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Iqbal M, Kamarullah W, Achmad C, Karwiky G, Akbar MR. The pivotal role of compelling high-risk electrocardiographic markers in prediction of ventricular arrhythmic risk in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102241. [PMID: 38040211 DOI: 10.1016/j.cpcardiol.2023.102241] [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: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Several investigations have shown that existing risk stratification processes remain insufficient for stratifying sudden cardiac death risk in arrhythmogenic right ventricular cardiomyopathy (ARVC). Multiple auxiliary parameters are investigated to offer a more precise prognostic model. Our aim was to assess the association between several ECG markers (epsilon waves, prolonged terminal activation duration (TAD) of QRS, fragmented QRS (fQRS), late potentials on signal-averaged electrocardiogram (SA-ECG), T-wave inversion (TWI) in right precordial leads, and extension of TWI in inferior leads) with the risk of developing poor outcomes in ARVC. METHODS A systematic literature search from several databases was conducted until September 9th, 2023. Studies were eligible if it investigated the relationship between the ECG markers with the risk of developing ventricular arrhythmic events. RESULTS This meta-analysis encompassed 25 studies with a total of 3767 participants. Our study disclosed that epsilon waves, prolonged TAD of QRS, fQRS, late potentials on SA-ECG, TWI in right precordial leads, and extension of TWI in inferior leads were associated with the incremental risk of ventricular arrhythmias, implantable cardioverter-defibrillator shock, and sudden cardiac death, with the risk ratios ranging from 1.46 to 2.11. In addition, diagnostic test accuracy meta-analysis stipulated that the extension of TWI in inferior leads had the uppermost overall area under curve (AUC) value amidst other ECG markers apropos of our outcomes of interest. CONCLUSION A multivariable risk assessment strategy based on the previously stated ECG markers potentially enhances the current risk stratification models in ARVC patients, especially extension of TWI in inferior leads.
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Affiliation(s)
- Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Kec. Sukajadi, Bandung, Jawa Barat, Indonesia.
| | - William Kamarullah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Kec. Sukajadi, Bandung, Jawa Barat, Indonesia
| | - Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Kec. Sukajadi, Bandung, Jawa Barat, Indonesia
| | - Giky Karwiky
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Kec. Sukajadi, Bandung, Jawa Barat, Indonesia
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Kec. Sukajadi, Bandung, Jawa Barat, Indonesia
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Higuchi S, Gerstenfeld EP, Scheinman MM. A small wave with major implications. Heart Rhythm 2023; 20:1416-1417. [PMID: 37777303 DOI: 10.1016/j.hrthm.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco, California
| | - Edward P Gerstenfeld
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco, California
| | - Melvin M Scheinman
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California, San Francisco, San Francisco, California.
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Trancuccio A, Kukavica D, Sugamiele A, Mazzanti A, Priori SG. Prevention of Sudden Death and Management of Ventricular Arrhythmias in Arrhythmogenic Cardiomyopathy. Card Electrophysiol Clin 2023; 15:349-365. [PMID: 37558305 DOI: 10.1016/j.ccep.2023.04.004] [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] [Indexed: 08/11/2023]
Abstract
Arrhythmogenic cardiomyopathy is an umbrella term for a group of inherited diseases of the cardiac muscle characterized by progressive fibro-fatty replacement of the myocardium. As suggested by the name, the disease confers electrical instability to the heart and increases the risk of the development of life-threatening arrhythmias, representing one of the leading causes of sudden cardiac death (SCD), especially in young athletes. In this review, the authors review the current knowledge of the disease, highlighting the state-of-the-art approaches to the prevention of the occurrence of SCD.
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Affiliation(s)
- Alessandro Trancuccio
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Deni Kukavica
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Andrea Sugamiele
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Andrea Mazzanti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Silvia G Priori
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Molecular Cardiology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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Abstract
PURPOSE OF REVIEW Review the current state of the art of arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis and risk stratification in the pediatric population. RECENT FINDINGS ARVC is an inherited cardiomyopathy characterized by progressive myocyte loss and fibrofatty replacement of predominantly the right ventricle and high risk of ventricular arrhythmias and sudden cardiac death (SCD). ARVC is one of the leading causes of arrhythmic cardiac arrest in young people. Early diagnosis and accurate risk assessment are challenging, especially in children who often exhibit little to no phenotype, even if genotype positive. Multimodal imaging provides more detailed assessment of the right ventricle and has been shown in pediatric patients to identify earlier preclinical disease expression. Identification of patients with ARVC allows the clinician to intervene early with appropriate exercise restrictions, even if genotype positive only without phenotypic expression. Emphasis should be placed on stratifying the patient's risk of ventricular arrhythmias and SCD. SUMMARY ARVC is a challenging diagnosis to make in adolescents who often do not exhibit clinical symptoms. Newer multimodal imaging techniques and improvements in genetic testing and biomarkers should help improve early diagnosis. Exercise restriction for children with ARVC has been shown to reduce disease advancement and decreases the risk of a life-threatening event.
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Kukavica D, Trancuccio A, Arnò C, Latini AC, Mazzanti A, Priori SG. Desmoplakin cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy: two distinct forms of cardiomyopathy? Minerva Cardiol Angiol 2021; 70:217-237. [PMID: 34338490 DOI: 10.23736/s2724-5683.21.05804-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The confirmation of a hypothesis that desmoplakin-related (DSP) cardiomyopathy could represent a distinct clinical entity from the classical, RV-dominant, form of arrhythmogenic cardiomyopathy (ACM), most frequently caused by PKP2 mutations, would without any shadow of doubt signify a turning point in the history of this disease. The concept of gene-specific diseases underneath the umbrella diagnosis of ACM would bring fundamental changes not only in the clinical, diagnostic and therapeutic approach, but also in terms of risk stratification, pushing the scientific community towards a more patient-centred view of the disease, similarly to what has already been done in other inherited arrhythmogenic disease (e.g., Long QT Syndrome; LQTS). We provide a state-of-the-art review, starting with a brief historical framework to give the necessary context and better focus the question. Then, we proceed with a novel, genotype-tophenotype-based comparison of the most important aspects of DSP-related cardiomyopathy with the classical, RV-dominant ACM: this allows us to ascertain not only that the differences between the forms exist, but are also clinically relevant and actionable, leading to the underrecognition of the atypical, DSP-related, LV-dominant forms when applying the current diagnostic criteria. These findings will usher an exciting era, in which the scientific community will try to answer a range of questions, starting from the reasons why different desmosomal mutations cause such different phenotypes.
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Affiliation(s)
- Deni Kukavica
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Molecular Cardiology, Fundación Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Alessandro Trancuccio
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Molecular Cardiology, Fundación Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Carlo Arnò
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy
| | - Alessia C Latini
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy
| | - Andrea Mazzanti
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Molecular Cardiology, Fundación Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Silvia G Priori
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy - .,Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Molecular Cardiology, Fundación Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
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Kommata V, Elshafie M, Sciaraffia E, Perez M, Augustine R, Blomström-Lundqvist C. QRS dispersion detected in ARVC patients and healthy gene carriers using 252-leads body surface mapping: an explorative study of a potential diagnostic tool for arrhythmogenic right ventricular cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1355-1364. [PMID: 34109638 DOI: 10.1111/pace.14295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/26/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers. METHODS ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12-lead resting ECG, signal-averaged ECG, echocardiographic examination, 24-hours Holter monitoring, and BSM with electrocardiographic imaging. All 252-leads BSM recordings and 12-leads ECG recordings were manually analyzed for QRS durations and QRS dispersion. RESULTS Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG-QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM-derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut-off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes. CONCLUSIONS QRS dispersion, when assessed by BSM versus 12-lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM-QRS dispersion in this respect.
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Affiliation(s)
- Varvara Kommata
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Marwa Elshafie
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Elena Sciaraffia
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Mauricio Perez
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Robin Augustine
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
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Hagiwara H, Watanabe M, Kamada R, Koya T, Nakao M, Anzai T. Epsilon wave disappearance by catheter ablation for ventricular arrhythmia from the left ventricular outflow tract. HeartRhythm Case Rep 2021; 7:343-346. [PMID: 34026529 PMCID: PMC8134790 DOI: 10.1016/j.hrcr.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hikaru Hagiwara
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaya Watanabe
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Rui Kamada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Taro Koya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Hoogendoorn JC, Venlet J, Out YNJ, Man S, Kumar S, Sramko M, Dechering DG, Nakajima I, Siontis KC, Watanabe M, Nakamura Y, Tedrow UB, Bogun F, Eckardt L, Peichl P, Stevenson WG, Zeppenfeld K. The precordial R' wave: A novel discriminator between cardiac sarcoidosis and arrhythmogenic right ventricular cardiomyopathy in patients presenting with ventricular tachycardia. Heart Rhythm 2021; 18:1539-1547. [PMID: 33957319 DOI: 10.1016/j.hrthm.2021.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/16/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cardiac sarcoidosis (CS) with right ventricular (RV) involvement can mimic arrhythmogenic right ventricular cardiomyopathy (ARVC). Histopathological differences may result in disease-specific RV activation patterns detectable on the 12-lead electrocardiogram. Dominant subepicardial scar in ARVC leads to delayed activation of areas with reduced voltages, translating into terminal activation delay and occasionally (epsilon) waves with a small amplitude. Conversely, patchy transmural RV scar in CS may lead to conduction block and therefore late activated areas with preserved voltages reflected as preserved R' waves. OBJECTIVE The purpose of this study was to evaluate the distinct terminal activation patterns in precordial leads V1 through V3 as a discriminator between CS and ARVC. METHODS Thirteen patients with CS affecting the RV and 23 patients with gene-positive ARVC referred for ventricular tachycardia ablation were retrospectively included in a multicenter approach. A non-ventricular-paced 12-lead surface electrocardiogram was analyzed for the presence and the surface area of the R' wave (any positive deflection from baseline after an S wave) in leads V1 through V3. RESULTS An R' wave in leads V1 through V3 was present in all patients with CS compared to 11 (48%) patients with ARVC (P = .002). An algorithm including a PR interval of ≥220 ms, the presence of an R' wave, and the surface area of the maximum R' wave in leads V1 through V3 of ≥1.65 mm2 had 85% sensitivity and 96% specificity for diagnosing CS, validated in a second cohort (18 CS and 40 ARVC) with 83% sensitivity and 88% specificity. CONCLUSION An easily applicable algorithm including PR prolongation and the surface area of the maximum R' wave in leads V1 through V3 of ≥1.65 mm2 distinguishes CS from ARVC. This QRS terminal activation in precordial leads V1 through V3 may reflect disease-specific scar patterns.
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Affiliation(s)
- Jarieke C Hoogendoorn
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Venlet
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Yannick N J Out
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Sumche Man
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Saurabh Kumar
- Department of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marek Sramko
- Department of Cardiology, Institute of Clinical and Experimental Medicine, Prague, The Czech Republic
| | - Dirk G Dechering
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany
| | - Ikutaro Nakajima
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Konstantinos C Siontis
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Masaya Watanabe
- Department of Cardiology, Hokkaido University Hospital, Hokkaido, Japan
| | - Yoshinori Nakamura
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Usha B Tedrow
- Department of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Frank Bogun
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Münster, Germany
| | - Petr Peichl
- Department of Cardiology, Institute of Clinical and Experimental Medicine, Prague, The Czech Republic
| | - William G Stevenson
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands.
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Platonov PG, Svensson A. Epsilon Waves as an Extreme Form of Depolarization Delay: Focusing on the Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia. Curr Cardiol Rev 2021; 17:17-23. [PMID: 32778035 PMCID: PMC8142367 DOI: 10.2174/1573403x16666200810105029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022] Open
Abstract
Revision of the Task Force diagnostic criteria (TFC) for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D), in 2010, has increased the sensitivity for the diagnosis of early and familial forms of the disease. Epsilon wave (EW) is a major diagnostic criterion in the context of ARVC/D, however, it remains unquantifiable and therefore, may leave room for substantial subjective interpretation, thus, explaining the existing high inter-observer variability in the assessment of EW. EW, when present, coexists with other disease characteristics, which are sufficient for ARVC/D diagnosis, making EW generally not required for ARVC/D diagnosis. Nevertheless, EW remains an important part of the electrocardiographic phenotype of ARVC/D that may be useful in planning diagnostic work-up, which needs to be recognized.
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Affiliation(s)
- Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University and Arrhythmia Clinic, Skane University Hospital, Lund, Sweden
| | - Anneli Svensson
- Department of Cardiology, Linkoping University Hospital, Linkoping, Sweden
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Mills KJ, Ferrer MS, Gonzalez MD. Prominent Epsilon Waves in a Patient With Cardiac Sarcoidosis. JACC Case Rep 2020; 2:577-582. [PMID: 34317297 PMCID: PMC8298533 DOI: 10.1016/j.jaccas.2019.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
Abstract
Epsilon waves are the surface manifestation of myocardial regions with delayed activation and are considered the hallmark of arrhythmogenic right ventricular cardiomyopathy. However, other conditions can also result in epsilon waves and simulate arrhythmogenic right ventricular cardiomyopathy. In this case, a patient presents with recurrent ventricular tachycardia and large epsilon waves due to cardiac sarcoidosis. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Kevin J. Mills
- Cardiovascular Disease Fellowship, Penn State College of Medicine at the Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Mario D. Gonzalez
- Electrophysiology Program, Penn State University Heart and Vascular Institute, Penn State University College of Medicine at the Milton S. Hershey Medical Center, Hershey Pennsylvania
- Address for correspondence: Dr. Mario D. Gonzalez, Penn State University Heart and Vascular Institute, Penn State University College of Medicine, 500 University Drive, Room H1511, Hershey, Pennsylvania 17033.
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Kubala M, Xie S, Santangeli P, Garcia FC, Supple GE, Schaller RD, Liang JJ, Pathak RK, Zado ES, Tschabrunn C, Arkles J, Callans DJ, Marchlinski FE. Analysis of local ventricular repolarization using unipolar recordings in patients with arrhythmogenic right ventricular cardiomyopathy. J Interv Card Electrophysiol 2020; 57:261-270. [DOI: 10.1007/s10840-019-00594-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
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12
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De Lazzari M, Zorzi A, Cipriani A, Susana A, Mastella G, Rizzo A, Rigato I, Bauce B, Giorgi B, Lacognata C, Iliceto S, Corrado D, Perazzolo Marra M. Relationship Between Electrocardiographic Findings and Cardiac Magnetic Resonance Phenotypes in Arrhythmogenic Cardiomyopathy. J Am Heart Assoc 2019; 7:e009855. [PMID: 30571483 PMCID: PMC6404435 DOI: 10.1161/jaha.118.009855] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The new designation of arrhythmogenic cardiomyopathy defines a broader spectrum of disease phenotypes, which include right dominant, biventricular, and left dominant variants. We evaluated the relationship between electrocardiographic findings and contrast‐enhanced cardiac magnetic resonance phenotypes in arrhythmogenic cardiomyopathy. Methods and Results We studied a consecutive cohort of patients with a definite diagnosis of arrhythmogenic cardiomyopathy, according to 2010 International Task Force criteria, who underwent electrocardiography and contrast‐enhanced cardiac magnetic resonance. Both depolarization and repolarization electrocardiographic abnormalities were correlated with the severity of dilatation/dysfunction, either global or regional, of both ventricles and the presence and regional distribution of late gadolinium enhancement. The study population included 79 patients (60% men). There was a statistically significant relationship between the presence and extent of T‐wave inversion across a 12‐lead ECG and increasing values of median right ventricular (RV) end‐diastolic volume (P<0.001) and decreasing values of RV ejection fraction (P<0.001). The extent of T‐wave inversion to lateral leads predicted a more severe RV dilatation rather than a left ventricular involvement because of the leftward displacement of the dilated RV, as evidenced by contrast‐enhanced cardiac magnetic resonance. A terminal activation delay of >55 ms in the right precordial leads (V1‐V3) was associated with higher RV volume (P=0.014) and lower RV ejection fraction (P=0.053). Low QRS voltages in limb leads predicted the presence (P=0.004) and amount (P<0.001) of left ventricular late gadolinium enhancement. Conclusions The study results indicated that electrocardiographic abnormalities predict the arrhythmogenic cardiomyopathy phenotype in terms of severity of RV disease and left ventricular involvement, which are among the most important determinants of the disease outcome.
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Affiliation(s)
- Manuel De Lazzari
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alessandro Zorzi
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alberto Cipriani
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Angela Susana
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Giulio Mastella
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Alessandro Rizzo
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Ilaria Rigato
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Barbara Bauce
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Benedetta Giorgi
- 2 Division of Radiology Department of Medicine University of Padova Italy
| | - Carmelo Lacognata
- 2 Division of Radiology Department of Medicine University of Padova Italy
| | - Sabino Iliceto
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
| | - Domenico Corrado
- 1 Department of Cardiac, Thoracic and Vascular Sciences University of Padova Italy
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Clinical Diagnosis, Imaging, and Genetics of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: JACC State-of-the-Art Review. J Am Coll Cardiol 2019; 72:784-804. [PMID: 30092956 DOI: 10.1016/j.jacc.2018.05.065] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 01/30/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited cardiomyopathy that can lead to sudden cardiac death and heart failure. Our understanding of its pathophysiology and clinical expressivity is continuously evolving. The diagnosis of ARVC/D remains particularly challenging due to the absence of specific unique diagnostic criteria, its variable expressivity, and incomplete penetrance. Advances in genetics have enlarged the clinical spectrum of the disease, highlighting possible phenotypes that overlap with arrhythmogenic dilated cardiomyopathy and channelopathies. The principal challenges for ARVC/D diagnosis include the following: earlier detection of the disease, particularly in cases of focal right ventricular involvement; differential diagnosis from other arrhythmogenic diseases affecting the right ventricle; and the development of new objective electrocardiographic and imaging criteria for diagnosis. This review provides an update on the diagnosis of ARVC/D, focusing on the contribution of emerging imaging techniques, such as echocardiogram/magnetic resonance imaging strain measurements or computed tomography scanning, new electrocardiographic parameters, and high-throughput sequencing.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 436] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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15
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Pérez-Riera AR, Barbosa-Barros R, Daminello-Raimundo R, de Abreu LC, García-Niebla J, de Deus Morais MJ, Nikus K, Marcus FI. Epsilon wave: A review of historical aspects. Indian Pacing Electrophysiol J 2019; 19:63-67. [PMID: 30796961 PMCID: PMC6450822 DOI: 10.1016/j.ipej.2019.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 11/28/2022] Open
Abstract
The epsilon wave of the electrocardiogram (ECG) together with fragmented QRS (fQRS), the terminal conduction delay, incomplete right bundle branch block (IRBBB) and complete/advanced RBBB (CRBBB) of peripheral origin are part of a spectrum of ventricular depolarization abnormalities of arrhythmogenic cardiomyopathy(AC). Although the epsilon wave is considered a major diagnostic criterion for AC since 2010 (AC Task Force Criteria), its diagnostic value is limited because it is a sign of the later stage of the disease. It would be more appropriate to say that the epsilon wave is a “hallmark” of AC, but is of low diagnostic sensitivity. Although the epsilon wave has high specificity for AC, it can be present in other pathological conditions. In this update we will cover the nomenclature, association with disease states and electrocardiographic aspects of the epsilon wave.
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Affiliation(s)
- Andrés Ricardo Pérez-Riera
- Laboratório de Pesquisa e Escrita Científica da Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil.
| | - Raimundo Barbosa-Barros
- Coronary Center of the Messejana Hospital Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Rodrigo Daminello-Raimundo
- Laboratório de Pesquisa e Escrita Científica da Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | - Luiz Carlos de Abreu
- Laboratório de Pesquisa e Escrita Científica da Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | - Javier García-Niebla
- Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, Islas Canarias, Spain
| | - Mauro José de Deus Morais
- Laboratório de Pesquisa e Escrita Científica da Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil; Centro de Ciências da Saúde e Desporto, Universidade Federal do Acre, Rio Branco, Acre, Brazil
| | - Kjell Nikus
- Heart Center, Tampere University Hospital and Faculty of Medicine and Life Sciences, University of Tampere, Finland
| | - Frank I Marcus
- Sarver Heart Center, The University of Arizona Health Sciences Hospital, Tucson, AZ, USA
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16
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Wang W, James CA, Calkins H. Diagnostic and therapeutic strategies for arrhythmogenic right ventricular dysplasia/cardiomyopathy patient. Europace 2019; 21:9-21. [PMID: 29688316 PMCID: PMC6321962 DOI: 10.1093/europace/euy063] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/16/2018] [Indexed: 12/21/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a rare inherited heart muscle disease characterized by ventricular tachyarrhythmia, predominant right ventricular dysfunction, and sudden cardiac death. Its pathophysiology involves close interaction between genetic mutations and exposure to physical activity. Mutations in genes encoding desmosomal protein are the most common genetic basis. Genetic testing plays important roles in diagnosis and screening of family members. Syncope, palpitation, and lightheadedness are the most common symptoms. The 2010 Task Force Criteria is the standard for diagnosis today. Implantation of a defibrillator in high-risk patients is the only therapy that provides adequate protection against sudden death. Selection of patients who are best candidates for defibrillator implantation is challenging. Exercise restriction is critical in affected individuals and at-risk family members. Antiarrhythmic drugs and ventricular tachycardia ablation are valuable but palliative components of the management. This review focuses on the current diagnostic and therapeutic strategies in ARVD/C and outlines the future area of development in this field.
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Affiliation(s)
- Weijia Wang
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
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17
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Bennett RG, Haqqani HM, Berruezo A, Della Bella P, Marchlinski FE, Hsu CJ, Kumar S. Arrhythmogenic Cardiomyopathy in 2018-2019: ARVC/ALVC or Both? Heart Lung Circ 2018; 28:164-177. [PMID: 30446243 DOI: 10.1016/j.hlc.2018.10.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 10/10/2018] [Accepted: 10/10/2018] [Indexed: 01/27/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is now commonly used to describe any form of non-hypertrophic, progressive cardiomyopathy characterised by fibrofatty infiltration of the ventricular myocardium. Right ventricular (RV) involvement refers to the classical arrhythmogenic right ventricular cardiomyopathy, but left ventricular, or bi-ventricular involvement are now recognised. ACM is mostly hereditary and associated with mutations in genes encoding proteins of the intercalated disc. ACM classically manifests as ventricular arrhythmias, and sudden death may be the first presentation of the disease. Heart failure is seen with advanced stages of the disease. Diagnosis can be challenging due to variable expressivity and incomplete penetrance, and is guided by established Taskforce criteria that incorporate electrical features (12-lead electrocardiography (ECG), features of ventricular arrhythmias), structural features (on imaging via echo and cardiac magnetic resonance imaging [MRI]), tissue characteristics (via biopsy), and familial/genetic evaluation. Electrical abnormalities may precede structural alterations, which also make diagnosis challenging, especially in differentiating ACM from other conditions such as benign right ventricular arrhythmias, channelopathies such as Brugada, or the Athlete's Heart. Genetic testing is critical in identifying familial mutations and initiating cascade testing, but finds a pathogenic mutation in only ∼50% of patients. Some critical genotype-phenotype correlations do exist and may help guide risk stratification and give clues to disease progression. Therapeutic strategies include restriction from high endurance and competitive sports, ß-blockers, antiarrhythmic drugs, heart failure medications, implantable cardioverter-defibrillators and combined endocardial/epicardial catheter ablation. Ablation has emerged as the treatment of choice for recurrent ventricular arrhythmias in ACM. This state-of-the-art review outlines the pathogenesis, diagnosis and treatment of ACM in the contemporary era.
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Affiliation(s)
| | - Haris M Haqqani
- Prince Charles Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Antonio Berruezo
- Cardiology Department, Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, San Raffaele Hospital, Milan, Italy
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Chi-Jen Hsu
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Applied Research Centre, Westmead Hospital, University of Sydney, Sydney, NSW, Australia.
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18
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Marchlinski FE, Edvardsen T. Arrhythmogenic Right Ventricular Cardiomyopathy: Better Tools for Detecting Early Disease and Progression. J Am Coll Cardiol 2018; 68:2198-2200. [PMID: 27855809 DOI: 10.1016/j.jacc.2016.09.916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 08/25/2016] [Accepted: 09/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Francis E Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Thor Edvardsen
- Department of Cardiology, Rikshospitalet, Oslo University Hospital and University of Oslo, Oslo, Norway
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19
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Calò L, Martino A, Goanta E, Okumura Y, de Ruvo E. Right bundle branch block and conduction disturbances in Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy. J Interv Card Electrophysiol 2018; 52:307-313. [DOI: 10.1007/s10840-018-0386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022]
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20
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Ozeke O, Cay S, Ozcan F, Karakurt M, Topaloglu S, Aras D. The fragmented QRS and epsilon wave in arrhythmogenic right ventricular dysplasia: Does before-and-after the end of the QRS complex matter? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1269-1270. [PMID: 30019491 DOI: 10.1111/pace.13455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/24/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Ozcan Ozeke
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Mustafa Karakurt
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Ankara, Turkey
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21
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Kubala M, Pathak RK, Xie S, Casado Arroyo R, Tschabrunn CM, Hayashi T, Garcia FC, Supple GE, Santangeli P, Frankel DS, Zado ES, Callans DJ, Marchlinski FE. Electrocardiographic Repolarization Abnormalities and Electroanatomic Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Arrhythm Electrophysiol 2018; 11:e005553. [DOI: 10.1161/circep.117.005553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 01/16/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Maciej Kubala
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Rajeev K. Pathak
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Shuanglun Xie
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Ruben Casado Arroyo
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Cory M. Tschabrunn
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Tatsuya Hayashi
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Fermin C. Garcia
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Gregory E. Supple
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David S. Frankel
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Erica S. Zado
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David J. Callans
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E. Marchlinski
- From the Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
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22
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Chung FP, Lin CY, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang TY, Chen SA. Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Korean Circ J 2018; 48:890-905. [PMID: 30238706 PMCID: PMC6158456 DOI: 10.4070/kcj.2018.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C.
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Affiliation(s)
- Fa Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chin Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Internal Medicine, Taipei Veterans General Hospital, Yuan-Shan Branch, I-LAN, Taiwan
| | - Yenn Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ting Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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23
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Nunes de Alencar Neto J, Baranchuk A, Bayés-Genís A, Bayés de Luna A. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: an electrocardiogram-based review. Europace 2017; 20:f3-f12. [DOI: 10.1093/europace/eux202] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- José Nunes de Alencar Neto
- Department of Cardiology, Hospital de Sao Paulo, Rua Napoleao de Barros, 715-Vila Clementino Sao Paulo, SP-CEP: 04024002, Sao Paulo, Brasil
| | - Adrian Baranchuk
- Cardiac Electrophysiology and Pacing, Kingston General Hospital K7L 2V7, Queen's University, Kingston, Ontario, Canada
| | - Antoni Bayés-Genís
- Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Carretera del Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Antoni Bayés de Luna
- Cardio Vascular Research Center, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, C/Sant Antoni Ma Claret, 167, 08025 Barcelona, Spain
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24
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Chrispin J, Assis F, Tandri H. Mapping the Electrical Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005524. [DOI: 10.1161/circep.117.005524] [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: 11/16/2022]
Affiliation(s)
- Jonathan Chrispin
- From the Center of Excellence for ARVC and Complex Ventricular Arrhythmias, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fabrizio Assis
- From the Center of Excellence for ARVC and Complex Ventricular Arrhythmias, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harikrishna Tandri
- From the Center of Excellence for ARVC and Complex Ventricular Arrhythmias, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
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25
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Scheinman MM, Hoffmayer KS. Still an Important Tool. JACC Clin Electrophysiol 2017; 3:666-668. [DOI: 10.1016/j.jacep.2017.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/13/2017] [Indexed: 11/25/2022]
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26
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Müssigbrodt A, Bertagnolli L, Efimova E, Kosiuk J, Dinov B, Bode K, Kircher S, Dagres N, Döring M, Richter S, Sommer P, Husser D, Bollmann A, Hindricks G, Arya A. Myocardial voltage ratio in arrhythmogenic right ventricular dysplasia/cardiomyopathy. Herzschrittmacherther Elektrophysiol 2017; 28:219-224. [PMID: 28536891 DOI: 10.1007/s00399-017-0508-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 06/07/2023]
Abstract
AIMS This study aimed to analyze the influence of scar distribution between the endocardium and the epicardium in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). METHODS Electroanatomical mapping data were derived from our ARVD/C registry. Myocardial voltage distribution between the endocardium and the epicardium was analyzed in 28 patients (18 men, 49.9 ± 13.0 years) with previous ventricular tachycardia (VT) ablation and complete right ventricular maps. RESULTS During the follow-up period of 28 ± 22 months after ablation, 18 of 28 patients (64.3%) remained free from VT recurrence. In univariate analysis, five variables associated with VT recurrence, i. e., advanced age, right ventricular (RV) myocardial voltage ratio ≥0.58, inducibility of VT after ablation, and longer procedure and fluoroscopy time. In binary logistic regression analysis only RV myocardial voltage ratio ≥0.58 (hazard ratio 11.667, 95% confidence interval 1.487-91.543, p = 0.012) remained associated with an increased risk of VT recurrence. CONCLUSION The myocardial voltage ratio (bipolar low voltage area/unipolar low voltage area) as a potential surrogate parameter for scar distribution between the endocardium and the epicardium is significantly associated with the outcome after VT ablation in ARVD/C.
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Affiliation(s)
- Andreas Müssigbrodt
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany.
| | - Livio Bertagnolli
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Elena Efimova
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Jedrzej Kosiuk
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Kerstin Bode
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Simon Kircher
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Michael Döring
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Sergio Richter
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Philipp Sommer
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Daniela Husser
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
| | - Arash Arya
- Department of Electrophysiology, Heart Centre, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
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