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Lynge TH, Albert CM, Basso C, Garcia R, Krahn AD, Semsarian C, Sheppard MN, Behr ER, Tfelt-Hansen J. Autopsy of all young sudden death cases is important to increase survival in family members left behind. Europace 2024; 26:euae128. [PMID: 38715537 PMCID: PMC11164113 DOI: 10.1093/europace/euae128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Sudden cardiac death (SCD) is an important public health problem worldwide, accounting for an estimated 6-20% of total mortality. A significant proportion of SCD is caused by inherited heart disease, especially among the young. An autopsy is crucial to establish a diagnosis of inherited heart disease, allowing for subsequent identification of family members who require cardiac evaluation. Autopsy of cases of unexplained sudden death in the young is recommended by both the European Society of Cardiology and the American Heart Association. Overall autopsy rates, however, have been declining in many countries across the globe, and there is a lack of skilled trained pathologists able to carry out full autopsies. Recent studies show that not all cases of sudden death in the young are autopsied, likely due to financial, administrative, and organizational limitations as well as awareness among police, legal authorities, and physicians. Consequently, diagnoses of inherited heart disease are likely missed, along with the opportunity for treatment and prevention among surviving relatives. This article reviews the evidence for the role of autopsy in sudden death, how the cardiologist should interpret the autopsy-record, and how this can be integrated and implemented in clinical practice. Finally, we identify areas for future research along with potential for healthcare reform aimed at increasing autopsy awareness and ultimately reducing mortality from SCD.
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Affiliation(s)
- Thomas H Lynge
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Cristina Basso
- The Cardiovascular Pathology Unit, Azienda Ospedaliera, Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Via Aristide Gabelli, 61, 35121 Padova PD, Italy
| | - Rodrigue Garcia
- Department of Cardiology, Poitiers University Hospital, Poitiers, France
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mary N Sheppard
- Cardiovascular Pathology Unit, Cardiovascular and Genetics Research Institute, St George’s, University of London, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Cardiovascular and Genetics Research Institute, St George’s University of London and St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- The Department of Forensic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Luna-Alcala S, Garcia-Cardenas M, Guerra EC, Martinez-Dominguez P, Cabello-Ganem A, Proaño-Bernal L, Chava-Ponte CA, Hernandez-Pacherres A, Espinola-Zavaleta N. Ventricular predominance in biventricular arrhythmogenic cardiomyopathy: Should new subtype criteria be recognized? Radiol Case Rep 2024; 19:2457-2463. [PMID: 38585407 PMCID: PMC10998062 DOI: 10.1016/j.radcr.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Arrhythmogenic cardiomyopathy is a biventricular disease in which the effect on the left ventricle can be either equivalent to or more severe than that on the right ventricle. It is a rare disease due to its low reported prevalence and typically becomes clinically evident during the second to fourth decade of life. It represents 4% of sudden cardiac death cases referred for autopsy and 10% of cases of unexplained cardiac arrest. We present a challenging case report of a 68-year-old man who arrived at the emergency room with chest discomfort, palpitations, and light-headedness before a syncopal episode with urinary incontinence. During monitoring, ventricular tachycardia was detected and was treated with cardioversion. However, a follow-up electrocardiogram revealed low QRS voltages in limb leads and T-wave inversion in the left precordial leads. The patient underwent a transthoracic echocardiogram and a gadolinium-based magnetic resonance imaging study to evaluate the possibility of acute decompensated heart failure. Both imaging studies revealed low ejection fraction and systolic dysfunction in both right and left ventricles. Furthermore, in the late gadolinium enhancement study, extensive left ventricular subepicardial enhancement with septal predominance in a ring pattern and an irregular morphology of the right ventricular free wall were observed. A diagnosis of biventricular arrhythmogenic cardiomyopathy was established based on the 2020 Padua Criteria. Although there is not a recognized classification within these criteria to establish its subtype, in our case there was a left ventricular predominance due to the presence of additional left ventricular categories.
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Affiliation(s)
- Santiago Luna-Alcala
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | | | - Enrique C. Guerra
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
- MD–PhD (PECEM) Program, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Pavel Martinez-Dominguez
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Aldo Cabello-Ganem
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Leonardo Proaño-Bernal
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | | | | | - Nilda Espinola-Zavaleta
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
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Scheel PJ, Cartella I, Murray B, Gilotra NA, Ammirati E. Role of genetics in inflammatory cardiomyopathy. Int J Cardiol 2024; 400:131777. [PMID: 38218248 DOI: 10.1016/j.ijcard.2024.131777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
Traditional cardiomyopathy paradigms segregate inflammatory etiologies from those caused by genetic variants. An identified or presumed trigger is implicated in acute myocarditis or chronic inflammatory cardiomyopathy but growing evidence suggests a significant proportion of patients have an underlying cardiomyopathy-associated genetic variant often even when a clear inflammatory trigger is identified. Recognizing a possible genetic contribution to inflammatory cardiomyopathy may have major downstream implications for both the patient and family. The presenting features of myocarditis (i.e. chest pain, arrhythmia, and/or heart failure) may provide insight into diagnostic considerations. One example is isolated cardiac sarcoidosis, a distinct inflammatory cardiomyopathy that carries diagnostic challenges and clinical overlap; genetic testing has increasingly reclassified cases of isolated cardiac sarcoidosis as genetic cardiomyopathy, notably altering management. On the other side, inflammatory presentations of genetic cardiomyopathies are likewise underappreciated and a growing area of investigation. Inflammation plays an important role in the pathogenesis of several familial cardiomyopathies, especially arrhythmogenic phenotypes. Given these clinical scenarios, and the implications on clinical decision making such as initiation of immunosuppression, sudden cardiac death prevention, and family screening, it is important to recognize when genetics may be playing a role.
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Affiliation(s)
- Paul J Scheel
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA.
| | - Iside Cartella
- De Gasperis Cardio Center, Transplant Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA
| | - Enrico Ammirati
- De Gasperis Cardio Center, Transplant Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy.
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Shen L, Liu S, Zhang Z, Xiong Y, Lai Z, Hu F, Zheng L, Yao Y. Catheter ablation of ventricular tachycardia in patients with arrhythmogenic right ventricular cardiomyopathy and biventricular involvement. Europace 2024; 26:euae059. [PMID: 38417843 PMCID: PMC10946245 DOI: 10.1093/europace/euae059] [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: 11/12/2023] [Revised: 01/09/2024] [Accepted: 02/26/2024] [Indexed: 03/01/2024] Open
Abstract
AIMS Catheter ablation of ventricular tachycardia (VT) improves VT-free survival in 'classic' arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aims to investigate electrophysiological features and ablation outcomes in patients with ARVC and biventricular (BiV) involvement. METHODS AND RESULTS We assembled a retrospective cohort of definite ARVC cases with sustained VTs. Patients were divided into the BiV (BiV involvement) group and the right ventricular (RV) (isolated RV involvement) group based on the left ventricular systolic function detected by cardiac magnetic resonance. All patients underwent electrophysiological mapping and VT ablation. Acute complete success was non-inducibility of any sustained VT, and the primary endpoint was VT recurrence. Ninety-eight patients (36 ± 14 years; 87% male) were enrolled, including 50 in the BiV group and 48 in the RV group. Biventricular involvement was associated with faster clinical VTs, a higher VT inducibility, and more extensive arrhythmogenic substrates (all P < 0.05). Left-sided VTs were observed in 20% of the BiV group cases and correlated with significantly reduced left ventricular systolic function. Catheter ablation achieved similar acute efficacy between these two groups, whereas the presence of left-sided VTs increased acute ablation failure (40 vs. 5%, P = 0.012). Over 51 ± 34 months [median, 48 (22-83) months] of follow-up, cumulative VT-free survival was 52% in the BiV group and 58% in the RV group (P = 0.353). A multivariate analysis showed that younger age, lower RV ejection fraction (RVEF), and non-acute complete ablation success were associated with VT recurrence in the BiV group. CONCLUSION Biventricular involvement implied a worse arrhythmic phenotype and increased the risk of left-sided VTs, while catheter ablation maintained its efficacy for VT control in this population. Younger age, lower RVEF, and non-acute complete success predicted VT recurrence after ablation.
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Affiliation(s)
- Lishui Shen
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai 200072, China
| | - Shangyu Liu
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang 050031, China
| | - Zhenhao Zhang
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Yulong Xiong
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Zihao Lai
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Feng Hu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Lihui Zheng
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Yan Yao
- Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
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