Evaluating the association between hybrid magnetic resonance positron emission tomography and cardiac-related outcomes in cardiac sarcoidosis
Authors: Trivieri Maria Giovanna , Robson Philip M. , Vergani Vittoria , LaRocca Gina , Romero-Daza Angelica M. , Abgral Ronan , Karakatsanis Nicolas A. , Parikh Aditya , Panagiota Christia , Palmisano Anna , DePalo Louis , Chang Helena L. , Rothstein Joseph H. , Fayad Rima A. , Miller Marc A. , Fuster Valentin , Narula Jagat , Dweck Marc R. , Jacobi Adam , Padilla Maria , Kovacic Jason C. , Fayad Zahi A. 
Published: January 2022

Objectives

To evaluate an extended hybrid MR/PET imaging strategy in cardiac sarcoidosis (CS) employing qualitative and quantitative assessment of PET tracer uptake, and to evaluate its association with cardiac-related outcomes.

Background

Invasive endomyocardial biopsy is the gold standard to diagnose CS, but it has poor sensitivity due to the patchy distribution of disease. Imaging with hybrid late gadolinium enhancement (LGE) MR and 18F-fluorodexyglucose (18F-FDG) PET allows simultaneous assessment of myocardial injury and disease activity and has shown promise for improved diagnosis of active CS based on the combined positive imaging outcome, MR(+)PET(+).

Methods

148 patients with suspected CS were enrolled for hybrid MR/PET imaging. Patients were classified based on presence/absence of LGE (MR+/MR-), presence/absence of 18F-FDG (PET+/PET-), and pattern of 18F-FDG uptake (focal/diffuse) into the following categories: MR(+)PET(+)FOCAL, MR(+)PET(+)DIFFUSE, MR(+)PET(-), MR(-)PET(+)FOCAL, MR(-)PET(+)DIFFUSE, MR(-)PET(-). Patients classified as MR(+)PET(+)FOCAL were designated as having active CS [aCS(+)], while all others were considered as having inactive or absent CS and designated aCS(-). Quantitative values of standard uptake value (SUVmax), target-to-background ratio (TBRmax), target-to-normal-myocardium ratio (TNMRmax) and T2 were measured. Occurrence of a cardiac-related clinical outcome was defined as any of the following during the 6-month period after imaging: cardiac arrest, ventricular arrhythmia, complete heart block, need for cardiac resynchronization/defibrillator/pacemaker/monitoring device (CRT-D, ICD/WCD, or ILR). MR/PET imaging results were compared to the presence of the composite clinical outcome.

Results

Patients designated aCS(+) had more than 4-fold increased odds of meeting the clinical endpoint compared to aCS(-) (unadjusted odds ratio 4.8; 95% CI 2.0-11.4; p<0.001). TNMRmax achieved an area under the receiver operating characteristic curve of 0.90 for separating aCS(+) from aCS(-).

Conclusions

Hybrid MR/PET imaging with an extended image-based classification of CS was statistically associated with clinical outcomes in CS. TNMRmax had high sensitivity and excellent specificity for quantifying the imaging-based classification of active CS.

Condensed Abstract

Imaging with hybrid late gadolinium enhancement (LGE) MR and 18F-fluorodexyglucose (18F-FDG) PET allows simultaneous assessment of myocardial injury and disease activity and has shown promise for improved diagnosis of active cardiac sarcoidosis (CS). In this study, 148 patients with suspected CS were enrolled for hybrid MR/PET imaging. Patients were classified based on presence/absence of LGE (MR+/MR-), presence/absence of 18F-FDG (PET+/PET-), and pattern of 18F-FDG uptake (focal/diffuse). Patients classified as MR(+)PET(+)FOCAL were designated as having active CS and, compared to patients with any other imaging pattern, they had more than 4-fold increased odds of cardiac-related outcome at 6 months from imaging.