{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T18:27:49Z","timestamp":1774290469543,"version":"3.50.1"},"reference-count":4,"publisher":"Oxford University Press (OUP)","issue":"3","license":[{"start":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T00:00:00Z","timestamp":1773014400000},"content-version":"vor","delay-in-days":8,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,3,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Cardiac sarcoidosis may present with arrhythmias and conduction disease years before the diagnosis is established. Device-related issues, such as elevated pacing thresholds, can be misleading and may reflect myocardial inflammation rather than true lead malfunction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case summary<\/jats:title>\n                    <jats:p>A 49-year-old woman with atrial fibrillation underwent dual-chamber pacemaker implantation in 2018 for syncope and alternating bundle branch block. Cardiac magnetic resonance imaging revealed septal fibrosis, while coronary angiography and biopsy were unremarkable. Two years later, she developed recurrent presyncope and elevated right ventricular pacing thresholds, prompting lead revision. In 2024, at age 56, she was re-hospitalized with syncope and again exhibited very high right ventricular pacing thresholds with intermittent loss of capture (LOC) and pacing dependency. Echocardiography revealed localized septal aneurysms, and implantation of a new right ventricular pacing lead was impossible due to superior vena cava occlusion. A hybrid pacing approach was therefore adopted, combining atrial pacing through the transvenous pacemaker and ventricular pacing in VDD mode (atrial-tracked ventricular pacing) via a leadless pacemaker. Given her young age, septal fibrosis, and aneurysms, further evaluation with positron emission tomography\u2013computed tomography revealed increased metabolic activity in the myocardium, lungs, and lymph nodes, consistent with systemic sarcoidosis. Diagnosis was confirmed by bronchoscopy with biopsy. Immunosuppressive therapy with corticosteroids and mycophenolate led to complete resolution of myocardial inflammatory activity and normalization of right ventricular pacing thresholds over 6 months.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This case highlights that elevated pacing thresholds in cardiac sarcoidosis may reflect disease activity rather than lead failure. Furthermore, in selected complex scenarios where conventional lead implantation is not feasible, combined transvenous atrial pacing and leadless ventricular pacing can provide effective and physiologic atrioventricular synchrony.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytag141","type":"journal-article","created":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T12:24:29Z","timestamp":1772454269000},"source":"Crossref","is-referenced-by-count":0,"title":["A wolf in sheep\u2019s clothing\u2014unmasking cardiac sarcoidosis through pacemaker dysfunction: a case report"],"prefix":"10.1093","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8391-8164","authenticated-orcid":false,"given":"Tardu","family":"\u00d6zkartal","sequence":"first","affiliation":[{"name":"Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale , Via Tesserete 48, Lugano CH-6900 ,","place":["Switzerland"]},{"name":"Faculty of Biomedical Sciences, Universit\u00e0 della Svizzera Italiana , Via la Santa 1, Lugano 6900 ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Bergonti","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale , Via Tesserete 48, Lugano CH-6900 ,","place":["Switzerland"]},{"name":"Faculty of Biomedical Sciences, Universit\u00e0 della Svizzera Italiana , Via la Santa 1, Lugano 6900 ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniele","family":"Faccenda","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale , Via Tesserete 48, Lugano CH-6900 ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1190-5967","authenticated-orcid":false,"given":"Maria Luce","family":"Caputo","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale , Via Tesserete 48, Lugano CH-6900 ,","place":["Switzerland"]},{"name":"Faculty of Biomedical Sciences, Universit\u00e0 della Svizzera Italiana , Via la Santa 1, Lugano 6900 ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giulio","family":"Conte","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale , Via Tesserete 48, Lugano CH-6900 ,","place":["Switzerland"]},{"name":"Faculty of Biomedical Sciences, Universit\u00e0 della Svizzera Italiana , Via la Santa 1, Lugano 6900 ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,3,9]]},"reference":[{"key":"2026032313394409400_ytag141-B1","doi-asserted-by":"publisher","first-page":"e1197","DOI":"10.1161\/CIR.0000000000001275","article-title":"Diagnosis and management of cardiac sarcoidosis: a scientific statement from the American Heart Association","volume":"149","author":"Cheng","year":"2024","journal-title":"Circulation"},{"key":"2026032313394409400_ytag141-B2","doi-asserted-by":"crossref","first-page":"2697","DOI":"10.1093\/eurheartj\/ehae356","article-title":"Management of cardiac sarcoidosis: a clinical consensus statement of the heart failure association, the European association of cardiovascular imaging, the ESC working group on myocardial & pericardial diseases, and the European heart rhythm association of the ESC","volume":"45","author":"Sharma","year":"2024","journal-title":"Eur Heart J"},{"key":"2026032313394409400_ytag141-B3","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1093\/europace\/eur435","article-title":"Sudden reversible pacemaker failure in a patient with cardiac sarcoidosis: an unfortunate case of ventricular septal pacing","volume":"14","author":"Takasugi","year":"2012","journal-title":"Europace"},{"key":"2026032313394409400_ytag141-B4","doi-asserted-by":"publisher","first-page":"3427","DOI":"10.1093\/eurheartj\/ehac075","article-title":"2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur Heart J"}],"container-title":["European Heart Journal - 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