Introduction: Cardiac Sarcoidosis (CS) is an inflammatory myocardial disease characterized by non-caseating granuloma (NG) deposition. Ventricular tachycardia is a life threatening complication of cardiac sarcoidosis which can lead to sudden cardiac death. According to the heart rhythm society consensus, catheter ablation is a last resort following immunosuppression and antiarrhythmic medication for treating ventricular tachycardia. Our case discusses the management of recurrent ventricular tachycardia in a complicated case of cardiac sarcoidosis patients. 

Case Presentation: A 62-year-old female with a history of chronic lymphoid lymphoma (CLL) presented with shortness of breath. The patient’s work-up showed complete heart block and cardiomyopathy. Left heart catheterization showed non-obstructive coronary arteries. The initial decision was made for pacemaker implantation; however, cardiac sarcoidosis was suspected based on complete heart block in the setting of non-ischemic cardiomyopathy. Cardiac MRI was done, which showed patchy transmural delayed hyper-enhancement in the inferior septal region. A bi-ventricular Implantable cardioverter defibrillator (ICD) was implanted. Patient was referred for a cardiac PET scan to outside facility, which showed increased FDG uptake in the inferior septum and inferior walls. 

Working Diagnosis: Cardiac Sarcoidosis

Management: The patient was started on steroids. A few months later patient presented with ventricular storm with thirty-nine total ICD shocks. She was treated with intravenous amiodarone and discharged on oral amiodarone and methotrexate therapy. Patient again experienced two ICD shocks in a course of four months due to ventricular tachycardia. She underwent VT ablation of the left ventricular inferior septum and right ventricular moderator band and apex. Since patient suffered from COVID 19 infection during that admission, amiodarone was changed to mexiletine to avoid lung toxicity. The patient experienced multiple ICD shocks six months later. During this admission, patient received aggressive treatment with sotalol and rituximab along with steroids, methotrexate, and mexiletine. The patient has not experienced ventricular tachycardia since the last episodes two years ago. Follow-up cardiac PET CT showed no scintigraphy evidence of active cardiac sarcoidosis. 

Conclusion: In cardiac sarcoidosis patients refractory to catheter ablation, a combination of antiarrhythmic medications along with immunosuppressive medications can help prevent recurrent ventricular tachycardia.