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Christie S, Idris S, Bennett RG, Deyell MW, Roston T, Laksman Z. Trigger and Substrate Mapping and Ablation for Ventricular Fibrillation in the Structurally Normal Heart. J Cardiovasc Dev Dis 2023; 10:jcdd10050200. [PMID: 37233167 DOI: 10.3390/jcdd10050200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
Sudden cardiac death (SCD) represents approximately 50% of all cardiovascular mortality in the United States. The majority of SCD occurs in individuals with structural heart disease; however, around 5% of individuals have no identifiable cause on autopsy. This proportion is even higher in those <40 years old, where SCD is particularly devastating. Ventricular fibrillation (VF) is often the terminal rhythm leading to SCD. Catheter ablation for VF has emerged as an effective tool to alter the natural history of this disease among high-risk individuals. Important advances have been made in the identification of several mechanisms involved in the initiation and maintenance of VF. Targeting the triggers of VF as well as the underlying substrate that perpetuates these lethal arrhythmias has the potential to eliminate further episodes. Although important gaps remain in our understanding of VF, catheter ablation has become an important option for individuals with refractory arrhythmias. This review outlines a contemporary approach to the mapping and ablation of VF in the structurally normal heart, specifically focusing on the following major conditions: idiopathic ventricular fibrillation, short-coupled ventricular fibrillation, and the J-wave syndromes-Brugada syndrome and early-repolarization syndrome.
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Affiliation(s)
- Simon Christie
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Sami Idris
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Richard G Bennett
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Marc W Deyell
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Thomas Roston
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Zachary Laksman
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
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El-Azrak M, Darar C, Boutaybi M, El Ouafi N, Bazid Z. Sudden Cardiac Death Risk Stratification of the Early Repolarization Syndrome: An Updated Review of the Literature. Curr Cardiol Rep 2023; 25:203-212. [PMID: 36763218 DOI: 10.1007/s11886-023-01842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Early repolarization syndrome (ERS), once thought to be innocuous, has now been shown to be responsible for ventricular arrythmias and sudden cardiac death occurrence. This review will help the clinician to identify the patients who are most at risk for arrhythmias, so that they can adopt a preventive or secondary treatment approach, either of which is still poorly defined. RECENT FINDINGS Patients at high risk are found to be particularly young men, with a personal or family history of syncope or sudden death, who have an inferolateral ER on the electrocardiogram, more elevated J-point, longer J-wave duration and wider J angle, a horizontal or descending ST segment, lower T/R ratio, and small and/or inverted waves. The association with a structural heart disease or another channelopathy potentiates this arrhythmic risk. Taken together, these parameters allow prediction of the malignancy of ER pattern with a certain reliability. Further research is however needed to develop concrete risk stratification algorithms and the therapeutic strategies taken in function of it.
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Affiliation(s)
- Mohammed El-Azrak
- Department of Cardiology, Mohammed VI University Hospital, Oujda, Morocco.
| | - Charmake Darar
- Department of Cardiology, Mohammed VI University Hospital, Oujda, Morocco
| | - Mohammed Boutaybi
- Department of Cardiology, Mohammed VI University Hospital, Oujda, Morocco
| | - Noha El Ouafi
- Department of Cardiology, Mohammed VI University Hospital, Oujda, Morocco.,Epidemiological Laboratory of Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Zakaria Bazid
- Department of Cardiology, Mohammed VI University Hospital, Oujda, Morocco
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Asatryan B, Barth AS. Sex-related differences in incidence, phenotype and risk of sudden cardiac death in inherited arrhythmia syndromes. Front Cardiovasc Med 2023; 9:1010748. [PMID: 36684594 PMCID: PMC9845907 DOI: 10.3389/fcvm.2022.1010748] [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: 08/03/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Inherited Arrhythmia Syndromes (IAS) including long QT and Brugada Syndrome, are characterized by life-threatening arrhythmias in the absence of apparent structural heart disease and are caused by pathogenic variants in genes encoding cardiac ion channels or associated proteins. Studies of large pedigrees of families affected by IAS have demonstrated incomplete penetrance and variable expressivity. Biological sex is one of several factors that have been recognized to modulate disease severity in IAS. There is a growing body of evidence linking sex hormones to the susceptibility to arrhythmias, yet, many sex-specific disease aspects remain underrecognized as female sex and women with IAS are underinvestigated and findings from male-predominant cohorts are often generalized to both sexes with minimal to no consideration of relevant sex-associated differences in prevalence, disease manifestations and outcome. In this review, we highlight current knowledge of sex-related biological differences in normal cardiac electrophysiology and sex-associated factors that influence IAS phenotypes.
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Affiliation(s)
- Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas S. Barth
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Andreas S. Barth ✉
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Leung J, Lee S, Zhou J, Jeevaratnam K, Lakhani I, Radford D, Coakley-Youngs E, Pay L, Çinier G, Altinsoy M, Behnoush AH, Mahmoudi E, Matusik PT, Bazoukis G, Garcia-Zamora S, Zeng S, Chen Z, Xia Y, Liu T, Tse G. Clinical Characteristics, Genetic Findings and Arrhythmic Outcomes of Patients with Catecholaminergic Polymorphic Ventricular Tachycardia from China: A Systematic Review. Life (Basel) 2022; 12:1104. [PMID: 35892906 PMCID: PMC9330865 DOI: 10.3390/life12081104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited cardiac ion channelopathy. The present study aims to examine the clinical characteristics, genetic basis, and arrhythmic outcomes of CPVT patients from China to elucidate the difference between CPVT patients in Asia and Western countries. METHODS PubMed and Embase were systematically searched for case reports or series reporting on CPVT patients from China until 19 February 2022 using the keyword: "Catecholaminergic Polymorphic Ventricular Tachycardia" or "CPVT", with the location limited to: "China" or "Hong Kong" or "Macau" in Embase, with no language or publication-type restriction. Articles that did not state a definite diagnosis of CPVT and articles with duplicate cases found in larger cohorts were excluded. All the included publications in this review were critically appraised based on the Joanna Briggs Institute Critical Appraisal Checklist. Clinical characteristics, genetic findings, and the primary outcome of spontaneous ventricular tachycardia/ventricular fibrillation (VT/VF) were analyzed. RESULTS A total of 58 unique cases from 15 studies (median presentation age: 8 (5.0-11.8) years old) were included. All patients, except one, presented at or before 19 years of age. There were 56 patients (96.6%) who were initially symptomatic. Premature ventricular complexes (PVCs) were present in 44 out of 51 patients (86.3%) and VT in 52 out of 58 patients (89.7%). Genetic tests were performed on 54 patients (93.1%) with a yield of 87%. RyR2, CASQ2, TERCL, and SCN10A mutations were found in 35 (71.4%), 12 (24.5%), 1 (0.02%) patient, and 1 patient (0.02%), respectively. There were 54 patients who were treated with beta-blockers, 8 received flecainide, 5 received amiodarone, 2 received verapamil and 2 received propafenone. Sympathectomy (n = 10), implantable cardioverter-defibrillator implantation (n = 8) and ablation (n = 1) were performed. On follow-up, 13 patients developed VT/VF. CONCLUSION This was the first systematic review of CPVT patients from China. Most patients had symptoms on initial presentation, with syncope as the presenting complaint. RyR2 mutation accounts for more than half of the CPVT cases, followed by CASQ2, TERCL and SCN10A mutations.
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Affiliation(s)
- Justin Leung
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China; (J.L.); (S.L.); (I.L.)
| | - Sharen Lee
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China; (J.L.); (S.L.); (I.L.)
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China;
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK;
| | - Ishan Lakhani
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China; (J.L.); (S.L.); (I.L.)
| | - Danny Radford
- Kent and Medway Medical School, Canterbury CT2 7FS, UK; (D.R.); (E.C.-Y.)
| | | | - Levent Pay
- Department of Cardiology, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul 34147, Turkey; (L.P.); (G.Ç.)
| | - Göksel Çinier
- Department of Cardiology, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul 34147, Turkey; (L.P.); (G.Ç.)
| | - Meltem Altinsoy
- Department of Cardiology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara 06145, Turkey;
| | - Amir Hossein Behnoush
- Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran 1416643931, Iran; (A.H.B.); (E.M.)
| | - Elham Mahmoudi
- Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran 1416643931, Iran; (A.H.B.); (E.M.)
| | - Paweł T. Matusik
- Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Kraków, Poland;
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca 6301, Cyprus;
- Medical School, University of Nicosia, Nicosia 2408, Cyprus
| | - Sebastian Garcia-Zamora
- Cardiac Intensive Care Unit, Department of Cardiology, Delta Clinic, Rosario S2000, Argentina;
| | - Shaoying Zeng
- Department of Pediatric Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China;
| | - Ziliang Chen
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China;
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian 116014, China;
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China;
| | - Gary Tse
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-UK Collaboration, Hong Kong, China; (J.L.); (S.L.); (I.L.)
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK;
- Kent and Medway Medical School, Canterbury CT2 7FS, UK; (D.R.); (E.C.-Y.)
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China;
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian 116014, China;
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Krahn AD, Tfelt-Hansen J, Tadros R, Steinberg C, Semsarian C, Han HC. Latent Causes of Sudden Cardiac Arrest. JACC Clin Electrophysiol 2022; 8:806-821. [PMID: 35738861 DOI: 10.1016/j.jacep.2021.12.014] [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: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 11/30/2022]
Abstract
Inherited arrhythmia syndromes are a common cause of apparently unexplained cardiac arrest or sudden cardiac death. These include long QT syndrome and Brugada syndrome, with a well-recognized phenotype in most patients with sufficiently severe disease to lead to cardiac arrest. Less common and typically less apparent conditions that may not be readily evident include catecholaminergic polymorphic ventricular tachycardia, short QT syndrome and early repolarization syndrome. In cardiac arrest patients whose extensive testing does not reveal an underlying etiology, a diagnosis of idiopathic ventricular fibrillation or short-coupled ventricular fibrillation is assigned. This review summarizes our current understanding of the less common inherited arrhythmia syndromes and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Christian Steinberg
- Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ-UL), Laval University, Inherited Arrhythmia Services, Départment of Cardiology and Cardiac Surgery, Québec, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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Abstract
PURPOSE OF REVIEW Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a life-threatening syndrome defined by exercise-induced or emotion-induced ventricular arrhythmias, typically caused by gain-of-function mutations in RYR2-encoded ryanodine receptor-2 (RyR2). This review will discuss recent advances and ongoing challenges in devising genotype-specific CPVT therapies. RECENT FINDINGS CPVT patients were once universally thought to be at high risk of sudden death; however, as more cases emerge, CPVT is being re-defined as a complex syndrome of variable expressivity. Treatment was traditionally limited to β-blockers and implantable cardioverter defibrillators, and although β-blockers remain a mainstay of treatment, implantable cardioverter defibrillator use is associated with adverse events and should be limited. New applications for older therapies, like flecainide and cardiac denervation, appear to better target the mechanistic basis of CPVT arrhythmias. Recent advances in our understanding of RyR2 structure and function can help in identifying novel therapeutic targets. SUMMARY CPVT is usually related to RyR2 or associated proteins. Emerging studies reveal several genotype-phenotype correlations, which may eventually influence therapeutic decision-making. Flecainide has improved CPVT outcomes and will likely have broader clinical indications in the near future. Gene therapy has shown promise in animal models but has yet to be studied in humans. Sudden death can occur as a sentinel symptom, making preventive therapy that targets molecular mechanism(s) of arrhythmia a key area of ongoing investigation. VIDEO ABSTRACT.
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Abstract
Early repolarization, Brugada syndrome, and pathologic J waves have been described for decades, but only recently experimental and clinical data have allowed reconciliation of Brugada and Early Repolarization under the common definition of J-wave syndromes. The concept was derived from studies showing, in both conditions, the presence of transmural dispersion of repolarization, localized conduction abnormalities, and abnormal transition between QRS and ST segment on electrocardiogram. Although several clinical studies have addressed the clinical presentation and epidemiology of J-wave syndromes, relevant knowledge gaps exist. Incomplete pathophysiologic understanding and uncertain electrocardiographic definitions limit effective risk stratification. Here, we review the current knowledge and recommendations for diagnosis and clinical management of these arrhythmogenic disorders.
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Affiliation(s)
- Silvia G Priori
- Molecular Cardiology, ICS Maugeri, IRCCS, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm 2017; 33:533-544. [PMID: 29255498 PMCID: PMC5728985 DOI: 10.1016/j.joa.2017.07.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/04/2017] [Accepted: 07/04/2017] [Indexed: 12/17/2022] Open
Abstract
Syncope is a clinical syndrome defined as a relatively brief self-limited transient loss of consciousness (TLOC) caused by a period of inadequate cerebral nutrient flow. Most often the trigger is an abrupt drop of systemic blood pressure. True syncope must be distinguished from other common non-syncope conditions in which real or apparent TLOC may occur such as seizures, concussions, or accidental falls. The causes of syncope are diverse, but in most instances, are relatively benign (e.g., reflex and orthostatic faints) with the main risks being accidents and/or injury. However, in some instances, syncope may be due to more worrisome conditions (particularly those associated with cardiac structural disease or channelopathies); in such circumstances, syncope may be an indicator of increased morbidity and mortality risk, including sudden cardiac death (SCD). Establishing an accurate basis for the etiology of syncope is crucial in order to initiate effective therapy. In this review, we focus primarily on the causes of syncope that are associated with increased SCD risk (i.e., sudden arrhythmic cardiac death), and the management of these patients. In addition, we discuss the limitations of our understanding of SCD in relation to syncope, and propose future studies that may ultimately address how to improve outcomes of syncope patients and reduce SCD risk.
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Affiliation(s)
| | | | - David G. Benditt
- From the Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Abstract
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited cardiac arrhythmia disorder that is characterized by emotion- and exercise-induced polymorphic ventricular arrhythmias and may lead to sudden cardiac death (SCD). CPVT plays an important role in SCD in the young and therefore recognition and adequate treatment of the disease are of vital importance. In the past years tremendous improvements have been made in the diagnostic methods and treatment of the disease. In this review, we summarize the clinical characteristics, genetics, and diagnostic and therapeutic strategies of CPVT and describe the most recent advances and some of the current challenges. (Circ J 2016; 80: 1285-1291).
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Affiliation(s)
- Krystien V Lieve
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Centre
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