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Case Reports
. 2025 Nov 4;30(41):105919.
doi: 10.1016/j.jaccas.2025.105919. Online ahead of print.

Accurate Diagnosis of Clinically Isolated Cardiac Sarcoidosis Using a Novel Unipolar Mapping Guided Endomyocardial Biopsy Technique

Hiro Kawata  1 , Benjamin Levin  2 , Ramakota Reddy  3 , Colin NewBill  4 , Donna Kang  5 , Sreekanth Karanam  3
Affiliations
Case Reports

Accurate Diagnosis of Clinically Isolated Cardiac Sarcoidosis Using a Novel Unipolar Mapping Guided Endomyocardial Biopsy Technique

Hiro Kawata et al. JACC Case Rep. .

Abstract

Background: In patients with isolated cardiac sarcoidosis, endomyocardial biopsy is required to confirm the diagnosis. However, endomyocardial biopsy has low sensitivity due to the patchy nature of cardiac inflammation in cardiac sarcoidosis, revealing noncaseating granulomas in <25% of patients.

Case summary: A 38-year-old healthy man developed cardiac arrest while he was exercising. Cardiac sarcoidosis or arrhythmogenic right ventricular cardiomyopathy was suspected based on electrocardiogram, echocardiography, and cardiac magnetic resonance findings. Using unipolar mapping on 3-dimensional electroanatomic mapping, the tip of the biopsy catheter was visualized, allowing targeted tissue sampling from the scar area. Histopathologic analysis confirmed a diagnosis of sarcoidosis.

Discussion: A novel unipolar ventricular mapping technique using electroanatomic mapping may improve the diagnostic yield for clinically isolated cardiac sarcoidosis, in which the disease is solely involving the heart.

Take-home message: Unipolar mapping integrated with 3-dimensional electroanatomic mapping allows for targeted visualization of biopsy sites, which may enhance diagnostic accuracy in cases of cardiac sarcoidosis.

Keywords: cardiac magnetic resonance; cardiomyopathy; electroanatomic mapping; positron emission tomography; ventricular fibrillation.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Kawata has received honoraria from Medtronic (Minneapolis, Minnesota, USA) and iRhythm (San Francisco, California, USA). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Visual Summary
Visual Summary
Electroanatomic Map Demonstrating Scar Localization and Biopsy Site in the Right Ventricle IVC = inferior vena cava; RA = right atrium; RV = right ventricle; SVC = superior vena cava.
Figure 1
Figure 1
Initial Electrocardiogram Shows Sinus Rhythm With Right Bundle Branch Block, Epsilon Waves, and T-Wave Inversions on the Precordial Leads (V1 to V3)
Figure 2
Figure 2
Cardiac Magnetic Resonance Images Demonstrating LGE (A) Short-axis view with diffuse late gadolinium enhancement (LGE) of the RV and anterior, septal, and inferior segments of the LV. (B) Two-chamber view with LGE in basal to mid anterior and inferior segments. (C) Four-chamber view with LGE in segments of the RV and mid inferoseptal segment of the LV. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
Figure 3
Figure 3
Electroanatomic Mapping–Guided Endomyocardial Biopsy Endocardial bipolar mapping of the RV was created with an HD-grid high-resolution mapping catheter. The local voltage <1.5 mV was defined as the scar zone (gray area). The biopsy tissue was obtained from the scar border (white dot). The green dot represents His potential. RVOT = right ventricular outflow tract. Other abbreviations as in Figure 2.
Figure 4
Figure 4
Endomyocardial Biopsy From Interventricular Septum of the Right Ventricle Myocardium with aggregates of epithelioid histiocytes and multinucleated giant cells (arrow) (nonnecrotizing granulomas).
Figure 5
Figure 5
Fluorodeoxyglucose Positron Emission Tomography Shows Patchy Diffuse Uptake Involving Most of the Myocardium Including the RV and LV (A) Four-chamber view, and (B) short-axis view. Abbreviations as in Figure 2.
See this image and copyright information in PMC

References

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