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Silvetti E, Lanza O, Romeo F, Martino A, Fedele E, Lanzillo C, Crescenzi C, Fanisio F, Calò L. The pivotal role of ECG in cardiomyopathies. Front Cardiovasc Med 2023; 10:1178163. [PMID: 37404739 PMCID: PMC10315483 DOI: 10.3389/fcvm.2023.1178163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/15/2023] [Indexed: 07/06/2023] Open
Abstract
Cardiomyopathies are a heterogeneous group of pathologies characterized by structural and functional alterations of the heart. Recent technological advances in cardiovascular imaging offer an opportunity for deep phenotypic and etiological definition. Electrocardiogram (ECG) is the first-line diagnostic tool in the evaluation of both asymptomatic and symptomatic individuals. Some electrocardiographic signs are pathognomonic or fall within validated diagnostic criteria of individual cardiomyopathy such as the inverted T waves in right precordial leads (V1-V3) or beyond in individuals with complete pubertal development in the absence of complete right bundle branch block for the diagnosis of arrhythmogenic cardiomyopathy of the right ventricle (ARVC) or the presence of low voltages typically seen in more than 60% of patients with amyloidosis. Most other electrocardiographic findings such as the presence of depolarization changes including QRS fragmentation, the presence of epsilon wave, the presence of reduced or increased voltages as well as alterations in the repolarization phase including the negative T waves in the lateral leads, or the profound inversion of the T waves or downsloping of the ST tract are more non-specific signs which can however raise the clinical suspicion of cardiomyopathy in order to initiate a diagnostic procedure especially using imaging techniques for diagnostic confirmation. Such electrocardiographic alterations not only have a counterpart in imaging investigations such as evidence of late gadolinium enhancement on magnetic resonance imaging, but may also have an important prognostic value once a definite diagnosis has been made. In addition, the presence of electrical stimulus conduction disturbances or advanced atrioventricular blocks that can be seen especially in conditions such as cardiac amyloidosis or sarcoidosis, or the presence of left bundle branch block or posterior fascicular block in dilated or arrhythmogenic left ventricular cardiomyopathies are recognized as a possible expression of advanced pathology. Similarly, the presence of ventricular arrhythmias with typical patterns such as non-sustained or sustained ventricular tachycardia of LBBB morphology in ARVC or non-sustained or sustained ventricular tachycardia with an RBBB morphology (excluding the "fascicular pattern") in arrhythmogenic left ventricle cardiomyopathy could have a significant impact on the course of each disease. It is therefore clear that a learned and careful interpretation of ECG features can raise suspicion of the presence of a cardiomyopathy, identify diagnostic "red flags" useful for orienting the diagnosis toward specific forms, and provide useful tools for risk stratification. The purpose of this review is to emphasize the important role of the ECG in the diagnostic workup, describing the main ECG findings of different cardiomyopathies.
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Alblaihed L, Kositz C, Brady WJ, Al-Salamah T, Mattu A. Diagnosis and management of arrhythmogenic right ventricular cardiomyopathy. Am J Emerg Med 2023; 65:146-153. [PMID: 36638611 DOI: 10.1016/j.ajem.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder of the myocardium that can lead to ventricular arrhythmia and sudden cardiac death. The condition has been identified as a significant cause of arrhythmic death among young people and athletes, therefore, early recognition of the disease by emergency clinicians is critical to prevent subsequent death. The diagnosis of ARVC can be very challenging and requires a systematic approach. This publication reviews the pathophysiology, classification, clinical presentations, and appropriate approach to diagnosis and management of ARVC.
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Affiliation(s)
- Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6(th) Floor, Suite 200, Baltimore, MD 21201, United States of America.
| | - Christine Kositz
- Depratment of Emergency Medicine, University of Maryland Shore Medical Center at Easton, 219 S Washington St, Easton, MD 21601, United States of America
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Tareq Al-Salamah
- Department of Emergency Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6(th) Floor, Suite 200, Baltimore, MD 21201, United States of America
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Abela M, Yamagata K, Buttigieg L, Xuereb S, Bonello J, Soler JF, Camilleri W, Grech N, Xuereb R, Sapiano K, Abela E, Callus A, Farrugia M, Felice T, Burg M, Sammut M, Xuereb RG, Grech V. The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT). Int J Cardiol 2023; 371:508-515. [PMID: 36087635 DOI: 10.1016/j.ijcard.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 09/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain. AIM This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years. METHODS Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance. RESULTS The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months). CONCLUSION Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta; Medical School, University of Malta, Malta; St. George's, University of London, London, United Kingdom.
| | | | - Lisa Buttigieg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Sara Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - John Bonello
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | | | | | - Neil Grech
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Rachel Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Karl Sapiano
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Estelle Abela
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Adrian Callus
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Maria Farrugia
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Tiziana Felice
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Melanie Burg
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Mark Sammut
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Robert G Xuereb
- Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Malta
| | - Victor Grech
- Medical School, University of Malta, Malta; Department of Paediatrics, Mater' Dei Hospital, Tal-Qroqq, Malta
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4
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Boonstra M, Kloosterman M, van der Schaaf I, Roudijk R, van Dam P, Loh P. ECG-based techniques to enhance clinical practice in cardiac genetic disease management. J Electrocardiol 2023; 76:55-60. [PMID: 36436475 DOI: 10.1016/j.jelectrocard.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/10/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Inherited cardiomyopathies are associated with a broad spectrum of potentially lethal phenotypes characterized by structural and electrical myocardial remodeling. Increased awareness and genetic cascade screening lead to more genotype-positive, yet phenotype-negative individuals to be evaluated and followed up. The predictive value of genetic testing is hampered by incomplete penetrance and high variability in disease onset, progression and severity. CLINICAL CHALLENGES Dilated cardiomyopathy usually manifests with symptoms of heart failure and ventricular arrhythmias (VA) develop in advanced disease. In arrhythmogenic cardiomyopathy (ACM), electrical remodeling can precede structural and functional changes and life-threatening VA can be the first disease manifestation. Early signs and symptoms may be subtle and go unnoticed. Physicians are in great need of appropriate screening and risk-stratification strategies. Task Force Criteria (TFC) were established to standardize the clinical diagnosis of ACM but risk-stratification remains challenging. Accurate prediction of disease progression in variation carriers is currently beyond the capabilities of diagnostic tests. PROPOSED DIAGNOSTIC TECHNIQUES We propose three ECG-based techniques; isopotential mapping, inverse ECG and CineECG, to enhance risk-stratification in ACM. With the use of isopotential mapping abnormal spatio-temporal activation and repolarization may be identified. Furthermore, by combining subject specific ≥12‑lead ECG data with cardiothoracic imaging using inverse ECG techniques, the direct link between ECG and cardiac anatomy can be obtained. CONCLUSION New ECG techniques may prove more sensitive to detect early de- and repolarization abnormalities in yet asymptomatic variation carriers. Early electrical signs of disease progression may be identified prior to symptoms. Furthermore, individualized risk-stratification may be enhanced.
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Affiliation(s)
- Machteld Boonstra
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Manon Kloosterman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Iris van der Schaaf
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rob Roudijk
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Peter van Dam
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Loh
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Boonstra MJ, Oostendorp TF, Roudijk RW, Kloosterman M, Asselbergs FW, Loh P, Van Dam PM. Incorporating structural abnormalities in equivalent dipole layer based ECG simulations. Front Physiol 2022; 13:1089343. [PMID: 36620207 PMCID: PMC9814485 DOI: 10.3389/fphys.2022.1089343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction: Electrical activity of the myocardium is recorded with the 12-lead ECG. ECG simulations can improve our understanding of the relation between abnormal ventricular activation in diseased myocardium and body surface potentials (BSP). However, in equivalent dipole layer (EDL)-based ECG simulations, the presence of diseased myocardium breaks the equivalence of the dipole layer. To simulate diseased myocardium, patches with altered electrophysiological characteristics were incorporated within the model. The relation between diseased myocardium and corresponding BSP was investigated in a simulation study. Methods: Activation sequences in normal and diseased myocardium were simulated and corresponding 64-lead BSP were computed in four models with distinct patch locations. QRS-complexes were compared using correlation coefficient (CC). The effect of different types of patch activation was assessed. Of one patient, simulated electrograms were compared to electrograms recorded during invasive electro-anatomical mapping. Results: Hundred-fifty-three abnormal activation sequences were simulated. Median QRS-CC of delayed versus dyssynchronous were significantly different (1.00 vs. 0.97, p < 0.001). Depending on the location of the patch, BSP leads were affected differently. Within diseased regions, fragmentation, low bipolar voltages and late potentials were observed in both recorded and simulated electrograms. Discussion: A novel method to simulate cardiomyopathy in EDL-based ECG simulations was established and evaluated. The new patch-based approach created a realistic relation between ECG waveforms and underlying activation sequences. Findings in the simulated cases were in agreement with clinical observations. With this method, our understanding of disease progression in cardiomyopathies may be further improved and used in advanced inverse ECG procedures.
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Affiliation(s)
- Machteld J Boonstra
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands,*Correspondence: Machteld J Boonstra,
| | - Thom F Oostendorp
- Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands
| | - Rob W Roudijk
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Manon Kloosterman
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands,Faculty of Population Health Sciences, Institute of Cardiovascular Science, University College London, London, United Kingdom,Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | - Peter Loh
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Peter M Van Dam
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands,ECG Excellence BV, Nieuwerbrug aan den Rijn, Weijland, Netherlands
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Miljoen H, Spera F, Van Kolen K, Saenen J, Claessen G, Huybrechts W, Sarkozy A, Heidbuchel H. Electrocardiographic phenotype of exercise-induced arrhythmogenic cardiomyopathy: A retrospective observational study. Front Cardiovasc Med 2022; 9:1052174. [PMID: 36505386 PMCID: PMC9726729 DOI: 10.3389/fcvm.2022.1052174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The right ventricle can be susceptible to pathologic alterations with exercise. This can cause changes to the ECG. Our aim was to identify the electrocardiographic phenotype of exercise induced (ExI) arrhythmogenic cardiomyopathy (ACM). Methods A retrospective analysis of ECGs at rest, peak exercise and 1 min of recovery in four groups of individuals was performed: Arrhythmogenic Cardiomyopathy with genetic confirmation (Gen-ACM; n = 16), (genetically negative) ExI-ACM (n = 15), control endurance athletes (End; n = 16) and sedentary individuals (Sed; n = 16). The occurrence of ventricular arrhythmias (VA) and, at each stage, QRS duration, Terminal Activation Delay (TAD), the ratio of the sum of the QRS durations in the right precordials (V1-V3) over that in the left precordials (V4-V6; R/L duration ratio), the presence of complete RBBB and T-wave inversion (TWI) beyond lead V2 were evaluated. Results At rest, complete RBBB was exclusively found in Gen-ACM (6%) and ExI-ACM (13%). No epsilon waves were identified. TWI beyond V2 was uniquely present in Gen-ACM (73%) and ExI-ACM (38%; p < 0.001). VA was present in Gen-ACM (88%); ExI-ACM (80%), End (25%) and Sed (19%; p < 0.001). The presence of R/L duration ratio of >1.2 and TAD ≥ 55 ms were not significantly different over the four groups (p = 0.584 and p = 0.218, respectively). At peak exercise the most striking finding was a significant decrease of the R/L duration ratio in individuals with ACM, which was the result of lateral precordial QRS prolongation. Conclusion ExI-ACM shares important ECG-features with Gen-ACM, suggesting a similar underlying pathogenesis regardless of the presence or absence of desmosomal mutations.
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Affiliation(s)
- Hielko Miljoen
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium,*Correspondence: Hielko Miljoen
| | - Francesco Spera
- Department of Cardiology, University Hospital, Antwerp, Belgium
| | | | - Johan Saenen
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, Cardiology, Leuven University, Leuven, Belgium
| | - Wim Huybrechts
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
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Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:533-553. [PMID: 35450611 DOI: 10.1016/j.jacep.2021.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/21/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) encompasses a group of conditions characterized by right ventricular fibrofatty infiltration, with a predominant arrhythmic presentation. First described in the late 1970s and early 1980s, it is now frequently recognized to have biventricular involvement. The prevalence is ∼1:2,000 to 1:5,000, depending on geographic location, and it has a slight male predominance. The diagnosis of ARVC is determined on the basis of fulfillment of task force criteria incorporating electrophysiological parameters, cardiac imaging findings, genetic factors, and histopathologic features. Risk stratification of patients with ARVC aims to identify those who are at increased risk of sudden cardiac death or sustained ventricular tachycardia. Factors including age, sex, electrophysiological features, and cardiac imaging investigations all contribute to risk stratification. The current management of ARVC includes exercise restriction, β-blocker therapy, consideration for implantable cardioverter-defibrillator insertion, and catheter ablation. This review summarizes our current understanding of ARVC and provides clinicians with a practical approach to diagnosis and management.
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Przybylski R, Abrams DJ. Clinical and genetic features of arrhythmogenic cardiomyopathy: the electrophysiology perspective. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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9
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Kommata V, Elshafie M, Sciaraffia E, Perez M, Augustine R, Blomström-Lundqvist C. QRS dispersion detected in ARVC patients and healthy gene carriers using 252-leads body surface mapping: an explorative study of a potential diagnostic tool for arrhythmogenic right ventricular cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1355-1364. [PMID: 34109638 DOI: 10.1111/pace.14295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/26/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers. METHODS ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12-lead resting ECG, signal-averaged ECG, echocardiographic examination, 24-hours Holter monitoring, and BSM with electrocardiographic imaging. All 252-leads BSM recordings and 12-leads ECG recordings were manually analyzed for QRS durations and QRS dispersion. RESULTS Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG-QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM-derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut-off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes. CONCLUSIONS QRS dispersion, when assessed by BSM versus 12-lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM-QRS dispersion in this respect.
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Affiliation(s)
- Varvara Kommata
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Marwa Elshafie
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Elena Sciaraffia
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Mauricio Perez
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Robin Augustine
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
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Gasperetti A, James CA, Cerrone M, Delmar M, Calkins H, Duru F. Arrhythmogenic right ventricular cardiomyopathy and sports activity: from molecular pathways in diseased hearts to new insights into the athletic heart mimicry. Eur Heart J 2021; 42:1231-1243. [PMID: 33200174 DOI: 10.1093/eurheartj/ehaa821] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/12/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease associated with a high risk of sudden cardiac death. Among other factors, physical exercise has been clearly identified as a strong determinant of phenotypic expression of the disease, arrhythmia risk, and disease progression. Because of this, current guidelines advise that individuals with ARVC should not participate in competitive or frequent high-intensity endurance exercise. Exercise-induced electrical and morphological para-physiological remodelling (the so-called 'athlete's heart') may mimic several of the classic features of ARVC. Therefore, the current International Task Force Criteria for disease diagnosis may not perform as well in athletes. Clear adjudication between the two conditions is often a real challenge, with false positives, that may lead to unnecessary treatments, and false negatives, which may leave patients unprotected, both of which are equally inacceptable. This review aims to summarize the molecular interactions caused by physical activity in inducing cardiac structural alterations, and the impact of sports on arrhythmia occurrence and other clinical consequences in patients with ARVC, and help the physicians in setting the two conditions apart.
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Cynthia A James
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Marina Cerrone
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Mario Delmar
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Firat Duru
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.,Center for Integrative Human Physiology, University of Zurich, Rämistrasse 71, Zurich 8006, Switzerland
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11
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Landry CH, Fatah M, Connelly KA, Angaran P, Hamilton RM, Dorian P. Evaluating the 12-Lead Electrocardiogram for Diagnosing ARVC in Young Populations: Implications for Preparticipation Screening of Athletes. CJC Open 2021; 3:498-503. [PMID: 34027353 PMCID: PMC8129442 DOI: 10.1016/j.cjco.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 10/24/2022] Open
Abstract
Background Arrhythmogenic right-ventricular cardiomyopathy (ARVC) is an identified cause of sport-related sudden cardiac arrest (SCA). Identifying athletes with ARVC and restricting them from exercise is believed to reduce the risk of SCA. The electrocardiogram (ECG) is considered to be an important component of screening for ARVC; however, the sensitivity of the 12-lead ECG to identify ARVC in young asymptomatic persons is unknown. Methods In this retrospective study, we identified 70 patients (49 ARVC-positive, based on Task Force Criteria, and 21 age-matched ARVC-negative persons from a paediatric arrhythmia database (<18 years of age); ECGs were analyzed for abnormalities, based on International Criteria for Interpretation of ECGs in Athletes, and ECG findings were adjudicated by group consensus. Results Of the 49 ARVC-positive patients (median age: 17 [interquartile range: 16-18], 65% male), 22% were found to have abnormal ECGs; the most common ECG findings were T-wave inversions. Patients with symptoms were more likely to have abnormal ECGs than asymptomatic patients (28% compared with 17%, respectively; P = 0.002). Of 16 gene-positive patients, 31% had abnormal ECGs. Patients with abnormal ECGs had larger right-ventricular end-diastolic volume indexes on magnetic resonance imaging than those with normal ECGs (P = 0.03). Conclusions The ECG was insensitive for detecting ARVC in young (age <18 years), asymptomatic patients, and is unlikely to provide significant diagnostic value for identifying ARVC on routine preparticipation screening of adolescent athletes.
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Affiliation(s)
- Cameron H Landry
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meena Fatah
- Department of Paediatrics (Cardiology) and the Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and the Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Robert M Hamilton
- Department of Paediatrics (Cardiology) and the Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Dorian
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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Lopez-Ayala JM, Gimeno-Blanes J, Lopez-Cuenca D, Molina MS, Gimeno-Blanes JR. Electrocardiographic Screening of Arrhythmogenic Cardiomyopathy in Genotype-Positive and Phenotype-Negative Relatives. Front Cardiovasc Med 2021; 8:646391. [PMID: 34026867 PMCID: PMC8137826 DOI: 10.3389/fcvm.2021.646391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Arrhythmogenic cardiomyopathy is a hereditary cause of ventricular arrhythmias and sudden death. Identifying the healthy genetic carriers who will develop the disease remains a challenge. A novel approach to the analysis of the digital electrocardiograms of mutation carriers through signal processing may identify early electrocardiographic abnormalities. Methods: A retrospective case–control study included a population of healthy genetics carriers and their wild-type relatives. Genotype-positive/phenotype-negative individuals bore mutations associated with the development of arrhythmogenic cardiomyopathy. The relatives included had a non-pathological 12-lead electrocardiogram, echocardiogram, and a cardiac magnetic resonance. Automatic digital electrocardiographic analyses comprised QRS and terminal activation delay duration, the number of QRS fragmentations, ST slope, and T-wave voltage. Results: Digital 12-lead electrocardiograms from 41 genotype-positive/ phenotype-negative (29 simple carriers and 12 double mutation carriers) and 73 wild-type relatives were analyzed. No differences in the QRS length, the number of QRS fragmentations, and the voltage of the T-wave were observed. After adjusting for potential confounders, double carriers showed an average ST-slope flatter than those of the simple carriers and wild type [5.18° (0.73–8.01), 7.15° (5.14–11.05), and 11.46° (3.94–17.49), respectively, p = 0.005]. There was a significant negative correlation between the ST slope and the age in genotype-positive/phenotype-negative relatives (r = 0.376, p = 0.021) not observed in their wild-type counterparts (r = 0.074, p = 0.570). Conclusions: A flattened ST segment may be an early sign of electrical remodeling that precedes T-wave inversion in healthy genetic carriers. A thorough analysis of the digital electrocardiographic signal may help identify and measure early electrical abnormalities.
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Affiliation(s)
| | - Javier Gimeno-Blanes
- Department of Signal Theory and Communications, Miguel Hernández University, Alicante, Spain
| | - David Lopez-Cuenca
- Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Maria Sabater Molina
- Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
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Platonov PG, Svensson A. Epsilon Waves as an Extreme Form of Depolarization Delay: Focusing on the Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia. Curr Cardiol Rev 2021; 17:17-23. [PMID: 32778035 PMCID: PMC8142367 DOI: 10.2174/1573403x16666200810105029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022] Open
Abstract
Revision of the Task Force diagnostic criteria (TFC) for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D), in 2010, has increased the sensitivity for the diagnosis of early and familial forms of the disease. Epsilon wave (EW) is a major diagnostic criterion in the context of ARVC/D, however, it remains unquantifiable and therefore, may leave room for substantial subjective interpretation, thus, explaining the existing high inter-observer variability in the assessment of EW. EW, when present, coexists with other disease characteristics, which are sufficient for ARVC/D diagnosis, making EW generally not required for ARVC/D diagnosis. Nevertheless, EW remains an important part of the electrocardiographic phenotype of ARVC/D that may be useful in planning diagnostic work-up, which needs to be recognized.
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Affiliation(s)
- Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University and Arrhythmia Clinic, Skane University Hospital, Lund, Sweden
| | - Anneli Svensson
- Department of Cardiology, Linkoping University Hospital, Linkoping, Sweden
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14
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Fujino M, Miyazaki A, Furukawa O, Somura J, Yoshida Y, Hayama Y, Kamakura S, Negishi J, Wada M, Kusano K, Ohuchi H. Electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy in school-aged children. Heart Vessels 2021; 36:863-873. [PMID: 33511492 DOI: 10.1007/s00380-020-01754-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
It can be difficult to distinguish children with early-stage arrhythmogenic right ventricular cardiomyopathy (ARVC) from those with benign premature ventricular contraction (PVC). We retrospectively evaluated six school-aged children with ARVC and compared with those of 20 with benign PVC. The median age at initial presentation was 11.4 and 10.2 years in ARVC and benign PVC, respectively. None of the ARVC patients fulfilled the diagnostic criteria of ARVC at initial presentation. At ARVC diagnosis, the treadmill exercise test and Holter monitoring showed provoked PVC during exercise and pleomorphic PVC in all ARVC cases, respectively. During the observation period, terminal activation duration (TAD) was prolonged in all ARVC patients. In addition, ΔTAD (5.5 [3-10] ms) were significantly longer than those with benign PVC (p < 0.001). A new notched S-wave in V1 appeared in four (67%) ARVC patients, who had myocardial abnormalities in the right ventricle, and in zero benign PVC. Our electrocardiographic findings, such as provoked PVC during exercise, pleomorphic PVC, prolonged TAD, and a new notched S-wave in V1 could contribute to the early detection of ARVC in school-aged children.
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Affiliation(s)
- Mitsuhiro Fujino
- Department of Pediatric Cardiology, The National Cerebral Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Pediatric Cardiology, The Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology, The National Cerebral Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan. .,Department of Congenital Heart Disease, Division of Transitional Medicine, Shizuoka General Hospital, 4-27-1 Kita-Ando, Aoi-ku, Shizuoka city, Shizuoka, 420-8527, Japan.
| | - Ouki Furukawa
- Department of Pediatrics, The Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Junpei Somura
- Department of Pediatrics, The Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Yoko Yoshida
- Department of Pediatric Electrophysiology, The Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Yohsuke Hayama
- Department of Pediatric Cardiology, The National Cerebral Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shiro Kamakura
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, The National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, The National Cerebral Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Mitsuru Wada
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, The National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kengo Kusano
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, The National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, The National Cerebral Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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15
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Cismaru G, Grosu A, Istratoaie S, Mada L, Ilea M, Gusetu G, Zdrenghea D, Pop D, Rosu R. Transesophageal and intracardiac ultrasound in arrhythmogenic right ventricular dysplasia/cardiomyopathy: Two case reports. Medicine (Baltimore) 2020; 99:e19817. [PMID: 32282747 PMCID: PMC7220632 DOI: 10.1097/md.0000000000019817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 01/15/2020] [Accepted: 03/04/2020] [Indexed: 11/17/2022] Open
Abstract
RATIONALE Two-dimensional echocardiography (2D echo) is a major tool for the diagnosis of Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). However 2D echo can skip regional localized anomalies of the right ventricular wall. We aimed to determine whether transesophageal and intracardiac ultrasound can provide additional information, on the right ventricular abnormalities compared to 2D echo. PATIENT CONCERNS Case 1 is a 30-year-old patient that presented in the Emergency Department with multiple episodes of fast monomorphic ventricular tachycardia (VT) manifested by palpitations and diziness. Case 2 is a 65-year-old patient that also presented with episodes of ventircular tachycardia associated with low blood pressure. DIAGNOSIS Both patients had a clear diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy confirmed by cardiac magnetic resonance imaging. INTERVENTION In both patients transesophageal and intracardiac ultrasound was performed, which brought more information on the diagnosis of ARVD/C compared to transthoracic echocardiograpy. OUTCOMES The first patient was implanted with an internal cardiac defibrillator and treated with Sotalol for VT recurrences. He presented episodes of VT during follow-up, treated with antitachycardia pacing. The second patient was implanted with an internal cardiac defibrillator and treated with Sotalol without any VT recurrence at 18 month-follow-up. LESSONS Transesophageal echocardiography and intracardiac echocardiography can provide additional information on small, focal structural abnormalities in patients with ARVD/C: bulges, saculations, aneurysms with or without associated thrombus, partial or complete loss of trabeculations and hypertrophy of the moderator band. These changes are particularly important in cases with "concealed" form of the disease in which no morphological abnormalities are evident in transthoracic echocardiograpy.
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Affiliation(s)
- Gabriel Cismaru
- 5th Department of Internal Medicine, Cardiology-Rehabilitation
| | - Alin Grosu
- 5th Department of Internal Medicine, Cardiology-Medical Clinic No5, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca
| | | | - Laura Mada
- Alba County Hospital, Department of Cardiology, Alba-Iulia, Romania
| | - Maria Ilea
- 5th Department of Internal Medicine, Cardiology-Rehabilitation
| | - Gabriel Gusetu
- 5th Department of Internal Medicine, Cardiology-Rehabilitation
| | | | - Dana Pop
- 5th Department of Internal Medicine, Cardiology-Rehabilitation
| | - Radu Rosu
- 5th Department of Internal Medicine, Cardiology-Rehabilitation
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16
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Roudijk RW, Bosman LP, van der Heijden JF, de Bakker JMT, Hauer RNW, van Tintelen JP, Asselbergs FW, te Riele ASJM, Loh P. Quantitative Approach to Fragmented QRS in Arrhythmogenic Cardiomyopathy: From Disease towards Asymptomatic Carriers of Pathogenic Variants. J Clin Med 2020; 9:jcm9020545. [PMID: 32079223 PMCID: PMC7073517 DOI: 10.3390/jcm9020545] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022] Open
Abstract
Fragmented QRS complexes (fQRS) are common in patients with arrhythmogenic cardiomyopathy (ACM). A new method of fQRS quantification may aid early disease detection in pathogenic variant carriers and assessment of prognosis in patients with early stage ACM. Patients with definite ACM (n = 221, 66%), carriers of a pathogenic ACM-associated variant without a definite ACM diagnosis (n = 57, 17%) and control subjects (n = 58, 17%) were included. Quantitative fQRS (Q-fQRS) was defined as the total amount of deflections in the QRS complex in all 12 electrocardiography (ECG) leads. Q-fQRS was scored by a single observer and reproducibility was determined by three independent observers. Q-fQRS count was feasible with acceptable intra- and inter-observer agreement. Q-fQRS count is significantly higher in patients with definite ACM (54 ± 15) and pathogenic variant carriers (55 ± 10) compared to controls (35 ± 5) (p < 0.001). In patients with ACM, Q-fQRS was not associated with sustained ventricular arrhythmia (p = 0.701) at baseline or during follow-up (p = 0.335). Both definite ACM patients and pathogenic variant carriers not fulfilling ACM diagnosis have a higher Q-fQRS than controls. This may indicate that increased Q-fQRS is an early sign of disease penetrance. In concealed and early stages of ACM the role of Q-fQRS for risk stratification is limited.
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Affiliation(s)
- Rob W. Roudijk
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Laurens P. Bosman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Jeroen F. van der Heijden
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
| | - Jacques M. T. de Bakker
- Department of Clinical and Experimental Cardiology, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Richard N. W. Hauer
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - J. Peter van Tintelen
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
- Department of Genetics, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands
| | - Folkert W. Asselbergs
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London WC1E, UK
- Health Data Research UK and Institute of Health Informatics, University College London, London WC1E, UK
| | - Anneline S. J. M. te Riele
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands;
| | - Peter Loh
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (R.W.R.); (L.P.B.); (J.F.v.d.H.); (R.N.W.H.); (F.W.A.); (A.S.J.M.t.R.)
- Correspondence: ; Tel.: +31-887556176
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17
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De Lazzari M, Zorzi A, Cipriani A, Susana A, Mastella G, Rizzo A, Rigato I, Bauce B, Giorgi B, Lacognata C, Iliceto S, Corrado D, Perazzolo Marra M. Relationship Between Electrocardiographic Findings and Cardiac Magnetic Resonance Phenotypes in Arrhythmogenic Cardiomyopathy. J Am Heart Assoc 2019; 7:e009855. [PMID: 30571483 PMCID: PMC6404435 DOI: 10.1161/jaha.118.009855] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The new designation of arrhythmogenic cardiomyopathy defines a broader spectrum of disease phenotypes, which include right dominant, biventricular, and left dominant variants. We evaluated the relationship between electrocardiographic findings and contrast‐enhanced cardiac magnetic resonance phenotypes in arrhythmogenic cardiomyopathy. Methods and Results We studied a consecutive cohort of patients with a definite diagnosis of arrhythmogenic cardiomyopathy, according to 2010 International Task Force criteria, who underwent electrocardiography and contrast‐enhanced cardiac magnetic resonance. Both depolarization and repolarization electrocardiographic abnormalities were correlated with the severity of dilatation/dysfunction, either global or regional, of both ventricles and the presence and regional distribution of late gadolinium enhancement. The study population included 79 patients (60% men). There was a statistically significant relationship between the presence and extent of T‐wave inversion across a 12‐lead ECG and increasing values of median right ventricular (RV) end‐diastolic volume (P<0.001) and decreasing values of RV ejection fraction (P<0.001). The extent of T‐wave inversion to lateral leads predicted a more severe RV dilatation rather than a left ventricular involvement because of the leftward displacement of the dilated RV, as evidenced by contrast‐enhanced cardiac magnetic resonance. A terminal activation delay of >55 ms in the right precordial leads (V1‐V3) was associated with higher RV volume (P=0.014) and lower RV ejection fraction (P=0.053). Low QRS voltages in limb leads predicted the presence (P=0.004) and amount (P<0.001) of left ventricular late gadolinium enhancement. Conclusions The study results indicated that electrocardiographic abnormalities predict the arrhythmogenic cardiomyopathy phenotype in terms of severity of RV disease and left ventricular involvement, which are among the most important determinants of the disease outcome.
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Affiliation(s)
- Manuel De Lazzari
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alessandro Zorzi
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alberto Cipriani
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Angela Susana
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Giulio Mastella
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alessandro Rizzo
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Ilaria Rigato
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Barbara Bauce
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Benedetta Giorgi
- 2 Division of Radiology Department of Medicine University of Padova Italy
| | - Carmelo Lacognata
- 2 Division of Radiology Department of Medicine University of Padova Italy
| | - Sabino Iliceto
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Domenico Corrado
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
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18
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Clinical Diagnosis, Imaging, and Genetics of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 72:784-804. [PMID: 30092956 DOI: 10.1016/j.jacc.2018.05.065] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 01/30/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited cardiomyopathy that can lead to sudden cardiac death and heart failure. Our understanding of its pathophysiology and clinical expressivity is continuously evolving. The diagnosis of ARVC/D remains particularly challenging due to the absence of specific unique diagnostic criteria, its variable expressivity, and incomplete penetrance. Advances in genetics have enlarged the clinical spectrum of the disease, highlighting possible phenotypes that overlap with arrhythmogenic dilated cardiomyopathy and channelopathies. The principal challenges for ARVC/D diagnosis include the following: earlier detection of the disease, particularly in cases of focal right ventricular involvement; differential diagnosis from other arrhythmogenic diseases affecting the right ventricle; and the development of new objective electrocardiographic and imaging criteria for diagnosis. This review provides an update on the diagnosis of ARVC/D, focusing on the contribution of emerging imaging techniques, such as echocardiogram/magnetic resonance imaging strain measurements or computed tomography scanning, new electrocardiographic parameters, and high-throughput sequencing.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 424] [Impact Index Per Article: 84.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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20
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Protonotarios A, Elliott PM. Arrhythmogenic cardiomyopathies (ACs): diagnosis, risk stratification and management. Heart 2019; 105:1117-1128. [PMID: 30792239 DOI: 10.1136/heartjnl-2017-311160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Alexandros Protonotarios
- UCL Institute of Cardiovascular Science, University College London, London, UK.,Inherited Cardiovascular Disease Unit, Barts Heart Centre, London, UK
| | - Perry M Elliott
- UCL Institute of Cardiovascular Science, University College London, London, UK.,Inherited Cardiovascular Disease Unit, Barts Heart Centre, London, UK
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21
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Wang W, James CA, Calkins H. Diagnostic and therapeutic strategies for arrhythmogenic right ventricular dysplasia/cardiomyopathy patient. Europace 2019; 21:9-21. [PMID: 29688316 PMCID: PMC6321962 DOI: 10.1093/europace/euy063] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/16/2018] [Indexed: 12/21/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a rare inherited heart muscle disease characterized by ventricular tachyarrhythmia, predominant right ventricular dysfunction, and sudden cardiac death. Its pathophysiology involves close interaction between genetic mutations and exposure to physical activity. Mutations in genes encoding desmosomal protein are the most common genetic basis. Genetic testing plays important roles in diagnosis and screening of family members. Syncope, palpitation, and lightheadedness are the most common symptoms. The 2010 Task Force Criteria is the standard for diagnosis today. Implantation of a defibrillator in high-risk patients is the only therapy that provides adequate protection against sudden death. Selection of patients who are best candidates for defibrillator implantation is challenging. Exercise restriction is critical in affected individuals and at-risk family members. Antiarrhythmic drugs and ventricular tachycardia ablation are valuable but palliative components of the management. This review focuses on the current diagnostic and therapeutic strategies in ARVD/C and outlines the future area of development in this field.
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Affiliation(s)
- Weijia Wang
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
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22
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Calò L, Martino A, Goanta E, Okumura Y, de Ruvo E. Right bundle branch block and conduction disturbances in Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy. J Interv Card Electrophysiol 2018; 52:307-313. [DOI: 10.1007/s10840-018-0386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022]
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Oomen AWGJ, Semsarian C, Puranik R, Sy RW. Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy: Progress and Pitfalls. Heart Lung Circ 2018; 27:1310-1317. [PMID: 29705385 DOI: 10.1016/j.hlc.2018.03.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 01/20/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that predominantly affects the right ventricle. With a prevalence in the range of 1:5000 to 1:2000 persons, ARVC is one of the leading causes of sudden cardiac death in young people and in athletes. Although early detection and treatment is important, the diagnosis of ARVC remains challenging. There is no single pathognomonic diagnostic finding in ARVC; rather, current international task force criteria specify diagnostic major and minor criteria in six categories: right ventricular imaging (including echocardiography and cardiac magnetic resonance imaging (MRI)), histology, repolarisation abnormalities, depolarisation and conduction abnormalities, arrhythmias and family history (including genetic testing). Combining findings from differing diagnostic modalities can establish a "definite", "borderline" or "possible" diagnosis of ARVC. However, there are limitations inherent in the current task force criteria, including the lack of specificity for ARVC; future iterations may be improved, for example, by enhanced imaging protocols able to detect subtle changes in the structure and function of the right ventricle, incorporation of electro-anatomical data, response to adrenergic challenge, and validated criteria for interpreting genetic variants.
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Affiliation(s)
- Ad W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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24
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Kimura Y, Takaki H, Inoue YY, Oguchi Y, Nagayama T, Nakashima T, Kawakami S, Nagase S, Noda T, Aiba T, Shimizu W, Kamakura S, Sugimachi M, Yasuda S, Shimokawa H, Kusano K. Isolated Late Activation Detected by Magnetocardiography Predicts Future Lethal Ventricular Arrhythmic Events in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy. Circ J 2017; 82:78-86. [PMID: 28855434 DOI: 10.1253/circj.cj-17-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Risk stratification of ventricular arrhythmias is vital to the optimal management in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). We hypothesized that 64-channel magnetocardiography (MCG) would be useful to detect isolated late activation (ILA) by overcoming the limitations of conventional noninvasive predictors of ventricular tachyarrhythmias, including epsilon waves, late potential (LP), and right ventricular ejection fraction (RVEF), in ARVC patients.Methods and Results:We evaluated ILA on MCG, defined as discrete activations re-emerging after the decay of main RV activation (%magnitude >5%), and conventional noninvasive predictors of ventricular tachyarrhythmias (epsilon waves, LP, and RVEF) in 40 patients with ARVC. ILA was noted in 24 (60%) patients. Most ILAs were found in RV lateral or inferior areas (17/24, 71%). We defined "delayed ILA" as ILA in which the conduction delay exceeded its median (50 ms). During a median follow-up of 42.5 months, major arrhythmic events (MAEs: 1 sudden cardiac death, 3 sustained ventricular tachycardias, and 4 appropriate implantable cardioverter defibrillator discharges) occurred more frequently in patients with delayed ILA (6/12) than in those without (2/28; log-rank: P=0.004). Cox regression analysis identified delayed ILA as the only independent predictor of MAEs (hazard ratio 7.63, 95% confidence interval 1.72-52.6, P=0.007), and other noninvasive parameters were not significant predictors. CONCLUSIONS MCG is useful to identify ARVC patients at high risk of future lethal ventricular arrhythmias.
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Affiliation(s)
- Yoshitaka Kimura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Hiroshi Takaki
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Yuko Y Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasutaka Oguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tomomi Nagayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Cardiovascular Medicine, Nippon Medical School
| | - Shiro Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Affiliation(s)
- Domenico Corrado
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova Medical School, Italy (D.C., C.B.); and Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (D.P.J.)
| | - Cristina Basso
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova Medical School, Italy (D.C., C.B.); and Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (D.P.J.)
| | - Daniel P. Judge
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova Medical School, Italy (D.C., C.B.); and Department of Medicine/Cardiology, Center for Inherited Heart Disease, Johns Hopkins University School of Medicine, Baltimore, MD (D.P.J.)
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26
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Cappelletto C, Stolfo D, De Luca A, Pinamonti B, Barbati G, Pivetta A, Gobbo M, Brun F, Merlo M, Sinagra G. Lifelong arrhythmic risk stratification in arrhythmogenic right ventricular cardiomyopathy: distribution of events and impact of periodical reassessment. Europace 2017. [DOI: 10.1093/europace/eux093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chiara Cappelletto
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Davide Stolfo
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Antonio De Luca
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Bruno Pinamonti
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Giulia Barbati
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
- Cardiovascular Center, Azienda per i Servizi Sanitari n. 1 (A.S.S. 1) of Trieste, Italy
| | - Alberto Pivetta
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Marco Gobbo
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Francesca Brun
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Marco Merlo
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
| | - Gianfranco Sinagra
- Department of Cardiology, University Hospital “Ospedali Riuniti”, SC Cardiologia, Polo Cardiologico, Ospedale di Cattinara, Via Valdoni 7, 34100 Trieste, Italy
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Novak J, Zorzi A, Castelletti S, Pantasis A, Rigato I, Corrado D, Mckenna W, Lambiase PD. Electrocardiographic differentiation of idiopathic right ventricular outflow tract ectopy from early arrhythmogenic right ventricular cardiomyopathy. Europace 2017; 19:622-628. [PMID: 28431055 PMCID: PMC5400079 DOI: 10.1093/europace/euw018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 01/15/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS The differentiation between idiopathic right ventricular outflow tract (RVOT) arrhythmias and early arrhythmogenic right ventricular cardiomyopathy (ARVC) can be challenging. We aimed to assess whether QRS morphological features and coupling interval of ventricular ectopic beats (VEBs) can improve differentiation between the two conditions. METHODS AND RESULTS Twenty desmosomal-gene mutation carriers (13 females, mean age 43 years) with no or mild ARVC phenotypic expression and 33 age- and sex-matched subjects with idiopathic RVOT arrhythmias were studied. All patients exhibited isolated monomorphic VEBs with left bundle branch block/inferior axis morphology. The predictive value of ectopic QRS morphology and coupling interval was evaluated. Five ectopic QRS features were significantly more common in desmosomal-gene mutation carriers than in idiopathic RVOT-ventricular arrhythmia patients: maximal QRS duration >160 ms (60 vs. 27%, P = 0.02), intrinsicoid deflection time >80 ms (65 vs. 24%, P = 0.01), initial QRS slurring (40 vs. 12%, P = 0.04), QS pattern in lead V1 (90 vs. 36%, P < 0.001), and QRS axis >90° in limb leads (60 vs. 24%, P = 0.01). In the multivariate analysis, intrinsicoid deflection time >80 ms [odds ratio (OR) = 9.9], QS pattern in lead V1 (OR = 28), and QRS axis >90° (OR = 5.7) remained independent predictors of early ARVC. The coupling interval did not differ between the two groups. CONCLUSIONS In patients with RVOT VEBs and no major electrocardiographic or echocardiographic abnormalities, the ectopic QRS morphology aids in the differential diagnosis between idiopathic RVOT arrhythmias and early ARVC.
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Affiliation(s)
- Jan Novak
- Institute of Cardiovascular Science, University College of London, London, UK
- Barts Heart Centre, St Barthomolew's Hospital, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Solothurner Spitaeler AG, Solothurn, Switzerland
| | - Alessandro Zorzi
- Institute of Cardiovascular Science, University College of London, London, UK
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Silvia Castelletti
- Institute of Cardiovascular Science, University College of London, London, UK
- Barts Heart Centre, St Barthomolew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Antonis Pantasis
- Institute of Cardiovascular Science, University College of London, London, UK
- Barts Heart Centre, St Barthomolew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Ilaria Rigato
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - William Mckenna
- Institute of Cardiovascular Science, University College of London, London, UK
- Barts Heart Centre, St Barthomolew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Pier D. Lambiase
- Institute of Cardiovascular Science, University College of London, London, UK
- Barts Heart Centre, St Barthomolew's Hospital, West Smithfield, London EC1A 7BE, UK
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Haugaa KH, Basso C, Badano LP, Bucciarelli-Ducci C, Cardim N, Gaemperli O, Galderisi M, Habib G, Knuuti J, Lancellotti P, McKenna W, Neglia D, Popescu BA, Edvardsen T. Comprehensive multi-modality imaging approach in arrhythmogenic cardiomyopathy-an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2017; 18:237-253. [PMID: 28069601 PMCID: PMC5837226 DOI: 10.1093/ehjci/jew229] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (AC) is a progressive disease with high risk of life-threatening ventricular arrhythmias. A genetic mutation is found in up to 50-60% of probands, mostly affecting desmosomal genes. Diagnosis of AC is made by a combination of data from different modalities including imaging, electrocardiogram, Holter monitoring, family history, genetic testing, and tissue properties. Being a progressive cardiomyopathy, repeated cardiac imaging is needed in AC patients. Repeated imaging is important also for risk assessment of ventricular arrhythmias. This expert consensus document gives clinical recommendations for how to use multi-modality imaging in the different aspects of AC disease, including diagnosis, family screening, follow-up, risk assessment, and differential diagnosis.
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Affiliation(s)
- Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Luigi P Badano
- Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol NHS Trust and University of Bristol and Bristol NIRH Cardiovascular Biomedical Research Unit, Bristol, UK
| | - Nuno Cardim
- Department of Cardiology, Multimodality Cardiac Imaging Center, Sports Cardiology and Cardiomyopathies Center, Hospital da Luz, Lisbon, Portugal
| | - Oliver Gaemperli
- Interventional Cardiology and Cardiac Imaging, University Heart Center Zurich, Zurich, Switzerland
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Gilbert Habib
- Aix-Marseille Université, Marseille and Cardiology Department, APHM, La Timone Hospital, Marseille, France
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu, Turku, Finland
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Department of Cardiology, University of Liège Hospital, Heart Valve Clinic, CHU Sart Tilman, Liège, Belgium and Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - William McKenna
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar and Imperial College, London, UK
| | - Danilo Neglia
- Cardiovascular Department at Fondazione Toscana G. Monasterio, CNR Institute of Clinical Physiology and Scuola Superiore San’Anna, Pisa, Italy
| | - Bogdan A Popescu
- University of Medicine and Pharmacy “Carol Davila”—Euroecolab, Institute of Cardiovascular Diseases “Prof. Dr. C. C. Iliescu,” Bucharest, Romania
| | - Thor Edvardsen
- Department of Cardiology, Center for Cardiological Innovation and Institute for Surgical Research, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
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29
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Affiliation(s)
- Domenico Corrado
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padua, Italy (D.C.); the University of Texas Southwestern Medical Center, Dallas (M.S.L.); and Johns Hopkins Medical Institutions, Baltimore (H.C.)
| | - Mark S Link
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padua, Italy (D.C.); the University of Texas Southwestern Medical Center, Dallas (M.S.L.); and Johns Hopkins Medical Institutions, Baltimore (H.C.)
| | - Hugh Calkins
- From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padua, Italy (D.C.); the University of Texas Southwestern Medical Center, Dallas (M.S.L.); and Johns Hopkins Medical Institutions, Baltimore (H.C.)
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30
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Quarta G, Papadakis M, Donna PD, Maurizi N, Iacovoni A, Gavazzi A, Senni M, Olivotto I. Grey zones in cardiomyopathies: defining boundaries between genetic and iatrogenic disease. Nat Rev Cardiol 2016; 14:102-112. [DOI: 10.1038/nrcardio.2016.175] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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31
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Virk HUH, Farooq S, Ghani AR, Arora S. QRS fragmentation: its role in sherlocking the arrhythmogenic heart. J Community Hosp Intern Med Perspect 2016; 6:31235. [PMID: 27406448 PMCID: PMC4942515 DOI: 10.3402/jchimp.v6.31235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/04/2016] [Accepted: 05/11/2016] [Indexed: 01/19/2023] Open
Abstract
The electrocardiogram (ECG) is a commonly available basic diagnostic modality in in-patient, out-patient, and emergency departments. In patients with coronary artery disease (CAD), the presence of a fragmented QRS (f-QRS), which is an extra R wave (R′), notching of the single R wave, notching of the S wave in at least two contiguous leads on the 12-lead ECG, is associated with a myocardial scar from previous myocardial injury. Furthermore, the presence of f-QRS has been shown to be associated with adverse outcomes in CAD and non-CAD patients. In the present paper, we will solely focus on the usefulness and utilization of f-QRS in predicting ventricular tachyarrhythmia in many heart diseases, that is, ischemic cardiomyopathy, non-ischemic cardiomyopathy, hypertrophic obstructive cardiomyopathy, Brugada syndrome, and arrhythmogenic right ventricular cardiomyopathy. In the majority of such cases, ventricular tachyarrhythmia results in sudden cardiac death. Diagnosing them beforehand can lead to prevention and/or early treatment of these arrhythmias to prevent potential morbidity and mortality.
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Affiliation(s)
| | - Salman Farooq
- Department of Neurology, Medical College of Wisconsin, Wisconsin, WI, USA
| | - Ali Raza Ghani
- Department of Medicine, Abington Jefferson Hospital, Abington, PA, USA
| | - Shilpkakumar Arora
- Department of Medicine, Mount Sinai St-Luke's West Hospital, New York, NY, USA
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32
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Ermakov S, Scheinman M. Arrhythmogenic Right Ventricular Cardiomyopathy - Antiarrhythmic Therapy. Arrhythm Electrophysiol Rev 2016; 4:86-9. [PMID: 26835106 DOI: 10.15420/aer.2015.04.02.86] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy is an inherited disorder characterised by progressive replacement of ventricular myocardium by fibrofatty tissue that predisposes patients to ventricular arrhythmias, heart failure and sudden death. Treatment focuses on slowing disease progression, decreasing the burden of arrhythmias and preventing sudden cardiac death through placement of implantable cardioverter-defibrillators (ICDs), catheter ablation and the use of antiarrhythmic medication. Although only ICDs have been demonstrated to affect patient mortality, antiarrhythmic medications are important adjuncts in reducing patient morbidity and inappropriate ICD therapy. Of the individual antiarrhythmic agents available, sotalol, beta-blockers and amiodarone appear to be most effective in arrhythmia suppression. Calcium-channel blockers may be effective in selected patients. For patients who are refractory to single agent therapy, combination therapy may be considered with the most effective combinations being sotalol + flecainide and amiodarone + beta-blockers.
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Affiliation(s)
- Simon Ermakov
- Stanford University Hospital and Clinics, California, US
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33
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Peters S. Electrocardiographic differences in desmosomal and non-desmosomal arrhythmogenic cardiomyopathy. Int J Cardiol 2016; 203:1005-6. [PMID: 26625331 DOI: 10.1016/j.ijcard.2015.11.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 11/16/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Stefan Peters
- St. Elisabeth Hospital gGmbH Salzgitter, Liebenhaller Str. 20, 38259 Salzgitter, Germany.
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MAST THOMASP, TESKE ARCOJ, TE RIELE ANNELINESJM, GROENEWEG JUDITHA, VAN DER HEIJDEN JEROENF, VELTHUIS BIRGITTAK, LOH PETER, DOEVENDANS PIETERA, VAN VEEN TOONA, DOOIJES DENNIS, DE BAKKER JACQUESM, HAUER RICHARDN, CRAMER MAARTENJ. Prolonged Electromechanical Interval Unmasks Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy in the Subclinical Stage. J Cardiovasc Electrophysiol 2016; 27:303-14. [DOI: 10.1111/jce.12882] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/07/2015] [Accepted: 11/10/2015] [Indexed: 01/26/2023]
Affiliation(s)
- THOMAS P. MAST
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - ARCO J. TESKE
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - ANNELINE SJM TE RIELE
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
- Division of Cardiology, Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland USA
| | - JUDITH A. GROENEWEG
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | | | - BIRGITTA K. VELTHUIS
- Department of Radiology; University Medical Centre Utrecht; Utrecht The Netherlands
| | - PETER LOH
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - PIETER A. DOEVENDANS
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - TOON A. VAN VEEN
- Department of Medical Physiology and Cardiology; University Medical Center Utrecht; The Netherlands
| | - DENNIS DOOIJES
- Department of Medical Genetics; University Medical Center Utrecht; Utrecht The Netherlands
| | - JACQUES M. DE BAKKER
- Department of Medical Physiology and Cardiology; University Medical Center Utrecht; The Netherlands
- Department of Experimental Cardiology; Heart Center; Academic Medical Center; Amsterdam The Netherlands
- ICIN-Netherlands Heart Institute; Utrecht The Netherlands
| | - RICHARD N. HAUER
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
- ICIN-Netherlands Heart Institute; Utrecht The Netherlands
| | - MAARTEN J. CRAMER
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
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Haugaa KH, Haland TF, Leren IS, Saberniak J, Edvardsen T. Arrhythmogenic right ventricular cardiomyopathy, clinical manifestations, and diagnosis. Europace 2015; 18:965-72. [PMID: 26498164 DOI: 10.1093/europace/euv340] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 09/09/2015] [Indexed: 12/17/2022] Open
Abstract
This review aims to give an update on the pathogenesis, clinical manifestations, and diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). Arrhythmogenic right ventricular cardiomyopathy is mainly an autosomal dominant inherited disease linked to mutations in genes encoding desmosomes or desmosome-related proteins. Classic symptoms include palpitations, cardiac syncope, and aborted cardiac arrest due to ventricular arrhythmias. Heart failure may develop in later stages. Diagnosis is based on the presence of major and minor criteria from the Task Force Criteria revised in 2010 (TFC 2010), which includes evaluation of findings from six different diagnostic categories. Based on this, patients are classified as having possible, borderline, or definite ARVC. Imaging is important in ARVC diagnosis, including both echocardiography and cardiac magnetic resonance imaging for detecting structural and functional abnormalities, but importantly these findings may occur after electrical alterations and ventricular arrhythmias. Electrocardiograms (ECGs) and signal-averaged ECGs are analysed for depolarization and repolarization abnormalities, including T-wave inversions as the most common ECG alteration. Ventricular arrhythmias are common in ARVC and are considered a major diagnostic criterion if originating from the RV inferior wall or apex. Family history of ARVC and detection of an ARVC-related mutation are included in the TFC 2010 and emphasize the importance of family screening. Electrophysiological studies are not included in the diagnostic criteria, but may be important for differential diagnosis including RV outflow tract tachycardia. Further differential diagnoses include sarcoidosis, congenital abnormalities, myocarditis, pulmonary hypertension, dilated cardiomyopathy, and athletic cardiac adaptation, which may mimic ARVC.
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Affiliation(s)
- Kristina H Haugaa
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway University of Oslo, PO Box 1072 Blindern, Oslo 0316, Norway
| | - Trine F Haland
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway University of Oslo, PO Box 1072 Blindern, Oslo 0316, Norway
| | - Ida S Leren
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway University of Oslo, PO Box 1072 Blindern, Oslo 0316, Norway
| | - Jørg Saberniak
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway University of Oslo, PO Box 1072 Blindern, Oslo 0316, Norway
| | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo 0372, Norway University of Oslo, PO Box 1072 Blindern, Oslo 0316, Norway
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PROTONOTARIOS ALEXANDROS, ANASTASAKIS ARIS, TSATSOPOULOU ADALENA, ANTONIADES LOIZOS, PRAPPA EFSTATHIA, SYRRIS PETROS, TOUSOULIS DIMITRIOS, McKENNA WILLIAMJ, PROTONOTARIOS NIKOS. Clinical Significance of Epsilon Waves in Arrhythmogenic Cardiomyopathy. J Cardiovasc Electrophysiol 2015; 26:1204-1210. [DOI: 10.1111/jce.12755] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/20/2015] [Accepted: 07/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - ARIS ANASTASAKIS
- 1 Department of Cardiology; University of Athens Medical School; Athens Greece
| | | | | | - EFSTATHIA PRAPPA
- 2 Department of Cardiology; Evangelismos General Hospital; Athens Greece
| | - PETROS SYRRIS
- Institute of Cardiovascular Science; University College London and The Heart Hospital, University College London Hospitals Trust; London UK
| | - DIMITRIOS TOUSOULIS
- 1 Department of Cardiology; University of Athens Medical School; Athens Greece
| | - WILLIAM J. McKENNA
- Institute of Cardiovascular Science; University College London and The Heart Hospital, University College London Hospitals Trust; London UK
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Peters S. Vectorcardiography: diagnostic advantage over electrocardiography in arrhythmogenic cardiomyopathy. Int J Cardiol 2015; 187:134-7. [DOI: 10.1016/j.ijcard.2015.03.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
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Exercise Triggers ARVC Phenotype in Mice Expressing a Disease-Causing Mutated Version of Human Plakophilin-2. J Am Coll Cardiol 2015; 65:1438-50. [DOI: 10.1016/j.jacc.2015.01.045] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 01/27/2015] [Accepted: 01/29/2015] [Indexed: 11/23/2022]
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Peters S. Is early sudden death in the course of arrhythmogenic cardiomyopathy due to initial Brugada syndrome? Int J Cardiol 2015; 182:107-8. [DOI: 10.1016/j.ijcard.2014.12.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/29/2014] [Indexed: 10/24/2022]
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Alcalde M, Campuzano O, Sarquella-Brugada G, Arbelo E, Allegue C, Partemi S, Iglesias A, Oliva A, Brugada J, Brugada R. Clinical interpretation of genetic variants in arrhythmogenic right ventricular cardiomyopathy. Clin Res Cardiol 2014; 104:288-303. [PMID: 25398255 DOI: 10.1007/s00392-014-0794-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/11/2014] [Indexed: 01/08/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy is an inherited cardiac entity characterized by right ventricular, or biventricular, fibrofatty replacement of myocardium. Structural alterations may lead to sudden cardiac death, mainly in young males during exercise. Autosomal dominant pattern of inheritance is reported in most parts of pathogenic genetic variations identified. Currently, 13 genes have been associated with the disease but nearly 40 % of clinically diagnosed cases remain without a genetic diagnosis. New genetic technologies allow further genetic analysis, generating a significant amount of genetic data in novel genes, which is often classified as of ambiguous significance. We focus on genetic advances of arrhythmogenic right ventricular cardiomyopathy, helping clinicians to interpret and translate genetic data into clinical practice.
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Affiliation(s)
- Mireia Alcalde
- Cardiovascular Genetics Centre, IDIBGI-University of Girona, C/Pic de Peguera 11, 17003, Girona, Spain
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QRS fragmentation and epsilon waves in Fontaine leads in arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2014; 176:1015-6. [DOI: 10.1016/j.ijcard.2014.07.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/24/2014] [Indexed: 11/22/2022]
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Markowitz SM, Weinsaft JW, Waldman L, Petashnick M, Liu CF, Cheung JW, Thomas G, Ip JE, Lerman BB. Reappraisal of cardiac magnetic resonance imaging in idiopathic outflow tract arrhythmias. J Cardiovasc Electrophysiol 2014; 25:1328-35. [PMID: 25091404 DOI: 10.1111/jce.12503] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/06/2014] [Accepted: 07/25/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Because of prognostic and therapeutic implications, the distinction between idiopathic right ventricular (RV) outflow tract (iRVOT) and arrhythmogenic RV cardiomyopathy (ARVC) is clinically important. Over the last 2 decades multiple reports have identified RV abnormalities using CMR in patients with idiopathic VT, suggesting a link between these arrhythmias and ARVC. The purpose of this study was to assess for structural abnormalities in patients with iRVOT tachycardia using contemporary cardiac magnetic resonance (CMR) imaging. METHODS AND RESULTS CMR was performed in 46 patients with iRVOT tachycardia and 16 normal controls, with quantitative evaluation of RV and left ventricular volumes and function, as well as assessment of myocardial fat and scar. iRVOT patients were similar to controls with respect to RV end-diastolic volumes (81 ± 19 mL/m(2) vs. 79 ± 18 mL/m(2) , P = 0.77) and RV ejection fraction (57 ± 8% vs. 59 ± 7%, P = 0.31). The prevalence of RV chamber dilation, defined using ARVC major task force criteria, was uncommon among iRVOT patients (9%) and controls (7%; P = 1.0). Regional RV wall motion abnormalities were present in 2 iRVOT patients who had concomitant RV dilation or dysfunction. CMR tissue characterization demonstrated absence of both myocardial scar and fat infiltration in all patients and controls. CONCLUSIONS In patients with the clinical diagnosis of iRVOT tachycardia, CMR reveals RV structure, function, and myocardial tissue characteristics similar to normal controls. These findings suggest that the vast majority of patients with RVOT arrhythmias have a primary electrical disorder that is not a forme-fruste of ARVC.
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Affiliation(s)
- Steven M Markowitz
- Division of Cardiology, Department of Medicine, Cornell University Medical Center, New York, USA
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Golcuk E, Yalin K, Kaya Bilge A, Elitok A, Aksu T, Akgun T, Bilal Karaayvaz E, Emet S, Adalet K. Usefulness of T(peak) -T(end) interval to distinguish arrhythmogenic right ventricular cardiomyopathy from idiopathic right ventricular outflow tract tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1665-70. [PMID: 25041179 DOI: 10.1111/pace.12464] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/28/2014] [Accepted: 05/31/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The two predominant etiologies of right ventricular tachycardia (VT) are arrhythmogenic right ventricular cardiomyopathy (ARVC) and idiopathic VT arising from the right ventricular outflow tract (RVOT). Discrimination between these two entities is critical, as their prognoses and therapeutic options differ. The Tpeak -Tend (Tpe) interval reflects the transmural repolarization dispersion and its prolongation is associated with high mortality. METHODS We compared the sinus rhythm electrocardiogram (ECG) of 43 patients (24 male, 43 ± 16 years) with VT originating from right ventricle. Five patients under antiarrhythmic drug therapy were excluded. Tpe interval was measured in each precordial leads and compared among patients with ARVC and RVOT-VT. RESULTS Twenty-five patients (16 male, 42 ± 16 years) met the Task Force criteria for the diagnosis of ARVC, and 13 patients (seven male, 45 ± 14 years) had idiopathic RVOT tachycardia. Patients with ARVC had significantly prolonged Tpe intervals in all precordial leads compared to patients with idiopathic RVOT VT (137.1 ± 32.6 ms vs 93.8 ± 16.9 ms; P < 0.001 in V1, 133.2 ± 35.5 ms vs 104.7 ± 16.9 ms; P = 0.01 in V2, 125.7 ± 31.5 ms vs 99.1 ± 19.6 ms; P = 0.09 in V3, 121.9 ± 26.5 ms vs 92.3 ± 19.7 ms; P = 0.001 in V4, 123.1 ± 26.5 ms vs 99.5 ± 20:1 ms; P = 0.04 in V5 and 126.9 ± 32.2 ms vs 89 ± 11.3 ms; P < 0.001 in V6, respectively). For the diagnosis of ARVC, Tpe cut-off value of 97 ms in V1 had 84% sensitivity and 62% specificity (area under curve = 0.880). CONCLUSION In patients with VT of RV origin, the prolonged Tpe interval in sinus rhythm electrocardiogram supports the diagnosis of ARVC.
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Affiliation(s)
- Ebru Golcuk
- Department of Cardiology, Kocaeli Derince Research and Training Hospital, Kocaeli, Turkey
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Zhang L, Liu L, Kowey PR, Fontaine GH. The electrocardiographic manifestations of arrhythmogenic right ventricular dysplasia. Curr Cardiol Rev 2014; 10:237-45. [PMID: 24827798 PMCID: PMC4040875 DOI: 10.2174/1573403x10666140514102928] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 01/28/2014] [Indexed: 01/21/2023] Open
Abstract
The ECG is abnormal in most patients with arrhythmogenic right ventricular dysplasia (ARVD). Right ventricular parietal block, reduced QRS amplitude, epsilon wave, T wave inversion in V1-3 and ventricular tachycardia in the morphology of left bundle branch block are the characteristic changes that reflect the underlying genetic predetermined pathology and pathoelectrophysiology. Recognizing the characteristic ECG changes in ARVD will be of help in making a correct diagnosis of this rare disease.
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Affiliation(s)
| | | | | | - Guy H Fontaine
- Lankenau Medical Center & Lankenau Institute for Medical Research, 558 MOB East, 100 Lancaster Avenue, Wynnewood, PA 19096, USA.
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Usefulness of electrocardiographic parameters for risk prediction in arrhythmogenic right ventricular dysplasia. Am J Cardiol 2014; 113:1728-34. [PMID: 24792740 DOI: 10.1016/j.amjcard.2014.02.031] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/12/2014] [Accepted: 02/12/2014] [Indexed: 12/29/2022]
Abstract
The value of electrocardiographic findings predicting adverse outcome in patients with arrhythmogenic right ventricular dysplasia (ARVD) is not well known. We hypothesized that ventricular depolarization and repolarization abnormalities on the 12-lead surface electrocardiogram (ECG) predict adverse outcome in patients with ARVD. ECGs of 111 patients screened for the 2010 ARVD Task Force Criteria from 3 Swiss tertiary care centers were digitized and analyzed with a digital caliper by 2 independent observers blinded to the outcome. ECGs were compared in 2 patient groups: (1) patients with major adverse cardiovascular events (MACE: a composite of cardiac death, heart transplantation, survived sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, or arrhythmic syncope) and (2) all remaining patients. A total of 51 patients (46%) experienced MACE during a follow-up period with median of 4.6 years (interquartile range 1.8 to 10.0). Kaplan-Meier analysis revealed reduced times to MACE for patients with repolarization abnormalities according to Task Force Criteria (p = 0.009), a precordial QRS amplitude ratio (∑QRS mV V1 to V3/∑QRS mV V1 to V6) of ≤ 0.48 (p = 0.019), and QRS fragmentation (p = 0.045). In multivariable Cox regression, a precordial QRS amplitude ratio of ≤ 0.48 (hazard ratio [HR] 2.92, 95% confidence interval [CI] 1.39 to 6.15, p = 0.005), inferior leads T-wave inversions (HR 2.44, 95% CI 1.15 to 5.18, p = 0.020), and QRS fragmentation (HR 2.65, 95% CI 1.1 to 6.34, p = 0.029) remained as independent predictors of MACE. In conclusion, in this multicenter, observational, long-term study, electrocardiographic findings were useful for risk stratification in patients with ARVD, with repolarization criteria, inferior leads TWI, a precordial QRS amplitude ratio of ≤ 0.48, and QRS fragmentation constituting valuable variables to predict adverse outcome.
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Peters S. QRS fragmentation in patients with arrhythmogenic right ventricular cardiomyopathy and complete right bundle branch block: a risk stratification. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:236-9. [PMID: 24062912 DOI: 10.1177/2048872612453922] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 06/15/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) and complete right bundle branch block (RBBB) very often have recurrent ventricular tachycardia and develop biventricular heart failure in the follow up, requiring heart transplantation and/or diuretics. In other patients with ARVC/D excluding RBBB, QRS fragmentation in the S wave of right precordial leads identifies patients with recurrent ventricular tachycardia, primary ventricular fibrillation, and recurrent implantable cardioverter defibrillator discharges; QRS fragmentation ≥3 leads characterized patients who died from sudden cardiac death. METHOD In a cohort of 374 patients with ARVC/D (208 males; mean±SD age 46.5±14.8 years), there were 22 patients with complete RBBB: 17 patients with ARVD/C developed complete RBBB and had biventricular heart failure in a follow up of 4-6 years. In five patients with ARVC/D, complete RBBB was initially evident. In all patients with ARVC/D and RBBB, QRS fragmentation ≥3 of all 12 ECG leads and QRS fragmentation in the S wave of right precordial leads were analysed. RESULTS QRS fragmentation ≥3 of all 12 ECG leads and in the S wave of right precordial leads were present in 16/17 patients who developed RBBB and none of the five patients with initial RBBB. In one patient with initial RBBB, QRS fragmentation ≥3 leads was present (r=17.45; p<0.0001). CONCLUSION Patients with recurrent ventricular tachycardia who develop biventricular heart failure requiring heart transplantation and/or diuretics are characterized by QRS fragmentation in the S wave of right precordial leads and ≥3 of all 12 ECG leads. These results are statistically significant. Patients with initial RBBB have an overall benign prognosis.
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Zusterzeel R, Ter Bekke RMA, Volders PGA, Leijten FMM, van den Wijngaard A, Serroyen J, Gorgels APM. Right-ventricular enlargement in arrhythmogenic right-ventricular cardiomyopathy is associated with decreased QRS amplitudes and T-wave negativity. Ann Noninvasive Electrocardiol 2013; 18:555-63. [PMID: 24303970 DOI: 10.1111/anec.12080] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Arrhythmogenic right-ventricular cardiomyopathy (ARVC) can lead to RV dilatation. We hypothesized that electrocardiographic characteristics including QRS amplitudes in the extremity- and precordial leads, the S amplitude in lead V1 , and extent of T-wave negativity over the precordial leads are related to RV dilatation in this condition. METHODS In 42 ARVC patients and 42 controls, we correlated total QRS amplitude in the extremity leads (∑QRSext ), precordial leads (∑QRSprec ) and in all leads (∑QRStot : summation of ∑QRSext and ∑QRSprec ), S amplitude in lead V1 and the extent of T-wave inversion in the precordial leads (V1 vs. beyond V1 ) with RV end diastolic diameter (RVEDD) by echocardiography. RESULTS In the ARVC group, the mean age was 46 ± 14 years, 31 patients were male, 28 had an implantable cardioverter defibrillator (ICD), and 7 had a LV ejection fraction (EF) < 55%. The control group was age- and gender matched to the ARVC cohort. In contrast to controls, the ∑QRSext (regression coefficient (RC), -0.29; P = 0.020), ∑QRSprec (RC, -0.20; P = 0.015), and ∑QRStot (RC, -0.14; P = 0.009) were lower with RV dilatation in ARVC. S amplitude in lead V1 was not related to RV diameter (RC, -0.98; P = 0.088). Precordial T-wave inversion beyond lead V1 (V2 -V6 ) was associated with a larger RV diameter (RC, 8.58; P = 0.012). CONCLUSIONS Summed QRS amplitudes in the extremity and precordial leads, and T-wave inversion beyond lead V1 are associated with RV dilatation in patients with ARVC.
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Affiliation(s)
- Robbert Zusterzeel
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
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Malignant arrhythmogenic right ventricular dysplasia/cardiomyopathy with a normal 12-lead electrocardiogram: a rare but underrecognized clinical entity. Heart Rhythm 2013; 10:1484-91. [PMID: 23816439 DOI: 10.1016/j.hrthm.2013.06.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND In Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C), a normal electrocardiogram (ECG) is considered reassuring. However, some patients with ARVD/C experiencing ventricular arrhythmias have a normal ECG. OBJECTIVES To estimate how often patients with ARVD/C experiencing ventricular arrhythmias have a normal ECG during sinus rhythm, and to provide a clinical profile of these patients. METHODS We included 145 patients with ARVD/C experiencing a documented sustained ventricular arrhythmia. Conventional 12-lead sinus rhythm ECGs within 6 months of the event were reviewed for diagnostic Task Force Criteria (TFC). ECGs were classified as abnormal (≥1 TFC), nonspecific (abnormal, no TFC), or normal. Cardiologic investigations within 6 months of the event were evaluated as per TFC in those with a nonspecific or normal ECG. RESULTS The ECG was nonspecific or normal in 17 of 145 (12%) subjects. Mean age of these patients was 41.3 ± 12.4 years and 14 (82%) were men, comparable to those with an abnormal ECG. Most patients with a nonspecific or normal ECG showed ≥1 TFC on Holter monitoring (n = 9 of 10) and signal-averaged ECG (n = 4 of 5), and all had nonsustained ventricular tachycardia recorded. Among 15 patients who underwent structural evaluation, 11 (73%) showed structural TFC (9 major and 2 minor). CONCLUSIONS Although most patients with ARVD/C experiencing arrhythmias have an abnormal ECG, a nonspecific or normal ECG does not preclude ARVD/C diagnosis. All patients with a nonspecific or normal ECG had alternative evidence of disease expression. These results alert the physician not to rely exclusively on ECG in ARVD/C, but to assess arrhythmic risk by comprehensive clinical evaluation.
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Zaidi A, Sharma S. Exercise and heart disease: from athletes and arrhythmias to hypertrophic cardiomyopathy and congenital heart disease. Future Cardiol 2013; 9:119-36. [PMID: 23259479 DOI: 10.2217/fca.12.81] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The beneficial effects of regular physical activity on cardiovascular health are well established, with convincing evidence of improvements in blood pressure, lipid profile and overall mortality. Conversely, individuals with pre-existing congenital, inherited or acquired heart conditions may experience functional cardiac deterioration or sudden death during even moderate exertion. Exclusion from high-level sporting activity may be mandated in some cases, and pre-participation screening of competitive athletes plays an important role in the identification of such individuals. The issue of screening is complicated by the fact that physiological cardiovascular adaptation in healthy athletes, including modest left ventricular hypertrophy and biventricular cavity dilatation, may create a diagnostic overlap with pathological conditions such as hypertrophic cardiomyopathy. Furthermore, much interest has focused recently on the possibility of irreversible cardiac remodeling in a proportion of veteran endurance athletes, with the potential for arrhythmogenesis and adverse cardiac events.
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Affiliation(s)
- Abbas Zaidi
- Department of Cardiovascular Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
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Romero J, Mejia-Lopez E, Manrique C, Lucariello R. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC/D): A Systematic Literature Review. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2013; 7:97-114. [PMID: 23761986 PMCID: PMC3667685 DOI: 10.4137/cmc.s10940] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic form of cardiomyopathy (CM) usually transmitted with an autosomal dominant pattern. It primary affects the right ventricle (RV), but may involve the left ventricle (LV) and culminate in biventricular heart failure (HF), life threatening ventricular arrhythmias and sudden cardiac death (SCD). It accounts for 11%-22% of cases of SCD in the young athlete population. Pathologically is characterized by myocardial atrophy, fibrofatty replacement and chamber dilation. Diagnosis is often difficult due to the nonspecific nature of the disease and the broad spectrum of phenotypic variations. Therefore consensus diagnostic criteria have been developed and combined electrocardiography, echocardiography, cardiac magnetic resonance imaging (CMRI) and myocardial biopsy. Early detection, family screening and risk stratification are the cornerstones in the diagnostic evaluation. Implantable cardioverter-defibrillator (ICD) implantation, ablative procedures and heart transplantation are currently the main therapeutic options.
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Affiliation(s)
- Jorge Romero
- Division of Cardiology, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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