1
|
Behr ER, Conte G, Wilde A. Is right ventricular outflow tract epicardial substrate ablation the standard of care in high-risk Brugada syndrome? Europace 2023; 26:euae020. [PMID: 38252938 PMCID: PMC10824472 DOI: 10.1093/europace/euae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Affiliation(s)
- Elijah R Behr
- Cardiovascular and Genomics Research Institute, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
- Cardiology Care Group, St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK
- Mayo Clinic Healthcare, London W1B 1PT, UK
| | - Giulio Conte
- Electrophysiology Unit, Department of Cardiology, Fondazione Cardiocentro Ticino, via Tesserete 48, Lugano, Switzerland
| | - Arthur Wilde
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart)
| |
Collapse
|
2
|
Melo L, Ciconte G, Christy A, Vicedomini G, Anastasia L, Pappone C, Grant E. Deep learning unmasks the ECG signature of Brugada syndrome. PNAS NEXUS 2023; 2:pgad327. [PMID: 37937270 PMCID: PMC10627411 DOI: 10.1093/pnasnexus/pgad327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023]
Abstract
One in 10 cases of sudden cardiac death strikes without warning as the result of an inherited arrhythmic cardiomyopathy, such as Brugada Syndrome (BrS). Normal physiological variations often obscure visible signs of this and related life-threatening channelopathies in conventional electrocardiograms (ECGs). Sodium channel blockers can reveal previously hidden diagnostic ECG features, however, their use carries the risk of life-threatening proarrhythmic side effects. The absence of a nonintrusive test places a grossly underestimated fraction of the population at risk of SCD. Here, we present a machine-learning algorithm that extracts, aligns, and classifies ECG waveforms for the presence of BrS. This protocol, which succeeds without the use of a sodium channel blocker (88.4% accuracy, 0.934 AUC in validation), can aid clinicians in identifying the presence of this potentially life-threatening heart disease.
Collapse
Affiliation(s)
- Luke Melo
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Giuseppe Ciconte
- Arrhythmia and Electrophysiology Center, IRCCS Policlinico San Donato, Milan 20097, Italy
| | - Ashton Christy
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| | - Gabriele Vicedomini
- Arrhythmia and Electrophysiology Center, IRCCS Policlinico San Donato, Milan 20097, Italy
| | - Luigi Anastasia
- Stem Cell Laboratory for Tissue Engineering, Università Vita-Salute San Raffaele, Milan 20132, Italy
| | - Carlo Pappone
- Arrhythmia and Electrophysiology Center, IRCCS Policlinico San Donato, Milan 20097, Italy
- Department of Cardiology, Università Vita-Salute San Raffaele, Milan 20132, Italy
| | - Edward Grant
- Department of Chemistry, University of British Columbia, Vancouver, BC V6T 1Z1, Canada
| |
Collapse
|
3
|
Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 749] [Impact Index Per Article: 374.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
4
|
Abstract
Brugada syndrome is a heritable channelopathy characterized by a peculiar electrocardiogram (ECG) pattern and increased risk of cardiac arrhythmias and sudden death. The arrhythmias originate because of an imbalance between the repolarizing and depolarizing currents that modulate the cardiac action potential. Even if an overt structural cardiomyopathy is not typical of Brugada syndrome, fibrosis and structural changes in the right ventricle contribute to a conduction slowing, which ultimately facilitates ventricular arrhythmias. Currently, Mendelian autosomal dominant transmission is detected in less than 25% of all clinical confirmed cases. Although 23 genes have been associated with the condition, only SCN5A, encoding the cardiac sodium channel, is considered clinically actionable and disease causing. The limited monogenic inheritance has pointed toward new perspectives on the possible complex genetic architecture of the disease, involving polygenic inheritance and a polygenic risk score that can influence penetrance and risk stratification. Expected final online publication date for the Annual Review of Genomics and Human Genetics, Volume 23 is October 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Collapse
Affiliation(s)
- Marina Cerrone
- Leon H. Charney Division of Cardiology, Grossman School of Medicine, New York University, New York, NY, USA;
| | - Sarah Costa
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | - Mario Delmar
- Leon H. Charney Division of Cardiology, Grossman School of Medicine, New York University, New York, NY, USA;
| |
Collapse
|
5
|
Li Y, Lang S, Akin I, Zhou X, El-Battrawy I. Brugada Syndrome: Different Experimental Models and the Role of Human Cardiomyocytes From Induced Pluripotent Stem Cells. J Am Heart Assoc 2022; 11:e024410. [PMID: 35322667 PMCID: PMC9075459 DOI: 10.1161/jaha.121.024410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Brugada syndrome (BrS) is an inherited and rare cardiac arrhythmogenic disease associated with an increased risk of ventricular fibrillation and sudden cardiac death. Different genes have been linked to BrS. The majority of mutations are located in the SCN5A gene, and the typical abnormal ECG is an elevation of the ST segment in the right precordial leads V1 to V3. The pathophysiological mechanisms of BrS were studied in different models, including animal models, heterologous expression systems, and human-induced pluripotent stem cell-derived cardiomyocyte models. Currently, only a few BrS studies have used human-induced pluripotent stem cell-derived cardiomyocytes, most of which have focused on genotype-phenotype correlations and drug screening. The combination of new technologies, such as clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 (CRISPR associated protein 9)-mediated genome editing and 3-dimensional engineered heart tissues, has provided novel insights into the pathophysiological mechanisms of the disease and could offer opportunities to improve the diagnosis and treatment of patients with BrS. This review aimed to compare different models of BrS for a better understanding of the roles of human-induced pluripotent stem cell-derived cardiomyocytes in current BrS research and personalized medicine at a later stage.
Collapse
Affiliation(s)
- Yingrui Li
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany
| | - Siegfried Lang
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Ibrahim Akin
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Xiaobo Zhou
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province Institute of Cardiovascular Research Southwest Medical University Luzhou Sichuan China.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany.,Department of Cardiology and Angiology Bergmannsheil Bochum Medical Clinic II Ruhr University Bochum Germany
| |
Collapse
|
6
|
Monasky MM, Micaglio E, D'Imperio S, Pappone C. The Mechanism of Ajmaline and Thus Brugada Syndrome: Not Only the Sodium Channel! Front Cardiovasc Med 2022; 8:782596. [PMID: 35004896 PMCID: PMC8733296 DOI: 10.3389/fcvm.2021.782596] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022] Open
Abstract
Ajmaline is an anti-arrhythmic drug that is used to unmask the type-1 Brugada syndrome (BrS) electrocardiogram pattern to diagnose the syndrome. Thus, the disease is defined at its core as a particular response to this or other drugs. Ajmaline is usually described as a sodium-channel blocker, and most research into the mechanism of BrS has centered around this idea that the sodium channel is somehow impaired in BrS, and thus the genetics research has placed much emphasis on sodium channel gene mutations, especially the gene SCN5A, to the point that it has even been suggested that only the SCN5A gene should be screened in BrS patients. However, pathogenic rare variants in SCN5A are identified in only 20–30% of cases, and recent data indicates that SCN5A variants are actually, in many cases, prognostic rather than diagnostic, resulting in a more severe phenotype. Furthermore, the misconception by some that ajmaline only influences the sodium current is flawed, in that ajmaline actually acts additionally on potassium and calcium currents, as well as mitochondria and metabolic pathways. Clinical studies have implicated several candidate genes in BrS, encoding not only for sodium, potassium, and calcium channel proteins, but also for signaling-related, scaffolding-related, sarcomeric, and mitochondrial proteins. Thus, these proteins, as well as any proteins that act upon them, could prove absolutely relevant in the mechanism of BrS.
Collapse
Affiliation(s)
- Michelle M Monasky
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Emanuele Micaglio
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Sara D'Imperio
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
7
|
Viskin S, Chorin E, Viskin D, Hochstadt A, Schwartz AL, Rosso R. Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy. Circulation 2021; 144:823-839. [PMID: 34491774 DOI: 10.1161/circulationaha.121.055783] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Polymorphic ventricular tachyarrhythmias are highly lethal arrhythmias. Several types of polymorphic ventricular tachycardia have similar electrocardiographic characteristics but have different modes of therapy. In fact, medications considered the treatment of choice for one form of polymorphic ventricular tachycardia, are contraindicated for the other. Yet confusion about terminology, and thus diagnosis and therapy, continues. We present an in-depth review of the different forms of polymorphic ventricular tachycardia and propose a practical step-by-step approach for distinguishing these malignant arrhythmias.
Collapse
Affiliation(s)
- Sami Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Ehud Chorin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Dana Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Aviram Hochstadt
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Arie Lorin Schwartz
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Raphael Rosso
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| |
Collapse
|
8
|
Rojas R, Kaul R, Frenkel D, Hoch EG, Iwai S, Jacobson JT, Aronow WS. Brugada syndrome clinical update. Hosp Pract (1995) 2021; 49:255-261. [PMID: 33730522 DOI: 10.1080/21548331.2021.1906012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Brugada syndrome (BrS) was initially described in southeast Asians with a structurally normal heart presenting with polymorphic ventricular tachycardia and fibrillation. This condition is marked by J-point elevation ≥ 2 mm with coved-type ST segment elevation followed by negative T wave inversions in at least one precordial lead (V1 or V2) when other etiologies have been excluded. These changes on electrocardiogram (EKG) can either be spontaneous or manifest after sodium channel blockade. The worldwide prevalence of BrS is about 0.4%; however, it is higher in the Asian population at 0.9%. This article will review the current hypotheses regarding the pathophysiology, spectrum of clinical presentation, strategies for prevention of sudden cardiac death and the treatment for recurrent arrhythmias in BrS.
Collapse
Affiliation(s)
- Rhadames Rojas
- Westchester Medical Center Health Network, Valhalla, NY, USA
| | - Risheek Kaul
- Westchester Medical Center Health Network, Valhalla, NY, USA
| | - Daniel Frenkel
- Westchester Medical Center Health Network, Valhalla, NY, USA.,New York Medical College School of Medicine, Valhalla, NY, USA
| | - Ethan G Hoch
- Westchester Medical Center Health Network, Valhalla, NY, USA
| | - Sei Iwai
- Westchester Medical Center Health Network, Valhalla, NY, USA
| | | | | |
Collapse
|
9
|
Sciarra L, Moriya M, Robles AG, Sarubbi B. Type 2 Brugada pattern: more doubts than certainties. Minerva Cardiol Angiol 2020; 69:426-428. [PMID: 33258571 DOI: 10.23736/s2724-5683.20.05471-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luigi Sciarra
- Unit of Cardiology, Casilino Polyclinic Hospital, Rome, Italy -
| | - Manabu Moriya
- Embassy of Japan in Honduras, Ministry of Foreign Affairs of Japan, Tokyo, Japan
| | | | - Berardo Sarubbi
- Unit of Adult Congenital Heart Disease, Monaldi Hospital, Naples, Italy
| |
Collapse
|
10
|
Rizzo A, de Asmundis C, Brugada P, La Meir M, Chierchia GB. Ablation for the treatment of Brugada syndrome: current status and future prospects. Expert Rev Med Devices 2020; 17:123-130. [PMID: 31986921 DOI: 10.1080/17434440.2020.1719831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Brugada syndrome (BrS) is an inherited disease characterized by an increased risk of sudden cardiac death (SCD). Therapeutic options in symptomatic patients are limited to implantable cardioverter defibrillator (ICD) and quinidine, but catheter ablation of the right ventricular outflow tract (RVOT) offers a potential cure. Different ablation strategies have been used to treat patients with symptomatic Brugada syndrome. Epicardial radiofrequency substrate ablation of the RVOT/right ventricle (RV) has emerged as a promising tool for the management of the disease.Areas covered: The historical management of BrS, endocardial and epicardial ablation techniques, the use of sodium channel blockers (SCB) and complications are summarized here.Expert opinion: Ventricular fibrillation (VF)-triggering premature ventricular contractions (PVCs) in patients with BrS are unpredictable, spontaneous ones are rarely present to be mapped, making this approach impractical. Furthermore, endocardial mapping for BrS substrates does not seem effective due to the epicardial pathological substrate localization. The size variation of the BrS substrate areas during SCB infusion suggests a dynamic process as arrhythmogenic basis and SCB infusion should guide BrS epicardial ablation of all abnormal potentials areas. If BrS epicardial ablation can truly provide long-term prevention of ventricular arrhythmias it may potentially become an alternative to ICD therapy.
Collapse
Affiliation(s)
- Alessandro Rizzo
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark La Meir
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
11
|
Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R. Present Status of Brugada Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 72:1046-1059. [PMID: 30139433 DOI: 10.1016/j.jacc.2018.06.037] [Citation(s) in RCA: 237] [Impact Index Per Article: 47.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 01/04/2023]
Abstract
The Brugada syndrome is an inherited disorder associated with risk of ventricular fibrillation and sudden cardiac death in a structurally normal heart. Diagnosis is based on a characteristic electrocardiographic pattern (coved type ST-segment elevation ≥2 mm followed by a negative T-wave in ≥1 of the right precordial leads V1 to V2), observed either spontaneously or during a sodium-channel blocker test. The prevalence varies among regions and ethnicities, affecting mostly males. The risk stratification and management of patients, principally asymptomatic, still remains challenging. The current main therapy is an implantable cardioverter-defibrillator, but radiofrequency catheter ablation has been recently reported as an effective new treatment. Since its first description in 1992, continuous achievements have expanded our understanding of the genetics basis and electrophysiological mechanisms underlying the disease. Currently, despite several genes identified, SCN5A has attracted most attention, and in approximately 30% of patients, a genetic variant may be implicated in causation after a comprehensive analysis.
Collapse
Affiliation(s)
- Josep Brugada
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Oscar Campuzano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Georgia Sarquella-Brugada
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - Ramon Brugada
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain; Cardiology Service, Hospital Josep Trueta, Girona, Spain
| |
Collapse
|
12
|
Natarajan KU, Krishna MR. Channelopathies – An update 2018. Indian Pacing Electrophysiol J 2019; 19:68-71. [PMID: 30904562 PMCID: PMC6450926 DOI: 10.1016/j.ipej.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/16/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- K U Natarajan
- Dept of Cardiology, Amrita Institute of Medical Sciences, India.
| | - Mani Ram Krishna
- Dept of Pediatric Cardiology, Amrita Institute of Medical Sciences, India
| |
Collapse
|
13
|
Pappone C, Santinelli V. Brugada Syndrome: Progress in Diagnosis and Management. Arrhythm Electrophysiol Rev 2019; 8:13-18. [PMID: 30918662 PMCID: PMC6434501 DOI: 10.15420/aer.2018.73.2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/21/2019] [Indexed: 01/09/2023] Open
Abstract
Brugada syndrome (BrS) represents an inherited disorder associated with risk of sudden cardiac death due to VF in patients without structural heart disease. Currently, BrS is diagnosed by typical cove-shaped ST-segment elevation >2 mm in >1 RV precordial lead V1, V2 occurring spontaneously or after a sodium-channel blocker provocation test without any further evidence of malignant arrhythmias. An ICD should always be implanted in symptomatic BrS patients to prevent sudden death, despite high rates of complications with these devices. In asymptomatic people, an electrophysiological study should be performed to evaluate the need for an ICD. The recent discovery of a functional substrate has revolutionised our approach to the pathophysiology and management of BrS. Promising new therapeutic options have emerged in the last 3 years. Ajmaline is able to determine the extension of the substrate by prolonging the duration and fragmentation of abnormal epicardial electrograms. Substrate ablation results in the disappearance of both coved-type ECG and ventricular tachycardia/VF inducibility. These findings are clinically relevant, suggesting that epicardial ablation guided by ajmaline infusion may be an effective therapeutic option in BrS, potentially removing the need for ICD implantation.
Collapse
Affiliation(s)
- Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese Milan, Italy
| | - Vincenzo Santinelli
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese Milan, Italy
| |
Collapse
|
14
|
Aras D, Ozeke O, Cay S, Ozcan F, Acar B, Topaloglu S. Ajmaline-induced epsilon wave: as a potential interim risk factor between the spontaneous- and drug-induced type 1 Brugada electrogram? Europace 2018; 20:1225-1226. [PMID: 29893843 DOI: 10.1093/europace/euy071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dursun Aras
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Burak Acar
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Electrophysiology, Health Science University, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
15
|
Ueoka A, Morita H, Watanabe A, Morimoto Y, Kawada S, Tachibana M, Miyamoto M, Nakagawa K, Nishii N, Ito H. Prognostic Significance of the Sodium Channel Blocker Test in Patients With Brugada Syndrome. J Am Heart Assoc 2018; 7:JAHA.118.008617. [PMID: 29748178 PMCID: PMC6015319 DOI: 10.1161/jaha.118.008617] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background A drug provocation test using a sodium channel blocker (SCB) can unmask a type 1 ECG pattern in patients with Brugada syndrome. However, the prognostic value of the results of an SCB challenge is limited in patients with non–type 1 ECG. We investigated the associations of future risk for ventricular fibrillation with SCB‐induced ECG changes and ventricular tachyarrhythmias (VTAs). Methods and Results We administered intravenous pilsicainide to 245 consecutive patients with Brugada syndrome (181 patients with spontaneous type 1 ECG, 64 patients with non–type 1 ECG). ECG parameters before and after the test and occurrence of drug‐induced VTAs were evaluated. During a mean follow‐up period of 113±57 months, fatal VTA events occurred in 31 patients (sudden death: n=3, ventricular tachycardia/ventricular fibrillation: n=28). Symptomatic patients and spontaneous type 1 ECG were associated with future fatal arrhythmic events. Univariable analysis of ECG parameters after the test showed that long PQ and QRS intervals, high ST level, and SCB‐induced VTAs were associated with later VTA events during follow‐up. Multivariable analysis showed that symptomatic patients, high ST level (V1) ≥0.3 mV after the test, and SCB‐induced VTAs were independent predictors for future fatal arrhythmic events (hazard ratios: 3.28, 2.80, and 3.62, 95% confidence intervals: 1.54–7.47, 1.32–6.35, and 1.64–7.75, respectively; P<0.05). Conclusions SCB‐induced VTAs and ST‐segment augmentation are associated with an increased risk of the development of ventricular tachycardia/ventricular fibrillation events during follow‐up in patients with Brugada syndrome.
Collapse
Affiliation(s)
- Akira Ueoka
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshimasa Morimoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Motomi Tachibana
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| |
Collapse
|
16
|
Affiliation(s)
- Sami Viskin
- Tel-Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Aviram Hochstadt
- Tel-Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Raphael Rosso
- Tel-Aviv Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|
17
|
Shelke A, Tachil A, Saggu D, Jesuraj ML, Yalagudri S, Narasimhan C. Catheter ablation for electrical storm in Brugada syndrome: Results of substrate based ablation. Indian Heart J 2018; 70:296-302. [PMID: 29716710 PMCID: PMC5993914 DOI: 10.1016/j.ihj.2017.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 06/23/2017] [Accepted: 07/29/2017] [Indexed: 11/17/2022] Open
Abstract
Background Brugada syndrome (BrS) is known to cause malignant ventricular arrhythmia (VA) and sudden cardiac death (SCD). Patients with implantable cardioverter defibrillator (ICD) may experience recurrent shocks from ICD. Recent reports indicate that radiofrequency ablation (RFA) in BrS is feasible, and effective. Catheter ablation of premature ventricular complexes (PVCs) triggering VA and substrate modification of right ventricular outflow tract (RVOT) has been described. Methods and results Five patients (4 males, age-23 to 32 years) with BrS and electrical storm (ES) despite being on isoprenaline infusion and cilostazol (phosphodiestrase-3 inhibitor) underwent 3 dimensional electroanatomic mapping and RFA. Ventricular fibrillation was easily inducible in two patients. Voltage map of right ventricle was created in sinus rhythm in all patients. Substrate modification of RVOT was performed endocardially in one patient, both endocardial and epicardial in three and only epicardially in one patient. Brugada pattern gradually resolved over one week in all patients post procedure. These patients completed follow up of median 40 months (1.5–70). One patient had inappropriate shock due to atrial fibrillation, one had an episode of VF and appropriate shock 24 months after the RFA. The remaining four patients had no device therapy or VA in device log on follow up. Conclusion Abnormal myocardial substrate is observed in RVOT among patients with BrS. Substrate modification in these patients may abolish Brugada pattern on the ECG and prevents spontaneous VAs on long term follow up.
Collapse
Affiliation(s)
- Abhijeet Shelke
- Department of Cardiology, Krishna Institute of Medical Sciences, Karad, Satara, Maharashtra, India
| | - Ajit Tachil
- Department of Cardiology, Lisie Hospital, Kochi, Kerala, India
| | - Daljeet Saggu
- Department of Arrhythmia and Electrophysiology, CARE Hospital, Hyderabad, India
| | - Masilamani Lawrance Jesuraj
- Department of Interventional Cardiology and Electrophysiology, Kovai Medical Centre and Hospital, Hyderabad, India
| | - Sachin Yalagudri
- Department of Arrhythmia and Electrophysiology, CARE Hospital, Hyderabad, India
| | - Calambur Narasimhan
- Department of Arrhythmia and Electrophysiology, CARE Hospital, Hyderabad, India.
| |
Collapse
|
18
|
Abstract
Brugada syndrome (BrS) is a cardiac disease caused by an inherited ion channelopathy associated with a propensity to develop ventricular fibrillation. Implantable cardioverter defibrillator implantation is recommended in BrS, based on the clinical presentation in the presence of diagnostic ECG criteria. Implantable cardioverter defibrillator implantation is not always indicated or sufficient in BrS, and is associated with a high device complication rate. Pharmacological therapy aimed at rebalancing the membrane action potential can prevent arrhythmogenesis in BrS. Quinidine, a class 1A antiarrhythmic drug with significant Ito blocking properties, is the most extensively used drug for the prevention of arrhythmias in BrS. The present review provides contemporary data gathered on all drugs effective in the therapy of BrS, and on ineffective or contraindicated antiarrhythmic drugs.
Collapse
Key Words
- Brugada syndrome,
- arrhythmia,
- bepridil,
- cilostazol,
- denopamine,
- disopyramide,
- isoproterenol,
- orciprenaline,
- pharmacology,
- quinidine,
- quinine
Collapse
Affiliation(s)
- Oholi Tovia Brodie
- University of Miami Miller School of Medicine Miami, USA.,Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Yoav Michowitz
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Bernard Belhassen
- Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| |
Collapse
|