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Alblaihed L, Kositz C, Brady WJ, Al-Salamah T, Mattu A. Diagnosis and management of arrhythmogenic right ventricular cardiomyopathy. Am J Emerg Med 2023; 65:146-153. [PMID: 36638611 DOI: 10.1016/j.ajem.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder of the myocardium that can lead to ventricular arrhythmia and sudden cardiac death. The condition has been identified as a significant cause of arrhythmic death among young people and athletes, therefore, early recognition of the disease by emergency clinicians is critical to prevent subsequent death. The diagnosis of ARVC can be very challenging and requires a systematic approach. This publication reviews the pathophysiology, classification, clinical presentations, and appropriate approach to diagnosis and management of ARVC.
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Affiliation(s)
- Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6(th) Floor, Suite 200, Baltimore, MD 21201, United States of America.
| | - Christine Kositz
- Depratment of Emergency Medicine, University of Maryland Shore Medical Center at Easton, 219 S Washington St, Easton, MD 21601, United States of America
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Tareq Al-Salamah
- Department of Emergency Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6(th) Floor, Suite 200, Baltimore, MD 21201, United States of America
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2
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Martini B, Martini N, De Mattia L, Buja G. Delayed depolarization and histologic abnormalities underlie the Brugada syndrome. Pacing Clin Electrophysiol 2023; 46:172-181. [PMID: 36542434 DOI: 10.1111/pace.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Brugada syndrome (BrS) is a controversial disease whose pathophysiology is still far from being fully understood. Unlike other cardiological disorders, a definite etiology has not yet been established so that it could be summarized under two main chapters: "functional" or "organic", "repolarization" or "depolarization" disorder. Despite initial descriptions leaned towards the organic substrate and delayed depolarization features, functional and repolarization theories have attracted most of the Cardiological attention for many years. Data from electrocardiography, endocavitary tracings, electroanatomic mapping and histopathology, however, demonstrated that BrS is mainly characterized by structural myocardial changes mostly at the right ventricular outflow tract (RVOT), but also at the right ventricle (RV) and by delayed conduction at the same sites. Conduction disorders at different levels may also be present and identify patients at high risk for major arrhythmic events. The aim of the present review is to provide the current state of art of the pathophysiology of BrS, focusing on electro-vectorcardiography and electrophysiological features, histopathology, echocardiography, and cardiac magnetic resonance imaging (CMRI).
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Affiliation(s)
| | - Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Gianfranco Buja
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
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3
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Abela M, Yamagata K, Buttigieg L, Xuereb S, Bonello J, Soler JF, Camilleri W, Grech N, Xuereb R, Sapiano K, Abela E, Callus A, Farrugia M, Felice T, Burg M, Sammut M, Xuereb RG, Grech V. The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT). Int J Cardiol 2023; 371:508-515. [PMID: 36087635 DOI: 10.1016/j.ijcard.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 09/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain. AIM This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years. METHODS Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance. RESULTS The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months). CONCLUSION Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta; Medical School, University of Malta, Malta; St. George's, University of London, London, United Kingdom.
| | | | - Lisa Buttigieg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Sara Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - John Bonello
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | | | | | - Neil Grech
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Rachel Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Karl Sapiano
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Estelle Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Adrian Callus
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Maria Farrugia
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Tiziana Felice
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Melanie Burg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Mark Sammut
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Robert G Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Victor Grech
- Medical School, University of Malta, Malta; Department of Paediatrics, Mater' Dei Hospital, Tal-Qroqq, Malta
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Papageorgiou VE, Zegkos T, Efthimiadis G, Tsaklidis G. Analysis of digitalized ECG signals based on artificial intelligence and spectral analysis methods specialized in ARVC. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3644. [PMID: 36053812 DOI: 10.1002/cnm.3644] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/13/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease that appears between the second and forth decade of a patient's life, being responsible for 20% of sudden cardiac deaths before the age of 35. The effective and punctual diagnosis of this disease based on electrocardiograms (ECGs) could have a vital role in reducing premature cardiovascular mortality. In our analysis, we first outline the digitalization process of paper-based ECG signals enhanced by a spatial filter aiming to eliminate dark regions in the dataset's images that do not correspond to ECG waveform, producing undesirable noise. Next, we propose the utilization of a low-complexity convolutional neural network for the detection of an arrhythmogenic heart disease, that has not been studied through the usage of deep learning methodology to date, achieving high classification accuracy, namely 99.98% training and 98.6% testing accuracy, on a disease the major identification criterion of which are infinitesimal millivolt variations in the ECG's morphology, in contrast with other arrhythmogenic abnormalities. Finally, by performing spectral analysis we investigate significant differentiations in the field of frequencies between normal ECGs and ECGs corresponding to patients suffering from ARVC. In 16 out of the 18 frequencies where we encounter statistically significant differentiations, the normal ECGs are characterized by greater normalized amplitudes compared to the abnormal ones. The overall research carried out in this article highlights the importance of integrating mathematical methods into the examination and effective diagnosis of various diseases, aiming to a substantial contribution to their successful treatment.
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Affiliation(s)
| | - Thomas Zegkos
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Efthimiadis
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Tsaklidis
- Department of Mathematics, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kommata V, Sciaraffia E, Blomström-Lundqvist C. Repolarisation abnormalities unmasked with a 252-lead BSM system in patients with ARVC and healthy Gene Carriers. Pacing Clin Electrophysiol 2022; 45:509-518. [PMID: 35077593 PMCID: PMC9314798 DOI: 10.1111/pace.14456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/26/2021] [Accepted: 01/23/2022] [Indexed: 11/30/2022]
Abstract
Background: Diagnosing arrhythmogenic right ventricular cardiomyopathy (ARVC) at an early stage can be challenging even after ECG recording and a combination of several imaging techniques. The purpose of this study was to explore if a body surface mapping (BSM) system with 252‐leads could identify repolarization abnormalities and thereby diagnose early stages of ARVC. Methods: ARVC patients, gene carriers without signs of ARVC and controls underwent a 12‐lead resting ECG, signal‐averaged ECG, echocardiography, 24‐hours Holter monitoring, and BSM with electrocardiographic imaging (ECGI). All 252‐leads, divided into four quadrants of the vest, were analyzed regarding concordances between T wave polarity and QRS main vector. Results: Of 40 patients included there were 12 ARVC patients, 20 gene carriers, and 8 controls. The ARVC patients had two different repolarization patterns, one with more pronounced negative T waves at the lower left panel and another with mixed changes that clearly differed from the controls, all of whom had a normal 12 lead ECGs and consistent repolarization patterns on their BSM recordings. The patterns observed in ARVC patients were also present in 5/20 (25%) gene carriers, three of whom had normal resting ECG. A novel repolarization index successfully detected all ARVC patients and 88% of gene carriers with pathologic repolarization pattern. Conclusions: The finding that abnormal repolarization patterns could be unmasked by BSM in 25% of healthy gene carriers, suggests that it may potentially be a useful tool for identifying early manifestations of ARVC. Further and larger studies are warranted to assess its diagnostic accuracy.
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Affiliation(s)
- Varvara Kommata
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, SE-75185, Sweden
| | - Elena Sciaraffia
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, SE-75185, Sweden
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Przybylski R, Abrams DJ. Clinical and genetic features of arrhythmogenic cardiomyopathy: the electrophysiology perspective. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Finocchiaro G, Barra B, Molaro S, Zampieri M, Monje-Garcia L, Evans C, Ermolao A, Georgiopoulos G, Sheikh N, Bastiaenen R, Roberts L, Masci PG, Sado D, Chiribiri A, Carr-White G. Prevalence and clinical correlates of exercise-induced ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy. Int J Cardiovasc Imaging 2021; 38:389-396. [PMID: 34480708 DOI: 10.1007/s10554-021-02395-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/25/2021] [Indexed: 11/26/2022]
Abstract
Exercise has a deleterious effect on the phenotypic expression of arrhythmogenic right ventricular cardiomyopathy (ARVC) and increases the risk of sudden death. The aim of the study was to determine the prevalence and correlates of exercise-induced arrhythmias during exercise tolerance test (ETT) in patients with ARVC. Between 2010 and 2019, 30 (47% males, mean age 42 ± 12 years) consecutive patients with a definite diagnosis of ARVC underwent a full genotypic and phenotypic characterization at our center. Exercise-induced arrhythmic response (EIAR) was defined by the development of complex or repetitive ventricular arrhythmias after stage 2 of exercise. A heart rate ≥ 85% of predicted was achieved by 23 (77%) patients. In 16 (53%) cases, a desmosomal pathogenic variant was found [most commonly PKP2 (n = 7) and DSP (n = 3)]. In 12 (40%) cases, an EIAR was observed. In 2 (6%) patients, ETT was interrupted due to the onset of ventricular tachycardia (sustained with a LBBB/inferior axis pattern in one case, and non-sustained LBBB/superior axis pattern in the other). Mean body surface area (BSA)-indexed left ventricular (LV) end-diastolic volumes (EDV) were higher in the EIAR group (92 ± 12 ml/m2 vs 80 ± 7 ml/m2, p = 0.002), as well as right ventricular EDV/BSA (110 ± 18 ml/m2 vs 91 ± 27 ml/m2, p = 0.04). Subepicardial/mid-wall LV late gadolinium enhancement (LGE) was more common in the EIAR group (67% vs 22%, p = 0.01). ARVC patients commonly exhibit exercise-induced ventricular arrhythmias. Patients with more significant RV remodeling and LV involvement (based on the presence of LV dilatation and LGE) appear more susceptible to exercise-induced arrhythmias.
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Affiliation(s)
- Gherardo Finocchiaro
- Department of Cardiovascular Imaging, King's College London, London, UK.
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK.
- Guy's and St Thomas' Hospital, Westminster Bridge Rd, Lambeth, London, SE1 7EH, UK.
| | - Barbara Barra
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
- Sport and Exercise Medicine Division, Department of Medicine, University of Padua, Padua, Italy
| | - Silvia Molaro
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Mattia Zampieri
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Laura Monje-Garcia
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Colin Evans
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Andrea Ermolao
- Sport and Exercise Medicine Division, Department of Medicine, University of Padua, Padua, Italy
| | - Georgios Georgiopoulos
- Department of Cardiovascular Imaging, King's College London, London, UK
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Nabeel Sheikh
- Department of Cardiovascular Imaging, King's College London, London, UK
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Rachel Bastiaenen
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Leema Roberts
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
| | | | - Dan Sado
- Department of Cardiology, King's College Hospital, King's College London, London, UK
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, King's College London, London, UK
| | - Gerald Carr-White
- Department of Cardiovascular Imaging, King's College London, London, UK
- Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
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8
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Abstract
Arrhythmogenic right ventricular cardiomyopathy, formerly called "arrhythmogenic right ventricular dysplasia," is an under-recognized clinical entity characterized by ventricular arrhythmias and a characteristic ventricular pathology. Diagnosis is often difficult due to the nonspecific nature of the disease and the broad spectrum of phenotypic variations. Therefore, consensus diagnostic criteria have been developed which combine electrocardiographic, echocardiographic, cardiac magnetic resonance imaging and histologic criteria. In 1994, an international task force first proposed the major and minor diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy based on family history, arrhythmias, electrocardiographic abnormalities, tissue characterization, and structural and functional right ventricular abnormalities. In 2010, the task force criteria were revised to include quantitative abnormalities. These diagnostic modalities and the most recent task force criteria are discussed in this review.
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Lopez-Ayala JM, Gimeno-Blanes J, Lopez-Cuenca D, Molina MS, Gimeno-Blanes JR. Electrocardiographic Screening of Arrhythmogenic Cardiomyopathy in Genotype-Positive and Phenotype-Negative Relatives. Front Cardiovasc Med 2021; 8:646391. [PMID: 34026867 PMCID: PMC8137826 DOI: 10.3389/fcvm.2021.646391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Arrhythmogenic cardiomyopathy is a hereditary cause of ventricular arrhythmias and sudden death. Identifying the healthy genetic carriers who will develop the disease remains a challenge. A novel approach to the analysis of the digital electrocardiograms of mutation carriers through signal processing may identify early electrocardiographic abnormalities. Methods: A retrospective case–control study included a population of healthy genetics carriers and their wild-type relatives. Genotype-positive/phenotype-negative individuals bore mutations associated with the development of arrhythmogenic cardiomyopathy. The relatives included had a non-pathological 12-lead electrocardiogram, echocardiogram, and a cardiac magnetic resonance. Automatic digital electrocardiographic analyses comprised QRS and terminal activation delay duration, the number of QRS fragmentations, ST slope, and T-wave voltage. Results: Digital 12-lead electrocardiograms from 41 genotype-positive/ phenotype-negative (29 simple carriers and 12 double mutation carriers) and 73 wild-type relatives were analyzed. No differences in the QRS length, the number of QRS fragmentations, and the voltage of the T-wave were observed. After adjusting for potential confounders, double carriers showed an average ST-slope flatter than those of the simple carriers and wild type [5.18° (0.73–8.01), 7.15° (5.14–11.05), and 11.46° (3.94–17.49), respectively, p = 0.005]. There was a significant negative correlation between the ST slope and the age in genotype-positive/phenotype-negative relatives (r = 0.376, p = 0.021) not observed in their wild-type counterparts (r = 0.074, p = 0.570). Conclusions: A flattened ST segment may be an early sign of electrical remodeling that precedes T-wave inversion in healthy genetic carriers. A thorough analysis of the digital electrocardiographic signal may help identify and measure early electrical abnormalities.
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Affiliation(s)
| | - Javier Gimeno-Blanes
- Department of Signal Theory and Communications, Miguel Hernández University, Alicante, Spain
| | - David Lopez-Cuenca
- Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Maria Sabater Molina
- Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
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10
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Holshouser JW, Littmann L. Usefulness of the Electrocardiogram in Establishing the Diagnosis and Prognosis of Arrhythmogenic Right Ventricular Cardiomyopathy. Am J Cardiol 2020; 125:828-830. [PMID: 31902477 DOI: 10.1016/j.amjcard.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/23/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022]
Abstract
A middle-aged man had repeat hospitalizations and interventions over several years for ventricular tachyarrhythmias and then, a 2-year history of progressive heart failure. Twelve-lead electrocardiogram recorded 10 months apart established the most likely cause and prognosis of the heart failure, and predicted its definitive treatment.
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Affiliation(s)
- J Warren Holshouser
- Sanger Heart and Vascular Institute, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina
| | - Laszlo Littmann
- Department of Internal Medicine, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 424] [Impact Index Per Article: 84.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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12
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Brosnan MJ, te Riele AS, Bosman LP, Hoorntje ET, van den Berg MP, Hauer RN, Flannery MD, Kalman JM, Prior DL, Tichnell C, Tandri H, Murray B, Calkins H, La Gerche A, James CA. Electrocardiographic Features Differentiating Arrhythmogenic Right Ventricular Cardiomyopathy From an Athlete’s Heart. JACC Clin Electrophysiol 2018; 4:1613-1625. [DOI: 10.1016/j.jacep.2018.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/22/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
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13
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Usefulness of Total 12-Lead QRS Voltage for Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy in Patients With Heart Failure Severe Enough to Warrant Orthotopic Heart Transplantation and Morphologic Illustration of Its Cardiac Diversity. Am J Cardiol 2018; 122:1051-1061. [PMID: 30146100 DOI: 10.1016/j.amjcard.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/06/2018] [Indexed: 01/15/2023]
Abstract
Although several electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) (also called dysplasia) have been described, total 12-lead QRS voltage is not one of them. This report describes total 12-lead QRS voltage in 11 patients with ARVC who underwent orthotopic heart transplantation (OHT) because of progressively severe heart failure. Additionally, it illustrates the varied morphologic features of ARVC. The total 12-lead nonpaced QRS voltages before OHT ranged from 28 to 118 mm (mean 74 ± 32), and those in the paced tracings, from 33 to 129 mm (62 ± 32). The voltages are the lowest we have encountered among 12 previously reported cardiovascular conditions. The heart weights among the 11 ARVC patients ranged from 285 to 670 g (mean 448 ± 125). Very low 12-lead QRS voltage is characteristic of patients with ARVC with heart failure severe enough to warrant OHT, and thus may serve as a clue to its diagnosis.
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14
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Finocchiaro G, Papadakis M, Dhutia H, Zaidi A, Malhotra A, Fabi E, Cappelletto C, Brook J, Papatheodorou E, Ensam B, Miles CJ, Bastiaenen R, Attard V, Homfray T, Sharma R, Tome M, Carr-White G, Merlo M, Behr ER, Sinagra G, Sharma S. Electrocardiographic differentiation between ‘benign T-wave inversion’ and arrhythmogenic right ventricular cardiomyopathy. Europace 2018; 21:332-338. [DOI: 10.1093/europace/euy179] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/12/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gherardo Finocchiaro
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Michael Papadakis
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Harshil Dhutia
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Abbas Zaidi
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Aneil Malhotra
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Elena Fabi
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Chiara Cappelletto
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Joe Brook
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Efstathios Papatheodorou
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Bode Ensam
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Christopher J Miles
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Rachel Bastiaenen
- Cardiovascular Department, Guy’s and St. Thomas’s Hospital, London, UK
| | - Virginia Attard
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Tessa Homfray
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Rajan Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Maite Tome
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Gerald Carr-White
- Cardiovascular Department, Guy’s and St. Thomas’s Hospital, London, UK
| | - Marco Merlo
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Elijah R Behr
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Gianfranco Sinagra
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
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Oomen AWGJ, Semsarian C, Puranik R, Sy RW. Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy: Progress and Pitfalls. Heart Lung Circ 2018; 27:1310-1317. [PMID: 29705385 DOI: 10.1016/j.hlc.2018.03.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 01/20/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that predominantly affects the right ventricle. With a prevalence in the range of 1:5000 to 1:2000 persons, ARVC is one of the leading causes of sudden cardiac death in young people and in athletes. Although early detection and treatment is important, the diagnosis of ARVC remains challenging. There is no single pathognomonic diagnostic finding in ARVC; rather, current international task force criteria specify diagnostic major and minor criteria in six categories: right ventricular imaging (including echocardiography and cardiac magnetic resonance imaging (MRI)), histology, repolarisation abnormalities, depolarisation and conduction abnormalities, arrhythmias and family history (including genetic testing). Combining findings from differing diagnostic modalities can establish a "definite", "borderline" or "possible" diagnosis of ARVC. However, there are limitations inherent in the current task force criteria, including the lack of specificity for ARVC; future iterations may be improved, for example, by enhanced imaging protocols able to detect subtle changes in the structure and function of the right ventricle, incorporation of electro-anatomical data, response to adrenergic challenge, and validated criteria for interpreting genetic variants.
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Affiliation(s)
- Ad W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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16
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Nunes de Alencar Neto J, Baranchuk A, Bayés-Genís A, Bayés de Luna A. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: an electrocardiogram-based review. Europace 2017; 20:f3-f12. [DOI: 10.1093/europace/eux202] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- José Nunes de Alencar Neto
- Department of Cardiology, Hospital de Sao Paulo, Rua Napoleao de Barros, 715-Vila Clementino Sao Paulo, SP-CEP: 04024002, Sao Paulo, Brasil
| | - Adrian Baranchuk
- Cardiac Electrophysiology and Pacing, Kingston General Hospital K7L 2V7, Queen's University, Kingston, Ontario, Canada
| | - Antoni Bayés-Genís
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Antoni Bayés de Luna
- Cardio Vascular Research Center, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, C/Sant Antoni Ma Claret, 167, 08025 Barcelona, Spain
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17
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Tschabrunn CM, Haqqani HM, Santangeli P, Zado ES, Marchlinski FE. 12-Lead Electrocardiogram to Localize Region of Abnormal Electroanatomic Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2017; 3:654-665. [DOI: 10.1016/j.jacep.2017.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/04/2017] [Accepted: 01/26/2017] [Indexed: 10/19/2022]
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18
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Gaido L, Battaglia A, Matta M, Giustetto C, Frea S, Imazio M, Richiardi E, Garberoglio L, Gaita F. Phenotypic expression of ARVC: How 12 lead ECG can predict left or right ventricle involvement. A familiar case series and a review of literature. Int J Cardiol 2017; 236:328-334. [PMID: 28283360 DOI: 10.1016/j.ijcard.2017.02.130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/27/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022]
Abstract
AIMS Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart-muscle disease primarily affecting the right ventricle (RV) and potentially causing sudden death in young people. The natural history of the disease is firstly characterized by a concealed form progressing over a biventricular involvement. Three different cases coming from the same family are presented together with a review of the literature. METHODS AND RESULTS Multi-parameter analysis including imaging and electrocardiographic analysis is presented since the first medical referral with follow-up ranging from 11 to 38years. Case 1 presented a typical RV involvement in agreement with the ECG pattern. Case 2 presented a prevalent left ventricular involvement leading from the beginning to a pattern of dilated cardiomyopathy in agreement with his ECG evolution over the years. On the other side, Case 3 came to observation with a typical RV involvement (similar to Case 1) but with ECG evolution of typical left ventricle involvement (similar to Case 2). The genetic analysis showed a mutation in desmoglein-2 (DSG2) gene: p. Arg49His. Comparison between size and localization of ventricular dyskinesia at cardiovascular imaging and the surface 12 lead electrocardiography are proposed. CONCLUSIONS ARVC may lead to an extreme phenotypic variability in clinical manifestations even within patients coming from the same family in which ARVC is caused by the same genetic mutation. ECG progression over time reflects disease evolution and in particular cases may anticipate wall motion abnormalities by years.
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Affiliation(s)
- Luca Gaido
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Alberto Battaglia
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy.
| | - Mario Matta
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Carla Giustetto
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Massimo Imazio
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Elena Richiardi
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Lucia Garberoglio
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, University of Turin, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Turin, Italy
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Yin K, Ding L, Li Y, Hua W. Long-term follow-up of arrhythmogenic right ventricular cardiomyopathy patients with an implantable cardioverter-defibrillator for prevention of sudden cardiac death. Clin Cardiol 2017; 40:216-221. [PMID: 28139837 DOI: 10.1002/clc.22648] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/25/2016] [Accepted: 10/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare inherited cardiomyopathy with a high burden of ventricular arrhythmia, which is an important cause of sudden cardiac death (SCD). Implantable cardioverter-defibrillator (ICD) is believed to be the most reliable management against SCD. HYPOTHESIS Ventricular arrhythmia does not necessarily confer a poor prognosis in ARVC patients with an ICD. METHODS A total of 39 ARVC patients (34 male) implanted with an ICD at our electrophysiology center and followed up continuously were included in this study. The mean age at diagnosis was 42.1 ± 14.8 years. RESULTS Thirty-three patients (84.6%) had suffered ventricular arrhythmia with hemodynamic compromise before ICD implantation. During a median follow-up of 48.6 months (interquartile range, 32.3-73.3), 3 patients (7.7%) died, 1 of sudden death, 1 of heart failure, and 1 of cerebral infarction. Twenty-eight patients (71.8%) experienced 540 appropriate ICD interventions. The first appropriate ICD intervention occurred more than 2 years after initial ICD implantation in 5 patients (12.8%). Twelve patients (30.8%) suffered from electrical storm. The event-free period was significantly shorter in patients who did not have broad precordial T wave inversion ≥V1-V3 (hazard ratio = 0.39, 95% confidence interval: 0.16-0.96). No significant difference was shown in antiarrhythmic drugs and radiofrequency catheter ablation before ICD implantation between patients with and without appropriate ICD therapies (P > 0.05). CONCLUSIONS Recurrence of sustained ventricular tachycardia/ventricular fibrillation is frequent in high-risk patients with ARVC. The prognosis is favorable for ARVC patients treated with an ICD for prevention of SCD.
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Affiliation(s)
- Kang Yin
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ligang Ding
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuqiu Li
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Kikuchi N, Yumino D, Shiga T, Suzuki A, Hagiwara N. Long-Term Prognostic Role of the Diagnostic Criteria for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia. JACC Clin Electrophysiol 2016; 2:107-115. [DOI: 10.1016/j.jacep.2015.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/10/2015] [Indexed: 10/22/2022]
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Yoshihara S, Matsunaga M, Yaegashi T, Suzuki S, Naito M, Takehara Y. Unusual Serial Electrocardiographic Changes which Progressed to Arrhythmogenic Right Ventricular Cardiomyopathy. Intern Med 2016; 55:1103-8. [PMID: 27150862 DOI: 10.2169/internalmedicine.55.5976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Left ventricular (LV) involvement in the advanced stage of arrhythmogenic right ventricular cardiomyopathy (ARVC) is a well recognized phenomenon. T wave inversion in the lateral leads has been reported to be an electrocardiographic marker of LV involvement. Variants of ARVC that preferentially affect the left ventricle (left-dominant subtype of arrhythmogenic cardiomyopathy) have recently been recognized. We herein report a case in which an initial electrocardiogram that was similar to the left-dominant subtype of arrhythmogenic cardiomyopathy progressed to definitive ARVC over a period of 7 years. This case supports the hypothesis that LV involvement in ARVC may precede the evident onset of significant RV dysfunction.
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Affiliation(s)
- Shu Yoshihara
- Department of Diagnostic Radiology, Iwata City Hospital, Japan
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Claessen G, Brosnan M, La Gerche A, Heidbuchel H. Signs of RV overload on the athlete's ECG. J Electrocardiol 2015; 48:399-406. [PMID: 25771700 DOI: 10.1016/j.jelectrocard.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Indexed: 01/02/2023]
Abstract
There is increasing evidence that regular intense endurance exercise can promote structural and electrical remodeling of the right ventricle (RV). These physiological changes can be profound and are frequently accompanied by ECG changes in the right precordial leads, thereby mimicking features observed in arrhythmogenic right ventricular cardiomyopathy (ARVC). Because the 12-lead ECG is used as both a screening and diagnostic tool for the detection of conditions associated with sudden death in athletes, it is of fundamental importance to have a good understanding of the ECG features that distinguish physiological adaptations to endurance exercise from those related to RV pathology as well as their potential overlap. This article describes ECG findings observed in healthy endurance athletes versus athletes with underlying RV pathology and illustrates their differentiation using 4 case presentations.
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Affiliation(s)
- Guido Claessen
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Maria Brosnan
- St Vincent's Hospital Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Andre La Gerche
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Hein Heidbuchel
- Hasselt University and Heart Center, Jessa Hospital, Hasselt, Belgium
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23
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Rotondi F, Amoroso G, Manganelli F. “Epsilon waves” in peripheral and precordial leads in arrhythmogenic right ventricular cardiomyopathy with severe right ventricular involvement. J Electrocardiol 2015; 48:210-2. [DOI: 10.1016/j.jelectrocard.2014.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Indexed: 10/24/2022]
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24
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Golcuk E, Yalin K, Kaya Bilge A, Elitok A, Aksu T, Akgun T, Bilal Karaayvaz E, Emet S, Adalet K. Usefulness of T(peak) -T(end) interval to distinguish arrhythmogenic right ventricular cardiomyopathy from idiopathic right ventricular outflow tract tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1665-70. [PMID: 25041179 DOI: 10.1111/pace.12464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/28/2014] [Accepted: 05/31/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The two predominant etiologies of right ventricular tachycardia (VT) are arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathic VT arising from the right ventricular outflow tract (RVOT). Discrimination between these two entities is critical, as their prognoses and therapeutic options differ. The Tpeak -Tend (Tpe) interval reflects the transmural repolarization dispersion and its prolongation is associated with high mortality. METHODS We compared the sinus rhythm electrocardiogram (ECG) of 43 patients (24 male, 43 ± 16 years) with VT originating from right ventricle. Five patients under antiarrhythmic drug therapy were excluded. Tpe interval was measured in each precordial leads and compared among patients with ARVC and RVOT-VT. RESULTS Twenty-five patients (16 male, 42 ± 16 years) met the Task Force criteria for the diagnosis of ARVC, and 13 patients (seven male, 45 ± 14 years) had idiopathic RVOT tachycardia. Patients with ARVC had significantly prolonged Tpe intervals in all precordial leads compared to patients with idiopathic RVOT VT (137.1 ± 32.6 ms vs 93.8 ± 16.9 ms; P < 0.001 in V1, 133.2 ± 35.5 ms vs 104.7 ± 16.9 ms; P = 0.01 in V2, 125.7 ± 31.5 ms vs 99.1 ± 19.6 ms; P = 0.09 in V3, 121.9 ± 26.5 ms vs 92.3 ± 19.7 ms; P = 0.001 in V4, 123.1 ± 26.5 ms vs 99.5 ± 20:1 ms; P = 0.04 in V5 and 126.9 ± 32.2 ms vs 89 ± 11.3 ms; P < 0.001 in V6, respectively). For the diagnosis of ARVC, Tpe cut-off value of 97 ms in V1 had 84% sensitivity and 62% specificity (area under curve = 0.880). CONCLUSION In patients with VT of RV origin, the prolonged Tpe interval in sinus rhythm electrocardiogram supports the diagnosis of ARVC.
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Affiliation(s)
- Ebru Golcuk
- Department of Cardiology, Kocaeli Derince Research and Training Hospital, Kocaeli, Turkey
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25
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Zhong-qun Z, Nikus KC, Pérez-Riera AR, Chong-quan W. Electrocardiographic findings in accessory right precordial leads in adults and seniors with notched S waves in lead V1-a preliminary study. Ann Noninvasive Electrocardiol 2013; 19:234-40. [PMID: 24118140 DOI: 10.1111/anec.12114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Atypical right bundle branch block (RBBB) may present with an rS pattern and notched S wave in lead V1 . The notched S wave may represent slowed conduction or delayed activation of the right ventricular conduction system or ventricular myocardium. METHODS We retrospectively analyzed the QRS patterns in accessory right precordial leads (from V3 R to V5 R) in 15 adults/senior individuals with notched S wave in lead V1 . RESULTS In the right accessory precordial leads, 13 showed triphasic QRS pattern with final R' wave in their QRS complexes. This QRS pattern in association with notched S wave in lead V1 is suggestive of the presence of RBBB (incomplete or complete). CONCLUSIONS A notched S wave in lead V1 and in the right precordial accessory leads associated with a final R' wave suggests the possibility of concealed RBBB (incomplete or complete).
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Affiliation(s)
- Zhan Zhong-qun
- Department of Cardiology, Shiyan Taihe Hospital, Hubei University of Medicine, Shiyan City, Hubei Province, China
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26
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Zorzi A, Migliore F, Elmaghawry M, Silvano M, Marra MP, Niero A, Nguyen K, Rigato I, Bauce B, Basso C, Thiene G, Iliceto S, Corrado D. Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification. J Cardiovasc Electrophysiol 2013; 24:1321-7. [PMID: 24016194 DOI: 10.1111/jce.12246] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/09/2013] [Accepted: 07/12/2013] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The extent of right ventricular (RV) electroanatomic scar (EAS) detected by endocardial voltage mapping (EVM) is a powerful invasive predictor of arrhythmic outcome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Electrocardiogram (ECG) and signal-averaged ECG are noninvasive tools of established clinical value for the diagnosis of electrical abnormalities in ARVC. This study was designed to assess the role of ECG and SAECG abnormalities for noninvasive estimation of the extent and regional distribution of RV-EAS and prediction of scar-related arrhythmic risk. METHODS AND RESULTS The study population included 49 consecutive patients (38 males, median age 35 years) with a definite diagnosis of ARVC and an abnormal EVM by CARTO system. At univariate analysis, the presence of epsilon waves, the degree of RV dilation, the severity of RV dysfunction, and the extent of negative T waves correlated with RV-EAS% area. Normal T-waves were associated with a median RV-EAS% area of 4.9% (4.5-6.4), negative T waves in V1-V3 of 22.0% (8.5-30.6), negative T waves in V1-V3 extending to lateral precordial leads (V4-V6) of 26.8% (11.5-35.2), and negative T waves in both precordial (V2-V6) and inferior leads of 30.2% (24.8-33.0) (P < 0.001). At multivariate analysis, the extent of negative T waves remained the only independent predictor of RV-EAS% area (B = 4.4, 95%CI 1.3-7.4, P = 0.006) and correlated with the arrhythmic event-rate during follow-up (P = 0.03). CONCLUSIONS In patients with ARVC, the extent of negative T-waves across 12-lead ECG allows noninvasive estimation of the amount of RV-EAS and prediction of EAS-related arrhythmic risk.
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Affiliation(s)
- Alessandro Zorzi
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
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27
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Zorzi A, ElMaghawry M, Rigato I, Cardoso Bianchini F, Crespi Ponta G, Michieli P, Migliore F, Perazzolo Marra M, Bauce B, Basso C, Schiavon M, Thiene G, Iliceto S, Corrado D. Exercise-induced normalization of right precordial negative T waves in arrhythmogenic right ventricular cardiomyopathy. Am J Cardiol 2013; 112:411-5. [PMID: 23647791 DOI: 10.1016/j.amjcard.2013.03.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/16/2013] [Accepted: 03/16/2013] [Indexed: 12/15/2022]
Abstract
Negative T waves (NTWs) in right precordial leads (V₁ to V₃) may be observed on the electrocardiogram (ECG) of healthy subjects but can also represent the hallmark of an underlying arrhythmogenic right ventricular cardiomyopathy (ARVC). It has been a consistent observation that NTWs usually become upright with exercise in healthy subjects without underlying heart disease. No systematic study has evaluated exercise-induced changes of NTWs in ARVC. We assessed the prevalence and relation to the clinical phenotype of exercise-induced right precordial NTWs changes in 35 patients with ARVC (19 men, mean age 22.2 ± 6.2 years). Forty-one healthy subjects with right precordial NTWs served as controls. At peak of exercise (mean power 149 ± 43 W, mean heart rate 83.6 ± 12.6% of target), NTWs persisted in 3 patients with ARVC (9%), completely normalized in 12 (34%), and partially reverted in 20 (57%). Patients with ARVC with or without NTWs normalization showed a similar clinical phenotype. The overall prevalence of right precordial T waves changes during exercise (normalization plus partial reversal) did not differ between patients with ARVC and controls (92% vs 88%, p = 1.0), whereas there was a statistically nonsignificant trend toward a greater prevalence of complete normalization in controls (56% vs 34%, p = 0.06). In conclusion, our study demonstrated that right precordial NTWs partially or completely revert with exercise in most patients with ARVC, and NTWs normalization is unrelated to the clinical phenotype. Exercise-induced NTWs changes are inaccurate in differentiating between ARVC patients and benign repolarization abnormalities.
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Affiliation(s)
- Alessandro Zorzi
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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28
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Saprungruang A, Tumkosit M, Kongphatthanayothin A. The presence of epsilon waves in all precordial leads (V1 -V6 ) in a 13-year-old boy with arrhythmogenic right ventricular dysplasia (ARVD). Ann Noninvasive Electrocardiol 2013; 18:484-6. [PMID: 24047494 DOI: 10.1111/anec.12063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Electrocardiographic feature is included in the diagnostic criteria for arrhythmogenic right ventricular dysplasia (ARVD) based on the Revised Task Force criteria 2010. The epsilon wave, which reflects delayed conduction of the right ventricle, is considered to be one of the major diagnostic criteria. We reported a 13-year-old Thai boy with ARVD who presented with ventricular tachycardia. The presence of epsilon wave in all precordial leads (V1 -V6 ) was observed in standard 12-lead EKG. Extensive scarring of the right and left ventricle was seen on cardiac MRI. The extensive Epsilon wave found in this patient may reflect the extensive ventricular wall involvement.
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Affiliation(s)
- Ankavipar Saprungruang
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
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29
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Samol A, Wollmann C, Vahlhaus C, Gerss J, Bruns HJ, Breithardt G, Schulze-Bahr E, Wichter T, Paul M. T-wave integral: an electrocardiographic marker discriminating patients with arrhythmogenic right ventricular cardiomyopathy from patients with right ventricular outflow tract tachycardia. ACTA ACUST UNITED AC 2012; 15:582-9. [DOI: 10.1093/europace/eus311] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Marcus FI, Abidov A. Arrhythmogenic right ventricular cardiomyopathy 2012: diagnostic challenges and treatment. J Cardiovasc Electrophysiol 2012; 23:1149-53. [PMID: 22909229 DOI: 10.1111/j.1540-8167.2012.02412.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The most common presentation of arrhythmogenic right ventricular cardiomyopathy (ARVC) is palpitations or ventricular tachycardia (VT) of left bundle branch morphology in a young or middle-aged individual. The 12-lead electrocardiogram may be normal or have T-wave inversion beyond V(1) in an otherwise healthy person who is suspected of having ARVC. The most frequent imaging abnormalities are an enlarged right ventricle, decrease in right ventricular (RV) function, and localized wall motion abnormalities. Risk factors for implantable cardioverter defibrillator include a history of aborted sudden death, syncope, young age, decreased left ventricular function, and marked decrease in RV function. Recent results of treatment with epicardial ablation are encouraging.
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Affiliation(s)
- Frank I Marcus
- Section of Cardiology, Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA.
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Cardiomyopathy classification: ongoing debate in the genomics era. Biochem Res Int 2012; 2012:796926. [PMID: 22924131 PMCID: PMC3423823 DOI: 10.1155/2012/796926] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/14/2012] [Accepted: 05/31/2012] [Indexed: 01/19/2023] Open
Abstract
Cardiomyopathies represent a group of diseases of the myocardium of the heart and include diseases both primarily of the cardiac muscle and systemic diseases leading to adverse effects on the heart muscle size, shape, and function. Traditionally cardiomyopathies were defined according to phenotypical appearance. Now, as our understanding of the pathophysiology of the different entities classified under each of the different phenotypes improves and our knowledge of the molecular and genetic basis for these entities progresses, the traditional classifications seem oversimplistic and do not reflect current understanding of this myriad of diseases and disease processes. Although our knowledge of the exact basis of many of the disease processes of cardiomyopathies is still in its infancy, it is important to have a classification system that has the ability to incorporate the coming tide of molecular and genetic information. This paper discusses how the traditional classification of cardiomyopathies based on morphology has evolved due to rapid advances in our understanding of the genetic and molecular basis for many of these clinical entities.
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Rickelt S, Pieperhoff S. Mutations with pathogenic potential in proteins located in or at the composite junctions of the intercalated disk connecting mammalian cardiomyocytes: a reference thesaurus for arrhythmogenic cardiomyopathies and for Naxos and Carvajal diseases. Cell Tissue Res 2012; 348:325-33. [PMID: 22450909 PMCID: PMC3349860 DOI: 10.1007/s00441-012-1365-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 02/03/2012] [Indexed: 01/30/2023]
Abstract
In the past decade, an avalanche of findings and reports has correlated arrhythmogenic ventricular cardiomyopathies (ARVC) and Naxos and Carvajal diseases with certain mutations in protein constituents of the special junctions connecting the polar regions (intercalated disks) of mature mammalian cardiomyocytes. These molecules, apparently together with some specific cytoskeletal proteins, are components of (or interact with) composite junctions. Composite junctions contain the amalgamated fusion products of the molecules that, in other cell types and tissues, occur in distinct separate junctions, i.e. desmosomes and adherens junctions. As the pertinent literature is still in an expanding phase and is obviously becoming important for various groups of researchers in basic cell and molecular biology, developmental biology, histology, physiology, cardiology, pathology and genetics, the relevant references so far recognized have been collected and are presented here in the following order: desmocollin-2 (Dsc2, DSC2), desmoglein-2 (Dsg2, DSG2), desmoplakin (DP, DSP), plakoglobin (PG, JUP), plakophilin-2 (Pkp2, PKP2) and some non-desmosomal proteins such as transmembrane protein 43 (TMEM43), ryanodine receptor 2 (RYR2), desmin, lamins A and C, striatin, titin and transforming growth factor-β3 (TGFβ3), followed by a collection of animal models and of reviews, commentaries, collections and comparative studies.
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Affiliation(s)
- Steffen Rickelt
- Helmholtz Group for Cell Biology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, Building TP4, 69120 Heidelberg, Germany
- Progen Biotechnik, Heidelberg, Germany
| | - Sebastian Pieperhoff
- BHF Centre for Cardiovascular Science, The Queen’s Medical Research Institute, University of Edinburgh, 47 Little France Crescent, EH164TJ Edinburgh, Scotland UK
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DeSimone CV, Sagar S, Moir C, Asirvatham SJ. Combined surgical and ablative cure for localized sternal compression-induced cardiomyopathy and ventricular tachyarrhythmia. J Thorac Cardiovasc Surg 2012; 144:e85-7. [PMID: 22502968 DOI: 10.1016/j.jtcvs.2012.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
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Stankovic I, Vlahovic-Stipac A, Putnikovic B, Neskovic AN. Distinguishing incomplete right bundle branch block in patients with arrhythmogenic right ventricular cardiomyopathy from normal variants: a potential role of Fontaine leads and Holter monitoring? Int J Cardiol 2012; 157:148-50. [PMID: 22459394 DOI: 10.1016/j.ijcard.2012.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
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Morin DP, Mauer AC, Gear K, Zareba W, Markowitz SM, Marcus FI, Lerman BB. Usefulness of precordial T-wave inversion to distinguish arrhythmogenic right ventricular cardiomyopathy from idiopathic ventricular tachycardia arising from the right ventricular outflow tract. Am J Cardiol 2010; 105:1821-4. [PMID: 20538137 PMCID: PMC2901677 DOI: 10.1016/j.amjcard.2010.01.365] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 01/29/2010] [Accepted: 01/29/2010] [Indexed: 10/19/2022]
Abstract
The 2 predominant causes of ventricular tachycardia (VT) arising from the right ventricle are arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathic VT arising from the right ventricular outflow tract (RVOT). These arrhythmias can be adrenergically mediated and may be difficult to distinguish clinically. A minor criterion for the diagnosis of ARVC is T-wave inversion (TWI) in the right precordial leads during sinus rhythm. However, there have been reports of precordial TWI identified in patients with RVOT tachycardia. The purpose of this study was to determine whether patterns of precordial TWI could differentiate between the 2 groups. A multicenter registry of 229 patients with VT of right ventricular origin was evaluated. After appropriate exclusions (n = 29), 79 patients (58% men, mean age 40 +/- 14 years) had ARVC, and 121 patients (41% men, mean age 48 +/- 14 years) had RVOT tachycardia. During sinus rhythm, 37 patients (47%) with ARVC and 5 patients (4%) with RVOT tachycardia had TWI in leads V(1) to V(3). For the diagnosis of ARVC, TWI in leads V(1) to V(3) had sensitivity of 47% and specificity of 96%. In conclusion, in patients with VT of right ventricular origin, the presence of TWI in electrocardiographic leads V(1) to V(3) supports the diagnosis of ARVC.
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Hakacova N. Cardiac imaging of anatomy and electrocardiology--and in hand in future steps. J Electrocardiol 2009; 42:103-5. [PMID: 19236998 DOI: 10.1016/j.jelectrocard.2008.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Indexed: 11/28/2022]
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