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Pasqualin G, Boccellino A, Chessa M, Ciconte G, Marcolin C, Micaglio E, Pappone C, Sturla F, Giamberti A. Ebstein's anomaly in children and adults: multidisciplinary insights into imaging and therapy. Heart 2024; 110:235-244. [PMID: 37487694 PMCID: PMC10850734 DOI: 10.1136/heartjnl-2023-322420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Although survival has significantly improved in the last four decades, the diagnosis of Ebstein's anomaly is still associated with a 20-fold increased risk of mortality, which generally drops after neonatal period and increases subtly thereafter. With increasing age of presentation, appropriate timing of intervention is challenged by a wide spectrum of disease and paucity of data on patient-tailored interventional strategies. The present review sought to shed light on the wide grey zone of post-neonatal Ebstein's manifestations, highlighting current gaps and achievements in knowledge for adequate risk assessment and appropriate therapeutic strategy.A 'wait-and-see' approach has been adopted in many circumstances, though its efficacy is now questioned by the awareness that Ebstein's anomaly is not a benign disease, even when asymptomatic. Moreover, older age at intervention showed a negative impact on post-surgical outcome.In order to tackle the extreme heterogeneity of Ebstein's anomaly, this review displays the multimodality imaging assessment necessary for a proper anatomical classification and the multidisciplinary approach needed for a comprehensive risk stratification and monitoring strategy. Currently available predictors of clinical outcome are summarised for both operated and unoperated patients, with the aim of supporting the decisional process on the choice of appropriate therapy and optimal timing for intervention.
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Affiliation(s)
- Giulia Pasqualin
- Pediatric and Adult Congenital Disease Heart Centre, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, Amsterdam, Netherlands
| | - Antonio Boccellino
- Arrhythmia and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Massimo Chessa
- Pediatric and Adult Congenital Disease Heart Centre, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart, Amsterdam, Netherlands
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milano, Italy
| | - Giuseppe Ciconte
- Arrhythmia and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milano, Italy
| | - Cecilia Marcolin
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milano, Italy
| | - Emanuele Micaglio
- Arrhythmia and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Carlo Pappone
- Arrhythmia and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milano, Italy
| | - Francesco Sturla
- 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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Akazawa Y, Fujioka T, Yazaki K, Strbad M, Hörer J, Kühn A, Hui W, Slorach C, Roehlig C, Mertens L, Bijnens BH, Vogt M, Friedberg MK. Right Ventricular Electromechanical Dyssynchrony and Its Relation to Right Ventricular Remodeling, Dysfunction, and Exercise Capacity in Ebstein Anomaly. J Am Soc Echocardiogr 2023:S0894-7317(23)00096-2. [PMID: 36841267 DOI: 10.1016/j.echo.2023.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 01/21/2023] [Accepted: 02/08/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Abnormal atrioventricular and intraventricular electrical conduction and dysfunction of the functional right ventricle (fRV) are common in Ebstein anomaly (EA). However, fRV mechanical dyssynchrony and its relation to fRV function are poorly characterized. We evaluated fRV mechanical dyssynchrony in EA patients in relation to fRV remodeling, dysfunction, and exercise intolerance. METHODS We retrospectively analyzed data from nonoperated EA patients and age-matched controls who underwent echocardiography, cardiovascular magnetic resonance imaging, and cardiopulmonary exercise testing to quantify right ventricular (RV) remodeling, dysfunction, and exercise capacity. The relation of these to fRV dyssynchrony was retrospectively investigated. Right ventricular mechanical dyssynchrony was defined by early fRV septal activation (right-sided septal flash), RV lateral wall prestretch/late contraction, postsystolic shortening, and intra-RV delay using two-dimensional strain echocardiography. The SD of time to peak shortening among the fRV segments was calculated as a parameter of mechanical dispersion. RESULTS Thirty-five EA patients (10 of whom were <18 years of age) and 35 age-matched controls were studied. Ebstein anomaly patients had worse RV function and increased intra-RV dyssynchrony versus controls. Nineteen of 35 (54%) EA patients had early septal activation with simultaneous stretch and consequent late activation and postsystolic shortening of RV lateral segments. Intra-fRV mechanical delay correlated with fRV end-diastolic volume index (r = 0.43, P < .05) and fRV end-systolic volume index (r = 0.63, P < .001). The fRV ejection fraction was lower in EA with versus without right-sided septal flash (44.9 ± 11.0 vs 54.2 ± 8.2, P = .012). The fRV mechanical dispersion correlated with the percentage of predicted peak VO2 (r = -0.35, P < .05). CONCLUSIONS In EA, fRV mechanical dyssynchrony is associated with fRV remodeling, dysfunction, and impaired exercise capacity. Mechanical dyssynchrony as a therapeutic target in selected EA patients warrants further study.
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Affiliation(s)
- Yohei Akazawa
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tao Fujioka
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kana Yazaki
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Andreas Kühn
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany
| | - Wei Hui
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Slorach
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christoph Roehlig
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany
| | - Luc Mertens
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bart H Bijnens
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; ICREA, Passeig de Lluís Companys, Barcelona, Spain
| | - Manfred Vogt
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universituät München, München, Germany; Kinderherz-Praxis München, München, Germany
| | - Mark K Friedberg
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada.
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Engstrom N, Dobson GP, Ng K, Lander K, Win K, Gupta A, Letson HL. Validation of CalECG software for primary prevention heart failure patients: Reducing inter-observer measurement variability. J Electrocardiol 2022; 74:128-133. [PMID: 36191576 DOI: 10.1016/j.jelectrocard.2022.09.011] [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: 06/26/2022] [Revised: 08/09/2022] [Accepted: 09/19/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In primary prevention heart failure patients the 12‑lead electrocardiogram (ECG) may be useful for the prediction of ventricular arrhythmias. However, inter-observer measurement variability first needs to be identified and any software used, validated. OBJECTIVE To compare manual ECG measures with CalECG software and to assess the reliability of visual recognition of fragmented QRS (fQRS) by advanced cardiology trainees. METHODS 30 pre-implant ECGs were assessed on patients who met guidelines for primary prevention Implantable Cardiac Defibrillator. Parameters included RR, PR, QT, QRS duration, axis location, fQRS and T wave peak to T wave end (TpTe). ECGs were analyzed by members of the cardiology department with different levels of experience, and compared to CalECG software. Interobserver agreement was assessed using Fleiss' Kappa (κ) and intraclass correlation coefficients (ICC). Pearson correlation coefficient (r) was used to compare human and software measures. RESULTS Strong/very strong correlation was recorded across manual ECG measures (ICC = 0.749-0.979, p ≤ 0.0001) with moderate/strong correlation for TpTe (ICC = 0.547-0.765, p ≤ 0.001). Advanced cardiology trainees demonstrated substantial agreement on ECG interpretation (κ = 0.788, p ≤ 0.0001), however, reliability of fQRS assessment was only moderate for identification (κ = 0.5, p ≤ 0.0001) and fair for location (κ = 0.295, p = 0.001). CalECG software showed strong/very strong correlation with manual measurement for standard measures (r = 0.756-0.977, p ≤ 0.001). Concordance between human and software TpTe measurements varied between leads, with V5 showing a non-significant weak correlation (r = 0.197). CONCLUSION CalECG software showed strong/very strong correlation with standard manual measures which affirms its use in ECG analysis. Advanced cardiology trainees showed greater variability in the identification and location of fQRS.
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Affiliation(s)
- Nathan Engstrom
- College of Medicine & Dentistry, Heart and Trauma Research Laboratory, James Cook University, 1 James Cook Drive, Townsville, QLD 4811, Australia; Cardiac Investigations, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia.
| | - Geoffrey P Dobson
- College of Medicine & Dentistry, Heart and Trauma Research Laboratory, James Cook University, 1 James Cook Drive, Townsville, QLD 4811, Australia.
| | - Kevin Ng
- Cardiology Clinic, Cairns Hospital, 165 Esplanade, Cairns, QLD 4870, Australia.
| | - Krystle Lander
- Cardiology Department, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia.
| | - Kyi Win
- Cardiology Department, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia.
| | - Anudeep Gupta
- Cardiology Department, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia.
| | - Hayley L Letson
- College of Medicine & Dentistry, Heart and Trauma Research Laboratory, James Cook University, 1 James Cook Drive, Townsville, QLD 4811, Australia.
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Saoussen A, Sana O, Kaouther H, Hela M, Fatma O. Electocardiographic features in Ebstein's disease. LA TUNISIE MEDICALE 2021; 99:614-622. [PMID: 35244913 PMCID: PMC8795996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Ebstein's disease (ED) is a rare and heterogeneous congenital heart disease affecting the tricuspid valve and the right ventricle. Few studies have analyzed the electrocardiographic features of this disease. AIM To describe the electrocardiographic features observed in Ebstein's disease. METHODS We conducted a retrospective descriptive study that enrolled 26 patients followed for ED. RESULTS The mean age of discovery of the ME was 103.5±99 months [0-31 years]. The diagnosis of ME is most often made between 5 and 10 years. We noted right atrial hypertrophy in 11 patients (42%), right ventricular hypertrophy in half of the patients. Right axial deviation was noted in 11 patients (42%). Eight patients (30%) had wide QRS≥ 120 ms. Seven of these 8 patients (27%) had a fragmented QRS appearance. A right bandle block was noted in 22 patients (84%), it was a complete block in 7 cases (27%). A preexcitation was found in 6 patients (23%). The localization of accessory pathway was right postero-septal in all cases. Rhythmic disorders were noted in 9 patients (34%). It was a junctional tachycardia in 3 patients (11%), atrial flutter in 4 patients (15%) and atrial fibrillation in 2 patients (7%). A second degree atriventricular block was observed in one patient, it was Mobitz I type. Two cases of postoperative rhythm disturbances were recorded: paroxysmal atrial fibrillation and junctional tachycardia related to Wolf Parkinson White (WPW) syndrome. CONCLUSION Surface ECG in the ED is often pathological with prevalence of rhythm disturbances related to WPW syndrome.
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Waldmann V, Combes N, Ladouceur M, Celermajer DS, Iserin L, Gatzoulis MA, Khairy P, Marijon E. Understanding Electrocardiography in Adult Patients With Congenital Heart Disease. JAMA Cardiol 2020; 5:1435-1444. [DOI: 10.1001/jamacardio.2020.3416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Victor Waldmann
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | - Nicolas Combes
- Pasteur Clinic, Toulouse, France
- Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
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Right Ventricular Diastolic Function and Right Atrial Function and Their Relation With Exercise Capacity in Ebstein Anomaly. Can J Cardiol 2019; 35:1824-1833. [DOI: 10.1016/j.cjca.2019.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/24/2019] [Accepted: 05/31/2019] [Indexed: 11/17/2022] Open
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El-Boraey A, El-Damaty A, El-Deeb H, Eshra M, Kharabish A, Farouk H, Sorour K. Relation between fragmented QRS complex to the right ventricular volumes and fraction of pulmonary regurgitation in patients with repaired tetralogy of Fallot. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pornprasertchai V, Vijarnsorn C, Kanjanauthai S, Chungsomprasong P, Chanthong P, Durongpisitkul K, Soongswang J. Contemporary outcomes and mortality risks of Ebstein anomaly: A single-center experience in Thailand. CONGENIT HEART DIS 2019; 14:619-627. [PMID: 30791188 DOI: 10.1111/chd.12759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/16/2018] [Accepted: 01/27/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The increasing number of patients with Ebstein anomaly (EA) surviving into adulthood implies improvements in the treatments for the complex lesion. We revisited the clinical outcomes of patients with EA to demonstrate their "real world" survival. OBJECTIVES To identify the survival and predictors of mortality in patients with EA who underwent medical or surgical management in the present era. METHODS All patients who had EA with atrioventricular concordance between 1994 and 2016 were retrospectively reviewed. Baseline characteristics, initial echocardiographic findings, treatments, and outcomes were explored. The survival analysis was performed at the end of 2017. A multivariate analysis was used to assess mortality risks. RESULTS A total of 153 patients (25.4 ± 20.4 years, 60% female) were analyzed. Of these, 89 patients had been diagnosed with EA in childhood. During the follow-up [median time of 5.2 years (3 days-23.5 years)], 32 patients (20.9%) died due to major cardiac adverse events. The overall survival at 1, 5, and 10 years were 89%, 82.2%, and 79%, respectively. Of the total 153 patients, 64 patients underwent at least one surgical intervention [median age of 17 years (1 day-64.4 years)]. The survival at 1, 5, and 10 years were 87.5%, 82.4%, and 77.7%, respectively, in patients with EA surgery. This survival is comparable to the survival of 89 nonoperated patients with EA: 89.9%, 87.5%, and 81.8%, at 1, 5, and 10 years, respectively. The significant predictors of mortality were: age at diagnosis ≤2 years, tricuspid valve (TV) z-score >3.80, TV displacement >19.5 mm/m2 , presence of severe tricuspid regurgitation, and absence of forward flow across the pulmonic valve at the initial diagnosis. CONCLUSION Patients with EA had a moderately good survival in this era. In this paper, we report five simple predictors of death in this patient population.
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Affiliation(s)
- Varisara Pornprasertchai
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chodchanok Vijarnsorn
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supaluck Kanjanauthai
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Paweena Chungsomprasong
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prakul Chanthong
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kritvikrom Durongpisitkul
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jarupim Soongswang
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lai L, Jiang R, Fang W, Yan C, Tang Y, Hua W, Fu M, Li X, Luo R. Prognostic impact of right bundle branch block in hospitalized patients with idiopathic dilated cardiomyopathy: a single-center cohort study. J Int Med Res 2018; 48:300060518801478. [PMID: 30318986 PMCID: PMC7287200 DOI: 10.1177/0300060518801478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Idiopathic dilated cardiomyopathy (IDCM) is a primary myocardial disease resulting in symptoms of heart failure. Right bundle branch block (RBBB) is associated with increased cardiovascular risk and all-cause mortality. Therefore, the present study was performed to identify the prognostic impact of RBBB in patients with IDCM. Methods In total, 165 hospitalized patients with IDCM were evaluated. Receiver operating characteristic curve analysis was used to determine the cutoff point, and Cox regression was used to assess risk factors. Results After a median follow-up of 73.1 months (interquartile range, 36.1–88.7 months), 59 (35.8%) patients had died. All-cause mortality was significantly higher in patients with than without RBBB (log-rank χ2 = 9.400), P<0.05. Significant independent predictors of all-cause mortality in patients with IDCM were RBBB (hazard ratio, 2.898; 95% confidence interval, 1.201–6.995) and the left ventricular end-diastolic dimension (LVEDD) (hazard ratio, 1.034; 95% confidence interval, 1.004–1.066) at admission. Patients with RBBB and an LVEDD of ≥63 mm had the highest mortality (log-rank χ2 = 14.854), P<0.05. Conclusion RBBB was an independent predictor of all-cause mortality, and the combination of RBBB and LVEDD provided more clinically relevant information than RBBB alone for assessing the risk of all-cause mortality in patients with IDCM.
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Affiliation(s)
- Li Lai
- Department of Radiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan, People's Republic of China
| | - Rong Jiang
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Hospital of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Wei Fang
- Medical School of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Chao Yan
- Medical School of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Yibin Tang
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Hospital of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Wei Hua
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute and Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Michael Fu
- Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Xiaoping Li
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Hospital of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China.,Medical School of the University of Electronic Science and Technology of China, Chengdu, People's Republic of China.,Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute and Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Rong Luo
- Institute of Cardiovascular Disease, Chengdu Medical College, People's Republic of China
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Prota C, Di Salvo G, Sabatino J, Josen M, Paredes J, Sirico D, Pernia MU, Hoschtitzky A, Michielon G, Citro R, Fraisse A, Ghez O. Prognostic value of echocardiographic parameters in pediatric patients with Ebstein's anomaly. Int J Cardiol 2018; 278:76-83. [PMID: 30686335 DOI: 10.1016/j.ijcard.2018.10.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/12/2018] [Accepted: 10/12/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Accurate risk stratification of patients with Ebstein's anomaly (EA) is crucial. Aim of the study was to assess the prognostic value of echocardiography, including 2D speckle tracking (STE) derived myocardial deformation indices, for predicting outcome in pediatric and young adult unrepaired EA patients. METHODS Fifty consecutive EA patients (1 day-18 years, 52% males) underwent echocardiography and were followed for a mean follow-up of 60 ± 41 months for clinical outcome (ventricular tachyarrhythmia, heart failure, need for surgery and/or death). Clinical and instrumental features of EA patients with stable disease were compared with those of EA patients with progressive disease. RESULTS Twenty-four (48%) EA patients had progressive disease. A more severe grade of tricuspid valve (TV) displacement [59.7 mm/m2 (IQR 27.5-83) vs 28.4 mm/m2 (IQR 17.5-47); p = 0.002], a lower functional right ventricle (RV) fractional area change (FAC) (29.2 ± 7.7% vs 36.7 ± 9.6%; p = 0.004), a higher Celermajer index [0.8 (IQR 0.7-0.98) vs 0.55 (IQR 0.4-0.7); p = 0.000], a lower functional RV-longitudinal strain (-10.2 ± 6.2% vs -16.2 ± 7.3%; p = 0.003) and a lower right atrium peak systolic strain (RA-PALS) (25.2 ± 13.5% vs 36.3 ± 12.5%; p = 0.004) were detected in progressive disease group compared to stable one, respectively. Functional RV-FAC and RA-PALS were independent predictors of progressive disease at multivariate analysis. CONCLUSION Our study demonstrated for the first time the prognostic role of RV-FAC and RA-PALS in a long-term follow-up of EA young patients. A complete echocardiographic evaluation should be regular part in the evaluation and risk-stratification of EA children.
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Affiliation(s)
- Costantina Prota
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom; Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Giovanni Di Salvo
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom.
| | - Jolanda Sabatino
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Manjit Josen
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Josefa Paredes
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Domenico Sirico
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Marisol Uy Pernia
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | | | - Guido Michielon
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Rodolfo Citro
- Heart Department, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Alain Fraisse
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Olivier Ghez
- Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
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Walsh EP. Ebstein’s Anomaly of the Tricuspid Valve. JACC Clin Electrophysiol 2018; 4:1271-1288. [DOI: 10.1016/j.jacep.2018.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 05/31/2018] [Indexed: 01/29/2023]
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12
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Steinmetz M, Usenbenz S, Kowallick JT, Hösch O, Staab W, Lange T, Kutty S, Lotz J, Hasenfuß G, Paul T, Schuster A. Left ventricular synchrony, torsion, and recoil mechanics in Ebstein's anomaly: insights from cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2017; 19:101. [PMID: 29237468 PMCID: PMC5729283 DOI: 10.1186/s12968-017-0414-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 11/23/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Disease progression and heart failure development in Ebstein's Anomaly (EA) of the tricuspid valve is characterized by both right and left ventricular (LV) deterioration. The mechanisms underlying LV dysfunction and their role in heart failure development are incompletely understood. We hypothesized that LV dyssynchrony and impaired torsion and recoil mechanics induced by paradoxical movement of the basal septum may play a role in heart failure development. METHODS 31 EA patients and 31 matched controls underwent prospective cardiovascular magnetic resonance (CMR). CMR feature tracking (CMR-FT) was performed on apical, midventricular and basal short-axis and 4D-volume analysis was performed using three long-axis views and a short axis cine stack employing dedicated software. Circumferential uniformity ratio estimates (CURE) time-to-peak-based circumferential systolic dyssynchrony index (C-SDI), 4D volume analysis derived SDI (4D-SDI), torsion (Tor) and systolic (sysTR) and diastolic torsion rate (diasTR) were calculated for the LV. QRS duration, brain natriuretic peptide, NYHA and Total R/L-Volume Index (R/L Index) were obtained. RESULTS EA patients (31.5 years; controls 31.4 years) had significantly longer QRS duration (123.35 ms ± 26.36 vs. 97.33 ms ± 11.89 p < 0.01) and showed more LV dyssynchrony (4D-SDI 7.60% ± 4.58 vs. 2.54% ± 0.62, p < 0.001; CURE 0.77 ± 0.05 vs. 0.86 ± 0.03, p < 0.001; C-SDI 7.70 ± 3.38 vs. 3.80 ± 0.91, p = 0.001). There were significant associations of LV dyssynchrony with heart failure parameters and QRS duration. Although torsion and recoil mechanics did not differ significantly (p > 0.05) there was an association of torsion and recoil mechanics with dyssynchrony parameters CURE (sysTR r = -0.426; p = 0.017, diasTR r = 0.419; p = 0.019), 4D-SDI (sysTR r = 0.383; p = 0.044) and C-SDI (diasTR r = -0.364; p = 0.044). CONCLUSIONS EA is characterized by LV intra-ventricular dyssynchrony, which is associated with heart failure and disease severity parameters. Markers of dyssynchrony can easily be quantified from CMR-FT, and may have a role in the assessment of altered cardiac function, carrying potential management implications for EA patients.
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Affiliation(s)
- Michael Steinmetz
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Simon Usenbenz
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Johannes Tammo Kowallick
- Institute for Diagostic and Interventional Radiology, Georg-August-University Göttingen, University Medical Center, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Olga Hösch
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Göttingen, Germany
| | - Wieland Staab
- Institute for Diagostic and Interventional Radiology, Georg-August-University Göttingen, University Medical Center, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Torben Lange
- Department of Cardiology and Pneumology, Georg-August-University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Götttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Shelby Kutty
- University of Nebraska Medical Center/ Children’s Hospital and Medical Center, Omaha, NE USA
| | - Joachim Lotz
- Institute for Diagostic and Interventional Radiology, Georg-August-University Göttingen, University Medical Center, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Gerd Hasenfuß
- Department of Cardiology and Pneumology, Georg-August-University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Götttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg-August University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Andreas Schuster
- Department of Cardiology and Pneumology, Georg-August-University Göttingen, University Medical Center, Robert-Koch-Str. 40, D-37099 Götttingen, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
- Department of Cardiology, Royal North Shore Hospital, The Kolling Institute, Nothern Clinical School, University of Sydney, Sydney, Australia
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13
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Vandenberk B, Robyns T, Goovaerts G, Claeys M, Helsen F, Van Soest S, Garweg C, Ector J, Van Huffel S, Willems R. Inter- and intra-observer variability of visual fragmented QRS scoring in ischemic and non-ischemic cardiomyopathy. J Electrocardiol 2017; 51:549-554. [PMID: 29275955 DOI: 10.1016/j.jelectrocard.2017.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Fragmented QRS (fQRS) on a 12-lead ECG has been linked with adverse outcome. However, the visual scoring of ECGs is prone to inter- and intra-observer variability. METHODS Five observers, two experienced and three novel, assessed fQRS in 712 digital ECGs, 100 were re-evaluated to assess intra-observer variability. Fleiss and Cohen's Kappa were calculated and compared between subgroups. RESULTS The inter-observer variability for assessing fQRS in all leads combined was substantial with a Kappa of 0.651. Experienced observers only had a better agreement with a Kappa of 0.823. Intra-observer variability ranged from 0.736 to 0.880. In the subgroup with ventricular pacing the inter-observer variability was even significantly larger when compared to ECGs with normal QRS duration (Kappa 0.493 vs 0.664, p<0.001). CONCLUSION The visual assessment of QRS fragmentation is prone to inter- and intra-observer variability, mainly influenced by the experience of the observers, the underlying rhythm and QRS morphology.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Tomas Robyns
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Griet Goovaerts
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium; Imec, Leuven, Belgium
| | - Mathias Claeys
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Frederik Helsen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Sofie Van Soest
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Garweg
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joris Ector
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Sabine Van Huffel
- Department of Electrical Engineering (ESAT), STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, KU Leuven, Leuven, Belgium; Imec, Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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14
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Benítez Ramos DB, Cabrera Ortega M, Castro Hevia J, Dorantes Sánchez M, Alemán Fernández AA, Castañeda Chirino O, Cruz Cardentey M, Martínez López F, Falcón Rodríguez R. Electrocardiographic Markers of Appropriate Implantable Cardioverter-Defibrillator Therapy in Young People with Congenital Heart Diseases. Pediatr Cardiol 2017; 38:1663-1671. [PMID: 28871362 DOI: 10.1007/s00246-017-1711-9] [Citation(s) in RCA: 2] [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: 03/22/2017] [Accepted: 08/09/2017] [Indexed: 11/24/2022]
Abstract
Implantable cardioverter-defibrillators (ICDs) are increasingly utilized in patients with congenital heart disease (CHD). Prediction of the occurrence of shocks is important if improved patient selection is desired. The electrocardiogram (ECG) has been the first-line tool predicting the risk of sudden death, but data in CHD patients are lacking. We aim to evaluate the predictive value of electrocardiographic markers of appropriate therapy of ICD in young people with CHD. We conducted a prospective, longitudinal study, in twenty-six CHD patients (mean age 24.7 ± 5.3 years) who underwent first ICD implantation. Forty-two age- and diagnosis-matched controls were recruited. Twelve-lead ECG and 24 h Holter analysis were performed during a mean follow-up of 38.9 months. Data included heart rate, heart rate variability, QRS duration (QRSd), QTc interval and its dispersion, Tpeak-Tend (Tp-Te) interval and its dispersion, presence of fragmented QRS (fQRS), T wave alternans, atrial arrhythmias, and non-sustained ventricular tachycardia. Implant indication was primary prevention in ten cases (38.5%) and secondary prevention in 16 (61.5%). Overall, 17 subjects (65.3%) received at least one appropriate and effective ICD discharge. fQRS was present in 64.7% of cases with ICD therapy compared with patients without events or controls (p < 0.0001). Tp-e and Tp-e dispersion were significantly prolonged in patients with recurrences (113.5 and 37.2 ms) versus patients without ICD discharge (89.6 and 24.1 ms) or controls (72.4 and 19.3 ms) (p < 0.0001 and p < 0.0001, respectively). On univariate Cox regression analysis QRSd (hazard ratio: 1.19 per ms, p = 0.003), QTc dispersion (hazard ratio: 1.57 per ms, p = 0.002), fQRS (hazard ratio: 3.58 p < 0.0001), Tp-e (hazard ratio: 2.27 per ms, p < 0.0001), and Tp-e dispersion (hazard ratio: 4.15 per ms, p < 0.0001), emerged as strong predictors of outcome. On multivariate Cox analysis fQRS, Tp-e and Tp-e dispersion remained in the model. The presence of fQRS, and both Tp-e and Tp-e dispersion are useful ECG tools in daily clinical practice to identify CHD patients at risk for appropriate ICD therapy.
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MESH Headings
- Adult
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/mortality
- Biomarkers
- Cohort Studies
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable/adverse effects
- Electrocardiography/methods
- Female
- Follow-Up Studies
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/mortality
- Heart Defects, Congenital/therapy
- Humans
- Longitudinal Studies
- Male
- Predictive Value of Tests
- Proportional Hazards Models
- Prospective Studies
- Risk Factors
- Survival Analysis
- Young Adult
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Affiliation(s)
- Dunia Bárbara Benítez Ramos
- Department of Pediatric Cardiology, Cardiocentro Pediátrico William Soler, San Francisco e/100 y Perla, Altahabana, Boyeros, Havana, 10800, Cuba.
| | - Michel Cabrera Ortega
- Section of Arrhythmia and Cardiac Pacing, Cardiocentro Pediátrico William Soler, 100 y Perla, Altahabana, Boyeros, Havana, Cuba
| | - Jesús Castro Hevia
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Margarita Dorantes Sánchez
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Ailema Amelia Alemán Fernández
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Osmin Castañeda Chirino
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Marlenis Cruz Cardentey
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Frank Martínez López
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
| | - Roylan Falcón Rodríguez
- Service of Arrhythmia and Cardiac Pacing, Instituto de Cardiología y Cirugía Cardiovascular, 17 y Paseo, Plaza de la Revolución, Vedado, Havana, Cuba
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15
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Kwok SY, Yeung SSS, Li VWY, Cheung YF. Ventricular mechanics after repair of subarterial and perimembranous VSDs. Eur J Clin Invest 2017; 47. [PMID: 29082523 DOI: 10.1111/eci.12852] [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: 08/03/2017] [Accepted: 10/25/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Emerging data suggest impaired biventricular function in adults late after repair of ventricular septal defect (VSD). We assessed and compared right (RV) and left ventricular (LV) mechanics in adolescents and adults after surgical closure of doubly committed subarterial and perimembranous VSDs. METHODS A total of 75 subjects were studied: 29 patients after subarterial VSD repair (group I), 17 patients after perimembranous VSD repair (group II) and 29 age-matched controls (group III). RV and LV mechanics were assessed using tissue Doppler and speckle-tracking echocardiography, while RV outflow systolic function was quantified by systolic excursion and fractional shortening (FS). RESULTS Compared with group III, groups I and II had significantly reduced tricuspid annular systolic and diastolic velocities, isovolumic myocardial acceleration, RV global longitudinal systolic and diastolic deformation parameters and RV outflow systolic excursion (all P < .05). Group I, but not II, had reduced RV outflow FS (P = .008) and the lowest global LV longitudinal systolic strain (P = .008) and systolic strain rate (P = .014). In group I, postoperative aortic regurgitation was associated with lower LV longitudinal systolic strain (P = .009) and early diastolic strain rate (P = .002), while right bundle branch block was associated with lower RV systolic strain rate (P = .048). As a group, RV outflow excursion (P < .001) and FS (P = .001) were correlated with LV global systolic strain. CONCLUSION Adolescents and adults late after repair of subarterial and perimembranous VSDs show impairment of RV systolic and diastolic myocardial deformation. The RV outflow function and LV systolic deformation appear to be worse after repair of subarterial defects.
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Affiliation(s)
- Sit-Yee Kwok
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Susanna So-Shan Yeung
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Vivian Wing-Yi Li
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Yiu-Fai Cheung
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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16
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Gonzalez-Melchor L, Nava S, Iturralde P, Marquez MF. The relevance of looking for right bundle branch block in catheter ablation of Ebstein's anomaly. J Electrocardiol 2017; 50:894-897. [DOI: 10.1016/j.jelectrocard.2017.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Indexed: 11/30/2022]
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17
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Perdreau E, Tsang V, Hughes ML, Ibrahim M, Kataria S, Janagarajan K, Iriart X, Khambadkone S, Marek J. Change in biventricular function after cone reconstruction of Ebstein’s anomaly: an echocardiographic study. Eur Heart J Cardiovasc Imaging 2017; 19:808-815. [DOI: 10.1093/ehjci/jex186] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/23/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- E Perdreau
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
- Hôpital du Haut-Lévèque, Bordeaux, France
| | - V Tsang
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
- The Bart’s Hospital, London, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - M L Hughes
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | | | - S Kataria
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - K Janagarajan
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - X Iriart
- Hôpital du Haut-Lévèque, Bordeaux, France
| | - S Khambadkone
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - J Marek
- Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
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18
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Rydman R, Shiina Y, Diller GP, Niwa K, Li W, Uemura H, Uebing A, Barbero U, Bouzas B, Ernst S, Wong T, Pennell DJ, Gatzoulis MA, Babu-Narayan SV. Major adverse events and atrial tachycardia in Ebstein's anomaly predicted by cardiovascular magnetic resonance. Heart 2017; 104:37-44. [PMID: 28684436 PMCID: PMC5749347 DOI: 10.1136/heartjnl-2017-311274] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives Patients with Ebstein’s anomaly of the tricuspid valve (EA) are at risk of tachyarrhythmia, congestive heart failure and sudden cardiac death. We sought to determine the value of cardiovascular magnetic resonance (CMR) for predicting these outcomes. Methods Seventy-nine consecutive adult patients (aged 37±15 years) with unrepaired EA underwent CMR and were followed prospectively for a median 3.4 (range 0.4–10.9) years for clinical outcomes, namely major adverse cardiovascular events (MACEs: sustained ventricular tachycardia/heart failure hospital admission/cardiac transplantation/death) and first-onset atrial tachyarrhythmia (AT). Results CMR-derived variables associated with MACE (n=6) were right ventricular (RV) or left ventricular (LV) ejection fraction (EF) (HR 2.06, 95% CI 1.168 to 3.623, p=0.012 and HR 2.35, 95% CI 1.348 to 4.082, p=0.003, respectively), LV stroke volume index (HR 2.82, 95% CI 1.212 to 7.092, p=0.028) and cardiac index (HR 1.71, 95% CI 1.002 to 1.366, p=0.037); all remained significant when tested solely for mortality. History of AT (HR 11.16, 95% CI 1.30 to 95.81, p=0.028) and New York Heart Association class >2 (HR 7.66, 95% CI 1.54 to 38.20, p=0.013) were also associated with MACE; AT preceded all but one MACE, suggesting its potential role as an early marker of adverse outcome (p=0.011). CMR variables associated with first-onset AT (n=17; 21.5%) included RVEF (HR 1.55, 95% CI 1.103 to 2.160, p=0.011), total R/L volume index (HR 1.18, 95% CI 1.06 to 1.32, p=0.002), RV/LV end diastolic volume ratio (HR 1.55, 95% CI 1.14 to 2.10, p=0.005) and apical septal leaflet displacement/total LV septal length (HR 1.03, 95% CI 1.00 to 1.07, p=0.041); the latter two combined enhanced risk prediction (HR 6.12, 95% CI 1.67 to 22.56, p=0.007). Conclusion CMR-derived indices carry prognostic information regarding MACE and first-onset AT among adults with unrepaired EA. CMR may be included in the periodic surveillance of these patients.
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Affiliation(s)
- Riikka Rydman
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Department of Molecular Medicine and Surgery, Section of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Yumi Shiina
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Cardiovascular Centre, St. Luke's International Hospital, Tokyo, Japan
| | - Gerhard-Paul Diller
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England.,Department of Cardiovascular Medicine, Division of Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Koichiro Niwa
- Cardiovascular Centre, St. Luke's International Hospital, Tokyo, Japan
| | - Wei Li
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Hideki Uemura
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Anselm Uebing
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Umberto Barbero
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Beatriz Bouzas
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Sabine Ernst
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Tom Wong
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England
| | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Michael A Gatzoulis
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
| | - Sonya V Babu-Narayan
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, England.,National Heart and Lung Institute, Imperial College, London, England
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19
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Abstract
Ebstein anomaly is a rare form of congenital heart disease with a uniquely high prevalence of arrhythmias. The most prevalent arrhythmia mechanisms are intrinsic to the underlying embryologic defects and may manifest at any stage. Current electrophysiological and surgical strategies are well equipped to address these arrhythmia mechanisms, yet despite available technology and a robust understanding of the mechanisms, these cases remain challenging. Surgical techniques that render arrhythmia substrates unreachable mandate comprehensive presurgical electrophysiological assessment and potential ablation. As the population ages, the need to address atrial fibrillation management and risk stratification for sudden cardiac death becomes ever more pertinent.
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Affiliation(s)
- Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC 20010, USA
| | - Dominic J Abrams
- Division of Cardiac Electrophysiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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20
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Acharya P, Ang JR, Gitler B. Ebstein Anomaly With QRS Fragmentation on Electrocardiogram. J Investig Med High Impact Case Rep 2017; 5:2324709616688710. [PMID: 28203575 PMCID: PMC5298433 DOI: 10.1177/2324709616688710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/29/2016] [Accepted: 12/05/2016] [Indexed: 11/16/2022] Open
Abstract
Ebstein anomaly is a rare congenital disorder that involves the tricuspid valve and the right ventricle. It is associated with interatrial communication, which allows for paradoxical embolization causing unilateral blindness. Abnormal conduction through the atrialized right ventricle leads to QRS fragmentation on electrocardiogram. Its presence suggests a more severe abnormality and a higher risk of arrhythmia. The QRS fragmentation disappears after corrective surgery with resection of the atrialized right ventricle.
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21
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Devarapally SR, Arora S, Ahmad A, Sood M, El Sergany A, Sacchi T, Saul B, Gaglani R, Heitner J. Right ventricular failure predicted from right bundle branch block: cardiac magnetic resonance imaging validation. Cardiovasc Diagn Ther 2016; 6:432-438. [PMID: 27747166 DOI: 10.21037/cdt.2016.04.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Right ventricular (RV) failure has proven to be independently associated with adverse outcomes. Electrocardiographic parameters assessing RV function are largely unknown, making echocardiography the first line for RV function assessment. It is however, limited by geometrical assumptions and is inferior to cardiac magnetic resonance imaging (CMRI) which is widely regarded as the most accurate tool for assessing RV function. METHODS We seek to determine the correlation of ECG parameters of right bundle branch block (RBBB) with RV ejection fraction (EF) and RV dimensions using the CMRI. QRS duration, R amplitude and R' duration were obtained from precordial lead V1; S duration and amplitude were obtained from lead I and AVL. RV systolic dysfunction was defined as RV EF <40%. RV systolic dysfunction group (mean EF of 24±10%) were compared with normal RV systolic function group which acted as control (mean EF of 48±8%). CMRI and ECG parameters were compared between the two groups. Rank correlations and scatter diagrams between individual CMRI parameters and ECG parameters were done using medcalc for windows, version 12.5. Sensitivity, specificity and area under the curve (AUC) were calculated. RESULTS RV systolic dysfunction group was found to have larger RV end systolic volumes (90±42 vs. 59±40 mL, P=0.02). ECG evaluation of RV dysfunction group revealed longer R' duration (103±22 vs. 84±18 msec, P=0.005) as compared to the control group. The specificity of R' duration >100 msec to detect RV systolic dysfunction was found to be 93%. R' duration was found to have an inverse correlation with RV EF (r=-0.49, P=0.007). CONCLUSIONS Larger RV end systolic volumes seen with RV dysfunction can affect the latter part of right bundle branch leading to prolonged R' duration. We here found prolonged R' duration in lead V1 to have a highly specific inverse correlation to RV systolic function. ECG can be used as an inexpensive tool for RV function assessment and should be used alongside echocardiography to evaluate RV dysfunction when CMRI is not available.
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Affiliation(s)
| | - Sameer Arora
- University of North Carolina at Chapel Hill, NC, USA
| | - Ali Ahmad
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
| | - Mike Sood
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
| | | | - Terrence Sacchi
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
| | - Barry Saul
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
| | - Rahul Gaglani
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
| | - John Heitner
- Department of Cardiology, Methodist Hospital, Brooklyn, NY, USA
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22
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Cano Ó, Andrés A, Alonso P, Osca J, Sancho-Tello MJ, Rueda J, Osa A, Martínez-Dolz L. Essential ECG clues in patients with congenital heart disease and arrhythmias. J Electrocardiol 2016; 50:243-250. [PMID: 27600095 DOI: 10.1016/j.jelectrocard.2016.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Indexed: 11/17/2022]
Abstract
The prevalence of adults with congenital heart disease has dramatically increased during the last decades due to significant advances in the surgical correction of these conditions. As a result, patient's survival has been prolonged and arrhythmias have become one of the principal causes of morbidity and mortality for these patients. The surface 12-lead ECG may play a critical role in the identification of the underlying heart disease of the patient, the recognition of the arrhythmia mechanism and may also help in the planification of the ablation procedure in this setting. Finally, important prognostic information can be also obtained from the ECG in these patients. The present review will offer an overview of the principal utilities of the surface ECG in the diagnosis and management of patients with CHD and arrhythmias.
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Affiliation(s)
- Óscar Cano
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - Ana Andrés
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pau Alonso
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Joaquín Osca
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - María-José Sancho-Tello
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Joaquín Rueda
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Osa
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Martínez-Dolz
- Electrophysiology Section and Adult Congenital Heart Disease Unit, Cardiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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23
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Galea J, Ellul S, Schembri A, Schembri-Wismayer P, Calleja-Agius J. Ebstein anomaly: a review. Neonatal Netw 2016; 33:268-74. [PMID: 25161135 DOI: 10.1891/0730-0832.33.5.268] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiac congenital abnormalities are a leading cause in neonatal mortality occurring in up to 1 in 200 of live births. Ebstein anomaly, also known as Kassamali anomaly, accounts for 1 percent of all congenital cardiac anomalies. This congenital abnormality involves malformation of the tricuspid valve and of the right ventricle. In this review, the causes of the anomaly are outlined and the pathophysiology is discussed, with a focus on the symptoms, management, and treatments available to date.
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24
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Kühn A, Meierhofer C, Rutz T, Rondak IC, Röhlig C, Schreiber C, Fratz S, Ewert P, Vogt M. Non-volumetric echocardiographic indices and qualitative assessment of right ventricular systolic function in Ebstein's anomaly: comparison with CMR-derived ejection fraction in 49 patients. Eur Heart J Cardiovasc Imaging 2015; 17:930-5. [DOI: 10.1093/ehjci/jev243] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 09/07/2015] [Indexed: 11/13/2022] Open
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25
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Alonso P, Andrés A, Rueda J, Buendía F, Igual B, Rodríguez M, Osa A, Arnau MA, Salvador A. Valor del electrocardiograma como predictor de disfunción ventricular derecha en pacientes con sobrecarga crónica de volumen del ventrículo derecho. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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26
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Hösch O, Ngyuen TT, Lauerer P, Schuster A, Kutty S, Staab W, Unterberg-Buchwald C, Sohns JM, Paul T, Lotz J, Steinmetz M. BNP and haematological parameters are markers of severity of Ebstein's anomaly: correlation with CMR and cardiopulmonary exercise testing. Eur Heart J Cardiovasc Imaging 2015; 16:670-5. [PMID: 25736309 DOI: 10.1093/ehjci/jeu312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/13/2014] [Indexed: 11/13/2022] Open
Abstract
AIMS Ebstein's anomaly (EA) involves a displaced and dysplastic tricuspid valve resulting in an atrialized portion of the right ventricle and an enlargement of the functional right ventricle and right atrium. Biomarkers targeting heart failure such as brain natriuretic peptide (BNP) or haematological parameters [haemoglobin (Hb) and haematocrit (Hct)] are upregulated in states of pulmonary hypoperfusion. We hypothesized that decreased pulmonary perfusion dependent on the stage of right heart failure is a possible mechanism in EA, and that it can be correlated with cardiac magnetic resonance (CMR) parameters. The aim of this study was to investigate the relationship between BNP and haematological parameters with functional parameters from CMR and exercise testing in patients with EA. METHODS AND RESULTS Twenty-five patients with non-corrected EA were studied prospectively (mean age 26 ± 14 years). BNP level was increased (74 ± 127 ng/L), and in 16% markedly above the heart failure cut-off level of 100 ng/L. Hb and Hct were increased above normal levels in 20 and 24% of patients, respectively. BNP and Hct/Hb correlated with CMR [total right/left (R/L)-Volume-Index, right atrium-end-diastolic volume index (EDVi), functional right ventricle (fRV)-EDVi, fRV-ejection fraction (EF), tricuspid regurgitation, pulmonary artery flow, and left ventricular EF] and exercise testing [workload/kg, oxygen uptake (VO2), ventilatory response to carbon dioxide production (VE/VCO2), oxygen (O2) pulse, and heart rate reserve]. The higher BNP and haematological parameters, the higher was the disease severity and the more limited was the physical exercise capacity. CONCLUSION In this EA cohort, BNP levels and haematological parameters correlated well with functional data from CMR and exercise testing. The total R/L-Volume-Index and BNP, and to some extent hematological parameters, may be useful as prognostic markers in patients with EA.
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Affiliation(s)
- Olga Hösch
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Heart Center, UMG, German Center for Cardiovascular Research, partner site Goettingen, DZHK, Robert-Koch-Str. 40, Göttingen 37075, Germany
| | - Thuy-Trang Ngyuen
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Heart Center, UMG, German Center for Cardiovascular Research, partner site Goettingen, DZHK, Robert-Koch-Str. 40, Göttingen 37075, Germany
| | - Peter Lauerer
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Heart Center, UMG, German Center for Cardiovascular Research, partner site Goettingen, DZHK, Robert-Koch-Str. 40, Göttingen 37075, Germany
| | - Andreas Schuster
- Department of Cardiology and Pneumology, University Medical Center, Georg-August-University Göttingen, Göttingen, Germany DZHK, German Center for Heart Research, partner site Göttingen, Göttingen, Germany
| | - Shelby Kutty
- University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, NE, USA
| | - Wieland Staab
- Institution for Diagnostic and Interventional Radiology, University Medical Center, Georg-August-University Göttingen, Heart Center, Göttingen, Germany
| | | | - Jan M Sohns
- DZHK, German Center for Heart Research, partner site Göttingen, Göttingen, Germany Institution for Diagnostic and Interventional Radiology, University Medical Center, Georg-August-University Göttingen, Heart Center, Göttingen, Germany
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Heart Center, UMG, German Center for Cardiovascular Research, partner site Goettingen, DZHK, Robert-Koch-Str. 40, Göttingen 37075, Germany DZHK, German Center for Heart Research, partner site Göttingen, Göttingen, Germany
| | - Joachim Lotz
- DZHK, German Center for Heart Research, partner site Göttingen, Göttingen, Germany Institution for Diagnostic and Interventional Radiology, University Medical Center, Georg-August-University Göttingen, Heart Center, Göttingen, Germany
| | - Michael Steinmetz
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center, Georg-August-University Göttingen, Heart Center, UMG, German Center for Cardiovascular Research, partner site Goettingen, DZHK, Robert-Koch-Str. 40, Göttingen 37075, Germany DZHK, German Center for Heart Research, partner site Göttingen, Göttingen, Germany
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27
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Alonso P, Andrés A, Rueda J, Buendía F, Igual B, Rodríguez M, Osa A, Arnau MA, Salvador A. Value of the Electrocardiogram as a Predictor of Right Ventricular Dysfunction in Patients With Chronic Right Ventricular Volume Overload. ACTA ACUST UNITED AC 2014; 68:390-7. [PMID: 25304084 DOI: 10.1016/j.rec.2014.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/09/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary regurgitation is a common complication in patients with repaired tetralogy of Fallot or congenital pulmonary stenosis. Electrocardiographic variables have been correlated with parameters used to evaluate right ventricular function. We aimed to analyze the diagnostic value of the width and fragmentation of the electrocardiogram in the identification of patients with right ventricular dysfunction and/or dilation. METHODS We selected 107 consecutive patients diagnosed with severe pulmonary insufficiency after repair of pulmonary stenosis or tetralogy of Fallot. The tests included electrocardiography, echocardiography, and magnetic resonance. Each electrocardiogram was analyzed manually to measure QRS duration. We defined QRS fragmentation as the presence of low-voltage waves in the terminal portion of the QRS complex in at least 2 contiguous leads. RESULTS We found a significant negative correlation between QRS width and right ventricular function, as well as a positive correlation with right ventricular volume. The receiver operating characteristic curve indicated a cut-off point for QRS width of 140ms, which showed good sensitivity for a diagnosis of right ventricular dilation (> 80%) and dysfunction (> 95%). In logistic regression models, a QRS duration > 140ms was found to be the only independent predictor of right ventricular dilation and dysfunction. CONCLUSIONS Electrocardiography is a rapid, widely available, and reproducible tool. QRS width constitutes an independent predictor of the presence of right ventricular dilation and dysfunction. This study is the first to provide a cutoff value for QRS width to screen for right ventricle involvement.
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Affiliation(s)
- Pau Alonso
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Ana Andrés
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Joaquín Rueda
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Francisco Buendía
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Begoña Igual
- ERESA, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - María Rodríguez
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Ana Osa
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Miguel A Arnau
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Antonio Salvador
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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28
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Arya P, Beroukhim R. Ebstein Anomaly: Assessment, Management, and Timing of Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:338. [DOI: 10.1007/s11936-014-0338-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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29
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Jain R, Singh R, Yamini S, Das MK. Fragmented ECG as a risk marker in cardiovascular diseases. Curr Cardiol Rev 2014; 10:277-86. [PMID: 24827794 PMCID: PMC4040879 DOI: 10.2174/1573403x10666140514103451] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 01/28/2014] [Indexed: 12/18/2022] Open
Abstract
Various noninvasive tests for risk stratification of sudden cardiac death (SCD) were studied, mostly in the context of structural heart disease such as coronary artery disease (CAD), cardiomyopathy and heart failure but have low positive predictive value for SCD. Fragmented QRS complexes (fQRS) on a 12-lead ECG is a marker of depolarization abnormality. fQRS include presence of various morphologies of the QRS wave with or without a Q wave and includes the presence of an additional R wave (R’) or notching in the nadir of the R’ (fragmentation) in two contiguous leads, corresponding to a major coronary artery territory. fQRS represents conduction delay from inhomogeneous activation of the ventricles due to myocardial scar. It has a high predictive value for myocardial scar and mortality in patients CAD. fQRS also predicts arrhythmic events and mortality in patients with implantable cardioverter defibrillator. It also signifies poor prognosis in patients with nonischemic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome. However, fQRS is a nonspecific finding and its diagnostic prognostic should only be interpreted in the presence of pertinent clinical evidence and type of myocardial involvement (structural vs. structurally normal heart).
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Affiliation(s)
| | | | | | - Mithilesh K Das
- Krannert Institute of Cardiology, Indiana University Health, 1800 North Capitol Avenue, Indianapolis, IN 46202, USA.
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30
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Hösch O, Sohns JM, Nguyen TT, Lauerer P, Rosenberg C, Kowallick JT, Kutty S, Unterberg C, Schuster A, Faßhauer M, Staab W, Paul T, Lotz J, Steinmetz M. The total right/left-volume index: a new and simplified cardiac magnetic resonance measure to evaluate the severity of Ebstein anomaly of the tricuspid valve: a comparison with heart failure markers from various modalities. Circ Cardiovasc Imaging 2014; 7:601-9. [PMID: 24807407 DOI: 10.1161/circimaging.113.001467] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The classification of clinical severity of Ebstein anomaly still remains a challenge. The aim of this study was to focus on the interaction of the pathologically altered right heart with the anatomically-supposedly-normal left heart and to derive from cardiac magnetic resonance (CMR) a simple imaging measure for the clinical severity of Ebstein anomaly. METHODS AND RESULTS Twenty-five patients at a mean age of 26±14 years with unrepaired Ebstein anomaly were examined in a prospective study. Disease severity was classified using CMR volumes and functional measurements in comparison with heart failure markers from clinical data, ECG, laboratory and cardiopulmonary exercise testing, and echocardiography. All examinations were completed within 24 hours. A total right/left-volume index was defined from end-diastolic volume measurements in CMR: total right/left-volume index=(RA+aRV+fRV)/(LA+LV). Mean total right/left-volume index was 2.6±1.7 (normal values: 1.1±0.1). This new total right/left-volume index correlated with almost all clinically used biomarkers of heart failure: brain natriuretic peptide (r=0.691; P=0.0003), QRS (r=0.432; P=0.039), peak oxygen consumption/kg (r=-0.479; P=0.024), ventilatory response to carbon dioxide production at anaerobic threshold (r=0.426; P=0.048), the severity of tricuspid regurgitation (r=0.692; P=0.009), tricuspid valve offset (r=0.583; P=0.004), and tricuspid annular plane systolic excursion (r=0.554; P=0.006). Previously described severity indices ([RA+aRV]/[fRV+LA+LV]) and fRV/LV end-diastolic volume corresponded only to some parameters. CONCLUSIONS In patients with Ebstein anomaly, the easily acquired index of right-sided to left-sided heart volumes from CMR correlated well with established heart failure markers. Our data suggest that the total right/left-volume index should be used as a new and simplified CMR measure, allowing more accurate assessment of disease severity than previously described scoring systems.
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Affiliation(s)
- Olga Hösch
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Jan Martin Sohns
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Thuy-Trang Nguyen
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Peter Lauerer
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Christina Rosenberg
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Johannes Tammo Kowallick
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Shelby Kutty
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Christina Unterberg
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Andreas Schuster
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Martin Faßhauer
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Wieland Staab
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Thomas Paul
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Joachim Lotz
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.)
| | - Michael Steinmetz
- From the Department of Pediatric Cardiology and Intensive Care Medicine (O.H., T.-T.N., P.L., T.P., M.S.), Institute for Diagnostic and Interventional Radiology (J.M.S., C.R., J.T.W., M.F., W.S., J.L.), and Department of Cardiology and Pneumology (C.U., A.S.), Georg-August University, Göttingen, Germany; German Centre for Cardiovascular Research, Germany (J.M.S., C.U., A.S., M.F., W.S., J.L., M.S.); and University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha (S.K.).
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31
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Park SJ, Chung S, On YK, Kim JS, Yang JH, Jun TG, Jang SY, Lee OJ, Song J, Kang IS, Huh J. Fragmented QRS complex in adult patients with Ebstein anomaly and its association with arrhythmic risk and the severity of the anomaly. Circ Arrhythm Electrophysiol 2013; 6:1148-55. [PMID: 24235269 DOI: 10.1161/circep.113.000636] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fragmented QRS complex (fQRS) on 12-lead ECG, a marker of myocardial scar, is a predictor of arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. We investigated whether the presence of fQRS is associated with the severity of the anomaly and with increased arrhythmic events in adult patients with Ebstein anomaly (EA). METHODS AND RESULTS In 51 consecutive adult patients with EA (median age, 37 years; 18 males), the severity index of EA calculated from echocardiographic data and clinical arrhythmic events were analyzed. The extent of fQRS in each patient was measured by counting the number of ECG leads showing fQRS. There were 35 (68.6%) patients with fQRS (fQRS group) and 16 (31.4%) patients without fQRS (non-fQRS group). fQRS was observed more frequently in the inferior (n=26) and precordial (n=25) leads versus the lateral leads (n=5). The patients in the fQRS group had a worse functional class, greater cardiothoracic ratios, more severe tricuspid regurgitation, larger atrialized right ventricular areas, higher EA severity scores, and more frequent arrhythmic events compared with those in the non-fQRS group. The atrialized right ventricular area showed a positive correlation with the fQRS extent (r=0.51; P<0.001). In multivariable Cox regression models, the presence of fQRS was independently associated with arrhythmic events (P=0.036). CONCLUSIONS Fragmented QRS on 12-lead ECG was associated with larger atrialized right ventricular area and an increased risk of arrhythmic events in adult patients with EA.
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Affiliation(s)
- Seung-Jung Park
- Departments of Medicine, Thoracic and Cardiovascular Surgery, and Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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