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Cianci V, Forzese E, Sapienza D, Cianci A, Ieni A, Germanà A, Guerrera MC, Omero F, Speranza D, Cracò A, Asmundo A, Gualniera P, Mondello C. Arrhythmogenic Right Ventricular Cardiomyopathy Post-Mortem Assessment: A Systematic Review. Int J Mol Sci 2024; 25:2467. [PMID: 38473714 PMCID: PMC10931616 DOI: 10.3390/ijms25052467] [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: 01/27/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder characterized by the progressive fibro-fatty replacement of the right ventricular myocardium, leading to myocardial atrophy. Although the structural changes usually affect the right ventricle, the pathology may also manifest with either isolated left ventricular myocardium or biventricular involvement. As ARVC shows an autosomal dominant pattern of inheritance with variable penetrance, the clinical presentation of the disease is highly heterogeneous, with different degrees of severity and patterns of myocardial involvement even in patients of the same familiar group with the same gene mutation: the pathology spectrum ranges from the absence of symptoms to sudden cardiac death (SCD) sustained by ventricular arrhythmias, which may, in some cases, be the first manifestation of an otherwise silent pathology. An evidence-based systematic review of the literature was conducted to evaluate the state of the art of the diagnostic techniques for the correct post-mortem identification of ARVC. The research was performed using the electronic databases PubMed and Scopus. A methodological approach to reach a correct post-mortem diagnosis of ARVC was described, analyzing the main post-mortem peculiar macroscopic, microscopic and radiological alterations. In addition, the importance of performing post-mortem genetic tests has been underlined, which may lead to the correct identification and characterization of the disease, especially in those ARVC forms where anatomopathological investigation does not show evident morphostructural damage. Furthermore, the usefulness of genetic testing is not exclusively limited to the correct diagnosis of the pathology, but is essential for promoting targeted screening programs to the deceased's family members. Nowadays, the post-mortem diagnosis of ARVC performed by forensic pathologist remains very challenging: therefore, the identification of a clear methodological approach may lead to both a reduction in under-diagnoses and to the improvement of knowledge on the disease.
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Affiliation(s)
- Vincenzo Cianci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
| | - Elena Forzese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
| | - Daniela Sapienza
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
| | - Alessio Cianci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Antonio Ieni
- Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, Section of Pathology, University of Messina, 98125 Messina, Italy;
| | - Antonino Germanà
- Zebrafish Neuromorphology Lab, Department of Veterinary Sciences, Via Palatucci Snc, University of Messina, 98168 Messina, Italy; (A.G.); (M.C.G.)
| | - Maria Cristina Guerrera
- Zebrafish Neuromorphology Lab, Department of Veterinary Sciences, Via Palatucci Snc, University of Messina, 98168 Messina, Italy; (A.G.); (M.C.G.)
| | - Fausto Omero
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy; (F.O.); (D.S.)
| | - Desirèe Speranza
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy; (F.O.); (D.S.)
| | - Annalisa Cracò
- Department of Biomedical Sciences and Morphological and Functional Imaging, Diagnostic and Interventional Radiology Unit, University Hospital Messina, 98125 Messina, Italy;
| | - Alessio Asmundo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
| | - Patrizia Gualniera
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
| | - Cristina Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Legal Medicine, University of Messina, Via Consolare Valeria, 1, 98125 Messina, Italy; (E.F.); (D.S.); (A.A.); (P.G.); (C.M.)
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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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Chen P, Hao Y, Qiu X, Xiao X, Zhu W, Xu Y, Qian W. Case Report: Primary Cardiac T-Cell Lymphoma With Complete Atrio-Ventricular Block Diagnosed by Endomyocardial Biopsy. Front Immunol 2022; 13:890059. [PMID: 35784303 PMCID: PMC9244709 DOI: 10.3389/fimmu.2022.890059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Primary cardiac lymphoma (PCL) is a rare disease, the definite diagnosis of which is sometimes difficult and mainly relies on endomyocardial biopsy. Primary cardiac T-cell lymphoma (PCTL) is an extremely rare sub-type of PCL. Here, we report on a 47-year-old female with PCTL who presented with fever, syncope, palpitations, and a third-degree atrioventricular block (AVB) on electrocardiogram. Chemotherapy was administered with two courses of methotrexate, cyclophosphamide, liposomal doxorubicin, vincristine, and dexamethasone (MTX-CHOP). As the tumor vanished, AVB changed from third degree to second degree and finally to sinus rhythm. In conclusion, endomyocardial biopsy is valuable in the diagnosis of primary cardiac lymphoma. It is worth noting that alterations in the electrocardiogram may indicate an attack on the heart by PCTL.
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Affiliation(s)
- Panpan Chen
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Yuanyuan Hao
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Xi Qiu
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Xibin Xiao
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Wei Zhu
- Department of Cardiology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Provincial Key Laboratory of Cardiovascular Research, Hangzhou, China
| | - Yang Xu
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Wenbin Qian
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory for Cancer Molecular Cell Biology, Life Sciences Institute, Zhejiang University, Hangzhou, China
- *Correspondence: Wenbin Qian,
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Gran F, Fidalgo A, Dolader P, Garrido M, Navarro A, Izquierdo-Blasco J, Balcells J, Codina-Sola M, Fernandez-Alvarez P, Sabaté-Rotés A, Betrián P, Fernández-Doblas J, Abella R, Roses-Noguer F. Differences between genetic dilated cardiomyopathy and myocarditis in children presenting with severe cardiac dysfunction. Eur J Pediatr 2022; 181:287-294. [PMID: 34286374 PMCID: PMC8294227 DOI: 10.1007/s00431-021-04175-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/18/2021] [Accepted: 06/19/2021] [Indexed: 11/24/2022]
Abstract
Acute myocarditis is an inflammatory disease of the myocardium, and it can present as severe heart failure in children. Differential diagnosis with genetic cardiomyopathy can be difficult. The objective of this study is to identify patterns of clinical presentation and to assess invasive and non-invasive measures to differentiate patients with acute myocarditis from patients with dilated genetic cardiomyopathy. We performed a retrospective descriptive study of all paediatric patients (0-16 years old) that presented with new-onset heart failure with left ventricle ejection fraction < 35% in whom we performed an endomyocardial biopsy (EMB) during the period from April 2007 to December 2020. The patients were classified into two groups: Group 1 included 18 patients with myocarditis. Group 2 included 9 patients with genetic cardiomyopathy. Findings favouring a diagnosis of myocarditis included a fulminant or acute presentation (77.8% vs 33.3%, p = 0.01), higher degree of cardiac enzyme elevation (p = 0.011), lower left ventricular dimension z-score (2.2 vs 5.4, p = 0.03) increase of ventricular wall thickness (88.8% vs 33.3%, p = 0.03) and oedema in the EMB. Seven (77.8%) patients with genetic cardiomyopathy had inflammation in the endomyocardial biopsy fulfilling the diagnostic criteria of inflammatory cardiomyopathy.Conclusion: Differentiating patients with a myocarditis from those with genetic cardiomyopathy can be challenging, even performing an EMB. Some patients with genetic cardiomyopathy fulfil the diagnostic criteria of inflammatory cardiomyopathy. Using invasive and non-invasive measures may be useful to develop a predictive model to differentiate myocarditis from genetic cardiomyopathy. What is Known: • Acute myocarditis could present with cardiogenic shock in paediatric patients. • Parvovirus B19 is the main cause of myocarditis in this population. What is New: • Current diagnostic criteria for myocarditis have limited use in paediatric patients presenting with new-onset heart failure. • Some patients with a genetic cardiomyopathy and a new-onset heart failure fulfill the diagnostic criteria of inflammatory cardiomyopathy.
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Affiliation(s)
- Ferran Gran
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Andrea Fidalgo
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Paola Dolader
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Marta Garrido
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Alexandra Navarro
- Department of Pathology, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jaume Izquierdo-Blasco
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Joan Balcells
- Paediatric Intensive Care Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marta Codina-Sola
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Paula Fernandez-Alvarez
- Department of Clinical and Molecular Genetics, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Barcelona, Spain
| | - Anna Sabaté-Rotés
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Pedro Betrián
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Joaquín Fernández-Doblas
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Raúl Abella
- Department of Paediatric Cardiac Surgery, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ferran Roses-Noguer
- Paediatric Cardiology Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Immunofluorescent Localization of Plakoglobin Is Altered in Endomyocardial Biopsy Samples from Dogs with Clinically Relevant Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Vet Sci 2021; 8:vetsci8110248. [PMID: 34822621 PMCID: PMC8623220 DOI: 10.3390/vetsci8110248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022] Open
Abstract
Diagnosing the early stages of canine Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is complicated by day-to-day arrhythmia variability, and absence of reliable, transthoracic echocardiographic features. Definitive diagnosis requires histopathologic identification of transmural fibrofatty replacement of the right ventricle. Reduction of immunofluorescent signal for plakoglobin (PG) at the intercalated disc (ID) is reported in ARVC-affected humans and boxers. Our objective was to determine whether reduced immunofluorescent signal for PG in endomyocardial biopsy samples (EMBs) correspond with a histopathologic diagnosis of ARVC. Here, 49 dogs were evaluated: 43 with advanced cardiac disease and 6 non-clinical boxers with mild to moderate ventricular arrhythmia (VA) burden. EMBs were obtained from all dogs; samples were prepared with antibodies recognizing cadherin (PC) and PG and evaluated with confocal microscopy. Investigators were blinded to breed and clinical status. ARVC was histopathologically diagnosed in 8 out of 49 dogs. Of these, three out of eight had clinical signs consistent with ARVC (two boxers, one English bulldog) and reduced PG signal at ID; five out of eight were non-clinical boxers with moderate VA and no reduction in PG. A total of 41 out of 49 dogs were histopathologically diagnosed with non-ARVC cardiac disease; 1 out of 41 showed reduction of PG at ID, while 40 out of 41 had no PG reduction. These results suggest that EMB PG signal is reduced in dogs with advanced ARVC, but not in the occult phase of the disease. Additionally, presence of PG at ID supports a diagnosis of non-ARVC cardiac disease in dogs with clinical signs. These results may offer an additional test that helps differentiate advanced ARVC from other myocardial diseases.
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Abstract
Arrhythmogenic right ventricular cardiomyopathy, formerly called "arrhythmogenic right ventricular dysplasia," is an under-recognized clinical entity characterized by ventricular arrhythmias and a characteristic ventricular pathology. 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 which combine electrocardiographic, echocardiographic, cardiac magnetic resonance imaging and histologic criteria. In 1994, an international task force first proposed the major and minor diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy based on family history, arrhythmias, electrocardiographic abnormalities, tissue characterization, and structural and functional right ventricular abnormalities. In 2010, the task force criteria were revised to include quantitative abnormalities. These diagnostic modalities and the most recent task force criteria are discussed in this review.
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Okonkwo ER, Schuetz C, Hyman B, Samuels B, Sayad D, Bower J. Electrocardiograms Revealing Epsilon Waves Following Use of Hormone Supplements in Young Cardiac Arrest Patient. Cureus 2021; 13:e14305. [PMID: 33968517 PMCID: PMC8098703 DOI: 10.7759/cureus.14305] [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] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION An underlying cardiomyopathy should be suspected in young patients presenting with ventricular arrhythmias and sudden cardiac arrest. Electrocardiograms revealing epsilon waves are associated with many serious conditions such as arrhythmogenic right ventricular cardiomyopathy, posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report features epsilon waves in a young cardiac arrest patient suspected of having an unrecognized cardiomyopathy that resulted in a fatal arrhythmia in the setting of exogenous bovine thyroid hormone and steroid use. Case presentation: A previously healthy 33-year-old male with a history of anabolic steroid use and bovine thyroid hormone use presented to the emergency department following witnessed cardiac arrest with bystander cardiopulmonary resuscitation (CPR). Upon emergency medical service (EMS) arrival, the patient was in ventricular fibrillation and received defibrillation with the return of spontaneous circulation. In the emergency department, he was unresponsive and required norepinephrine to maintain blood pressure. An epsilon wave and a prolonged QTc interval were noted on his electrocardiogram (ECG). CT angiogram of the chest and CT head were negative for acute abnormalities. Pertinent laboratory work-up included a lactate level of 12.0 mmol/L, thyroid-stimulating hormone of 0.02 ulU/L, and a free thyroxine level of 0.04 ng/dL. Cardiac ultrasound showed globally decreasedleft ventricular function with an ejection fraction of 25-30% and mild dilation of the right ventricle. A cardiac MRI was ordered but the patient had recurrent ventricular fibrillation and was too unstable to complete. He suffered anoxic brain injury with no improvements in neurologic function and was transitioned to comfort care. The patient died two months later in hospice care. The cause of cardiac arrest was attributed to the patient's steroid and bovine thyroid supplementation, but autopsy results revealed histologic evidence of possible arrhythmogenic right ventricular cardiomyopathy. Discussion: Epsilon waves are widely known to be associated with structural abnormalities of the heart, most notably, arrhythmogenic right ventricular cardiomyopathies. Epsilon waves may be present in a variety of other medical conditions including posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report describes an epsilon wave found in a patient with suspected arrhythmogenic right ventricular cardiomyopathy that suffered a fatal arrhythmia triggered by bovine thyroid hormone and steroid use.
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Affiliation(s)
- Enola R Okonkwo
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christian Schuetz
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Bryan Hyman
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Brian Samuels
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Dany Sayad
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - James Bower
- Cardiology, Sanger Heart & Vascular Institute, Charlotte, USA
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Reza N, Musunuru K, Owens AT. From Hypertrophy to Heart Failure: What Is New in Genetic Cardiomyopathies. Curr Heart Fail Rep 2020; 16:157-167. [PMID: 31243690 DOI: 10.1007/s11897-019-00435-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this review is to provide an update on the recent advances in the research and clinical care of patients with the major phenotypes of inherited cardiomyopathies-hypertrophic, dilated, and arrhythmogenic. Developments in genetics, risk stratification, therapies, and disease modeling will be discussed. RECENT Diagnostic, prognostic, and therapeutic tools which incorporate genetic and genomic data are being steadily incorporated into the routine clinical care of patients with genetic cardiomyopathies. Human pluripotent stem cells are a breakthrough model system for the study of genetic variation associated with inherited cardiovascular disease. Next-generation sequencing technology and molecular-based diagnostics and therapeutics have emerged as valuable tools to improve the recognition and care of patients with hypertrophic, dilated, and arrhythmogenic cardiomyopathies. Improved adjudication of variant pathogenicity and management of genotype-positive/phenotype-negative individuals are imminent challenges in this realm of precision medicine.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, and Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Cardiovascular Institute, Philadelphia, PA, 19104, USA.
| | - Kiran Musunuru
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 11 South Pavilion, Room 11-134, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Anjali Tiku Owens
- Division of Cardiovascular Medicine, Department of Medicine, and Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Cardiovascular Institute, Philadelphia, PA, 19104, USA
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Rato J, Ataíde R, Martins D, Moldovan O, Cavaco D, Anjos R. Arrhythmogenic right ventricular cardiomyopathy presenting as myocarditis in young patients: a concealed relationship. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:424-426. [PMID: 31753771 DOI: 10.1016/j.rec.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/16/2019] [Indexed: 06/10/2023]
Affiliation(s)
- João Rato
- Department of Pediatric Cardiology, Hospital de Santa Cruz - Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.
| | - Rita Ataíde
- Department of Pediatric Cardiology, Hospital de Santa Cruz - Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Duarte Martins
- Department of Pediatric Cardiology, Hospital de Santa Cruz - Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Oana Moldovan
- Medical Genetics Service, Pediatric Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Diogo Cavaco
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Rui Anjos
- Department of Pediatric Cardiology, Hospital de Santa Cruz - Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
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Rato J, Ataíde R, Martins D, Moldovan O, Cavaco D, Anjos R. Miocardiopatía arritmogénica del ventrículo derecho en pacientes jóvenes con miocarditis: una asociación oculta. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Arrhythmogenic Left Ventricular Cardiomyopathy: A Clinical and CMR Study. Sci Rep 2020; 10:533. [PMID: 31953454 PMCID: PMC6969116 DOI: 10.1038/s41598-019-57203-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022] Open
Abstract
The clinical features, CMR characteristics and outcomes of arrhythmogenic left ventricular cardiomyopathy (ALVC), which is a very rare nonischemic cardiomyopathy, are currently not well studied. The purpose of the study is to investigate the clinical and cardiovascular magnetic resonance (CMR) imaging characteristics of arrhythmogenic left ventricular cardiomyopathy (ALVC). Fifty-three consecutive patients with ALVC were divided into two groups: ALVC patients without right ventricular (RV) involvement (n = 36, group 1) and those with RV involvement (n = 17, group 2). Clinical symptoms, cardiac electrophysiological findings, and CMR parameters (morphology, ventricular function, and myocardial fibrosis and fatty infiltration) were evaluated in both groups. The two groups showed no significant difference in age, gender, or presenting symptoms (P > 0.05). Right bundle branch block ventricular arrhythmia was less common in patients without RV involvement (50.0% vs.64.7%, P = 0.031). There were no significant differences in left ventricular function between the two groups, however right ventricular ejection fraction was significantly lower in group 2 (40.1 ± 4.0% vs. 48.7 ± 3.9%, P < 0.001). Inverse correlations of left ventricular ejection fraction with fat volume (r = −0.883, p = 0.001), late gadolinium enhancement (LGE) volume (r = −0.892, 0.013), ratio of fat/LGE (r = −0.848, p < 0.001), indexed left ventricular end diastolic volume (r = −0.877, p < 0.001) and indexed left ventricular end systolic volume (r = −0.943, p < 0.001) were all significant. ALVC is a rare disease with fibro-fatty replacement predominantly in the left ventricle, impaired left ventricular systolic function, and ventricular arrhythmias originating from the left ventricle. ALVC with right ventricular involvement may have a worse prognosis.
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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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Divakaran S, Stewart GC, Lakdawala NK, Padera RF, Zhou W, Desai AS, Givertz MM, Mehra MR, Kwong RY, Hedgire SS, Ghoshhajra BB, Taqueti VR, Skali H, Dorbala S, Blankstein R, Di Carli MF. Diagnostic Accuracy of Advanced Imaging in Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2019; 12:e008975. [PMID: 31177817 DOI: 10.1161/circimaging.118.008975] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The diagnostic yield of cardiac sarcoidosis (CS) by endomyocardial biopsy is limited. Fluorodeoxyglucose (FDG) positron emission tomography (PET) and cardiac magnetic resonance imaging (MRI) may facilitate noninvasive diagnosis, but the accuracy of this approach is not well defined. We aimed to correlate findings from FDG PET and cardiac MRI with histological findings from explanted hearts of patients who underwent cardiac transplantation. Methods We analyzed the explanted heart histology for all patients who underwent cardiac transplant at our center from April 2008 to July 2018 and had pretransplant FDG PET (n=18) or cardiac MRI (n=31). The likelihood of CS based on FDG PET or cardiac MRI was categorized in a blinded fashion using a previously published method. RESULTS: Using a CS probable cutoff for FDG PET resulted in a sensitivity of 100.0% (95% CI, 54.1%-100.0%) and a specificity of 33.3% (95% CI, 9.9%-65.1%). Three of the 9 CS probable by FDG PET cases were found to be arrhythmogenic cardiomyopathy. The test characteristics of cardiac MRI are more challenging to comment on using our data as there was only one confirmed case of CS on post-transplant histological assessment. Of the 8 CS highly probable or probable cases by cardiac MRI, 3 were found to be dilated cardiomyopathy, and 2 were found to be end-stage hypertrophic cardiomyopathy. Conclusions FDG PET and cardiac MRI can help facilitate the diagnosis of CS in patients with advanced heart failure with a high degree of sensitivity but lower specificity.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Garrick C Stewart
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Neal K Lakdawala
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Robert F Padera
- Department of Pathology (R.F.P.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael M Givertz
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mandeep R Mehra
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Y Kwong
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sandeep S Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (S.S.H., B.B.G.)
| | - Brian B Ghoshhajra
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (S.S.H., B.B.G.)
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology (S.D., W.Z., R.Y.K., V.R.T., H.S., S.D., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Division, Department of Medicine (S.D., G.C.S., N.K.L., A.S.D., M.M.G., M.R.M., R.Y.K., H.S., R.B., M.F.D.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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14
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Finding the right pathway is the key to success. HeartRhythm Case Rep 2019; 5:187-190. [PMID: 30997331 PMCID: PMC6453558 DOI: 10.1016/j.hrcr.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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McDiarmid AK, Pellicori P, Cleland JG, Plein S. Taxonomy of segmental myocardial systolic dysfunction. Eur Heart J 2017; 38:942-954. [PMID: 27147609 PMCID: PMC5381597 DOI: 10.1093/eurheartj/ehw140] [Citation(s) in RCA: 5] [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: 11/03/2015] [Accepted: 03/10/2016] [Indexed: 12/13/2022] Open
Abstract
The terms used to describe different states of myocardial health and disease are poorly defined. Imprecision and inconsistency in nomenclature can lead to difficulty in interpreting and applying trial outcomes to clinical practice. In particular, the terms ‘viable’ and ‘hibernating’ are commonly applied interchangeably and incorrectly to myocardium that exhibits chronic contractile dysfunction in patients with ischaemic heart disease. The range of inherent differences amongst imaging modalities used to define myocardial health and disease add further challenges to consistent definitions. The results of several large trials have led to renewed discussion about the classification of dysfunctional myocardial segments. This article aims to describe the diverse myocardial pathologies that may affect the myocardium in ischaemic heart disease and cardiomyopathy, and how they may be assessed with non-invasive imaging techniques in order to provide a taxonomy of myocardial dysfunction.
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Affiliation(s)
- Adam K McDiarmid
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Pierpaolo Pellicori
- Academic Cardiology Unit, University of Hull, Castle Hill Hospital, Kingston upon Hull, UK
| | - John G Cleland
- Academic Cardiology Unit, University of Hull, Castle Hill Hospital, Kingston upon Hull, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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16
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Akdis D, Brunckhorst C, Duru F, Saguner AM. Arrhythmogenic Cardiomyopathy: Electrical and Structural Phenotypes. Arrhythm Electrophysiol Rev 2016; 5:90-101. [PMID: 27617087 PMCID: PMC5013177 DOI: 10.15420/aer.2016.4.3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 08/03/2016] [Indexed: 12/12/2022] Open
Abstract
This overview gives an update on the molecular mechanisms, clinical manifestations, diagnosis and therapy of arrhythmogenic cardiomyopathy (ACM). ACM is mostly hereditary and associated with mutations in genes encoding proteins of the intercalated disc. Three subtypes have been proposed: the classical right-dominant subtype generally referred to as ARVC/D, biventricular forms with early biventricular involvement and left-dominant subtypes with predominant LV involvement. Typical symptoms include palpitations, arrhythmic (pre)syncope and sudden cardiac arrest due to ventricular arrhythmias, which typically occur in athletes. At later stages, heart failure may occur. Diagnosis is established with the 2010 Task Force Criteria (TFC). Modern imaging tools are crucial for ACM diagnosis, including both echocardiography and cardiac magnetic resonance imaging for detecting functional and structural alternations. Of note, structural findings often become visible after electrical alterations, such as premature ventricular beats, ventricular fibrillation (VF) and ventricular tachycardia (VT). 12-lead ECG is important to assess for depolarisation and repolarisation abnormalities, including T-wave inversions as the most common ECG abnormality. Family history and the detection of causative mutations, mostly affecting the desmosome, have been incorporated in the TFC, and stress the importance of cascade family screening. Differential diagnoses include idiopathic right ventricular outflow tract (RVOT) VT, sarcoidosis, congenital heart disease, myocarditis, dilated cardiomyopathy, athlete's heart, Brugada syndrome and RV infarction. Therapeutic strategies include restriction from endurance and competitive sports, β-blockers, antiarrhythmic drugs, heart failure medication, implantable cardioverter-defibrillators and endocardial/epicardial catheter ablation.
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Affiliation(s)
- Deniz Akdis
- Department of Cardiology, University Heart Center, Zurich, Switzerland
| | | | - Firat Duru
- Department of Cardiology, University Heart Center, Zurich, Switzerland; Center for Integrative Human Physiology, University of Zurich, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center, Zurich, Switzerland
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17
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Bicsák Á, Jellen A, Tuppy H, Poeschl WP. Sudden death after major head and neck cancer surgery due to undetected arrhythmogenic right ventricle cardiomyopathy (ARVC). Oral Maxillofac Surg 2016; 20:431-434. [PMID: 27357590 DOI: 10.1007/s10006-016-0567-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 06/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral squamous cell carcinoma is the sixth most frequent malignancy in Austria. The incidence of arrhythmogenic right ventricle dysplasia (ARVC), an important cause of sudden cardiac death, is estimated at 1:5000 to 1:1000. CASE REPORT We present a case of a 75-year-old woman who underwent major oncologic surgery for T4aN0M0 maxillary squamous cell carcinoma and reconstruction with a scapular-latissimus dorsi microvascular flap. The patient died suddenly during her postoperative care. Autopsy revealed pericardiac tamponade due to rupture of the right ventricular wall. Histologic examination showed ARVC in a sample taken directly from the ruptured area. Cause of death was secondary arrhythmia originating from the ARVC. The arrhythmia had led to rupture of the right ventricular wall and sudden cardiac death. DISCUSSION As per our current knowledge, no cases of maxillary cancer and ARVC as co-morbidities have been reported in the literature. The patient had been given anti-arrhythmia treatment for previously detected atrial fibrillation, which could have been why the arrhythmia was not apparent on the electrocardiogram. Thus, although the appropriate preoperative diagnostics were performed according to current oncologic and anesthesiology guidelines, the potentially lethal cardiac condition of the patient could not be detected.
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Affiliation(s)
- Ákos Bicsák
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria.
| | - Alice Jellen
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria
| | - Herwig Tuppy
- Department of Pathology, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, 4600, Austria
| | - Wolfgang Paul Poeschl
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria
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18
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McGregor SM, Husain AN. A Brief Review and Update of the Clinicopathologic Diagnosis of Arrhythmogenic Cardiomyopathy. Arch Pathol Lab Med 2015; 139:1181-6. [PMID: 26317457 DOI: 10.5858/arpa.2014-0114-rs] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Arrhythmogenic cardiomyopathy (AC) has traditionally been regarded as a rare disease with variably penetrant autosomal-dominant inheritance. Recent years have revealed that AC is actually a spectrum of disease with prevalence much higher than previously thought. Diagnosis can be quite challenging because of highly variable clinical presentation, even among family members sharing a mutation. Unlike other cardiomyopathies, AC has a concealed phase during which patients have arrhythmias in the absence of structural heart disease but remain at risk of sudden cardiac death. Importantly, it is in the setting of sudden cardiac death that pathologists are most likely to encounter AC. It is critical that these findings not be overlooked, as family members of the deceased may also be affected and could potentially avoid such a dismal outcome. With time, advances in ancillary studies are likely to expand the role for pathologists in AC diagnosis.
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Affiliation(s)
- Stephanie M McGregor
- From the Department of Pathology, University of Chicago Medicine, Chicago, Illinois
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19
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Saguner AM, Brunckhorst C, Duru F. Arrhythmogenic ventricular cardiomyopathy: A paradigm shift from right to biventricular disease. World J Cardiol 2014; 6:154-174. [PMID: 24772256 PMCID: PMC3999336 DOI: 10.4330/wjc.v6.i4.154] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 01/29/2014] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
Arrhythmogenic ventricular cardiomyopathy (AVC) is generally referred to as arrhythmogenic right ventricular (RV) cardiomyopathy/dysplasia and constitutes an inherited cardiomyopathy. Affected patients may succumb to sudden cardiac death (SCD), ventricular tachyarrhythmias (VTA) and heart failure. Genetic studies have identified causative mutations in genes encoding proteins of the intercalated disk that lead to reduced myocardial electro-mechanical stability. The term arrhythmogenic RV cardiomyopathy is somewhat misleading as biventricular involvement or isolated left ventricular (LV) involvement may be present and thus a broader term such as AVC should be preferred. The diagnosis is established on a point score basis according to the revised 2010 task force criteria utilizing imaging modalities, demonstrating fibrous replacement through biopsy, electrocardiographic abnormalities, ventricular arrhythmias and a positive family history including identification of genetic mutations. Although several risk factors for SCD such as previous cardiac arrest, syncope, documented VTA, severe RV/LV dysfunction and young age at manifestation have been identified, risk stratification still needs improvement, especially in asymptomatic family members. Particularly, the role of genetic testing and environmental factors has to be further elucidated. Therapeutic interventions include restriction from physical exercise, beta-blockers, sotalol, amiodarone, implantable cardioverter-defibrillators and catheter ablation. Life-long follow-up is warranted in symptomatic patients, but also asymptomatic carriers of pathogenic mutations.
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20
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Iyer VR, Chin AJ. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2013; 163C:185-97. [PMID: 23824749 DOI: 10.1002/ajmg.c.31368] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a progressive genetic cardiomyopathy characterized by progressive fatty and fibrous replacement of ventricular myocardium. The clinical presentation is marked by ventricular arrhythmias, some fatal. The disease has evolved from a primary electrical/electrophysiological disorder (in the 1980s-1990s) to a diagnostic imaging conundrum (in the 2000s) to the current day understanding of a genetic cardiomyopathy caused by defects in cell-cell adhesion proteins or intracellular signaling components. The pathogenesis, clinical presentation, and the genetics of the disease are discussed in this review.
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Affiliation(s)
- V Ramesh Iyer
- Perelman School of Medicine, University of Pennsylvania, PA, USA
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21
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Histological and ultrastructural abnormalities in murine desmoglein 2-mutant hearts. Cell Tissue Res 2012; 348:249-59. [PMID: 22293975 DOI: 10.1007/s00441-011-1322-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 12/16/2011] [Indexed: 12/21/2022]
Abstract
Mice carrying a deletion of the adhesive extracellular domain of the desmosomal cadherin desmoglein 2 develop an arrhythmogenic right ventricular cardiomyopathylike phenotype with ventricular dilation, fibrosis and arrhythmia. To unravel the sequence of myocardial alterations and to identify potential pathomechanisms, histological analyses were performed on mutant hearts from the juvenile to the adult state, i.e., between 2 and 13 weeks. At an age of 2 weeks 30% of mutants presented lesions,which were visible as white plaques on the heart surface or in the septum. From 4 weeks onwards, all mutants displayed a cardiac phenotype. Dying cardiomyocytes with calcification were found in lesions of all ages. But lesions of young mutant animals contained high amounts of CD45+ immune cells and little collagen fibers, whereas lesions of the older animals were collagen-rich and harbored only a small but still significantly increased number of CD45+ cells. Electron microscopy further showed that distinct desmosomes cannot be distinguished in intercalated discs of mutant hearts. Widening of the intercellular cleft and even complete dissociation of intercalated discs were often observed close to lesions. Disturbed sarcomer structure, altered Z-discs, multiple autophagic vacuoles and swollen mitochondria were other prominent pathological features. Taken together, the following scenario is suggested: mutant desmoglein 2 cannot fully support the increased mechanical requirements placed on intercalated disc adhesion during postnatal heart development, resulting in compromised adhesion and cell stress. This induces cardiomyocyte death, aseptic inflammation and fibrotic replacement. The acute stage of scar formation is followed by permanent impairment of the cardiac function.
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22
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Ma D, Wei H, Lu J, Ho S, Zhang G, Sun X, Oh Y, Tan SH, Ng ML, Shim W, Wong P, Liew R. Generation of patient-specific induced pluripotent stem cell-derived cardiomyocytes as a cellular model of arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2012; 34:1122-33. [PMID: 22798562 DOI: 10.1093/eurheartj/ehs226] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a primary heart muscle disorder associated with sudden cardiac death. Its pathophysiology is still poorly understood. We aimed to produce an in vitro cellular model of ARVC using patient-specific induced pluripotent stem cell (iPSC)-derived cardiomyocytes and determine whether the model could recapitulate key features of the disease phenotype. METHODS AND RESULTS Dermal fibroblasts were obtained from a 30-year-old man with a clinical diagnosis of ARVC, harbouring a plakophilin 2 (PKP2) gene mutation. Four stable iPSC lines were generated using retroviral reprogramming, and functional cardiomyocytes were derived. Gene expression levels of desmosomal proteins (PKP2 and plakoglobin) in cardiomyocytes from ARVC-iPSCs were significantly lower compared with cardiomyocytes from control iPSCs (P< 0.01); there were no significant differences in the expression of desmoplakin, N-cadherin, and connexin 43 between the two groups. Cardiomyocytes derived from ARVC-iPSCs exhibited markedly reduced immunofluorescence signals when stained for PKP2 and plakoglobin, but similar levels of staining for desmoplakin, N-cadherin, and connexin 43 compared with control cardiomyocytes. Transmission electron microscopy showed that ARVC-iPSC cardiomyocytes were larger and contained darker lipid droplets compared with control cardiomyocytes. After 2 weeks of cell exposure to adiopgenic differentiation medium, ARVC-iPSC cardiomyocytes were found to contain a significantly greater amount of lipid, calculated using Oil Red O staining, compared with controls (734 ± 35.6 vs. 8.1 ± 0.49 a.u., respectively; n = 7, P = 0.001). CONCLUSION Patient-specific iPSC-derived cardiomyocytes display key features of ARVC, including reduced cell surface localization of desmosomal proteins and a more adipogenic phenotype.
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Affiliation(s)
- Dongrui Ma
- Research and Development Unit (RDU), National Heart Centre Singapore, 17 Third Hospital Avenue, Singapore 168752, Singapore
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23
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Rickelt S, Pieperhoff S. Mutations with pathogenic potential in proteins located in or at the composite junctions of the intercalated disk connecting mammalian cardiomyocytes: a reference thesaurus for arrhythmogenic cardiomyopathies and for Naxos and Carvajal diseases. Cell Tissue Res 2012; 348:325-33. [PMID: 22450909 PMCID: PMC3349860 DOI: 10.1007/s00441-012-1365-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 02/03/2012] [Indexed: 01/30/2023]
Abstract
In the past decade, an avalanche of findings and reports has correlated arrhythmogenic ventricular cardiomyopathies (ARVC) and Naxos and Carvajal diseases with certain mutations in protein constituents of the special junctions connecting the polar regions (intercalated disks) of mature mammalian cardiomyocytes. These molecules, apparently together with some specific cytoskeletal proteins, are components of (or interact with) composite junctions. Composite junctions contain the amalgamated fusion products of the molecules that, in other cell types and tissues, occur in distinct separate junctions, i.e. desmosomes and adherens junctions. As the pertinent literature is still in an expanding phase and is obviously becoming important for various groups of researchers in basic cell and molecular biology, developmental biology, histology, physiology, cardiology, pathology and genetics, the relevant references so far recognized have been collected and are presented here in the following order: desmocollin-2 (Dsc2, DSC2), desmoglein-2 (Dsg2, DSG2), desmoplakin (DP, DSP), plakoglobin (PG, JUP), plakophilin-2 (Pkp2, PKP2) and some non-desmosomal proteins such as transmembrane protein 43 (TMEM43), ryanodine receptor 2 (RYR2), desmin, lamins A and C, striatin, titin and transforming growth factor-β3 (TGFβ3), followed by a collection of animal models and of reviews, commentaries, collections and comparative studies.
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Affiliation(s)
- Steffen Rickelt
- Helmholtz Group for Cell Biology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, Building TP4, 69120 Heidelberg, Germany
- Progen Biotechnik, Heidelberg, Germany
| | - Sebastian Pieperhoff
- BHF Centre for Cardiovascular Science, The Queen’s Medical Research Institute, University of Edinburgh, 47 Little France Crescent, EH164TJ Edinburgh, Scotland UK
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