Multidisciplinary approach in cardiac sarcoidosis: to biopsy or not?

PURPOSE OF REVIEW: Cardiac sarcoidosis (CS) is associated with significant morbidity and mortality, yet its diagnosis remains challenging due to heterogeneous clinical presentations and patchy myocardial involvement. Although endomyocardial biopsy has historically been regarded as the diagnostic gold standard, its limited sensitivity, tendency to provide false negative and inconclusive results and procedural risks have led to increasing reliance on noninvasive imaging. This review assesses the contemporary role of endomyocardial biopsy (EMB) within a multidisciplinary diagnostic framework and evaluates whether tissue diagnosis remains necessary in modern clinical practice. RECENT FINDINGS: Recent studies highlight the expanding role of cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging in diagnosing, phenotyping, and risk stratifying CS. Targeted biopsy strategies guided by imaging or electroanatomical mapping have demonstrated improved diagnostic yield compared with random sampling. Multidisciplinary team-based decision-making has emerged as a key determinant in selecting patients for biopsy, particularly when histological confirmation is likely to influence immunosuppressive therapy, device implantation, or prognostic assessment. SUMMARY: EMB retains an important but selective role in CS. Integration of multimodality imaging and multidisciplinary assessment optimizes patient selection, enhances procedural safety, and ensures that biopsy findings meaningfully inform management. Future research should refine biopsy indications and integrate imaging with molecular and biomarker-based approaches to improve diagnostic accuracy and prognostication.