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University of Capetown Capetown, Republic of South Africa
With interest I read the article by Dr. Tadamura and colleagues [1] about the effectiveness of delayed enhanced MRI for the identification of cardiac sarcoidosis. The authors statement that, to the best of their knowledge, no previous studies had been published about the usefulness of delayed enhanced MRI for this condition mystified me. Dhote et al. [2] and Vignaux et al. [3, 4] published three articles evaluating a total of 50 patients for cardiac sarcoidosis with delayed enhanced MRI. Shimada et al. [5], who evaluated 16 patients for cardiac sarcoidosis, and Schulz-Menger et al. [6], who evaluated six patients for cardiac sarcoidosis, had reported on the value of delayed enhanced MRI even before the authors of those three studies [2-4].
Furthermore, Vignaux et al. [3, 4] also showed the value of T2-weighted imaging in assessing active granulomatous inflammation. The value of MRI might have been stressed even further if they had performed T2-weighted studies and compared the findings with findings on gallium-67 scintigraphy.
Because treatment with corticosteroids strongly influences the findings of gallium scintigraphy [7], Tadamura et al. [1] should have provided readers with the number of patients who had received treatment with corticosteroids before undergoing evaluation on gallium scintigraphy.
Tadamura et al. [1] mention the fact that diagnostic coronary angiography was performed in patients with suspected coronary artery disease. Because eight of 10 patients were 52 years old or older, had ECG abnormalities, and had delayed myocardial enhancement but were not assessed with exercise thallium-201 scintigraphy, the angiography findings should have been included.
Tadamura et al. [1] conclude with the surprising statement that "...delayed enhanced MRI is considered useful for the early identification of cardiac involvement in sarcoidosis." Although this might be the case, the fact that all patients presented with dyspnea, chest pain, palpitations, or syncope and with ECG abnormalities, is not sufficient to draw this conclusion from the population presented.
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Kyoto University Graduate School of Medicine Sakyo-ku, Kyoto 606-8507, Japan
I would like to thank Dr. Smedema for showing interest in our article [1]. I think that there is a misunderstanding about delayed enhanced MRI. In each study that Smedema has pointed out [2-6], a conventional T1-weighted contrast-enhanced spin-echo sequence was used. This conventional sequence needs a relatively long acquisition time. Therefore, images are acquired without breath-holding, which frequently produces respiration motion artifacts [7]. In addition, the contrast between normal and diseased myocardium is not always sufficient [7]. Therefore, we used a new technique—an inversion recovery prepared segmented T1-weighted gradient-echo sequence with breath-holding—for the identification of cardiac involvement of sarcoidosis.
From a technical point of view, the images acquired with the conventional T1-weighted contrast-enhanced spin-echo sequence [2-6] and those obtained with the inversion recovery prepared T1-weighted gradient-echo sequence [1] are not identical. In addition, the images in those studies [2-6] were not necessarily acquired during a delayed phase because the delay time after contrast injection was not clearly described.
In the current study [1], T2-weighted images were not acquired in all cases. Therefore, I cannot comment on this issue. In terms of assessing disease activity, T2-weighted images may be effective.
Three patients had a history of corticosteroid therapy in the current study [1].
In our study, cardiologists clinically excluded coronary artery disease by assessing risk factors; symptoms; stress perfusion imaging; and, if necessary, coronary angiography.
As Smedema pointed out, the conclusion my colleagues and I made may go too far. From our observations, we can safely say that delayed enhanced MRI is useful for the identification of cardiac involvement compared with radionuclide imaging.
With interest, I recently read the articles by Smedema et al. [8, 9] concerning cardiac sarcoidosis and cardiovascular magnetic resonance (CMR). I think that his article is quite reasonable and the results are similar in various points with ours. I believe the recognition that CMR is a useful diagnostic tool to determine cardiac involvement is common.
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