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Compagnucci P, Selimi A, Cipolletta L, Volpato G, Gasperetti A, Valeri Y, Parisi Q, Curcio A, Natale A, Dello Russo A, Casella M. Arrhythmic Mitral Valve Prolapse and Sports Activity: Pathophysiology, Risk Stratification, and Sports Eligibility Assessment. J Clin Med 2024; 13:1350. [PMID: 38592178 PMCID: PMC10932446 DOI: 10.3390/jcm13051350] [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: 01/09/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Although mitral valve prolapse (MVP) is the most prevalent valvular abnormality in Western countries and generally carries a good prognosis, a small subset of patients is exposed to a significant risk of malignant ventricular arrhythmias (VAs) and sudden cardiac death (SCD), the so-called arrhythmic MVP (AMVP) syndrome. Recent work has emphasized phenotypical risk features of severe AMVP and clarified its pathophysiology. However, the appropriate assessment and risk stratification of patients with suspected AMVP remains a clinical conundrum, with the possibility of both overestimating and underestimating the risk of malignant VAs, with the inappropriate use of advanced imaging and invasive electrophysiology study on one hand, and the catastrophic occurrence of SCD on the other. Furthermore, the sports eligibility assessment of athletes with AMVP remains ill defined, especially in the grey zone of intermediate arrhythmic risk. The definition, epidemiology, pathophysiology, risk stratification, and treatment of AMVP are covered in the present review. Considering recent guidelines and expert consensus statements, we propose a comprehensive pathway to facilitate appropriate counseling concerning the practice of competitive/leisure-time sports, envisioning shared decision making and the multidisciplinary "sports heart team" evaluation of borderline cases. Our final aim is to encourage an active lifestyle without compromising patients' safety.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Adelina Selimi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
- Department of Cardiology, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Antonio Curcio
- Division of Cardiology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX 78705, USA;
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA 92037, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Medical, Special and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy
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Pistelli L, Vetta G, Parlavecchio A, Crea P, Parisi F, Magnocavallo M, Caminiti R, Frea S, Vairo A, Desalvo P, Faletti R, Gatti M, Dattilo G, Parollo M, Di Cori A, Bongiorni MG, De Santis G, Borgi M, Franzino M, Licordari R, Zucchelli G, Rocca GDD, Giustetto C. Arrhythmic risk profile in mitral valve prolapse: A systematic review and metanalysis of 1715 patients. J Cardiovasc Electrophysiol 2024; 35:290-300. [PMID: 38098308 DOI: 10.1111/jce.16149] [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: 03/29/2023] [Revised: 09/27/2023] [Accepted: 11/23/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Mitral valve prolapse (MVP) is a common clinical condition in the general population. A subgroup of patients with MVP may experience ventricular arrhythmias and sudden cardiac death ("arrhythmic mitral valve prolapse" [AMVP]) but how to stratify arrhythmic risk is still unclear. Our meta-analysis aims to identify predictive factors for arrhythmic risk in patients with MVP. METHODS We systematically searched Medline, Cochrane, Journals@Ovid, Scopus electronic databases for studies published up to December 28, 2022 and comparing AMVP and nonarrhythmic mitral valve prolapse (NAMVP) for what concerns history, electrocardiographic, echocardiographic and cardiac magnetic resonance features. The effect size was estimated using a random-effect model as odds ratio (OR) and mean difference (MD). RESULTS A total of 10 studies enrolling 1715 patients were included. Late gadolinium enhancement (LGE) (OR: 16.67; p = .005), T-wave inversion (TWI) (OR: 2.63; p < .0001), bileaflet MVP (OR: 1.92; p < .0001) and mitral anulus disjunction (MAD) (OR: 2.60; p < .0001) were more represented among patients with AMVP than in NAMVP. Patients with AMVP were shown to have longer anterior mitral leaflet (AML) (MD: 2.63 mm; p < .0001), posterior mitral leaflet (MD: 2.96 mm; p < .0001), thicker AML (MD: 0.49 mm; p < .0001), longer MAD length (MD: 1.24 mm; p < .0001) and higher amount of LGE (MD: 1.41%; p < .0001) than NAMVP. AMVP showed increased mechanical dispersion (MD: 8.04 ms; 95% confidence interval: 5.13-10.96; p < .0001) compared with NAMVP. CONCLUSIONS Our meta-analysis proved that LGE, TWI, bileaflet MVP, and MAD are predictive factors for arrhythmic risk in MVP patients.
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Affiliation(s)
- Lorenzo Pistelli
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giampaolo Vetta
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Parlavecchio
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Pasquale Crea
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesca Parisi
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michele Magnocavallo
- Arrhythmology Unit, S. Giovanni Calibita Hospital, Cardiology Division, Rome, Italy
| | - Rodolfo Caminiti
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Simone Frea
- Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Division of Cardiology, Turin, Italy
| | - Alessandro Vairo
- Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Division of Cardiology, Turin, Italy
| | - Paolo Desalvo
- Department of Medical Sciences, University of Turin, Turin, Italy
- Cardiology Unit, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Riccardo Faletti
- Radiology Unit, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Gatti
- Radiology Unit, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giuseppe Dattilo
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Matteo Parollo
- Second Division of Cardiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Di Cori
- Second Division of Cardiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Giulia De Santis
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marco Borgi
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marco Franzino
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Licordari
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giulio Zucchelli
- Second Division of Cardiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giovanni Domenico Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Carla Giustetto
- Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Division of Cardiology, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Bazoukis G, Saplaouras A, Vlachos K, Mililis P, Letsas KP, Efremidis M, Liu T, Tse G. Predictors of Ventricular Arrhythmias in Patients With Mitral Valve Prolapse: A Meta-analysis. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00115. [PMID: 37335822 DOI: 10.1097/crd.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Mitral valve prolapse (MVP) has an estimated prevalence of 2-3% in the general population. Patients with MVP have an increased risk of ventricular arrhythmic events. The aim of this meta-analysis was to identify easily obtained markers that can be used for the arrhythmic risk stratification of MVP patients. This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement). The search strategy identified 23 studies that were finally included in the study. The quantitative synthesis showed that late gadolinium enhancement (LGE) [RR 6.40 (2.11-19.39), I2 77%, P = 0.001], longer QTc interval [mean difference: 14.2 (8.92-19.49) I2 0%, P < 0.001], T-wave inversion in inferior leads [RR 1.60 (1.39-1.86), I2 0%, P < 0.001], mitral annular disjunction (MAD) [RR 1.77 (1.29-2.44), I2 37%, P = 0.0005], lower left ventricular ejection fraction (LVEF) [mean difference: -0.77 (-1.48, -0.07) I2 0%, P = 0.03], bileaflet MVP [RR 1.32 (1.16-1.49), I2 0%, P < 0.001], increased anterior [mean difference: 0.45 (0.28, 0.61), I2 0%, P < 0.001] and posterior [mean difference: 0.39 (0.26, 0.52), I2 0%, P < 0.001] mitral leaflet thickness were significantly associated with ventricular arrhythmias in MVP patients. On the other hand, gender, QRS duration, anterior, and posterior mitral leaflet length were not associated with increased risk of arrhythmias. In conclusion, inferior T-wave inversions, QTc interval, LGE, LVEF, MAD, bileaflet MVP, anterior, and posterior mitral leaflet thickness are easily obtained markers that can be used for the risk stratification of patients with MVP. Prospective studies should be designed for the better stratification of this population.
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Affiliation(s)
- George Bazoukis
- From the Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | | | | | - Panagiotis Mililis
- Onassis Cardiac Surgery Center, Electrophysiology Department, Athens, Greece
| | | | - Michael Efremidis
- Onassis Cardiac Surgery Center, Electrophysiology Department, Athens, Greece
| | - 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, China
| | - Gary Tse
- Kent and Medway Medical School, Canterbury, Kent, United Kingdom
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Sabbag A, Essayagh B, Barrera JDR, Basso C, Berni A, Cosyns B, Deharo JC, Deneke T, Di Biase L, Enriquez-Sarano M, Donal E, Imai K, Lim HS, Marsan NA, Turagam MK, Peichl P, Po SS, Haugaa KH, Shah D, de Riva Silva M, Bertrand P, Saba M, Dweck M, Townsend SN, Ngarmukos T, Fenelon G, Santangeli P, Sade LE, Corrado D, Lambiase P, Sanders P, Delacrétaz E, Jahangir A, Kaufman ES, Saggu DK, Pierard L, Delgado V, Lancellotti P. EHRA expert consensus statement on arrhythmic mitral valve prolapse and mitral annular disjunction complex in collaboration with the ESC Council on valvular heart disease and the European Association of Cardiovascular Imaging endorsed cby the Heart Rhythm Society, by the Asia Pacific Heart Rhythm Society, and by the Latin American Heart Rhythm Society. Europace 2022; 24:1981-2003. [PMID: 35951656 DOI: 10.1093/europace/euac125] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel
| | - Benjamin Essayagh
- Department of Cardiovascular Medicine, Simone Veil Hospital, Cannes 06400, France.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester 55905, Minnesota
| | | | - Cristina Basso
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università degli Studi di Padova, Padova 35128, Italy
| | - Ana Berni
- Cardiology and Cardiac Electrophysiology, EP Lab. Hospital Angeles Pedregal. Mexico City 10700, Board member, Mexican Society of Cardiology
| | - Bernard Cosyns
- Cardiology Department, Centrum voor hart en vaatziekten, Universitair Ziekenhuis Brussel, Free University of Brussels, Brussels 1090, Belgium
| | - Jean-Claude Deharo
- Department of Cardiology, L'hôpital de la Timone, Marseille, 13005, France
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, 97616, Germany
| | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY 10467, USA
| | | | - Erwan Donal
- Service de Cardiologie, CCP-CHU Pontchaillou, Rennes 35033, France
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima 737-0023, Japan
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, University of Melbourne, Melbourne 3010, Australia
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague 73117, Czech Republic
| | - Sunny S Po
- Heart Rhythm Institute and Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center, Oklahoma City, OK 0372, USA
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dipen Shah
- Cantonal Hospital, Cardiology Department, CH-1211 Geneva, Switzerland
| | - Marta de Riva Silva
- Department of Cardiology, Leiden University Medical Center, Leiden 2333, The Netherlands
| | - Philippe Bertrand
- Ziekenhuis Oost-Limburg, Hasselt University, Genk, Hasselt 3600, Belgium
| | - Magdi Saba
- Consultant and Reader in Cardiac Electrophysiology, Director, Advanced Ventricular Arrhythmia Training and Research Program, St. George's Hospital NHS Foundation Trust, St. George's, University of London, SW17 0QT, UK
| | - Marc Dweck
- Centre for cardiovascular science, University of Edinburgh, EH16 4TJ, UK
| | - Santiago Nava Townsend
- Instituto Nacional De Cardiologia Ich, Electrophysiology Department, Mexico Df 14080, Mexico
| | - Tachapong Ngarmukos
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 73170, Thailand
| | - Guilherme Fenelon
- Coordenador - Centro de Arritmia, Hospital Israelita Albert Einstein, São Paulo - SP, 05652-900, Brazil
| | | | - Leyla Elif Sade
- University of Pittsburgh, UPMC, Heart and Vascular Institute, ittsburgh, PA 15219, USA.,C.H.U. du Sart-Tilman, Universite de Liege, Liege 4000, Belgium
| | - Domenico Corrado
- Full Professor of Cardiovascular Medicine, Director, Inherited Arrhythmogenic Cardiomyopathies and Sports Cardiology Unit, Dept. of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padova 35122, Italy
| | - Pier Lambiase
- UCL & Barts Heart Centre, Co-Director of Cardiovascular Research Barts NHS Trust, Inherited Arrhythmia Clinical Lead, UCL MRC DTP Theme Lead, BHRS Committee Research Lead, Institute of Cardiovascular Science, UCL, Department of Cardiology, Barts Heart Centre E1 1BB, UK
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australia 5000, Australia
| | - Etienne Delacrétaz
- Clinique Cecil Hirslanden Lausanne & University Hospital Fribourg, Cardiology 1003, Switzerland
| | - Arshad Jahangir
- University of Wisconsin School of Medicine and Public Health, Milwaukee, MI 53705, USA
| | - Elizabeth S Kaufman
- Clinical Electrophysiologist, MetroHealth Medical Center, Professor, Case Western Reserve University 44106, USA
| | - Daljeet Kaur Saggu
- Consultant Cardiologist and Electrophysiologist, AIG HOSPITAL, Hyderabad 500032, India
| | - Luc Pierard
- C.H.U. du Sart-Tilman, Universite de Liege, Liege 4000, Belgium
| | - Victoria Delgado
- Heart Institute, Hospital University Germans Trias i Pujol, Badalona 08916, Spain
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Han HC, Ha FJ, Teh AW, Calafiore P, Jones EF, Johns J, Koshy AN, O'Donnell D, Hare DL, Farouque O, Lim HS. Mitral Valve Prolapse and Sudden Cardiac Death: A Systematic Review. J Am Heart Assoc 2019; 7:e010584. [PMID: 30486705 PMCID: PMC6405538 DOI: 10.1161/jaha.118.010584] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The relationship between mitral valve prolapse (MVP) and sudden cardiac death (SCD) remains controversial. In this systematic review, we evaluate the relationship between isolated MVP and SCD to better define a potential high‐risk subtype. In addition, we determine whether premortem parameters could predict SCD in patients with MVP and the incidence of SCD in MVP. Methods and Results Electronic searches were conducted in PubMed and Embase for all English literature articles published between 1960 and 2018 regarding MVP and SCD or cardiac arrest. We also identified articles investigating predictors of ventricular arrhythmias or SCD and cohort studies reporting SCD outcomes in MVP. From 2180 citations, there were 79 articles describing 161 cases of MVP with SCD or cardiac arrest. The median age was 30 years and 69% of cases were female. Cardiac arrest occurred during situations of stress in 47% and was caused by ventricular fibrillation in 81%. Premature ventricular complexes on Holter monitoring (92%) were common. Most cases had bileaflet involvement (70%) with redundancy (99%) and nonsevere mitral regurgitation (83%). From 22 articles describing predictors for ventricular arrhythmias or SCD in MVP, leaflet redundancy was the only independent predictor of SCD. The incidence of SCD with MVP was estimated at 217 events per 100 000 person‐years. Conclusions Isolated MVP and SCD predominantly affects young females with redundant bileaflet prolapse, with cardiac arrest usually occurring as a result of ventricular arrhythmias. To better understand the complex relationship between MVP and SCD, standardized reporting of clinical, electrophysiological, and cardiac imaging parameters with longitudinal follow‐up is required.
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Affiliation(s)
- Hui-Chen Han
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Francis J Ha
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Andrew W Teh
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia.,3 Department of Cardiology Eastern Health Monash University Melbourne Australia
| | - Paul Calafiore
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Elizabeth F Jones
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Jennifer Johns
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Anoop N Koshy
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - David O'Donnell
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - David L Hare
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Omar Farouque
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia
| | - Han S Lim
- 1 Department of Cardiology Austin Health University of Melbourne Melbourne Australia.,2 Department of Cardiology Northern Health University of Melbourne Melbourne Australia
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Enriquez A, Shirai Y, Huang J, Liang J, Briceño D, Hayashi T, Muser D, Fulton B, Han Y, Perez A, Frankel DS, Schaller R, Supple G, Callans D, Marchlinski F, Garcia F, Santangeli P. Papillary muscle ventricular arrhythmias in patients with arrhythmic mitral valve prolapse: Electrophysiologic substrate and catheter ablation outcomes. J Cardiovasc Electrophysiol 2019; 30:827-835. [PMID: 30843306 DOI: 10.1111/jce.13900] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/06/2019] [Accepted: 02/15/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mitral valve prolapse (MVP) is a common valve condition and has been associated with sudden cardiac death. Premature ventricular contractions (PVCs) from the papillary muscles (PMs) may play a role as triggers for ventricular fibrillation (VF) in these patients. OBJECTIVES To characterize the electrophysiological substrate and outcomes of catheter ablation in patients with MVP and PM PVCs. METHODS Of 597 patients undergoing ablation of ventricular arrhythmias during the period 2012-2015, we identified 25 patients with MVP and PVCs mapped to the PMs (64% female). PVC-triggered VF was the presentation in 4 patients and a fifth patient died suddenly during follow-up. The left ventricle ejection fraction (LVEF) was 50.5% ± 11.8% and PVC burden was 24.4% ± 13.1%. A cardiac magnetic resonance imaging was performed in nine cases and areas of late gadolinium enhancement were found in four of them. A detailed LV voltage map was performed in 11 patients, three of which exhibited bipolar voltage abnormalities. Complete PVC elimination was achieved in 19 (76%) patients and a significant reduction in PVC burden was observed in two (8%). In patients in which the ablation was successful, the PVC burden decreased from 20.4% ± 10.8% to 6.3% ± 9.5% (P = 0.001). In 5/6 patients with depressed LVEF and successful ablation, the LV function improved postablation. No significant differences were identified between patients with and without VF. CONCLUSIONS PM PVCs are a source of VF in patients with MVP and can induce PVC-mediated cardiomyopathy that reverses after PVC suppression. Catheter ablation is highly successful with more than 80% PVC elimination or burden reduction.
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Affiliation(s)
- Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada.,Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yasuhiro Shirai
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Huang
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson Liang
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Briceño
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tatsuya Hayashi
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniele Muser
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Fulton
- Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yuchi Han
- Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Armando Perez
- Arrhythmia Service, Department of Medicine, Hospital Guillermo Gran Benavente, Concepcion, Chile
| | - David S Frankel
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Schaller
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Supple
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Callans
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin Garcia
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Lee A, Hamilton‐Craig C, Denman R, Haqqani HM. Catheter ablation of papillary muscle arrhythmias: Implications of mitral valve prolapse and systolic dysfunction. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:750-758. [DOI: 10.1111/pace.13363] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/26/2018] [Accepted: 04/08/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Lee
- Department of CardiologyThe Prince Charles Hospital Brisbane Australia
- Faculty of MedicineThe University of Queensland Brisbane Australia
| | - Christian Hamilton‐Craig
- Department of CardiologyThe Prince Charles Hospital Brisbane Australia
- Faculty of MedicineThe University of Queensland Brisbane Australia
| | - Russell Denman
- Department of CardiologyThe Prince Charles Hospital Brisbane Australia
| | - Haris M. Haqqani
- Department of CardiologyThe Prince Charles Hospital Brisbane Australia
- Faculty of MedicineThe University of Queensland Brisbane Australia
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8
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Ventricular premature contraction associated with mitral valve prolapse. Int J Cardiol 2016; 221:1144-9. [DOI: 10.1016/j.ijcard.2016.06.252] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/03/2016] [Accepted: 06/26/2016] [Indexed: 11/22/2022]
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Prolonged Tp-e Interval and Tp-e/QT Ratio in Children with Mitral Valve Prolapse. Pediatr Cardiol 2016; 37:1169-74. [PMID: 27251411 DOI: 10.1007/s00246-016-1414-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
Although it is considered to be a benign condition, previous studies have shown that a subset of patients with mitral valve prolapse (MVP) may be at risk of ventricular arrhythmia and sudden cardiac death (SCD). Previous studies have suggested that the interval between the peak and the end of the T wave (Tp-e) can be used as a marker for the transmural dispersion of repolarization. Increased Tp-e interval and Tp-e/QT ratio are associated with ventricular arrhythmias and SCD. The aim of this study was to assess alterations in ventricular repolarization by using the Tp-e interval and Tp-e/QT ratio in children with MVP and to investigate their relationships with the degree of valvular regurgitation. This study prospectively investigated 110 children with MVP and 107 age- and sex-matched healthy control subjects. Tp-e interval, Tp-e/QT ratio, and QT and QTc dispersions were measured from a 12-lead electrocardiogram and compared between groups. QT and QTc dispersions, Tp-e interval, and Tp-e/QTc ratio were found to be significantly higher in patients with MVP. A positive correlation was found between Tp-e/QTc ratio and increase in the degree of mitral regurgitation (MR) (p < 0.05; r = 0.2). However, the degree of MR was not associated with QT, QTc, or Tp-e intervals; QT, QTc, or Tp-e dispersions; or Tp-e/QT ratio (all p values >0.05). Individuals with MVP may be more prone to ventricular arrhythmias due to prolonged QTd, QTcd, and Tp-e interval and increased Tp-e/QT and Tp-e/QTc ratios. Therefore, due to their longer life expectancy, children with MVP should be followed up on regarding life-threatening arrhythmias.
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Narayanan K, Uy-Evanado A, Teodorescu C, Reinier K, Nichols GA, Gunson K, Jui J, Chugh SS. Mitral valve prolapse and sudden cardiac arrest in the community. Heart Rhythm 2015; 13:498-503. [PMID: 26416619 DOI: 10.1016/j.hrthm.2015.09.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mitral valve prolapse (MVP) is relatively common in the general population with recently reported prevalence of 1% and familial clustering (Framingham Heart Study). However, its association with ventricular arrhythmias and sudden cardiac arrest (SCA) remains controversial. OBJECTIVES The purpose of this study was to characterize the frequency and clinical profile of patients with MVP who suffer SCA in the community. METHODS Patients with SCA cases were prospectively identified in the population-based Oregon Sudden Unexpected Death Study (population ~1 million). The presence of MVP was identified from echocardiograms recorded prior but unrelated to the SCA event. The detailed clinical profile of patients with SCA and MVP was compared with that of SCA patients without MVP to identify potential differences. RESULTS A total of 729 SCA patients were evaluated over a 12-year period (mean age 69.5 ± 14.8 years; 64.6% men). MVP was observed in 17 (2.3%) prior to the SCA event (95% confidence interval 1.2%-3.4%). Mitral regurgitation was present in 14 SCA patients with MVP (82.3%) and was moderate or severe in 10 (58.8%). Compared with SCA patients without MVP, SCA patients with MVP were younger (mean age 60.9 ± 16.4 years vs 69.7 ± 14.7 years; P = .02), with fewer risk factors (diabetes 5.9% vs 46.4%; P = .001; hypertension 41.2% vs 78.9%; P = .001) or known coronary disease (29.4% vs 65.6%; P < .001). CONCLUSION MVP was observed in a small proportion (2.3%) of SCA patients in the general population, suggesting a low risk overall. Since SCA patients with MVP were characterized by younger age and relatively low cardiovascular comorbidity, a focus on imaging for valve structure/insufficiency as well as genetics could aid future risk stratification approaches.
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Affiliation(s)
- Kumar Narayanan
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey Uy-Evanado
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carmen Teodorescu
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kyndaron Reinier
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Karen Gunson
- Department of Pathology, Oregon Health and Science University, Portland, Oregon
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Sumeet S Chugh
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Rajani AR, Murugesan V, Baslaib FO, Rafiq MA. Mitral valve prolapse and electrolyte abnormality: a dangerous combination for ventricular arrhythmias. BMJ Case Rep 2014; 2014:bcr-2014-205055. [PMID: 24827670 DOI: 10.1136/bcr-2014-205055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old woman with a history of bileaflet mitral valve prolapse and moderate mitral regurgitation presented to our emergency with untractable polymorphic wide complex tachycardia and unstable haemodynamics. After cardiopulmonary resuscitation, return of spontaneous circulation was achieved 30 min later. Her post-resuscitation ECG showed a prolonged QT interval which progressively normalised over the same day. Her laboratory investigations revealed hypocalcaemia while other electrolytes were within normal limits. A diagnosis of ventricular arrhythmia secondary to structural heart disease further precipitated by hypocalcaemia was made. Further hospital stay did not reveal a recurrence of prolonged QT interval or other arrhythmias except for an episode of non-sustained ventricular tachycardia. However, the patient suffered diffuse hypoxic brain encephalopathy secondary to prolonged cardiopulmonary resuscitation.
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Affiliation(s)
- Ali Raza Rajani
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Vagishwari Murugesan
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Fahad Omar Baslaib
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Muhammad Anwer Rafiq
- Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
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Hu X, Zhao Q. Autonomic dysregulation as a novel underlying cause of mitral valve prolapse: a hypothesis. Med Sci Monit 2011; 17:HY27-31. [PMID: 21873953 PMCID: PMC3560509 DOI: 10.12659/msm.881918] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 02/24/2011] [Indexed: 01/09/2023] Open
Abstract
Mitral valve prolapse is a common valvular abnormality that is caused by myxomatous degeneration, characterized macroscopically by leaflet thickening and redundancy accompanied with histologically marked proliferation of the spongiosa and mucopolysaccharide acid replacement of leaflet collagen in the prolapse leaflets. Nevertheless, the discrepant natural history and various concomitant syndromes cannot be explained completely by the current genetic autosomal dominant inheritance theory. In addition, autonomic dysregulation has been commonly reported in mitral valve prolapse, but has never been indicated as a major underlying cause. This article attempts to interpret the occurrence of primary pathology and progression in mitral valve prolapse on a common basis of improper autonomic tone. The imbalanced background of autonomic nervous firing leads to disharmonized synthetic/catabolism balance in the extracellular matrix, disrupted transition in the interstitial cellular component and invalided anti-inflammatory pathway in the endothelium, which trigger and accelerate the progression of this condition. Such a hypothesis not only unifies the seemingly disparate syndromes and valvular disorder, but also has implications for future biopharmaceutical and mechanical treatment.
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Affiliation(s)
- Xiang Hu
- Xiang Hu, Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P.R.C., e-mail: , and Qiang Zhao, Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P.R.C., e-mail:
| | - Qiang Zhao
- Xiang Hu, Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P.R.C., e-mail: , and Qiang Zhao, Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P.R.C., e-mail:
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AKCAY MURAT, YUCE MURAT, PALA SELCUK, AKCAKOYUN MUSTAFA, ERGELEN MEHMET, KARGIN RAMAZAN, EMIROGLU YUNUS, OZDEMIR NIHAL, KAYMAZ CIHANGIR, OZKAN MEHMET. Anterior Mitral Valve Length is Associated with Ventricular Tachycardia in Patients with Classical Mitral Valve Prolapse. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1224-30. [DOI: 10.1111/j.1540-8159.2010.02798.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging 2009; 26:139-45. [PMID: 19847667 DOI: 10.1007/s10554-009-9514-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 09/16/2009] [Indexed: 10/20/2022]
Abstract
Arrhythmias have been reported to occur frequently in symptomatic patients with mitral valve prolapse (MVP). The mechanisms causing ventricular arrhythmias in patients with MVP have not been fully investigated. The purpose of this study was to determine the clinical, echocardiographic and heart rate variability parameters, and plasma concentrations of electrolytes and inflammatory markers in predicting ventricular arrhythmias in patients with MVP. A total of 58 consecutive patients with MVP were included in this study. We performed electrocardiography, echocardiography, holter analysis, routine biochemical tests including plasma concentrations of electrolytes and inflammatory markers, and evaluated the clinical characteristics. Ventricular arrhythmia defined as occurrence of any of the followings: ventricular premature contractions (VPCs), VPC couplets, and ventricular tachycardia documented by holter analysis, continuous monitoring or by electrocardiography. Twenty patients (34%) had ventricular arrhythmias, and 38 (66%) patients had no ventricular arrhythmias. Seventeen patients had VPC, 2 patients had VPC couplets and 1 patient had ventricular tachycardia. Univariable predictors of ventricular arrhythmias included isovolumetric relaxation time and the occurrence of moderate to severe mitral regurgitation. Multivariable logistic regression analysis showed that occurrence of moderate to severe mitral regurgitation was the only independent predictor of ventricular arrhythmias (relative risk: 8.42, 95% confidence interval: 1.49-47.64, p = 0.01). Present study showed that the only independent predictor of ventricular arrhythmias in patients with MVP is the occurrence of moderate to severe mitral regurgitation.
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 698] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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17
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Médeau V, Moreau F, Trinquart L, Clemessy M, Wémeau JL, Vantyghem MC, Plouin PF, Reznik Y. Clinical and biochemical characteristics of normotensive patients with primary aldosteronism: a comparison with hypertensive cases. Clin Endocrinol (Oxf) 2008; 69:20-8. [PMID: 18284637 DOI: 10.1111/j.1365-2265.2008.03213.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE It is unknown why some patients with biochemical evidence of primary aldosteronism (PA) do not develop hypertension. We aimed to compare clinical and biochemical characteristics of normotensive and hypertensive patients with PA. DESIGN AND PATIENTS Retrospective comparison of 10 normotensive and 168 hypertensive patients with PA for office or ambulatory blood pressure, serum potassium, plasma aldosterone and renin concentrations; the aldosterone:renin ratio, and tumour size. Comparison of initial hormonal pattern and drop in blood pressure following adrenalectomy in five normotensive and nine hypertensive patients matched for age, sex and body mass index. RESULTS The 10 normotensive patients were women and presented with hypokalemia or an adrenal mass. Age, plasma aldosterone and renin concentrations were similar in normotensive and hypertensive cases, but kalemia and body mass index were significantly lower in the normotensive patients. Mean tumour diameter was larger in the normotensive patients than in the hypertensive matched patients with an adenoma (P < 0.01). In normotensive patients, diastolic blood pressure and upright aldosterone correlated negatively with kalemia. Blood pressure was lowered similarly after adrenalectomy in five normotensive PA patients and in their matched hypertensive counterparts. Aldosterone synthase expression was detected in four out of five adrenal tumours. CONCLUSIONS Blood pressure may be normal in patients with well-documented PA. The occurrence of hypokalemia, despite a normal blood pressure profile, suggests that protective mechanisms against hypertension are present in normotensive patients.
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Affiliation(s)
- Virginie Médeau
- Département d'Hypertension, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
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18
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1-148. [PMID: 16875962 DOI: 10.1016/j.jacc.2006.05.021] [Citation(s) in RCA: 1091] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114:e84-231. [PMID: 16880336 DOI: 10.1161/circulationaha.106.176857] [Citation(s) in RCA: 1391] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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20
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21
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ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Bobkowski W, Siwińska A, Zachwieja J, Mroziński B, Rzeźnik-Bieniaszewska A, Maciejewski J. A prospective study to determine the significance of ventricular late potentials in children with mitral valvar prolapse. Cardiol Young 2002; 12:333-8. [PMID: 12206555 DOI: 10.1017/s1047951100012920] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We aimed prospectively to determine the incidence of ventricular arrhythmias and ventricular late potentials in children with mitral valvar prolapse, and to assess whether signal-averaged electrocardiography could identify which such children were at high risk of developing ventricular tachycardia. In all, we examined 151 children with mitral valvar prolapse, at an age of 12.2 +/- 3.1 years, and 164 healthy subjects aged 12.3 +/- 3.7 years. All children underwent 24-hour ambulatory Holter monitoring and echocardiography. The children with mitral valvar prolapse were followed prospectively for a mean of 64 months. There was a significantly higher prevalence of ventricular arrhythmias in those with prolapse than in the controls (p < 0.0001). Runs of ventricular tachycardia were observed in 3 children with mitral valvar prolapse compared with one from the control group. Late potentials were more frequently observed in the children with mitral valvar prolapse than in those who were healthy (p < 0.0001), and also in those with prolapse suffering ventricular arrhythmias compared with those without ventricular arrhythmias (p < 0.02). During follow-up, 24 children with prolapsing mitral valves developed non-sustained ventricular tachycardia, giving a frequency of 3.1/100 subject-years. The sensitivity of late potentials was low, at 52%, for the identification of children with mitral valvar prolapse who developed ventricular tachycardia, although the specificity was high at 90%. This gave a positive predictive value of 50%, and a negative predictive value of 91%. We conclude that prolapse of the mitral valve predisposes to the development of ventricular arrhythmias and late potentials in children. An abnormal signal-averaged electrocardiogram is a specific, but not very sensitive, predictor for the development of ventricular tachycardia in such children.
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Affiliation(s)
- Waldemar Bobkowski
- Department of Pediatric Cardiology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland.
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23
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Herrmann BL, Bruch C, Saller B, Ferdin S, Dagres N, Ose C, Erbel R, Mann K. Occurrence of ventricular late potentials in patients with active acromegaly. Clin Endocrinol (Oxf) 2001; 55:201-7. [PMID: 11531926 DOI: 10.1046/j.1365-2265.2001.01319.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Patients with acromegaly have an increased risk of ventricular dysrhythmias and sudden death. Late potentials in a signal-averaged electrocardiogram (SAECG), a predictor of ventricular dysrhythmias, are frequently seen in patients after previous myocardial infarction, but little is known about the prevalence of late potentials in acromegaly. The aim of our study was to investigate the prevalence of late potentials in patients with acromegaly and their relation to the activity of the disease and to myocardial hypertrophy. PATIENTS The study included 48 patients with acromegaly [27 males, 21 females, mean age 52.3 +/- 14.2 years, 16 active disease, 32 cured or 'well controlled', under treatment with sandostatin analogues (12/32)] and 38 healthy volunteers as a control group. RESULTS Late potentials were detected in 9/16 (56%) patients with active acromegaly vs. 2/32 (6%) with cured/well controlled acromegaly (P = 0.001), defined as normal age-related IGF-1 levels and GH levels suppressible below 1 microg/l after an oral glucose load (75 g). Late potentials were not related to muscle mass index (127 +/- 35 active vs. 123 +/- 34 g/m2 cured/well controlled). The association of disease activity with the detection of late potentials was independent of age, gender, duration of the disease and body mass index. In comparison to the control group, the prevalence of late potentials was significantly higher in patients with acromegaly (23%) than in the control group (0%; P < 0.001). CONCLUSIONS Late potentials in the SAECG are frequently seen in active acromegaly and may represent an early and sensitive parameter to detect myocardial injury in acromegaly.
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Affiliation(s)
- B L Herrmann
- Division of Endocrinology, University of Essen, Germany.
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Affiliation(s)
- W Jacobs
- Division of Cardiology, University of Texas Medical Branch, Galveston 77555-0553, USA
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Abstract
The patient with nonsustained ventricular tachycardia represents a common management problem for the cardiologist. The challenges posed by this type of arrhythmia differs from those posed by other arrhythmias, because most instances of nonsustained ventricular tachycardia do not cause symptoms. This article reviews common situations in which nonsustained ventricular tachycardia occurs and their appropriate management.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Cardiomyopathy, Dilated/complications
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/physiopathology
- Coronary Disease/complications
- Coronary Disease/diagnosis
- Coronary Disease/physiopathology
- Death, Sudden, Cardiac/prevention & control
- Diagnosis, Differential
- Electric Countershock
- Electrocardiography, Ambulatory
- Heart Rate
- Humans
- Mitral Valve Prolapse/complications
- Mitral Valve Prolapse/diagnosis
- Mitral Valve Prolapse/physiopathology
- Prognosis
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/therapy
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Affiliation(s)
- A E Buxton
- Cardiovascular Division, Brown University School of Medicine, Rhode Island Hospital, Providence, USA
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26
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Ulgen MS, Biyik I, Karadede A, Temamogullari AV, Alan S, Toprak N. Relation between QT dispersion and ventricular arrhythmias in uncomplicated isolated mitral valve prolapse. JAPANESE CIRCULATION JOURNAL 1999; 63:929-33. [PMID: 10614836 DOI: 10.1253/jcj.63.929] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Complications of mitral valve prolapse (MVP), among which serious ventricular arrhythmia and sudden death are of major importance, affect many individuals due to the high incidence of MVP itself in the community despite the actual low incidence of these complications. The present study investigated the incidence and distribution of ventricular arrhythmias according to their severity and relationship with the QT interval and dispersion of repolarization in uncomplicated isolated MVP (IMVP) cases. Fifty-eight uncomplicated IMVP patients, 33 patients with accompanying tricuspid valve prolapse (TVP), to compare its relationship with ventricular arrhythmia, and 60 age- and sex-matched control subjects were enrolled in the study. Individuals with accompanying cardiac or systemic disease, or who were on drug therapy that could potentially affect QT characteristics, were excluded. The incidence of ventricular arrhythmia was 48% in the IMVP group and 64% in the TVP group; the difference was statistically insignificant. In addition, the differences of the QT and Q peak T values were insignificant, whereas QT dispersion (QTd) and Q peak T dispersion (QpeakTd) values were significantly higher in the patient group (60+/-14, 54+/-14 ms, respectively) compared with the control group (42+/-10, 38+/-10 ms, respectively, p<0.001). Complex ventricular arrhythmias (Lown Grade > or =III) in the IMVP group had a significant relationship with QTd and QpeakTd (p<0.001), but not with QT or QpeakT. As a result of the study, it is concluded that TVP accompanying MVP does not increase the incidence of ventricular arrhythmia, that ventricular arrhythmia is related to QT dispersion rather than QT interval in IMVP, that the QT dispersion is a fairly good marker for identifying the high-risk group for serious ventricular arrhythmia and sudden death, and that QpeakT dispersion measurement is an additional indicator that could be an alternative when QT is difficult to determine in conditions such as high heart rate or the presence of U wave.
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Affiliation(s)
- M S Ulgen
- Department of Cardiology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey.
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27
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Abstract
Most ventricular tachycardias encountered in clinical practice occur in patients who have structural heart disease. Idiopathic ventricular tachycardia refers to those arrhythmias that occur in patients without structural heart disease, metabolic/electrolyte abnormalities, or the long QT syndrome. Three commonly recognized forms of idiopathic ventricular tachycardia include: (a) ventricular tachycardia associated with mitral valve prolapse, (b) ventricular tachycardia originating from the right ventricular outflow tract, and (c) ventricular tachycardia originating from the left ventricle. Recently, a fourth type of idiopathic ventricular tachycardia, termed the Brugada syndrome, has been identified as responsible for some cases of cardiac arrest in persons without apparent structural heart disease. Each form of ventricular tachycardia may be considered a discrete syndrome based on its electrocardiographic characteristics, mechanisms, responses to pharmacologic intervention, and prognosis (good in most cases). Ventricular tachycardias range from the common to the exotic, but all represent syndromes with which the internist and general cardiologist should be familiar.
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Affiliation(s)
- G T Altemose
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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28
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ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol 1998; 32:1486-588. [PMID: 9809971 DOI: 10.1016/s0735-1097(98)00454-9] [Citation(s) in RCA: 540] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mäkijärvi M, Breithardt G, Reinhardt L, Fetsch T, Borggrefe M, Martinez-Rubio A. Signal-Averaged Electrocardiogram: Update 1997. Ann Noninvasive Electrocardiol 1997. [DOI: 10.1111/j.1542-474x.1997.tb00204.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davidson TW, Davis JL, Douglas PS, Gillam LD. ACC/AHA Guidelines for the Clinical Application of Echocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. Circulation 1997; 95:1686-744. [PMID: 9118558 DOI: 10.1161/01.cir.95.6.1686] [Citation(s) in RCA: 377] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Fauchier JP, Fauchier L, Babuty D, Cosnay P. Time-domain signal-averaged electrocardiogram in nonischemic ventricular tachycardia. Pacing Clin Electrophysiol 1996; 19:231-44. [PMID: 8834693 DOI: 10.1111/j.1540-8159.1996.tb03315.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The prevalence of late ventricular potentials (LVPs) detected by signal averaged ECG (SAECG) is variable in nonischemic heart diseases. In idiopathic dilated cardiomyopathy, the prevalence increases from about 25% to 70%-90% in cases of spontaneous sustained ventricular tachycardia (VT), is not significantly correlated with hemodynamic and Holter data, and has a good positive predictive value for induced and spontaneous sustained VT. However, its predictive value for cardiac death has not been established. In primary hypertrophic cardiomyopathy, LVPs are rare (about 10%), not correlated to hemodynamic data, enhanced in cases of spontaneous sustained VT (up to 77%), and have a good predictive value of induced VT. LVP-SAECG are frequent in arrhythmogenic right ventricular dysplasia (ARVD) (70%-80%). They can identify patients with VT and an unapparent or limited form of this disease, or ARVD with few ventricular arrhythmias. The prevalence (26%-37%) of LVPs in mitral valve prolapse is clearly higher than in normal individuals or in other valvular diseases and is enhanced in cases of spontaneous and induced VT. Its significance remains speculative. After surgical repair of tetralogy of Fallot, LVPs can identify a group of patients with higher probability of induced and spontaneous risk of VT. The usefulness and significance of LVPs in other nonischemic cardiac diseases have not to date been established. In "true" idiopathic VT, without proved structural cardiac disease, the prevalence of LVPs does not exceed that observed in normal individuals (0%-5%), but in "apparent" idiopathic VT the prevalence of LVPs rises to 20%-40%. In these latter cases more invasive techniques must be used to discover a limited form of myocardiopathy.
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Affiliation(s)
- J P Fauchier
- Cardiology B Department, Hospital Trousseau, Tours, France
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Banasiak W, Pajak I, Ponikowski P, Lacheta W, Wiech K, Piepoli M, Telichowski C. P-wave signal-averaged electrocardiogram in patients with idiopathic mitral valve prolapse syndrome and supraventricular arrhythmias. Int J Cardiol 1995; 50:175-80. [PMID: 7591329 DOI: 10.1016/0167-5273(95)02395-d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The aim of the study was to assess whether the P-wave triggered signal-averaged ECG (SAECG) used in patients with idiopathic mitral valve prolapse syndrome could predict the risk of the development of supraventricular arrhythmias. Fifty patients with idiopathic mitral valve prolapse syndrome (15 men, 35 women, mean age: 37 +/- 9 years) were prospectively studied. P-wave triggered SAECG was recorded with a commercially available system (HIPEC-200HA Aerotel). The following parameters were calculated: the root-mean-square voltage for the terminal 10, 20, 30 ms of filtered P-wave (RMS10,20,30) and time duration of filtered P-wave (PWD). Nine patients with mitral valve prolapse syndrome (18%) revealed the occurrence of supraventricular arrhythmias on Holter monitoring whereas of the remaining 41 (82%), no clinically relevant supraventricular arrhythmias were detected. We found PWD values to be significantly longer in patients with supraventricular arrhythmias when compared with those without arrhythmias: 119.8 +/- 6.9 ms vs. 111.7 +/- 12.1 ms, respectively, P < 0.02. We conclude that P-wave triggered SAECG could be a useful technique for detecting patients with idiopathic mitral valve prolapse syndrome at risk of paroxysmal supraventricular arrhythmias.
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Affiliation(s)
- W Banasiak
- Department of Cardiology, Clinical Military Hospital, Wroclaw, Poland
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