mmol/l) and chloride (64 mmol/l) were markedly reduced, while creatinine (2.5 mg/dl) and urea (82 mg/dl) were elevated due to renal failure. The chest radiogram demonstrated central venous congestion, cardiomegaly and right pericardial infiltration. There were no obvious changes due to sarcoidosis and computed tomography did not indicate pulmonary involvement by sarcoidosis. The echocardiogram revealed severe impairment of left ventricular function with an ejection fraction of ca. 14%.

DIAGNOSIS, TREATMENT AND COURSE: Heart failure (NYHA class IV), caused by a dilated cardiomyopathy of sarcoidosis, was accompanied by pneumonia which responded to antibiotics. But the chronic heart failure failed to improve on drug treatment and cardiac transplantation was undertaken. The explanted myocardium was examined histologically, immunologically and virologically. Antibodies were demonstrated against vascular endothelium, sarcolemma and endocardium (IgG and IgA), but not by PCR against cytomegalovirus, enterovirus and adenovirus. The transplantation was without complication and, under azathioprine and methylprednisolone, one rejection had occurred until now. The patient has been working full-time since 2 years in his previous occupation of lorry driver. There has been no evidence of renewed sarcoidosis activity.

CONCLUSION: Sarcoidosis may involve the myocardium in up to 25% of cases. Clinically relevant symptoms are even more rare. Sarcoidosis should be included in the differential diagnosis of unexplained serious arrhythmias or cardiomyopathy, particularly in young persons. Cardiac transplantation may have to be contemplated if drug or pacemaker treatment fails to control heart failure.