Clinical Images

An Ace Angiographic Diagnosis

Holly Morgan, MBBCh, MRCP; James Cullen, MD, FRCP; David Turpie, MBChB, MRCP, BSc

Holly Morgan, MBBCh, MRCP; James Cullen, MD, FRCP; David Turpie, MBChB, MRCP, BSc

J INVASIVE CARDIOL 2020;32(9):E244-E245. 

Key words: extracardiac structures, sarcoidosis

A 72-year-old female presented to our district general hospital with sudden-onset central chest pain, on a background of a 6-month history of increasing breathlessness. She had no significant past medical history, was on no regular medications, and was a non-smoker. Electrocardiography showed inferior T-wave inversion, and the initial high-sensitivity troponin I was 1420 ng/L. She was taken to the catheterization laboratory for coronary angiography. Right radial access was converted to right femoral due to radial spasm and tortuous subclavian anatomy.

Angiography revealed a severe proximal lesion in the right coronary artery to which percutaneous coronary intervention was performed (Figure 1A). The patient experienced intermittent complete heart block during the procedure; she remained hemodynamically stable and pacing was not required. Extracardiac calcified masses were identified during screening (Figures 1B and 1C; Video 1).

Post procedure, the patient underwent a chest radiograph (Figure 1D). She was referred to the respiratory physicians and a diagnosis of sarcoidosis was confirmed on lymph node biopsy. Echocardiography showed normal left ventricular size and function, septal flattening suggestive of right ventricular pressure and volume overload, no significant valvular disease, and a small anterior pericardial effusion. 

Sarcoidosis was first described in 1877 and its exact mechanism remains poorly understood. The prevalence of cardiac involvement can vary from 5%-25% and varies significantly across countries and ethnic populations. Conduction disease is the most common cardiac manifestation, often presenting as complete heart block. Ventricular arrhythmia and congestive cardiac failure may also occur. Cardiac involvement confers a significantly worse prognosis than isolated respiratory sarcoidosis. Complete heart block complicated this patient’s procedure, but was considered to be a consequence of right coronary intervention as opposed to a manifestation of cardiac sarcoidosis.

Interventional cardiologists should maintain awareness of extracardiac structures when undertaking cardiac catheterization, as pathology outside of the coronary arteries may be identified.

View the Accompanying Video Series Here

From the Cardiology Department, Royal Gwent Hospital, Wales, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 19, 2019.

Address for correspondence: Dr Holly Morgan, Cardiology Department, Royal Gwent Hospital, Cardiff Rd, Newport NP20 2UB, United Kingdom. Email: