Abstract 17979: Cardiogenic Shock - The Index Presentation of Cardiac Sarcoidosis; Challenges in Diagnosis and Management

Cardiac sarcoidosis often presents with ventricular dysrhythmias but can manifest as cardiogenic shock. We discuss a patient who presented with the latter requiring escalating support serving multiple challenges including making a definitive diagnosis & its management.

59 year-old male presented in cardiogenic shock requiring inotropic assisted diuresis. Due to continued clinical decline, he underwent Impella 5.5 placement for mechanical circulatory support (MCS). Echocardiogram showed ejection fraction of 25-30% with global hypokinesis. Reviewing his prior medical records, revealed a lymph node biopsy with non-caseating granulomas 5 years ago concerning for sarcoidosis. Due to his dependence on temporary MCS, we were unable to confirm with a cardiac MRI. Knowing that FDG-PET can only elucidate the site of active sarcoidosis, it was pursued as the only viable imaging modality. His FDG-PET scan was positive for involvement of the inferior wall & right atrium. He was placed on immunosuppression with mycophenolate mofetil & prednisone. During his hospitalization, serial FDG-PET scans were performed showing resolution of active inflammation which allowed for weaning of immunosuppressants.

Despite treating his active disease, his course was complicated by worsening renal failure requiring hemodialysis, MCS-dependent heart failure, placement of a left ventricular assist device (LVAD) and fungemia. Following treatment, he was placed on lifelong suppression with fluconazole. Given his renal failure and infection, he was not a candidate for heart transplant. His infection also precluded our ability for long-term immunosuppression.

There are no guidelines or detailed pathways on managing cardiogenic shock in patients with cardiac sarcoidosis. Our case highlights the challenges faced when shock is the index presentation as it increases the risk of end organ damage which therefore requires expedited work up for destination therapy. Though LVAD is a viable option for patients with cardiac sarcoidosis, duration of immunosuppression, long term follow up for scar, risk and treatment of infection in patients that are not transplant candidates is largely unexplored. More studies are needed to help guide management of shock in this patient population.