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Pupaza A, Cinteza E, Vasile CM, Nicolescu A, Vatasescu R. Assessment of Sudden Cardiac Death Risk in Pediatric Primary Electrical Disorders: A Comprehensive Overview. Diagnostics (Basel) 2023; 13:3551. [PMID: 38066791 PMCID: PMC10706572 DOI: 10.3390/diagnostics13233551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 06/30/2024] Open
Abstract
Sudden cardiac death (SCD) in children is a devastating event, often linked to primary electrical diseases (PED) of the heart. PEDs, often referred to as channelopathies, are a group of genetic disorders that disrupt the normal ion channel function in cardiac cells, leading to arrhythmias and sudden cardiac death. This paper investigates the unique challenges of risk assessment and stratification for channelopathy-related SCD in pediatric patients-Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, idiopathic ventricular fibrillation, long QT syndrome, Anderson-Tawil syndrome, short QT syndrome, and early repolarization syndrome. We explore the intricate interplay of genetic, clinical, and electrophysiological factors that contribute to the complex nature of these conditions. Recognizing the significance of early identification and tailored management, this paper underscores the need for a comprehensive risk stratification approach specifically designed for pediatric populations. By integrating genetic testing, family history, and advanced electrophysiological evaluation, clinicians can enhance their ability to identify children at the highest risk for SCD, ultimately paving the way for more effective preventive strategies and improved outcomes in this vulnerable patient group.
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Affiliation(s)
- Adelina Pupaza
- Department of Cardiology, Clinic Emergency Hospital Bucharest, 050098 Bucharest, Romania;
| | - Eliza Cinteza
- Department of Pediatrics, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pediatric Cardiology, “Marie Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania;
| | - Corina Maria Vasile
- Pediatric and Adult Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, 33600 Bordeaux, France;
| | - Alin Nicolescu
- Department of Pediatric Cardiology, “Marie Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania;
| | - Radu Vatasescu
- Department of Cardiology, Clinic Emergency Hospital Bucharest, 050098 Bucharest, Romania;
- Cardio-Thoracic Department, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania
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2
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Oreto L, Briuglia S, Capra AP, Ruiz VG, Di Pino A. Bidirectional Ventricular Tachycardia and Prominent U Waves: Look at Fingers and Muscles and Use Flecainide. J Pediatr Pharmacol Ther 2023; 28:662-666. [PMID: 38025154 PMCID: PMC10681079 DOI: 10.5863/1551-6776-28.7.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/27/2023] [Indexed: 12/01/2023]
Abstract
We present a case of bidirectional ventricular tachycardia in a 15-year-old boy asymptomatic for arrhythmias, whose major complaint was muscle weakness. At our first evaluation he was receiving sotalol for his ventricular arrhythmias. In addition to bidirectional tachycardia, electrocardiogram during sinus rhythm showed prominent U waves and prolonged QT-U interval. These electrocardiographic signs, along with the evidence of clinodactyly and mild hypertelorism, led us to the diagnosis of Andersen-Tawil syndrome, confirmed by genetic analysis that revealed a "de novo" missense mutation of KCNJ2 gene. Monotherapy with flecainide was rapidly effective and almost eliminated ventricular arrhythmias. After a 4-year follow-up there were no adverse events, flecainide has been well tolerated without significant modification of the QRS or repolarization, and ventricular arrhythmias have not been relapsed to date. The case highlights the importance of a correct clinical diagnosis, which is crucial for the optimal selection of the most appropriate drug therapy, which is expected not to be harmful, before being beneficial.
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Affiliation(s)
- Lilia Oreto
- Mediterranean Pediatric Cardiology Center (LO, VGR, AD), Bambino Gesù Children’s Hospital, Taormina, Italy
| | - Silvana Briuglia
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (SB, APC), University of Messina, Messina, Italy
| | - Anna Paola Capra
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (SB, APC), University of Messina, Messina, Italy
| | - Victoria Garcia Ruiz
- Mediterranean Pediatric Cardiology Center (LO, VGR, AD), Bambino Gesù Children’s Hospital, Taormina, Italy
| | - Alfredo Di Pino
- Mediterranean Pediatric Cardiology Center (LO, VGR, AD), Bambino Gesù Children’s Hospital, Taormina, Italy
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3
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Vivekanandam V, Suetterlin K, Matthews E, Thornton J, Jayaseelan D, Shah S, Morrow JM, Yousry T, Hanna MG. Muscle MRI in periodic paralysis shows myopathy is common and correlates with intramuscular fat accumulation. Muscle Nerve 2023; 68:439-450. [PMID: 37515374 DOI: 10.1002/mus.27947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION/AIMS The periodic paralyses are muscle channelopathies: hypokalemic periodic paralysis (CACNA1S and SCN4A variants), hyperkalemic periodic paralysis (SCN4A variants), and Andersen-Tawil syndrome (KCNJ2). Both episodic weakness and disabling fixed weakness can occur. Little literature exists on magnetic resonance imaging (MRI) in muscle channelopathies. We undertake muscle MRI across all subsets of periodic paralysis and correlate with clinical features. METHODS A total of 45 participants and eight healthy controls were enrolled and underwent T1-weighted and short-tau-inversion-recovery (STIR) MRI imaging of leg muscles. Muscles were scored using the modified Mercuri Scale. RESULTS A total of 17 patients had CACNA1S variants, 16 SCN4A, and 12 KCNJ2. Thirty-one (69%) had weakness, and 9 (20%) required a gait-aid/wheelchair. A total of 78% of patients had intramuscular fat accumulation on MRI. Patients with SCN4A variants were most severely affected. In SCN4A, the anterior thigh and posterior calf were more affected, in contrast to the posterior thigh and posterior calf in KCNJ2. We identified a pattern of peri-tendinous STIR hyperintensity in nine patients. There were moderate correlations between Mercuri, STIR scores, and age. Intramuscular fat accumulation was seen in seven patients with no fixed weakness. DISCUSSION We demonstrate a significant burden of disease in patients with periodic paralyses. MRI intramuscular fat accumulation may be helpful in detecting early muscle involvement, particularly in those without fixed weakness. Longitudinal studies are needed to assess the role of muscle MRI in quantifying disease progression over time and as a potential biomarker in clinical trials.
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Affiliation(s)
- Vinojini Vivekanandam
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Karen Suetterlin
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Emma Matthews
- Atkinson-Morley Neuromuscular Centre, Department of Neurology, St George's University Hospitals NHS Foundation Trust, and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - John Thornton
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, UCL, London, UK
| | - Dipa Jayaseelan
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Sachit Shah
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, UCL, London, UK
| | - Jasper M Morrow
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Tarek Yousry
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, UCL, London, UK
| | - Michael G Hanna
- Queen Square Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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4
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Ma JF, Zhou Y, Fu HX. Ventricular fibrillation induced by fever in structurally normal hearts. Front Cardiovasc Med 2023; 10:1230295. [PMID: 37817866 PMCID: PMC10561293 DOI: 10.3389/fcvm.2023.1230295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/25/2023] [Indexed: 10/12/2023] Open
Abstract
Ventricular fibrillation (VF) is a life-threatening arrhythmia that usually happens in patients with structural heart diseases. However, fever-induced ventricular fibrillation in structurally normal hearts was reported, and the four main diseases associated with these cases were Brugada syndrome, long QT syndrome, idiopathic ventricular fibrillation, and non-cardiovascular diseases. In this review, we analyzed this phenomenon and its clinical characteristics.
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Affiliation(s)
- Ji-Fang Ma
- Department of Cardiology, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
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Matthews E, Palace J, Ramdas S, Sansone V, Tristani-Firouzi M, Vicart S, Willis T. Care Recommendations for the Investigation and Management of Children With Skeletal Muscle Channelopathies. Pediatr Neurol 2023; 145:102-111. [PMID: 37315339 DOI: 10.1016/j.pediatrneurol.2023.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Abstract
The field of pediatric skeletal muscle channelopathies has seen major new advances in terms of a wider understanding of clinical presentations and new phenotypes. Skeletal muscle channelopathies cause significant disability and even death in some of the newly described phenotypes. Despite this, there are virtually no data on the epidemiology and longitudinal natural history of these conditions or randomized controlled trial evidence of efficacy or tolerability of any treatment in children, and thus best practice care recommendations do not exist. Clinical history, and to a lesser extent examination, is key to eliciting symptoms and signs that indicate a differential diagnosis of muscle channelopathy. Normal routine investigations should not deter one from the diagnosis. Specialist neurophysiologic investigations have an additional role, but their availability should not delay genetic testing. New phenotypes are increasingly likely to be identified by next-generation sequencing panels. Many treatments or interventions for symptomatic patients are available, with anecdotal data to support their benefit, but we lack trial data on efficacy, safety, or superiority. This lack of trial data in turn can lead to hesitancy in prescribing among doctors or in accepting medication by parents. Holistic management addressing work, education, activity, and additional symptoms of pain and fatigue provides significant benefit. Preventable morbidity and sometimes mortality occurs if the diagnosis and therefore treatment is delayed. Advances in genetic sequencing technology and greater access to testing may help to refine recently identified phenotypes, including histology, as more cases are described. Randomized controlled treatment trials are required to inform best practice care recommendations. A holistic approach to management is essential and should not be overlooked. Good quality data on prevalence, health burden, and optimal treatment are urgently needed.
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Affiliation(s)
- Emma Matthews
- Department of Neurology, Atkinson-Morley Neuromuscular Centre, St George's University Hospitals NHS Foundation Trust, and Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
| | - Jacqueline Palace
- Clinical Neurology, John Radcliffe Hospital, Oxford University Foundation Trust, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sithara Ramdas
- Department of Paediatrics, MDUK Neuromuscular Centre, University of Oxford, Oxford, UK; Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, UK
| | - Valeria Sansone
- Neurorehabilitation Unit, Neuromuscular Omnicentre Clinical Center, Niguarda Hospital, University of Milan, Milan, Italy
| | - Martin Tristani-Firouzi
- Nora Eccles Harrison Cardiovascular Research and Training Institute and the Division of Paediatric Cardiology, University of Utah, Salt Lake City, Utah
| | - Savine Vicart
- Reference Centre for Neuromuscular Disorders, APHP, Institute of Myology, Pitié-Salpêtrière Hospital, Paris, France
| | - Tracey Willis
- Robert Jones and Agnes Hunt Orthopaedic Hospital, NHS Foundation Trust, Oswestry, England
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Manuel AIM, Gutiérrez LK, Pedrosa MLV, Uréndez FMC, Jiménez FJB, Carrascoso IM, Pérez PS, Macías Á, Jalife J. Molecular stratification of arrhythmogenic mechanisms in the Andersen Tawil Syndrome. Cardiovasc Res 2022; 119:919-932. [PMID: 35892314 PMCID: PMC10153646 DOI: 10.1093/cvr/cvac118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/20/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022] Open
Abstract
Andersen Tawil Syndrome (ATS) is a rare inheritable disease associated with loss-of-function mutations in KCNJ2, the gene coding the strong inward rectifier potassium channel Kir2.1, which forms an essential membrane protein controlling cardiac excitability. ATS is usually marked by a triad of periodic paralysis, life-threatening cardiac arrhythmias and dysmorphic features, but its expression is variable and not all patients with a phenotype linked to ATS have a known genetic alteration. The mechanisms underlying this arrhythmogenic syndrome are poorly understood. Knowing such mechanisms would be essential to distinguish ATS from other channelopathies with overlapping phenotypes and to develop individualized therapies. For example, the recently suggested role of Kir2.1 as a countercurrent to sarcoplasmic calcium reuptake might explain the arrhythmogenic mechanisms of ATS and its overlap with catecholaminergic polymorphic ventricular tachycardia (CPVT). Here we summarize current knowledge on the mechanisms of arrhythmias leading to sudden cardiac death in ATS. We first provide an overview of the syndrome and its pathophysiology, from the patient´s bedside to the protein, and discuss the role of essential regulators and interactors that could play a role in cases of ATS. The review highlights novel ideas related to some post-translational channel interactions with partner proteins that might help define the molecular bases of the arrhythmia phenotype. We then propose a new all-embracing classification of the currently known ATS loss-of-function mutations according to their position in the Kir2.1 channel structure and their functional implications. We also discuss specific ATS pathogenic variants, their clinical manifestations and treatment stratification. The goal is to provide a deeper mechanistic understanding of the syndrome toward the development of novel targets and personalized treatment strategies.
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Affiliation(s)
| | - Lilian K Gutiérrez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
| | | | | | - Francisco José Bermúdez Jiménez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain.,Departamento de Cardiología, Hospital Virgen de las Nieves, GranadaSpain
| | | | - Patricia Sánchez Pérez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
| | - Álvaro Macías
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, 28029 Madrid, Spain.,CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Departments of Medicine and Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
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Ünal Yüksekgönül A, Azak E, Akalın A, Ertuğrul İ, Kılıç E, Utine GE, Karagöz T. Efficacy of flecainide in bidirectional ventricular tachycardia and tachycardia-induced cardiomyopathy with Andersen-Tawil syndrome. Eur J Med Genet 2022; 65:104499. [DOI: 10.1016/j.ejmg.2022.104499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/30/2022]
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Dolci C, Sansone VA, Gibelli D, Cappella A, Sforza C. Distinctive facial features in Andersen-Tawil syndrome: A three-dimensional stereophotogrammetric analysis. Am J Med Genet A 2020; 185:781-789. [PMID: 33369085 DOI: 10.1002/ajmg.a.62040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/19/2020] [Accepted: 12/14/2020] [Indexed: 01/28/2023]
Abstract
Andersen-Tawil syndrome (ATS) is a rare potassium channelopathy causing periodic paralysis, cardiac arrhythmias, and dysmorphic features. A detailed analysis of the face could facilitate diagnosis of ATS, as approximately 30% of patients do not show variants in KCNJ2 gene, and diagnosis is established by clinical findings. We aimed to characterize the face in ATS through a quantitative approach, as facial anomalies may be unnoticed on visual inspection. Facial images of 12 subjects with genetically confirmed ATS (six males, six females, age 5-67 years) were acquired through stereophotogrammetry. Using 38 soft-tissue landmarks, linear distances, angles, and ratios were calculated and expressed as z-score values, with reference to 477 healthy subjects matched for sex and age. All patients showed decreased lower facial height with shortening of philtrum (mean z-score ± SD: -1.5 ± 0.9), smaller mid and lower facial depths (-1.9 ± 0.7; -2.3 ± 0.9), short palpebral fissures (right -1.2 ± 0.4; left -1.6 ± 0.6), smaller mandibular ramus length (-2.1 ± 0.4), and increased nasal width/length ratio (1.4 ± 0.5) with smaller nostril axis length (right -1.8 ± 0.8, left -1.6 ± 0.7). Hypertelorism and low-set ears were detected in two-thirds of patients. The study quantified facial dysmorphysm in ATS, extending information about known features, and detecting unrecorded philtrum and nostril characteristics, which may be distinctive traits of the disorder.
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Affiliation(s)
- Claudia Dolci
- Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico (LAFAS), Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Valeria A Sansone
- NEuroMuscularOmnicenter, NEMO Clinical Center, Neurorehabilitation Unit, Università degli Studi di Milano, Milan, Italy
| | - Daniele Gibelli
- Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico (LAFAS), Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Annalisa Cappella
- Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico (LAFAS), Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Chiarella Sforza
- Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell'Apparato Stomatognatico (LAFAS), Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
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Abstract
Andersen-Tawil syndrome (ATS) is a very rare orphan genetic multisystem channelopathy without structural heart disease (with rare exceptions). ATS type 1 is inherited in an autosomal dominant fashion and is caused by mutations in the KCNJ2 gene, which encodes the α subunit of the K+ channel protein Kir2.1 (in ≈ 50-60% of cases). ATS type 2 is in turn linked to a rare mutation in the KCNJ5-GIRK4 gene that encodes the G protein-sensitive-activated inwardly rectifying K+ channel Kir3.4 (15%), which carries the acetylcholine-induced potassium current. About 30% of cases are de novo/sporadic, suggesting that additional as-yet unidentified genes also cause the disorder. A triad of periodic muscle paralysis, repolarization changes in the electrocardiogram, and structural body changes characterize ATS. The typical muscular change is episodic flaccid muscle weakness. Prolongation of the QU/QUc intervals and normal or minimally prolonged QT/QTc intervals with a tendency to ventricular arrhythmias are typical repolarization changes. Bidirectional ventricular tachycardia is the hallmark ventricular arrhythmia, but also premature ventricular contractions, and rarely, polymorphic ventricular tachycardia of torsade de pointes type may be present. Patients with ATS have characteristic physical developmental dysmorphisms that affect the face, skull, limbs, thorax, and stature. Mild learning difficulties and a distinct neurocognitive phenotype (deficits in executive function and abstract reasoning) have been described. About 60% of affected individuals have all features of the major triad. The purpose of this review is to present historical aspects, nomenclature (observations/criticisms), epidemiology, genetics, electrocardiography, arrhythmias, electrophysiological mechanisms, diagnostic criteria/clues of periodic paralysis, prognosis, and management of ATS.
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