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Steinfurt J, Bezzina CR, Biermann J, Staudacher D, Marschall C, Trolese L, Faber TS, Duerschmied D, Zehender M, Bode C, Wilde AAM, Odening KE, Lodder EM. Two siblings with early repolarization syndrome: clinical and genetic characterization by whole-exome sequencing. Europace 2021; 23:775-780. [PMID: 33324992 PMCID: PMC8139820 DOI: 10.1093/europace/euaa357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/10/2020] [Indexed: 01/23/2023] Open
Abstract
Aims The early repolarization syndrome (ERS) can cause ventricular fibrillation (VF) and sudden death in young, otherwise healthy individuals. There are limited data suggesting that ERS might be heritable. The aim of this study was to characterize the clinical phenotype and to identify a causal variant in an affected family using an exome-sequencing approach. Methods and results Early repolarization syndrome was diagnosed according to the recently proposed Shanghai ERS Score. After sequencing of known ERS candidate genes, whole-exome sequencing (WES) was performed. The index patient (23 years, female) showed a dynamic inferolateral early repolarization (ER) pattern and electrical storm with intractable VF. Isoproterenol enabled successful termination of electrical storm with no recurrence on hydroquinidine therapy during 33 months of follow-up. The index patient’s brother (25 years) had a persistent inferior ER pattern with malignant features and a history of syncope. Both parents were asymptomatic and showed no ER pattern. While there was no pathogenic variant in candidate genes, WES detected a novel missense variant affecting a highly conserved residue (p. H2245R) in the ANK3 gene encoding Ankyrin-G in the two siblings and the father. Conclusion We identified two siblings with a malignant ERS phenotype sharing a novel ANK3 variant. A potentially pathogenic role of the novel ANK3 variant is suggested by the direct interaction of Ankyrin-G with the cardiac sodium channel, however, more patients with ANK3 variants and ERS would be required to establish ANK3 as novel ERS susceptibility gene. Our study provides additional evidence that ERS might be a heritable condition.
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Affiliation(s)
- Johannes Steinfurt
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Connie R Bezzina
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Jürgen Biermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Dawid Staudacher
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | | | - Luca Trolese
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Thomas S Faber
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Katja E Odening
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Elisabeth M Lodder
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
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Hassanzadeh M, Mardani E, Hosseinpour A, Mehdipour Namdar Z, Shahrzad S, Aslani A. Signal averaged ECG in patients with early repolarization. J Arrhythm 2021; 37:432-437. [PMID: 33850585 PMCID: PMC8022001 DOI: 10.1002/joa3.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/30/2021] [Accepted: 02/14/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Early repolarization (ER) pattern is diagnosed when the J-point is elevated on the patient's electrocardiogram. The aim of this study was to evaluate signal-averaged electrocardiography (SAECG) in patients with ER pattern. METHODS Subjects were divided into three groups: 1-patients with normal ECG pattern (control group); 2-patients with J-point elevation in the inferior leads; and 3-patients with J-point elevation in non-inferior leads. RESULTS The mean filtered QRS duration in groups with J-point elevation in inferior leads and non-inferior leads and in the control, was 86.4 ± 23.4 msec, 84.8 ± 26.6 msec, and 85.8 ± 24.8 msec, respectively, indicating no significant difference across the three groups. The mean duration of terminal QRS < 40µV was 21.2 ± 4.2 msec, 22.8 ± 4.6 msec, and 23.1 ± 4.5 msec in the mentioned groups, respectively, without a significant difference between the groups. Additionally, the mean root-mean-square voltage of terminal 40 msec was 34.5 ± 8.3 µV, 35.3 ± 8.6µV, and 35.7 ± 9.2 µV in patients with increased J-point in inferior leads, non-inferior leads, and the control group, respectively, showing no difference between the groups. CONCLUSION In conclusion, we found that parameters in SAECG did not have any significant difference between patients with ER pattern and healthy individuals. Moreover, we concluded that SAECG cannot distinguish the patients with elevated J-point in inferior leads from non-inferior leads. Overall, SAECG does not appear to be a reliable diagnostic tool for the assessment of ER pattern.
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Affiliation(s)
| | | | - Alireza Hosseinpour
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | | | | | - Amir Aslani
- Shiraz University of Medical SciencesShirazIran
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Stoller M, Boehler A, Bloch N, Seiler C, Heg D, Branca M, Roten L. Effect of acute myocardial ischemia on inferolateral early repolarization. Heart Rhythm 2020; 17:922-930. [PMID: 31981736 DOI: 10.1016/j.hrthm.2020.01.019] [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: 06/30/2019] [Accepted: 01/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inferolateral early repolarization (ER) is associated with an increase in arrhythmic risk, particularly in the presence of myocardial ischemia. OBJECTIVE The purpose of this study was to determine the effect of myocardial ischemia on ER. METHODS We retrospectively analyzed procedural electrocardiograms (ECGs) of patients with ER undergoing a controlled, 1-minute coronary balloon occlusion for collateral function testing. ECG leads with ER were analyzed immediately before coronary balloon occlusion (PRE), at 60 seconds of coronary balloon occlusion (OCCL), and >30 seconds after balloon deflation. RESULTS Seventy-seven patients with ER in the preprocedural ECG (86% inferior, 20% lateral) underwent 135 coronary balloon occlusions during which a J wave was recorded in 224 leads (ER leads). From PRE to OCCL, ST-segment amplitude (ST) in the ER lead increased in 94 cases (44%) from 0.00 ± 0.03 to 0.05 ± 0.06 mV (P < .0001). In this group, J-wave amplitude (JWA) increased from 0.10 ± 0.07 to 0.13 ± 0.09 mV (P < .0001). ST in the ER lead decreased or was unchanged in 121 cases (56%) from PRE to OCCL (from 0.01 ± 0.05 to -0.02 ± 0.04 mV; P < .0001). In this group, JWA decreased from 0.10 ± 0.05 to 0.08 ± 0.07 mV (P < .0001). The change in JWA was related to the change in ST (linear regression analysis; R2 = 0.34; P < .0001), while there was no relation between the change in R-wave amplitude and the change in ST (R2 = 0.0003; P = .83). CONCLUSION During acute ischemia, JWA mirrors ST-segment changes. This may explain increased arrhythmic vulnerability of patients with ER during myocardial ischemia. It also adds weight to the hypothesis of ER being a phenomenon of repolarization.
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Affiliation(s)
- Michael Stoller
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alexander Boehler
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nando Bloch
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit Bern and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Mattia Branca
- Clinical Trials Unit Bern and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
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Baseline ST elevation and myocardial scar: Results from the multi-ethnic study of atherosclerosis. J Electrocardiol 2019; 56:29-33. [PMID: 31247443 DOI: 10.1016/j.jelectrocard.2019.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/18/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The mechanism of ST elevation on baseline electrocardiograms (ECG) unknown but it may be associated with abnormal myocardial substrate. This paper evaluates whether clinically unrecognized myocardial scar on cardiac magnetic resonance imaging (CMR) is associated with ST elevation at baseline. METHODS The Multi-Ethnic Study of Atherosclerosis (MESA) study is a population-based cohort in the United States. Participants were aged 45 through 84 years and free of clinical cardiovascular disease at enrollment in 2000-2002. Our cohort included 1365 participants who underwent both ECG and contrast enhanced CMR in the 5th examination (2010-2012). Multivariable logistic regression examined the association of ST elevation and CMR defined regional myocardial scar after adjusting for cardiovascular risk factors. RESULTS Of 1365 participants (58 ±9 years, 52% men), 105 (8%) had scar on CMR. Of these, the scar in 40 participants followed an ischemic pattern and in the other 65 participants followed a non-ischemic pattern. ST elevation at the 5th examination was present in 435 participants: 40 (0.9%) had ST elevations in inferior and 427 (98%) in lateral leads. 2/40 (5%) and 22/427 (5%) participants with inferior and lateral ST elevations, respectively, had evidence of scar. 15 (1.0%) had myocardial scar noted in the basal anterior region. In the fully adjusted models, ST elevation was associated with scar in basal anterior region (OR 18.2, p = 0.031). CONCLUSIONS In a community population, ST elevation at baseline in the inferior or lateral leads was associated with myocardial scar in the basal inferior and anterior segments. The previously described association between ST elevation and increased mortality may be mediated by myocardial scar.
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Trenor B, Cardona K, Saiz J, Noble D, Giles W. Cardiac action potential repolarization revisited: early repolarization shows all-or-none behaviour. J Physiol 2017; 595:6599-6612. [PMID: 28815597 PMCID: PMC5663823 DOI: 10.1113/jp273651] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/09/2017] [Indexed: 12/15/2022] Open
Abstract
In healthy mammalian hearts the action potential (AP) waveform initiates and modulates each contraction, or heartbeat. As a result, AP height and duration are key physiological variables. In addition, rate-dependent changes in ventricular AP duration (APD), and variations in APD at a fixed heart rate are both reliable biomarkers of electrophysiological stability. Present guidelines for the likelihood that candidate drugs will increase arrhythmias rely on small changes in APD and Q-T intervals as criteria for safety pharmacology decisions. However, both of these measurements correspond to the final repolarization of the AP. Emerging clinical evidence draws attention to the early repolarization phase of the action potential (and the J-wave of the ECG) as an additional important biomarker for arrhythmogenesis. Here we provide a mechanistic background to this early repolarization syndrome by summarizing the evidence that both the initial depolarization and repolarization phases of the cardiac action potential can exhibit distinct time- and voltage-dependent thresholds, and also demonstrating that both can show regenerative all-or-none behaviour. An important consequence of this is that not all of the dynamics of action potential repolarization in human ventricle can be captured by data from single myocytes when these results are expressed as 'repolarization reserve'. For example, the complex pattern of cell-to-cell current flow that is responsible for AP conduction (propagation) within the mammalian myocardium can change APD and the Q-T interval of the electrocardiogram alter APD stability, and modulate responsiveness to pharmacological agents (such as Class III anti-arrhythmic drugs).
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Affiliation(s)
- Beatriz Trenor
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Karen Cardona
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Javier Saiz
- Centro de Investigación e BioingenieríaUniversitat Politècnica de ValènciaValenciaSpain
| | - Denis Noble
- University Laboratory of PhysiologyUniversity of OxfordOxfordOX1 3PTUK
| | - Wayne Giles
- Faculties of Kinesiology and MedicineUniversity of CalgaryCalgaryAlbertaCanadaT2N 1N4
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Meijborg VMF, Potse M, Conrath CE, Belterman CNW, De Bakker JMT, Coronel R. Reduced Sodium Current in the Lateral Ventricular Wall Induces Inferolateral J-Waves. Front Physiol 2016; 7:365. [PMID: 27616994 PMCID: PMC5000556 DOI: 10.3389/fphys.2016.00365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/09/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND J-waves in inferolateral leads are associated with a higher risk for idiopathic ventricular fibrillation. We aimed to test potential mechanisms (depolarization or repolarization dependent) responsible for inferolateral J-waves. We hypothesized that inferolateral J-waves can be caused by regional delayed activation of myocardium that is activated late during normal conditions. METHODS Computer simulations were performed to evaluate how J-point elevation is influenced by reducing sodium current conductivity (GNa), increasing transient outward current conductivity (Gto), or cellular uncoupling in three predefined ventricular regions (lateral, anterior, or septal). Two pig hearts were Langendorff-perfused with selective perfusion with a sodium channel blocker of lateral or anterior/septal regions. Volume-conducted pseudo-electrocardiograms (ECG) were recorded to detect the presence of J-waves. Epicardial unipolar electrograms were simultaneously recorded to obtain activation times (AT). RESULTS Simulation data showed that conduction slowing, caused by reduced sodium current, in lateral, but not in other regions induced inferolateral J-waves. An increase in transient outward potassium current or cellular uncoupling in the lateral zone elicited slight J-point elevations which did not meet J-wave criteria. Additional conduction slowing in the entire heart attenuated J-waves and J-point elevations on the ECG, because of masking by the QRS. Experimental data confirmed that conduction slowing attributed to sodium channel blockade in the left lateral but not in the anterior/septal ventricular region induced inferolateral J-waves. J-waves coincided with the delayed activation. CONCLUSION Reduced sodium current in the left lateral ventricular myocardium can cause inferolateral J-waves on the ECG.
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Affiliation(s)
- Veronique M F Meijborg
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Interuniversity Cardiology Institute of the NetherlandsUtrecht, Netherlands
| | - Mark Potse
- Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France; Modélisation et calculs pour l'électrophysiologie cardiaque (Carmen) team, Inria Bordeaux Sud-OuestBordeaux, France; Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italianaLugano, Switzerland
| | - Chantal E Conrath
- Department of Clinical and Experimental Cardiology, Academic Medical Center Amsterdam, Netherlands
| | - Charly N W Belterman
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France
| | - Jacques M T De Bakker
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Interuniversity Cardiology Institute of the NetherlandsUtrecht, Netherlands; Department of Medical Physiology, University of UtrechtUtrecht, Netherlands
| | - Ruben Coronel
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France
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Mercer BN, Begg GA, Page SP, Bennett CP, Tayebjee MH, Mahida S. Early Repolarization Syndrome; Mechanistic Theories and Clinical Correlates. Front Physiol 2016; 7:266. [PMID: 27445855 PMCID: PMC4927622 DOI: 10.3389/fphys.2016.00266] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/15/2016] [Indexed: 12/20/2022] Open
Abstract
The early repolarization (ER) pattern on the 12-lead electrocardiogram is characterized by J point elevation in the inferior and/or lateral leads. The ER pattern is associated with an increased risk of ventricular arrhythmias and sudden cardiac death (SCD). Based on studies in animal models and genetic studies, it has been proposed that J point elevation in ER is a manifestation of augmented dispersion of repolarization which creates a substrate for ventricular arrhythmia. A competing theory regarding early repolarization syndrome (ERS) proposes that the syndrome arises as a consequence of abnormal depolarization. In recent years, multiple clinical studies have described the characteristics of ER patients with VF in more detail. The majority of these studies have provided evidence to support basic science observations. However, not all clinical observations correlate with basic science findings. This review will provide an overview of basic science and genetic research in ER and correlate basic science evidence with the clinical phenotype.
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Affiliation(s)
- Ben N. Mercer
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
| | - Gordon A. Begg
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
| | - Stephen P. Page
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
- Regional Inherited Cardiovascular Conditions Service, Leeds General InfirmaryLeeds, UK
| | | | | | - Saagar Mahida
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
- Regional Inherited Cardiovascular Conditions Service, Leeds General InfirmaryLeeds, UK
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The association of J wave and ventricular tachycardia before device implantation with device interventions for ventricular tachyarrhythmia. J Electrocardiol 2015; 48:721-8. [DOI: 10.1016/j.jelectrocard.2015.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Indexed: 11/20/2022]
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Macfarlane PW, Antzelevitch C, Haissaguerre M, Huikuri HV, Potse M, Rosso R, Sacher F, Tikkanen JT, Wellens H, Yan GX. The Early Repolarization Pattern. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.05.033] [Citation(s) in RCA: 185] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Affiliation(s)
- Pieter G Postema
- Department of cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands.
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