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Bhattacharya D, Namboodiri N, Valaparambil A, Valakada J, Mohanan Nair KK. Cardiac magnetic resonance imaging in right ventricular outflow tract arrhythmia: a retrospective analysis from a tertiary care centre in South India. Acta Cardiol 2021; 76:1019-1024. [PMID: 34412572 DOI: 10.1080/00015385.2021.1965749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Arrhythmia arising from right ventricular outflow tract (RVOT) is the most common cause of idiopathic ventricular arrhythmia. Previous studies involving cardiac magnetic resonance imaging (MRI) in these patients are known to show abnormalities in up to 60% of patients. METHODOLOGY This was a retrospective descriptive analysis of patients having idiopathic RVOT arrhythmia who underwent cardiac MRI between January 2010 and December 2020. Clinical and demographic details were recorded from the electronic medical records and cardiac MRI of all patients were reviewed. RESULTS Among 214 patients with RVOT arrhythmia, 64 underwent cardiac MRI. A total of 41 patients, who did not have any abnormality on baseline echocardiogram were included in the study. There was male preponderance (56.1%), with median age of 43 years. About 43.9% had syncope. Twenty-four-hour Holter study revealed a premature ventricular complex (PVC) burden of 26.3 ± 11.7%. MRI showed structural abnormalities in 51.2% of patients, which commonly included RV sacculations and aneurysms. Late gadolinium enhancement (LGE) was seen in six patients, which was mostly seen in RV free wall. Right ventricular (RV) systolic dysfunction was evident in 29.3%. About 9.8% fulfilled the criteria for arrhythmogenic RV cardiomyopathy (ARVC). Out of 23 patients with baseline abnormalities on ECHO, 87% had structural abnormalities on MRI, and 43.5% fulfilled the criteria for ARVC. CONCLUSIONS Additional imaging by cardiac MRI helps to identify structural abnormalities in 51.2% of patients with RVOT arrhythmias, even with normal baseline echocardiogram and electrocardiogram (ECG). It is useful tool to rule out ARVC in this subset of patients, and can help in increasing the diagnostic yield in the early stages.
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Affiliation(s)
- Deepanjan Bhattacharya
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Narayanan Namboodiri
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Ajitkumar Valaparambil
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Jineesh Valakada
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Krishna Kumar Mohanan Nair
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Scorza R, Jansson A, Sörensson P, Rosenqvist M, Frykman V. Magnetic Resonance Detects Structural Heart Disease in Patients with Frequent Ventricular Ectopy and Normal Echocardiographic Findings. Diagnostics (Basel) 2021; 11:1505. [PMID: 34441439 PMCID: PMC8392672 DOI: 10.3390/diagnostics11081505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023] Open
Abstract
The prognosis of patients with ventricular ectopy and a normal heart, as evaluated by echocardiography, is virtually unknown. Cardiac magnetic resonance (CMR) can detect focal ventricular anomalies that could act as a possible site of origin for premature ventricular contractions (PVCs). The aim of this study was to investigate the presence of cardiac anomalies in patients with normal findings at echocardiogram. METHODS Fifty-one consecutive patients (23 women, 28 men, mean age 59 years) with very high PVC burden (>10,000 PVC/day) and normal findings at standard echocardiography and exercise test were examined with CMR. The outcome was pathologic findings, defined as impaired ejection fraction, regional wall motion abnormalities, abnormal ventricular volume, myocardial edema and fibrosis. RESULTS Sixteen out of 51 patients (32%) had structural ventricular abnormalities at CMR. In five patients CMR showed impairment of the left ventricular and/or right ventricular systolic function, and six patients had a dilated left and/or right ventricle. Regional wall motion abnormalities were seen in six patients and fibrosis in four. No patient had CMR signs of edema or met CMR criteria for arrhythmogenic right ventricular cardiomyopathy. Five patients had extra-ventricular findings (enlarged atria in three cases, enlarged thoracic aorta in one case and pericardial effusion in one case). CONCLUSIONS In this study 16 out of 51 patients with a high PVC burden and normal findings at echocardiography showed signs of pathology in the ventricles with CMR. These findings indicate that CMR should be considered in evaluating patients with a high PVC burden and a normal standard investigation.
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Affiliation(s)
- Raffaele Scorza
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Anders Jansson
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Peder Sörensson
- Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Mårten Rosenqvist
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Viveka Frykman
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
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Spartera M. Features of a covert cardiomyopathy are present in patients with unexplained syncope and incident ventricular tachycardia. Int J Cardiovasc Imaging 2021; 37:2621-2623. [PMID: 34146205 DOI: 10.1007/s10554-021-02313-0] [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: 11/25/2022]
Affiliation(s)
- Marco Spartera
- University of Oxford, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
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Nikolaidou C, Kotanidis CP, Wijesurendra R, Leal-Pelado J, Kouskouras K, Vassilikos VP, Karvounis H, Ntusi N, Antoniades C, Neubauer S, Karamitsos TD. Cardiac Magnetic Resonance to Detect the Underlying Substrate in Patients with Frequent Idiopathic Ventricular Arrhythmias. Diagnostics (Basel) 2021; 11:1109. [PMID: 34207123 PMCID: PMC8233842 DOI: 10.3390/diagnostics11061109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A routine diagnostic work-up does not identify structural abnormalities in a substantial proportion of patients with idiopathic ventricular arrhythmias (VAs). We investigated the added value of cardiac magnetic resonance (CMR) imaging in this group of patients. METHODS A single-centre prospective study was undertaken of 72 patients (mean age 46 ± 16 years; 53% females) with frequent premature ventricular contractions (PVCs ≥ 500/24 h) and/or non-sustained ventricular tachycardia (NSVT), an otherwise normal electrocardiogram, normal echocardiography and no coronary artery disease. RESULTS CMR provided an additional diagnostic yield in 54.2% of patients. The most prevalent diagnosis was previous myocarditis (23.6%) followed by possible PVC-related cardiomyopathy (20.8%), non-ischaemic cardiomyopathy (8.3%) and ischaemic heart disease (1.4%). The predictors of abnormal CMR findings were male gender, age and PVCs/NSVT non-outflow tract-related or with multiple morphologies. Patients with VAs had an impaired peak left ventricular (LV) global radial strain (GRS) compared with the controls (28.88% (IQR: 25.87% to 33.97%) vs. 36.65% (IQR: 33.19% to 40.2%), p < 0.001) and a global circumferential strain (GCS) (-17.66% (IQR: -19.62% to -16.23%) vs. -20.66% (IQR: -21.72% to -19.6%), p < 0.001). CONCLUSION CMR reveals abnormalities in a significant proportion of patients with frequent idiopathic VAs. Male gender, age and non-outflow tract PVC origin can be clinical indicators for CMR referral.
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Affiliation(s)
- Chrysovalantou Nikolaidou
- Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford OX3 9DU, UK; (C.N.); (R.W.); (J.L.-P.); (S.N.)
- First Department of Cardiology, AHEPA Hospital, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
| | - Christos P. Kotanidis
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK; (C.P.K.); (C.A.)
| | - Rohan Wijesurendra
- Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford OX3 9DU, UK; (C.N.); (R.W.); (J.L.-P.); (S.N.)
| | - Joana Leal-Pelado
- Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford OX3 9DU, UK; (C.N.); (R.W.); (J.L.-P.); (S.N.)
| | - Konstantinos Kouskouras
- Department of Radiology, AHEPA Hospital, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
| | - Vassilios P. Vassilikos
- Third Department of Cardiology, Hippokration Hospital, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 546 43 Thessaloniki, Greece;
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA Hospital, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
| | - Ntobeko Ntusi
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, 7925 Cape Town, South Africa;
| | - Charalambos Antoniades
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK; (C.P.K.); (C.A.)
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford OX3 9DU, UK; (C.N.); (R.W.); (J.L.-P.); (S.N.)
| | - Theodoros D. Karamitsos
- First Department of Cardiology, AHEPA Hospital, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
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Fonseca M, Parreira L, Farinha JM, Marinheiro R, Esteves A, Gonçalves S, Caria R. Premature ventricular contractions of the right ventricular outflow tract: is there an incipient underlying disease? New insights from a speckle tracking echocardiography study. Indian Pacing Electrophysiol J 2021; 21:147-152. [PMID: 33607220 PMCID: PMC8116808 DOI: 10.1016/j.ipej.2021.02.007] [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] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
Context Premature ventricular contractions (PVCs) originating in the right ventricular outflow tract (RVOT) are traditionally considered idiopathic and benign. Echocardiographic conventional measurements are typically normal. Aims To assess whether right ventricle longitudinal strain, determined by two-dimensional speckle tracking echocardiography, differ between RVOT PVCs patients (treated with catheter ablation) and healthy controls. Methods We retrospectively selected patients with PVCs from the RVOT who underwent electrophysiological study and catheter ablation between 2016 and 2019. Patients with documented structural heart disease were excluded. Transthoracic echocardiography was performed and right ventricle global longitudinal strain (RV-GLS), free wall longitudinal strain (RVFW-LS) and left ventricle global longitudinal strain (LV-GLS) were determined as well as conventional ultrasound measurements of RV and LV function. Results We studied 21 patients with RVOT PVCs and 13 controls. Patients with PVCs from the RVOT had lower values of RV-GLS and RVFW-LS compared with the control group (−19.4% versus −22.5%, P = 0.015 and −22.1% versus −25.5, P = 0.041, respectively). They also had lower values of LV-GLS, although still within the normal range (−19.1% versus −20.9%, P = 0.047). Regarding RVOT PVCs patients only, RV-GLS and RVFW-LS had no correlation with the PVCs burden prior to catheter ablation and they did not differ between the patients in whom the catheter ablation was successful and those in whom it was not. RV-GLS also had a positive correlation with RVOT proximal diameter (r = 0.487, P = 0.025). Conclusions In this group of RVOT PVCs patients, we found worse RV longitudinal strain values (and therefore sub-clinical myocardial dysfunction) when compared to healthy controls.
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Affiliation(s)
- Marta Fonseca
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Leonor Parreira
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | | | - Rita Marinheiro
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Ana Esteves
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Sara Gonçalves
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Rui Caria
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
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Palumbo P, Cannizzaro E, Di Cesare A, Bruno F, Schicchi N, Giovagnoni A, Splendiani A, Barile A, Masciocchi C, Di Cesare E. Cardiac magnetic resonance in arrhythmogenic cardiomyopathies. Radiol Med 2020; 125:1087-1101. [PMID: 32978708 DOI: 10.1007/s11547-020-01289-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Abstract
Over the past few years, the approach to the 'arrhythmic patient' has profoundly changed. An early clinical presentation of arrhythmia is often accompanied by non-specific symptoms and followed by inconclusive electrocardiographic findings. In this scenario, cardiac magnetic resonance (CMR) has been established as a clinical tool of fundamental importance for a correct prognostic stratification of the arrhythmic patient. This technique provides a high-spatial-resolution tomographic evaluation of the heart, which allows studying accurately the ventricular volumes, identifying even segmental kinetic anomalies and properly detecting diffuse or focal tissue alterations through an excellent tissue characterization, while depicting different patterns of fibrosis distribution, myocardial edema or fatty substitution. Through these capabilities, CMR has a pivotal role for the adequate management of the arrhythmic patient, allowing the identification of those phenotypic manifestations characteristic of structural heart diseases. Therefore, CMR provides valuable information to reclassify the patient within the wide spectrum of potentially arrhythmogenic heart diseases, the definition of which remains the major determinants for both an adequate treatment and a poor prognosis. The purpose of this review study was to focus on the role of CMR in the evaluation of the main cardiac clinical entities associated with arrhythmogenic phenomena and to present a brief debate on the main pathophysiological mechanisms involved in the arrhythmogenesis process.
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Affiliation(s)
- Pierpaolo Palumbo
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy.
| | | | - Annamaria Di Cesare
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Nicolò Schicchi
- Department of Radiology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Andrea Giovagnoni
- Department of Radiology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Ernesto Di Cesare
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Jia R, Xu Y, Luo Y, Yang C, Zou S, Gong S, Yangzong C, Guo R, Liu G, Cui K. The ratio of main pulmonary artery to ascending aorta diameter is associated with the right ventricular outflow tract ventriculararrhythmias. J Interv Card Electrophysiol 2020; 62:57-62. [PMID: 32951116 DOI: 10.1007/s10840-020-00872-1] [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: 07/14/2020] [Accepted: 09/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although outflow tract (OT) ventricular arrhythmias (VAs) are generally regarded as benign, the relationship between circulation pressure and VAs has received considerable attention in recent years. Previous studies have shown that the ratio of main pulmonary artery (MPA) to ascending aorta (AA) diameter is associated with pulmonary pressure. Here, we investigated whether an elevated MPA/AA ratio is associated with right ventricular OT (RVOT) VAs. METHODS A total of 67 patients with OT VAs (47 patients with RVOT and 20 patients with LVOT) who underwent cardiac multidetector computed tomography and radiofrequency ablation were enrolled in this study. MPA and AA diameters were measured at the level of the bifurcation of the pulmonary artery. According to the MPA/AA ratio, patients were further divided into two groups: the MPA/AA ratio abnormal group (n = 19), which is defined as MPA/AA ratio ≥ 0.9, and the MPA/AA ratio normal group (n = 48) consisting of patients with an MPA/AA ratio < 0.9. RESULTS Patients with RVOT VAs exhibited an elevated MPA/AA ratio (0.84 ± 0.11 vs. 0.75 ± 0.11, p = 0.006). Furthermore, this MPA/AA ratio was shown to be an independent predictor for RVOT VAs (p = 0.013, 95% confidence interval: 1.016-1.145), with an abnormal MPA/AA ratio increasing the odds of RVOT VAs 5.1-fold in patients with OT VAs. CONCLUSION Patients with RVOT VAs exhibited significantly higher MPA/AA ratios compared with those LVOT VAs. The MPA/AA ratio was showed to be an independent predictor RVOT VAs.
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Affiliation(s)
- Ruikun Jia
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ying Xu
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yichun Luo
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610000, People's Republic of China
| | - Chao Yang
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Song Zou
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Shenzhen Gong
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ciren Yangzong
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ran Guo
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guobin Liu
- Department of Cardiovascular Medicine, The First People's Hospital of Jintang County, Chengdu, 610041, People's Republic of China.
| | - Kaijun Cui
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Parreira L, Marinheiro R, Carmo P, Mesquita D, Farinha J, Amador P, Ferreira A, Fonseca M, Costa F, Cavaco D, Caria R, Adragão P. Idiopathic Premature Ventricular Contractions From the Outflow Tract Display an Underlying Substrate That Can Be Unmasked by a Type 2 Brugada Electrocardiographic Pattern at High Right Precordial Leads. Front Physiol 2020; 11:969. [PMID: 32848884 PMCID: PMC7426514 DOI: 10.3389/fphys.2020.00969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/16/2020] [Indexed: 01/12/2023] Open
Abstract
Background: Patients with premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT) and apparently normal hearts, can have ST elevation similar to type 2 or type 3 Brugada pattern in the electrocardiographic (ECG) performed at a higher position. Cardiac magnetic resonance (CMR), has shown conflicting data regarding existence of structural abnormalities in patients with idiopathic PVCs from the RVOT. Objective: Our aim was to evaluate the prevalence of low voltage areas (LVAs) in the RVOT of patients with PVCS from the outflow tract, and in a control group. Secondly, assess for the presence of a non-invasive ECG marker. Methods: A 56 consecutive patients, 45 with frequent PVCs (>10000/24 h) LBBB, vertical axis, negative in aVL and 11 subjects without PVCs. Arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An ECG was performed with V1-V2 at the level of the second intercostal space and the presence of ST-segment elevation with a Type 2 or 3 Brugada pattern (Type 2 BrP) was assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV represented the LVA. The area adjacent to the pulmonary valve usually displays voltage between 0.5 and 1.5 mV and is classified as transitional-voltage zone. Presence of LVAs outside this transitional-voltage zone were estimated. We compared two groups with and without ST-segment elevation and tested for the association between ECG pattern and LVAs. Results: None of the patients in the control group had ST-segment elevation or LVAs. In the PVC group, no patient had type 1 Brugada pattern, 29 patients (64%) had type 2 or 3 ST-segment elevation (Type 2 BrP), and 28 (62%) had LVAs outside the transitional-voltage zone. LVAs were more frequent in patients with Type 2 BrP; 93% versus 4%, p < 0.0001. The ECG pattern was associated with the presence of LVAs, OR (95% CI): 202.50 (16.92-2423), p < 0.0001. Conclusion: Low voltage areas were frequently present in the RVOT of patients with idiopathic PVCs. They were absent in controls and can be unmasked by the presence of Type 2 BrP in high right precordial leads.
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Affiliation(s)
- Leonor Parreira
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Rita Marinheiro
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Carmo
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Dinis Mesquita
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - José Farinha
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Amador
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - António Ferreira
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Marta Fonseca
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Francisco Costa
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Diogo Cavaco
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Rui Caria
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Adragão
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
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Concealed structural heart disease discovered at cardiac magnetic resonance in patients with ventricular extrasystoles from ventricular outflow tract and apparently normal hearts. J Interv Card Electrophysiol 2020; 61:45-53. [PMID: 32462549 DOI: 10.1007/s10840-020-00771-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outflow tract (OT) premature ventricular contractions (PVCs) are commonly found in clinical practice; in most cases, PVCs are benign and observed in structurally normal hearts, not requiring any therapeutic intervention. In this study, we therefore sought to evaluate with cardiac magnetic resonance (CMR) patients with PVC and apparently normal heart at echocardiographic examination, in order to identify possible substrates linked with higher prevalence of arrhythmias or structural heart disease. METHODS Thirty-three consecutive patients with frequent PVCs originating from the ventricular OT (right and left) were enrolled in the study and assessed by echocardiography and CMR. All patients had normal baseline electrocardiogram. RESULTS CMR showed structural changes in 5 patients out of 33; in 3 cases, areas of fibrosis limited in one case to the middle basal segments of the interventricular septum and in two patients to the middle basal segments of the inferior-lateral wall were found. In 2 other cases, however, late gadolinium enhancement showed significant anomalies characterized in one patient by extensive areas of subepicardial fibrosis of the left ventricle, suitable with arrhythmogenic left dominant dysplasia; in another patient, a marked trabeculation of left ventricular medium apical segments suitable with non-compaction myocardium was present. CONCLUSIONS CMR may identify cases of structural heart disease in subjects with OT PVCs and apparently normal electrocardiogram and echocardiogram examinations. A preliminary screening with CMR may be considered before any further invasive electrophysiology assessment and therapeutic planning.
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10
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Letsas KP, Efremidis M, Vlachos K, Asvestas D, Takigawa M, Bazoukis G, Frontera A, Giannopoulos G, Saplaouras A, Sakellaropoulou A, Mililis P, Dragasis S, Megarisiotou A, Valkanas K, Tse G, Liu T, Deftereos S, Sideris A, Baranchuk A, Jais P. Right ventricular outflow tract low‐voltage areas identify the site of origin of idiopathic ventricular arrhythmias: A high‐density mapping study. J Cardiovasc Electrophysiol 2019; 30:2362-2369. [PMID: 31502366 DOI: 10.1111/jce.14155] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/30/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Konstantinos P. Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Konstantinos Vlachos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - Dimitrios Asvestas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Masateru Takigawa
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Antonio Frontera
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - George Giannopoulos
- Department of Cardiology “G. Gennimatas” General Hospital of Athens Athens Greece
| | - Athanasios Saplaouras
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Antigoni Sakellaropoulou
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Panagiotis Mililis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Stylianos Dragasis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Athanasia Megarisiotou
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Kosmas Valkanas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine Chinese University of Hong Kong Hong Kong, SAR China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine Chinese University of Hong Kong Hong Kong, SAR China
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Spyridon Deftereos
- Department of Cardiology “G. Gennimatas” General Hospital of Athens Athens Greece
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Adrian Baranchuk
- Division of Cardiology Queen's University, Kingston General Hospital Ontario Canada
| | - Pierre Jais
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
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11
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Mukherjee RK, Whitaker J, Williams SE, Razavi R, O'Neill MD. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation. Europace 2019; 20:1721-1732. [PMID: 29584897 PMCID: PMC6212773 DOI: 10.1093/europace/euy040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/19/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome.
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Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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12
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Heermann P, Fritsch H, Koopmann M, Sporns P, Paul M, Heindel W, Schulze-Bahr E, Schülke C. Biventricular myocardial strain analysis using cardiac magnetic resonance feature tracking (CMR-FT) in patients with distinct types of right ventricular diseases comparing arrhythmogenic right ventricular cardiomyopathy (ARVC), right ventricular outflow-tract tachycardia (RVOT-VT), and Brugada syndrome (BrS). Clin Res Cardiol 2019; 108:1147-1162. [DOI: 10.1007/s00392-019-01450-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/05/2019] [Indexed: 12/25/2022]
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13
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Parreira L, Marinheiro R, Carmo P, Amador P, Teixeira T, Cavaco D, Costa F, Reis-Santos K, Adragão P. Premature ventricular contractions of the right ventricular outflow tract: Upward displacement of the ECG unmasks ST elevation in V1 associated with the presence of low voltage areas. Rev Port Cardiol 2019; 38:83-91. [PMID: 30797606 DOI: 10.1016/j.repc.2018.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/26/2018] [Accepted: 06/03/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION AND AIMS Frequent premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT) are usually considered a benign entity and the ECG is typically normal. The aim of this study was to assess whether upward displacement of the ECG to the second intercostal space (ICS) would reveal any abnormal pattern. METHODS A total of 18 consecutive patients with apparently normal hearts were studied, mean age 44±16 years, 12 women, who underwent catheter ablation of the RVOT due to frequent PVCs. A 12-lead ECG was performed in the standard position and repeated in a higher position, at the level of the second ICS. Three-dimensional bipolar electroanatomical voltage mapping (EVM) was performed in all patients and low voltage areas (LVAs) were defined as areas with amplitude <1.5 mV. RESULTS The ECG in the second ICS was normal in eleven patients but in seven (39%) it revealed a pattern of ST-segment elevation in V1. EVM revealed the presence of LVAs in six patients (33%) which included the earliest activation site (EAS) in five. The ST elevation was associated with the presence of LVAs (p<0.0001) and with the LVAs at the EAS (p=0.002). CONCLUSION In this group of patients with apparently normal hearts and with frequent PVCs of the RVOT, upward displacement of the ECG revealed the presence of ST elevation in more than one third of patients, and the ST elevation was associated with the presence of LVAs in the RVOT.
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Affiliation(s)
- Leonor Parreira
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal; Hospital da Luz, Arrhythmology Department, Lisboa, Portugal.
| | - Rita Marinheiro
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal
| | - Pedro Carmo
- Hospital da Luz, Arrhythmology Department, Lisboa, Portugal
| | - Pedro Amador
- Hospital da Luz, Arrhythmology Department, Lisboa, Portugal
| | - Tiago Teixeira
- Hospital da Luz, Arrhythmology Department, Lisboa, Portugal
| | - Diogo Cavaco
- Hospital da Luz, Arrhythmology Department, Lisboa, Portugal
| | | | | | - Pedro Adragão
- Hospital da Luz, Arrhythmology Department, Lisboa, Portugal
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14
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Parreira L, Marinheiro R, Carmo P, Amador P, Teixeira T, Cavaco D, Costa F, Reis-Santos K, Adragão P. Premature ventricular contractions of the right ventricular outflow tract: Upward displacement of the ECG unmasks ST elevation in V1 associated with the presence of low voltage areas. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2018.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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15
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Muser D, Santangeli P, Selvanayagam JB, Nucifora G. Role of Cardiac Magnetic Resonance Imaging in Patients with Idiopathic Ventricular Arrhythmias. Curr Cardiol Rev 2019; 15:12-23. [PMID: 30251607 PMCID: PMC6367696 DOI: 10.2174/1573403x14666180925095923] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 01/14/2023] Open
Abstract
Ventricular Arrhythmias (VAs) may present with a wide spectrum of clinical manifestations ranging from mildly symptomatic frequent premature ventricular contractions to lifethreatening events such as sustained ventricular tachycardia, ventricular fibrillation and sudden cardiac death. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias which are commonly associated with Structural Heart Diseases (SHD) such as ischemic heart disease, healed myocarditis and non-ischemic cardiomyopathies. However, the arrhythmogenic substrate may remain unclear in up to 50% of the cases after a routine diagnostic workup, comprehensive of 12-lead surface ECG, transthoracic echocardiography and coronary angiography/ computed tomography. Whenever any abnormality cannot be identified, VAs are referred as to "idiopathic". In the last decade, Cardiac Magnetic Resonance (CMR) imaging has acquired a growing role in the identification and characterization of myocardial arrhythmogenic substrate, not only being able to accurately and reproducibly quantify biventricular function, but, more importantly, providing information about the presence of myocardial structural abnormalities such as myocardial fatty replacement, myocardial oedema, and necrosis/ fibrosis, which may otherwise remain unrecognized. Moreover, CMR has recently demonstrated to be of great value in guiding interventional treatments, such as radiofrequency ablation, by reliably identifying VA sites of origin and improving long-term outcomes. In the present manuscript, we review the available data regarding the utility of CMR in the workup of apparently "idiopathic" VAs with a special focus on its prognostic relevance and its application in planning and guiding interventional treatments.
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Affiliation(s)
| | | | | | - Gaetano Nucifora
- Address correspondence to this author author at the Cardiac Imaging Unit, Manchester University NHS Foundation Trust, Manchester, UK; E-mail:
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16
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Lerman BB, Cheung JW, Ip JE, Liu CF, Thomas G, Markowitz SM. Mechanistic subtypes of focal right ventricular tachycardia. J Cardiovasc Electrophysiol 2018; 29:1181-1188. [DOI: 10.1111/jce.13505] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Bruce B. Lerman
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
| | - Jim W. Cheung
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
| | - James E. Ip
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
| | - Christopher F. Liu
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
| | - George Thomas
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
| | - Steven M. Markowitz
- Division of Cardiology, Department of Medicine; Cornell University Medical Center, New York Presbyterian Hospital; New York NY USA
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17
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Ip JE, Lerman BB. Idiopathic malignant premature ventricular contractions. Trends Cardiovasc Med 2018; 28:295-302. [DOI: 10.1016/j.tcm.2017.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/01/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
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18
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Chaszczewski KJ, Sosnowski C, Ganesan R. Vagal Termination of Ventricular Tachycardia in a Pediatric Patient. Pediatrics 2018; 141:S412-S415. [PMID: 29610162 DOI: 10.1542/peds.2016-3792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/24/2022] Open
Abstract
Ventricular tachycardia is a rare clinical entity in pediatric patients and typically requires chemical and/or electrical intervention to convert into a sustained sinus rhythm. However, for certain forms originating from the right ventricular outflow tract, conversion with adenosine and vagal maneuvers has been demonstrated in adult patients. In this case, we suggest that pediatric patients with right ventricular outflow tract ventricular tachycardia who are hemodynamically stable may benefit from a trial of vagal maneuvers.
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Affiliation(s)
| | - Cyndi Sosnowski
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Rani Ganesan
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
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19
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MiR-320a as a Potential Novel Circulating Biomarker of Arrhythmogenic CardioMyopathy. Sci Rep 2017; 7:4802. [PMID: 28684747 PMCID: PMC5500514 DOI: 10.1038/s41598-017-05001-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/23/2017] [Indexed: 12/21/2022] Open
Abstract
Diagnosis of Arrhythmogenic CardioMyopathy (ACM) is challenging and often late after disease onset. No circulating biomarkers are available to date. Given their involvement in several cardiovascular diseases, plasma microRNAs warranted investigation as potential non-invasive diagnostic tools in ACM. We sought to identify circulating microRNAs differentially expressed in ACM with respect to Healthy Controls (HC) and Idiopathic Ventricular Tachycardia patients (IVT), often in differential diagnosis. ACM and HC subjects were screened for plasmatic expression of 377 microRNAs and validation was performed in 36 ACM, 53 HC, 21 IVT. Variable importance in data partition was estimated through Random Forest analysis and accuracy by Receiver Operating Curves. Plasmatic miR-320a showed 0.53 ± 0.04 fold expression difference in ACM vs. HC (p < 0.01). A similar trend was observed when comparing ACM (n = 13) and HC (n = 17) with athletic lifestyle, a ACM precipitating factor. Importantly, ACM patients miR-320a showed 0.78 ± 0.05 fold expression change vs. IVT (p = 0.03). When compared to non-invasive ACM diagnostic parameters, miR-320a ranked highly in discriminating ACM vs. IVT and it increased their accuracy. Finally, miR-320a expression did not correlate with ACM severity. Our data suggest that miR-320a may be considered a novel potential biomarker of ACM, specifically useful in ACM vs. IVT differentiation.
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20
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Tang X, Yu S, Yu Y, Ren H, Li S, Zhou L, Yang Z, Wu H, Zhou W, Gong L. Left ventricular myocardial strain in ventricular arrhythmia without structural heart disease using cardiac magnetic resonance. Am J Transl Res 2017; 9:3006-3016. [PMID: 28670388 PMCID: PMC5489900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/11/2017] [Indexed: 06/07/2023]
Abstract
Ventricular arrhythmia (VA) in structurally normal heart is considered as benign. However, these arrhythmias have been recently reported to induce left ventricular (LV) dysfunction. Up to now, there is no efficacious method to detect abnormal myocardial systolic function in VA patients. Therefore, in the current study, we used cardiac magnetic resonance feature tracking (CMR-FT) on balanced steady state free precision (SSFP) cine images to investigate LV myocardial strain in 42 VA patients without known heart disease as well as in 29 normal volunteers. As compared with controls, VA patients had lower peak values of radial and circumferential strain (RS, CS) in both basal and middle parts of LV and the peak value of longitudinal strain (LS) in VA patients was also decreased in middle LV. Moreover, as revealed by LV myocardial segmental peak strain, reduced RS, CS and LS peaks in VA were more significant in anterior, inferoseptal and anterolateral segments, especially for the patients with frequent premature ventricular complexes. Our results suggested that VA in normal heart is associated with abnormal segmental wall motion, which can be efficaciously detected by CMR-FT derived strain analysis. And early clinical management should be considered to prevent further significant symptoms in these patients.
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Affiliation(s)
- Xuepei Tang
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Sisi Yu
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Yaohan Yu
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Haibo Ren
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Shuhao Li
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Li Zhou
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Zhen Yang
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Hailong Wu
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Wei Zhou
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
| | - Lianggeng Gong
- Department of MRI, The Second Affiliated Hospital of Nanchang UniversityNanchang, Jiangxi, China
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21
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Tan AY, Ellenbogen K. Ventricular Arrhythmias in Apparently Normal Hearts: Who Needs an Implantable Cardiac Defibrillator? Card Electrophysiol Clin 2016; 8:613-21. [PMID: 27521094 DOI: 10.1016/j.ccep.2016.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Idiopathic ventricular tachycardia is often considered a benign form of ventricular arrhythmia in patients without apparent structural heart disease. However, a subset of patients may develop malignant ventricular arrhythmias and present with syncope and sudden cardiac arrest. Survivors of cardiac arrest are candidates for implantable cardiac defibrillators (ICDs). The indications for ICDs in patients with less than a full-blown cardiac arrest presentation but with electrocardiographically high-risk ectopy features remain uncertain. This article addresses some of the uncertainties and pitfalls in ICD risk stratification in this patient group and explores potential mechanisms for malignant conversion of benign premature ventricular complexes to sustained arrhythmia.
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Affiliation(s)
- Alex Y Tan
- Electrophysiology Section, Division of Cardiology, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA; VCU Pauley Heart Center, Medical College of Virginia, Virginia Commonwealth University School of Medicine, 1250 E Marshall Street, Richmond, VA 23298, USA.
| | - Kenneth Ellenbogen
- VCU Pauley Heart Center, Medical College of Virginia, Virginia Commonwealth University School of Medicine, 1250 E Marshall Street, Richmond, VA 23298, USA
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22
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Saberniak J, Leren IS, Haland TF, Beitnes JO, Hopp E, Borgquist R, Edvardsen T, Haugaa KH. Comparison of patients with early-phase arrhythmogenic right ventricular cardiomyopathy and right ventricular outflow tract ventricular tachycardia. Eur Heart J Cardiovasc Imaging 2016; 18:62-69. [PMID: 26903598 PMCID: PMC5217739 DOI: 10.1093/ehjci/jew014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 01/15/2016] [Indexed: 12/04/2022] Open
Abstract
Aims Differentiation between early-phase arrhythmogenic right ventricular cardiomyopathy (ARVC) and right ventricular outflow tract (RVOT)-ventricular tachycardia (VT) can be challenging, and correct diagnosis is important. We compared electrocardiogram (ECG) parameters and morphological right ventricular (RV) abnormalities and investigated if ECG and cardiac imaging can help to discriminate early-phase ARVC from RVOT-VT patients. Methods and results We included 44 consecutive RVOT-VT (47 ± 14 years) and 121 ARVC patients (42 ± 17 years). Of the ARVC patients, 77 had definite ARVC and 44 had early-phase ARVC disease. All underwent clinical examination, ECG, and Holter monitoring. Frequency of premature ventricular complexes (PVC) was expressed as percent per total beats/24 h (%PVC), and PVC configuration was recorded. By echocardiography, we assessed indexed RV basal diameter (RVD), indexed RVOT diameter, and RV and left ventricular (LV) function. RV mechanical dispersion (RVMD), reflecting RV contraction heterogeneity, was assessed by speckle-tracking strain echocardiography. RV ejection fraction (RVEF) was assessed by cardiac magnetic resonance imaging (CMR). Patients with early-phase ARVC had lower %PVC by Holter and PVC more frequently originated from the RV lateral free wall (both P < 0.001). RVD was larger (21 ± 3 vs. 19 ± 2 mm, P < 0.01), RVMD was more pronounced (22 ± 15 vs. 15 ± 13 ms, P = 0.03), and RVEF by CMR was decreased (41 ± 8 vs. 49 ± 4%, P < 0.001) in early-phase ARVC vs. RVOT-VT patients. Conclusion Patients with early-phase ARVC had structural abnormalities with lower RVEF, increased RVD, and pronounced RVMD in addition to lower %PVC by Holter compared with RVOT-VT patients. These parameters can help correct diagnosis in patients with unclear phenotypes.
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Affiliation(s)
- Jørg Saberniak
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Ida S Leren
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Trine F Haland
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jan Otto Beitnes
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Einar Hopp
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rasmus Borgquist
- Arrhythmia Clinic, Lund University, Skane University Hospital, Lund, Sweden
| | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristina H Haugaa
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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23
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Prati G, Vitrella G, Allocca G, Muser D, Buttignoni SC, Piccoli G, Morocutti G, Delise P, Pinamonti B, Proclemer A, Sinagra G, Nucifora G. Right Ventricular Strain and Dyssynchrony Assessment in Arrhythmogenic Right Ventricular Cardiomyopathy: Cardiac Magnetic Resonance Feature-Tracking Study. Circ Cardiovasc Imaging 2016; 8:e003647; discussion e003647. [PMID: 26534932 DOI: 10.1161/circimaging.115.003647] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Analysis of right ventricular (RV) regional dysfunction by cardiac magnetic resonance (CMR) imaging in arrhythmogenic RV cardiomyopathy (ARVC) may be inadequate because of the complex contraction pattern of the RV. Aim of this study was to determine the use of RV strain and dyssynchrony assessment in ARVC using feature-tracking CMR analysis. METHODS AND RESULTS Thirty-two consecutive patients with ARVC referred to CMR imaging were included. Thirty-two patients with idiopathic RV outflow tract arrhythmias and 32 control subjects, matched for age and sex to the ARVC group, were included for comparison purpose. CMR imaging was performed to assess biventricular function; feature-tracking analysis was applied to the cine CMR images to assess regional and global longitudinal, circumferential, and radial RV strains and RV dyssynchrony (defined as the SD of the time-to-peak strain of the RV segments). RV global longitudinal strain (-17±5% versus -26±6% versus -29±6%; P<0.001), global circumferential strain (-9±4% versus -12±4% versus -13±5%; P=0.001), and global radial strain (18 [12-26]% versus 22 [15-32]% versus 27 [20-39]%; P=0.015) were significantly lower and SD of the time-to-peak RV strain in all 3 directions were significantly higher among patients with ARVC compared with patients with RV outflow tract arrhythmias and controls. RV global longitudinal strain >-23.2%, SD of the time-to-peak RV longitudinal strain >113.1 ms, and SD of the time-to-peak RV circumferential strain >177.1 ms allowed correct identification of 88%, 75%, and 63% of ARVC patients with no or only minor CMR criteria for ARVC diagnosis. CONCLUSIONS Strain analysis by feature-tracking CMR helps to objectively quantify global and regional RV dysfunction and RV dyssynchrony in patients with ARVC and provides incremental value over conventional cine CMR imaging.
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Affiliation(s)
- Giulio Prati
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Giancarlo Vitrella
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Giuseppe Allocca
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Daniele Muser
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Sonja Cukon Buttignoni
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Gianluca Piccoli
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Giorgio Morocutti
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Pietro Delise
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Bruno Pinamonti
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Alessandro Proclemer
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Gianfranco Sinagra
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy
| | - Gaetano Nucifora
- From the Cardiothoracic Department, University Hospital "Santa Maria della Misericordia," Udine, Italy (G.P., D.M., G.M., A.P., G.N.); Cardiovascular Department, University Hospital "Ospedali Riuniti," Trieste, Italy (G.P., G.V., B.P., G.S.); Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy (G.P., D.M.); and Divisions of Cardiology (G.A., S.C.B., P.D.) and Radiology (G.P.), "Santa Maria dei Battuti" Hospital, Conegliano, Italy.
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Right Ventricular Outflow Tract Tachycardia with Structural Abnormalities of the Right Ventricle and Left Ventricular Diverticulum. Case Rep Cardiol 2015; 2015:708687. [PMID: 26509086 PMCID: PMC4609788 DOI: 10.1155/2015/708687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/21/2015] [Accepted: 08/03/2015] [Indexed: 11/17/2022] Open
Abstract
A 43-year-old woman presented to the emergency room with a sustained ventricular tachycardia (VT). ECG showed a QRS in left bundle branch block morphology with inferior axis. Echocardiography, ventricular angiography, and cardiac magnetic resonance imaging (CMRI) revealed a normal right ventricle and a left ventricular diverticulum. Electrophysiology studies with epicardial voltage mapping identified a large fibrotic area in the inferolateral layer of the right ventricular wall and a small area of fibrotic tissue at the anterior right ventricular outflow tract. VT ablation was successfully performed with combined epicardial and endocardial approaches.
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Affiliation(s)
- Bruce B. Lerman
- From the Division of Cardiology, Department of Medicine, Cornell University, Medical Center, New York, NY
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Incremental value of cardiac magnetic resonance imaging in the diagnostic work-up of patients with apparently idiopathic ventricular arrhythmias of left ventricular origin. Int J Cardiol 2015; 180:142-4. [DOI: 10.1016/j.ijcard.2014.11.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/23/2014] [Indexed: 01/01/2023]
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Lerman BB. Outflow tract ventricular arrhythmias: An update. Trends Cardiovasc Med 2015; 25:550-8. [PMID: 25846938 DOI: 10.1016/j.tcm.2015.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/22/2015] [Accepted: 01/22/2015] [Indexed: 11/25/2022]
Abstract
During the last 20 years, the molecular etiology for many ventricular tachyarrhythmias once referred to as "idiopathic," has been elucidated. These arrhythmias are due to mutations in ion channels or structural proteins and include ventricular tachyarrhythmias due to long and short QT syndromes, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (VT). However, the basis for the most common form of idiopathic ventricular arrhythmia, which originates from right or left ventricular outflow tracts, has remained elusive. Although traditionally considered a benign ventricular arrhythmia, it is now appreciated that some outflow tract arrhythmias also trigger polymorphic VT or sudden cardiac death or result in cardiomyopathy. The current understanding of outflow tract arrhythmias will be examined.
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Affiliation(s)
- Bruce B Lerman
- Department of Medicine, Cornell University Medical Center, New York, NY.
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Rillig A, Lin T, Ouyang F, Kuck KH, Tilz RR. Which Is The Appropriate Arrhythmia Burden To Offer RF Ablation For RVOT Tachycardias? J Atr Fibrillation 2014; 7:1157. [PMID: 27957135 DOI: 10.4022/jafib.1157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 12/14/2022]
Abstract
Premature ventricular complexes (PVCs) and ventricular tachycardia (VT) in patients with structurally normal hearts originate from the right ventricular outflow tract (RVOT) in the majority of cases. In the last few decades catheter ablation of these arrhythmias has been proven to be effective. RVOT VT/PVCs may cause disabling symptoms or arrhythmia induced cardiomyopathy. However, the PVC burden at which catheter ablation should be recommended is still controversial. What adds to the controversy is why some patients with only a low number of PVCs can be highly symptomatic and may even develop arrhythmia induced cardiomyopathy, whilst others may have a higher PVC/VT burden and remain asymptomatic and do not develop cardiomyopathy for a long period of time. Therefore, although catheter ablation of RVOT PVCs has high success and low complication rates, the time point of when ablation should be recommended is currently still under debate. This review discusses the treatment strategies and prognosis for RVOT tachycardias and focuses on the question of which arrhythmia burden is appropriate to offer RF ablation.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Tina Lin
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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