Monomorphic Ventricular Tachycardia and Mediastinal Adenopathy due to Granulomatous Infiltration in Patients With Preserved Ventricular Function

Study Questions:

What is the clinical course of patients with sustained monomorphic ventricular tachycardia (SMVT) due to tuberculosis or sarcoidosis?

Methods:

Fourteen patients (mean age 44 years, mean ejection fraction 58%) who presented with SMVT were found to have tuberculosis or sarcoidosis. The median duration of follow-up was 25 months.

Results:

Mid-myocardial scars were found by magnetic resonance imaging in 82% of patients, and photon emission tomography demonstrated myocardial inflammation in 92%. All patients had mediastinal adenopathy, and noncaseating granulomas were present in 13 of 14 lymph node biopsies. Eleven of the 14 patients were found to have tuberculosis. SMVT recurred in 75% of patients treated with antiarrhythmic drugs and in all five patients treated with radiofrequency catheter ablation (RFCA) plus antiarrhythmic drugs. Disease-specific therapy resulted in suppression of SMVT in 82% of patients. Six of nine patients who received an implantable cardioverter-defibrillator (ICD) had appropriate ICD therapies. One patient died from heart failure during follow-up.

Conclusions:

Myocardial tuberculosis or sarcoidosis can present with SMVT in the absence of symptoms of extracardiac disease. Optimal management consists of a combination of antiarrhythmic drug therapy, disease-specific therapy, and an ICD.

Perspective:

This study was performed in India, where tuberculosis is endemic. In the United States, cardiac sarcoidosis is much more common than cardiac tuberculosis, and should be suspected in patients who present with SMVT and hilar adenopathy. The SMVT typically is pleomorphic in cardiac sarcoidosis, and RFCA should be considered palliative, not curative.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Sarcoidosis, Tachycardia, Ventricular, Follow-Up Studies, Cardiomyopathies, India, Heart Failure, Granuloma, Catheter Ablation, Defibrillators, Implantable, United States


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