1
|
Mayfield JJ, Bogomolovas J, Abraham MR, Sullivan K, Seo Y, Sheikh F, Scheinman M. Recurrent Myocarditis in Patients With Desmosomal Pathogenic Variants: Is Self Antigen Presentation the Link? JACC Clin Electrophysiol 2023; 9:2024-2033. [PMID: 37480874 DOI: 10.1016/j.jacep.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/10/2023] [Accepted: 04/15/2023] [Indexed: 07/24/2023]
Abstract
Myocarditis is frequently associated with viral infections. Increasing evidence points to an association between myocarditis and inherited cardiomyopathies, though it is unclear whether myocarditis is a driver or an accessory. We present a primary vignette and case series highlighting recurrent myocarditis in patients later found to harbor pathogenic desmosomal variants and provide clinical and basic science context, exploring 2 potentially overlapping hypotheses: that stress induces cellular injury and death in structurally abnormal myocytes and that recurrent viral myocardial and truncated desomosomal protein byproducts as 2 hits could lead to loss of immune tolerance and subsequent autoreactivity.
Collapse
Affiliation(s)
- Jacob J Mayfield
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Julius Bogomolovas
- Department of Medicine, University of California-San Diego, La Jolla, California, USA
| | - M Roselle Abraham
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA; Department of Radiology, University of California-San Francisco, San Francisco, California, USA
| | - Kathryn Sullivan
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Youngho Seo
- Department of Radiology, University of California-San Francisco, San Francisco, California, USA
| | - Farah Sheikh
- Department of Medicine, University of California-San Diego, La Jolla, California, USA.
| | - Melvin Scheinman
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.
| |
Collapse
|
2
|
Castelletti S, Orini M, Vischer AS, McKenna WJ, Lambiase PD, Pantazis A, Crotti L. Circadian and Seasonal Pattern of Arrhythmic Events in Arrhythmogenic Cardiomyopathy Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2872. [PMID: 36833593 PMCID: PMC9956986 DOI: 10.3390/ijerph20042872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/22/2023] [Accepted: 01/28/2023] [Indexed: 05/28/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiac disease associated with an increased risk of life-threatening arrhythmias. The aim of the present study was to evaluate the association of ventricular arrhythmias (VA) with circadian and seasonal variation in ARVC. One hundred two ARVC patients with an implantable cardioverter defibrillator (ICD) were enrolled in the study. Arrhythmic events included (a) any initial ventricular tachycardia (VT) or fibrillation (VF) prompting ICD implantation, (b) any VT or non-sustained VT (NSVT) recorded by the ICD, and (c) appropriate ICD shocks/therapy. Differences in the annual incidence of events across seasons (winter, spring, summer, autumn) and period of the day (night, morning, afternoon, evening) were assessed both for all cardiac events and major arrhythmic events. In total, 67 events prior to implantation and 263 ICD events were recorded. These included 135 major (58 ICD therapies, 57 self-terminating VT, 20 sustained VT) and 148 minor (NSVT) events. A significant increase in the frequency of events was observed in the afternoon versus in the nights and mornings (p = 0.016). The lowest number of events was registered in the summer, with a peak in the winter (p < 0.001). Results were also confirmed when excluding NSVT. Arrhythmic events in ARVC follow a seasonal variation and a circadian rhythm. They are more prevalent in the late afternoon, the most active period of the day, and in the winter, supporting the role of physical activity and inflammation as triggers of events.
Collapse
Affiliation(s)
- Silvia Castelletti
- Istituto Auxologico Italiano, IRCCS, Department of Cardiology, Piazzale Brescia 20, 20149 Milan, Italy
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
| | - Annina S. Vischer
- Medical Outpatient Department, ESH Hypertension Centre of Excellence, University Hospital Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - William J. McKenna
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- Department of Cardiology, University of A Coruña, 15001 A Coruña, Spain
| | - Pier D. Lambiase
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- The Barts Heart Centre, Barts Health NHS Trust, London E1 1BB, UK
| | - Antonios Pantazis
- National Heart and Lung Institute, Imperial College London, London SW7 2BX, UK
- Cardiovascular Research Centre, Royal Brompton and Harefield Hospitals, London SW3 6NP, UK
| | - Lia Crotti
- Istituto Auxologico Italiano, IRCCS, Department of Cardiology, Piazzale Brescia 20, 20149 Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| |
Collapse
|
3
|
Meraviglia V, Alcalde M, Campuzano O, Bellin M. Inflammation in the Pathogenesis of Arrhythmogenic Cardiomyopathy: Secondary Event or Active Driver? Front Cardiovasc Med 2022; 8:784715. [PMID: 34988129 PMCID: PMC8720743 DOI: 10.3389/fcvm.2021.784715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 12/27/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a rare inherited cardiac disease characterized by arrhythmia and progressive fibro-fatty replacement of the myocardium, which leads to heart failure and sudden cardiac death. Inflammation contributes to disease progression, and it is characterized by inflammatory cell infiltrates in the damaged myocardium and inflammatory mediators in the blood of ACM patients. However, the molecular basis of inflammatory process in ACM remains under investigated and it is unclear whether inflammation is a primary event leading to arrhythmia and myocardial damage or it is a secondary response triggered by cardiomyocyte death. Here, we provide an overview of the proposed players and triggers involved in inflammation in ACM, focusing on those studied using in vivo and in vitro models. Deepening current knowledge of inflammation-related mechanisms in ACM could help identifying novel therapeutic perspectives, such as anti-inflammatory therapy.
Collapse
Affiliation(s)
- Viviana Meraviglia
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Mireia Alcalde
- Cardiovascular Genetics Center, University of Girona-IdIBGi, Girona, Spain.,Centro Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Oscar Campuzano
- Cardiovascular Genetics Center, University of Girona-IdIBGi, Girona, Spain.,Centro Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - Milena Bellin
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands.,Department of Biology, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| |
Collapse
|
4
|
Asatryan B, Asimaki A, Landstrom AP, Khanji MY, Odening KE, Cooper LT, Marchlinski FE, Gelzer AR, Semsarian C, Reichlin T, Owens AT, Chahal CAA. Inflammation and Immune Response in Arrhythmogenic Cardiomyopathy: State-of-the-Art Review. Circulation 2021; 144:1646-1655. [PMID: 34780255 PMCID: PMC9034711 DOI: 10.1161/circulationaha.121.055890] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a primary disease of the myocardium, predominantly caused by genetic defects in proteins of the cardiac intercalated disc, particularly, desmosomes. Transmission is mostly autosomal dominant with incomplete penetrance. ACM also has wide phenotype variability, ranging from premature ventricular contractions to sudden cardiac death and heart failure. Among other drivers and modulators of phenotype, inflammation in response to viral infection and immune triggers have been postulated to be an aggravator of cardiac myocyte damage and necrosis. This theory is supported by multiple pieces of evidence, including the presence of inflammatory infiltrates in more than two-thirds of ACM hearts, detection of different cardiotropic viruses in sporadic cases of ACM, the fact that patients with ACM often fulfill the histological criteria of active myocarditis, and the abundance of anti-desmoglein-2, antiheart, and anti-intercalated disk autoantibodies in patients with arrhythmogenic right ventricular cardiomyopathy. In keeping with the frequent familial occurrence of ACM, it has been proposed that, in addition to genetic predisposition to progressive myocardial damage, a heritable susceptibility to viral infections and immune reactions may explain familial clustering of ACM. Moreover, considerable in vitro and in vivo evidence implicates activated inflammatory signaling in ACM. Although the role of inflammation/immune response in ACM is not entirely clear, inflammation as a driver of phenotype and a potential target for mechanism-based therapy warrants further research. This review discusses the present evidence supporting the role of inflammatory and immune responses in ACM pathogenesis and proposes opportunities for translational and clinical investigation.
Collapse
Affiliation(s)
- Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital (B.A., K.E.O., T.R.), University of Bern, Switzerland
| | - Angeliki Asimaki
- Cardiovascular and Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (A.A.)
| | - Andrew P Landstrom
- Division of Cardiology, Department of Pediatrics (A.P.L.), Duke University School of Medicine, Durham, NC
- Department of Cell Biology (A.P.L.), Duke University School of Medicine, Durham, NC
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom (M.Y.K., A.A.C.)
- NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, United Kingdom (M.Y.K.)
- Department of Cardiology, Newham University Hospital, London, United Kingdom (M.Y.K.)
| | - Katja E Odening
- Department of Cardiology, Inselspital, Bern University Hospital (B.A., K.E.O., T.R.), University of Bern, Switzerland
- Department of Physiology (K.E.O.), University of Bern, Switzerland
| | - Leslie T Cooper
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (F.E.M., A.A.C.)
| | - Francis E Marchlinski
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia (A.R.G.)
| | - Anna R Gelzer
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.S.), The University of Sydney, New South Wales, Australia
| | - Christopher Semsarian
- Sydney Medical School Faculty of Medicine and Health (C.S.), The University of Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (C.S.)
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital (B.A., K.E.O., T.R.), University of Bern, Switzerland
| | - Anjali T Owens
- Center for Inherited Cardiac Disease, Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.O.)
| | - C Anwar A Chahal
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom (M.Y.K., A.A.C.)
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia (A.R.G.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (A.A.C.)
- WellSpan Center for Inherited Cardiovascular Diseases, WellSpan Health, Lancaster, PA (A.A.C.)
| |
Collapse
|
5
|
Zhang J, Liang Y, Bradford WH, Sheikh F. Desmosomes: emerging pathways and non-canonical functions in cardiac arrhythmias and disease. Biophys Rev 2021; 13:697-706. [PMID: 34765046 PMCID: PMC8555023 DOI: 10.1007/s12551-021-00829-2] [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: 07/23/2021] [Accepted: 08/12/2021] [Indexed: 12/14/2022] Open
Abstract
Desmosomes are critical adhesion structures in cardiomyocytes, with mutation/loss linked to the heritable cardiac disease, arrhythmogenic right ventricular cardiomyopathy (ARVC). Early studies revealed the ability of desmosomal protein loss to trigger ARVC disease features including structural remodeling, arrhythmias, and inflammation; however, the precise mechanisms contributing to diverse disease presentations are not fully understood. Recent mechanistic studies demonstrated the protein degradation component CSN6 is a resident cardiac desmosomal protein which selectively restricts cardiomyocyte desmosomal degradation and disease. This suggests defects in protein degradation can trigger the structural remodeling underlying ARVC. Additionally, a subset of ARVC-related mutations show enhanced vulnerability to calpain-mediated degradation, further supporting the relevance of these mechanisms in disease. Desmosomal gene mutations/loss has been shown to impact arrhythmogenic pathways in the absence of structural disease within ARVC patients and model systems. Studies have shown the involvement of connexins, calcium handling machinery, and sodium channels as early drivers of arrhythmias, suggesting these may be distinct pathways regulating electrical function from the desmosome. Emerging evidence has suggested inflammation may be an early mechanism in disease pathogenesis, as clinical reports have shown an overlap between myocarditis and ARVC. Recent studies focus on the association between desmosomal mutations/loss and inflammatory processes including autoantibodies and signaling pathways as a way to understand the involvement of inflammation in ARVC pathogenesis. A specific focus will be to dissect ongoing fields of investigation to highlight diverse pathogenic pathways associated with desmosomal mutations/loss.
Collapse
Affiliation(s)
- Jing Zhang
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093 USA
| | - Yan Liang
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093 USA
| | - William H. Bradford
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093 USA
| | - Farah Sheikh
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093 USA
| |
Collapse
|
6
|
Abstract
Arrhythmogenic cardiomyopathy is a genetic disorder characterized by the risk of life-threatening arrhythmias, myocardial dysfunction and fibrofatty replacement of myocardial tissue. Mutations in genes that encode components of desmosomes, the adhesive junctions that connect cardiomyocytes, are the predominant cause of arrhythmogenic cardiomyopathy and can be identified in about half of patients with the condition. However, the molecular mechanisms leading to myocardial destruction, remodelling and arrhythmic predisposition remain poorly understood. Through the development of animal, induced pluripotent stem cell and other models of disease, advances in our understanding of the pathogenic mechanisms of arrhythmogenic cardiomyopathy over the past decade have brought several signalling pathways into focus. These pathways include canonical and non-canonical WNT signalling, the Hippo-Yes-associated protein (YAP) pathway and transforming growth factor-β signalling. These studies have begun to identify potential therapeutic targets whose modulation has shown promise in preclinical models. In this Review, we summarize and discuss the reported molecular mechanisms underlying the pathogenesis of arrhythmogenic cardiomyopathy.
Collapse
|
7
|
Hoorntje ET, Te Rijdt WP, James CA, Pilichou K, Basso C, Judge DP, Bezzina CR, van Tintelen JP. Arrhythmogenic cardiomyopathy: pathology, genetics, and concepts in pathogenesis. Cardiovasc Res 2018; 113:1521-1531. [PMID: 28957532 DOI: 10.1093/cvr/cvx150] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a rare, heritable heart disease characterized by fibro-fatty replacement of the myocardium and a high degree of electric instability. It was first thought to be a congenital disorder, but is now regarded as a dystrophic heart muscle disease that develops over time. There is no curative treatment and current treatment strategies focus on attenuating the symptoms, slowing disease progression, and preventing life-threatening arrhythmias and sudden cardiac death. Identification of mutations in genes encoding desmosomal proteins and in other genes has led to insights into the disease pathogenesis and greatly facilitated identification of family members at risk. The disease phenotype is, however, highly variable and characterized by incomplete penetrance. Although the reasons are still poorly understood, sex, endurance exercise and a gene-dosage effect seem to play a role in these phenomena. The discovery of the genes and mutations implicated in ACM has allowed animal and cellular models to be generated, enabling researchers to start unravelling it's underlying molecular mechanisms. Observations in humans and in animal models suggest that reduced cell-cell adhesion affects gap junction and ion channel remodelling at the intercalated disc, and along with impaired desmosomal function, these can lead to perturbations in signalling cascades like the Wnt/β-catenin and Hippo/YAP pathways. Perturbations of these pathways are also thought to lead to fibro-fatty replacement. A better understanding of the molecular processes may lead to new therapies that target specific pathways involved in ACM.
Collapse
Affiliation(s)
- Edgar T Hoorntje
- Department of Genetics, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Wouter P Te Rijdt
- Department of Genetics, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Cynthia A James
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Kalliopi Pilichou
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua 35121, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua 35121, Italy
| | - Daniel P Judge
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Connie R Bezzina
- Department of Clinical and Experimental Cardiology, Heart Centre, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Peter van Tintelen
- Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands.,Department of Clinical Genetics, Academic Medical Centre Amsterdam, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
8
|
Que D, Yang P, Song X, Liu L. Traditional vs. genetic pathogenesis of arrhythmogenic right ventricular cardiomyopathy. Europace 2015; 17:1770-6. [DOI: 10.1093/europace/euv042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/08/2015] [Indexed: 12/22/2022] Open
|
9
|
Patel DM, Green KJ. Desmosomes in the Heart: A Review of Clinical and Mechanistic Analyses. ACTA ACUST UNITED AC 2014; 21:109-28. [DOI: 10.3109/15419061.2014.906533] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
10
|
Meurs K, Stern J, Sisson D, Kittleson M, Cunningham S, Ames M, Atkins C, DeFrancesco T, Hodge T, Keene B, Reina Doreste Y, Leuthy M, Motsinger-Reif A, Tou S. Association of Dilated Cardiomyopathy with the Striatin Mutation Genotype in Boxer Dogs. J Vet Intern Med 2013; 27:1437-40. [DOI: 10.1111/jvim.12163] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 04/26/2013] [Accepted: 07/16/2013] [Indexed: 12/16/2022] Open
Affiliation(s)
- K.M. Meurs
- North Carolina State University College of Veterinary Medicine; Raleigh NC
- Ohio State University College of Veterinary Medicine; Columbus OH
| | - J.A. Stern
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - D.D. Sisson
- Oregon State University College of Veterinary Medicine; Corvalis OR
| | - M.D. Kittleson
- University of California-Davis School of Veterinary Medicine; Davis CA
| | - S.M. Cunningham
- Cummings School of Veterinary Medicine at Tufts; North Grafton MA
| | - M.K. Ames
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - C.E. Atkins
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - T. DeFrancesco
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - T.E. Hodge
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - B.W. Keene
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - Y. Reina Doreste
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| | - M. Leuthy
- Chicago Veterinary and Emergency Center; Chicago IL
| | - A.A. Motsinger-Reif
- North Carolina State University College of Agricultural and Life Sciences and College of Physical and Mathematical Sciences; Raleigh NC
| | - S.P. Tou
- North Carolina State University College of Veterinary Medicine; Raleigh NC
| |
Collapse
|
11
|
Riley MP, Zado E, Bala R, Callans DJ, Cooper J, Dixit S, Garcia F, Gerstenfeld EP, Hutchinson MD, Lin D, Patel V, Verdino R, Marchlinski FE. Lack of uniform progression of endocardial scar in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy and ventricular tachycardia. Circ Arrhythm Electrophysiol 2010; 3:332-8. [PMID: 20558846 DOI: 10.1161/circep.109.919530] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The endocardial substrate for ventricular arrhythmias in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is thought to be caused by a progressive degenerative process. Many clinical decisions and treatment plans are guided by this pathophysiologic assumption, but the extent of progression of macroscopic endocardial scar and right ventricular (RV) dilatation have not been assessed. METHODS AND RESULTS Eleven patients with ARVD/C and ventricular tachycardia had 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average, 291+/-122 points per map; range, 114 to 558 points) performed a mean of 57 months apart (minimum, 9 months) as part of ventricular tachycardia ablation procedures. Voltage-defined scar (<1.5 mV) and RV volume were measured by area and volume measurement software and compared. Two of the 11 patients had a clear increase in scar area (47 cm(2); 32 cm(2)) confirmed by visual inspection. The remaining 9 (81%; 95% CI, 48% to 98%) patients had no increase (<10-cm(2) difference) in scar area between studies. In contrast, 10 of the 11 patients had a significant increase in RV volume, with an average increase of 24% (212+/-67 mL to 263+/-52 mL; P< or =0.01). CONCLUSIONS In patients with ARVD/C and ventricular tachycardia, progressive RV dilatation is the rule, and rapid progression of significant macroscopic endocardial scar occurs in only a subset of patients. These results have important management implications, suggesting that efforts to prevent RV dilatation in this population are needed and that an aggressive substrate-based ablation strategy offers the potential to provide long-term ventricular tachycardia control.
Collapse
Affiliation(s)
- Michael P Riley
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Flavivirus-like particles in the cardiac myocyte of a patient with arrhythmogenic right ventricular cardiomyopathy. Chin Med J (Engl) 2007. [DOI: 10.1097/00029330-200712020-00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
13
|
Schultheiss HP, Noutsias M, Kühl U, Gross U, Lassner D, Poller W, Pauschinger M. [Cardiomyopathies II. Hypertrophic cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy]. Internist (Berl) 2006; 46:1373-85, quiz 1386-7. [PMID: 16237514 DOI: 10.1007/s00108-005-1492-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This review focuses on hypertrophic (HCM), restrictive (RCM) and arrhythmogenic right ventricular cardiomyopathies (ARVC). The clinical phenotype of HCM depends not only on the gene mutations involved, but also on "modifier genes". It is characterized by an asymmetrical hypertrophy. Investigations of endomyocardial biopsies (EMBs) typically reveal a disarray of the hypertrophied cardiomyocytes. Percutaneous septum ablation has gained relevance as the treatment of choice in hypertrophic obstructive cardiomyopathy. Myocardial and endomyocardial RCM-forms can be differentiated. Enlargement of the atria in concert with normal dimensions of the ventricles and almost normal systolic contractility as well as the dip-plateau phenomenon are characteristic findings in RCM. EMB diagnostics are pivotal to identify the causes underlying secondary RCM types. Treatment is directed at heart failure and specifically at the underlying disease. With ARVC, apoptosis, viral infection/inflammation and genetic dystrophy result in fibrofatty degeneration primarily of the right, and with further progression also of the left ventricle. The primary treatment goal in ARVC is prevention of sudden cardiac death. As for other cardiomyopathies, there is increasing evidence for the superiority of ICD compared with pharmacological approaches.
Collapse
Affiliation(s)
- H-P Schultheiss
- Medizinische Klinik II, Kardiologie und Pneumologie, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin.
| | | | | | | | | | | | | |
Collapse
|
14
|
Calabrese F, Basso C, Carturan E, Valente M, Thiene G. Arrhythmogenic right ventricular cardiomyopathy/dysplasia: is there a role for viruses? Cardiovasc Pathol 2006; 15:11-7. [PMID: 16414451 DOI: 10.1016/j.carpath.2005.10.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Revised: 08/02/2005] [Accepted: 10/03/2005] [Indexed: 12/13/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a primary heart muscle disease characterized structurally by progressive fibrofatty replacement of the right ventricle and clinically by life-threatening ventricular arrhythmias with left bundle branch block morphology. Recently, there has been a great deal of interest on ARVC/D as a cause of sudden death in young people, and it has been reported as the most common cause of exercise-related sudden death among competitive athletes in Italy. An autosomic dominant familial occurrence has been recognized, and four disease-causing genes have been recently identified in the dominant forms: ryanodinic cardiac receptor 2, desmoplakin, plakophilin 2, and transforming growth factor (TGF)-beta3. Furthermore, plakoglobin has been identified as the first gene responsible for the recessive variant of ARVC/D associated with palmoplantar keratosis and woolly hair (Naxos disease). However, although much progress has been made in molecular genetics, up to today, the pathogenesis of the disease is still unclear. The occurrence of myocyte apoptosis has been documented, suggesting that recurrent bouts of apoptosis may account for progressive atrophy of the myocardium, which is then replaced by fibrofatty tissue. Considering the frequent finding of myocarditis at histology, an inflammatory theory has been advanced, and infective mechanisms have been postulated to contribute to the onset and the progression of the disease. Cardiotropic viruses have been detected in some ARVC/D cases, and they have been proposed as possible etiologic agents. Several etiopathogenetic theories are herein presented in detail with particular attention to the inflammatory/infective one and its possible links between this and the genetic/dystrophic theories are discussed.
Collapse
Affiliation(s)
- Fiorella Calabrese
- Institute of Pathological Anatomy, University of Padua Medical School, 35121 Padua, Italy.
| | | | | | | | | |
Collapse
|
15
|
Abstract
This article outlines the up-to-date understanding of the molecular basis of disorders that cause sudden death. Several arrhythmic disorders that cause sudden death have been well-described at the molecular level, including the long QT syndromes and Brugada syndrome; this article reviews the current scientific knowledge of these diseases. Hypertrophic cardiomyopathy, a myocardial disorder that causes sudden death also has been well-studied. Finally, a disorder in which myocardial abnormalities and rhythm abnormalities coexist, arrhythmogenic right ventricular dysplasia, is described.
Collapse
MESH Headings
- Arrhythmias, Cardiac/genetics
- Arrhythmias, Cardiac/physiopathology
- Arrhythmogenic Right Ventricular Dysplasia/genetics
- Arrhythmogenic Right Ventricular Dysplasia/physiopathology
- Cardiomyopathy, Hypertrophic, Familial/genetics
- Cardiomyopathy, Hypertrophic, Familial/physiopathology
- Child
- Death, Sudden, Cardiac/etiology
- ERG1 Potassium Channel
- Ether-A-Go-Go Potassium Channels
- Humans
- KCNQ Potassium Channels
- KCNQ1 Potassium Channel
- Long QT Syndrome/complications
- Long QT Syndrome/genetics
- Long QT Syndrome/therapy
- NAV1.5 Voltage-Gated Sodium Channel
- Potassium Channels/physiology
- Potassium Channels, Voltage-Gated
- Sodium Channels/physiology
- Syndrome
- Tachycardia, Ventricular/genetics
- Wolff-Parkinson-White Syndrome/physiopathology
Collapse
Affiliation(s)
- Jeffrey A Towbin
- Department of Pediatrics (Cardiology), Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, FC. 430.09, Houston, TX 77030, USA.
| |
Collapse
|
16
|
Abstract
Over the past year there have been few significant breakthroughs in the understanding of the etiologies of viral myocarditis or dilated cardiomyopathy (DCM). One interesting trend has been the increasing number of reports of myocarditis associated with parvovirus B19 infection. Whether this is simply a result of improved diagnostics, or reflects an underlying change in the etiology is unclear. However, studies of the underlying mechanisms of these disorders have resulted in several reports linking the acquired and viral forms. Over the past few years the cytoarchitecture has been a focus of study for familial DCM. During the last year, one key molecule, dystrophin, has been shown to be disrupted in patients with end-stage cardiomyopathy, irrespective or etiology, mutated in patients with sporadic forms of disease and identified as a potential susceptibility gene for viral infection of the myocardium. The shared cellular receptor, the Coxsackievirus B-Adenovirus receptor (CAR), for the two most common viral agents associated with acquired myocarditis and DCM, was shown to be up-regulated in patients with DCM, potentially making the expression of this protein a marker of susceptibility to virus infection. However, a study of the CAR gene in patients with DCM or myocarditis did not identify any genetic mutations in these patients. Finally a receptor for viral double stranded RNA (TLR-3) was identified. The role of this receptor in the innate immune response against cardiotropic viruses has yet to be elucidated.
Collapse
Affiliation(s)
- Neil E Bowles
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | |
Collapse
|
17
|
Toniolo A, Falcone V, Bernasconi C, Basolo F, Speziale P, Onodera T. DNA immunization of mice against the VP1 capsid protein of coxsackievirus B4. Scand J Immunol 2002; 56:448-55. [PMID: 12410794 DOI: 10.1046/j.1365-3083.2002.01145.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The protective activity of a DNA plasmid encoding the immunodominant capsid protein VP1 of coxsackievirus B4 (CBV-4) was studied in BALB/c mice. The plasmid pCI-B4-1-c - which gave the highest expression level of VP1 in cultured monkey and human cells - was chosen for immunization. Two injections of pCI-B4-1-c (1 month apart) into the regenerating mouse muscle tissue induced a specific antibody response to CBV-4, as shown by immunoenzyme and neutralization assays. Upon challenge with live CBV-4, the mortality rate of mice vaccinated with the recombinant plasmid was significantly reduced (21% versus >58%) as compared with that of mice that had been either nontreated or injected with a control plasmid devoid of the insert. The VP1-based vaccine, however, did not provide complete protection as - after virus challenge - moderate viraemia occurred together with modest plasma elevations of pathogenesis-related enzymes (amylase and creatine kinase). Yet, immunofluorescence of the small intestine and heart did confirm the protective effect of the VP1-encoding vaccine. In order to obtain a more complete protection against CBV-4, it may be beneficial to immunize mice with combinations of separate DNA plasmids encoding not only VP1 but also the VP2 and VP3 capsid proteins.
Collapse
Affiliation(s)
- A Toniolo
- Department of Clinical and Biological Sciences, University of Insubria, Varese Department of Oncology, University of Pisa, Pisa Department of Biochemistry, University of Pavia, Pavia, Italy.
| | | | | | | | | | | |
Collapse
|
18
|
Mikolaenko I, Conner MG. Pathologic quiz case: a 35-year old woman with a history of arrhythmia and liver failure. Arch Pathol Lab Med 2002; 126:751-2. [PMID: 12087973 DOI: 10.5858/2002-126-0751-pqcayo] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Irina Mikolaenko
- Department of Pathology, Division of Anatomic Pathology, University of Alabama at Birmingham, 35233-6823, USA
| | | |
Collapse
|
19
|
Abstract
Recent advances in molecular genetics of arrhythmogenic right ventricular cardiomyopathy (ARVD) are reviewed. In particular, the finding of mutations in the gene coding for cardiac ryanodine receptor (hRYR2), both in patients affected with ARVD2 and in patients affected with catecholaminergic ventricular arrhythmias or with familial ventricular tachyarrhythmia, is discussed. Novel data support the hypothesis that apoptosis may be a key step in molecular pathogenesis of ARVDs. A series of studies on drugs with apparent protective effect against apoptosis in myocardial cells might open new perspectives in the therapeutic approach.
Collapse
Affiliation(s)
- Gian Antonio Danieli
- Human Molecular Genetics Unit, Department of Biology, University of Padua, Italy.
| | | |
Collapse
|
20
|
Bowles NE, Ni J, Marcus F, Towbin JA. The detection of cardiotropic viruses in the myocardium of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. J Am Coll Cardiol 2002; 39:892-5. [PMID: 11869858 DOI: 10.1016/s0735-1097(02)01688-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to investigate the role of cardiotropic viruses, including adenovirus, cytomegalovirus (CMV), enterovirus and parvovirus, in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). BACKGROUND Arrhythmogenic right ventricular dysplasia/cardiomyopathy is characterized by a gradual loss of myocytes, inflammatory infiltrates and replacement by fatty and fibrous tissue. It has been speculated that ARVD/C is a sequela of viral myocarditis in some patients, and the role of the coxsackievirus B3 has been debated. METHODS Myocardial samples from 12 patients with ARVD/C were analyzed by polymerase chain reaction for the presence of cardiotropic viruses. RESULTS Enteroviral sequences were detected in seven patients and adenovirus type 5 in another two patients. During the same period, 215 control samples were analyzed in which only CMV (n = 2) and enterovirus (n = 1) were detected. This suggests a link between ARVD/C and the presence of viral genome (enterovirus or adenovirus) in the myocardium. CONCLUSIONS We report that cardiotropic viruses are more frequently identified in patients with ARVD/C than in control subjects. However, the role of these viruses in ARVD/C pathogenesis remains unknown.
Collapse
Affiliation(s)
- Neil E Bowles
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | | | | | |
Collapse
|
21
|
Abstract
Arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) is a cardiomyopathy characterized pathologically by fibrofatty replacement primarily of the RV and clinically by life-threatening ventricular arrhythmias in apparently healthy young people. The prevalence of the disease has been estimated at 1 in 5,000 individuals, although this estimate will likely increase as awareness of the condition increases among physicians. Arrhythmogenic RV cardiomyopathy is recognized as a cause of sudden death during athletic activity because of its association with ventricular arrhythmias that are provoked by exercise-induced catecholamine discharge. Diagnosis may be difficult because many of the electrocardiographic abnormalities mimic patterns seen in normal children, and the disease often involves only patchy areas of the RV. For this reason, international diagnostic criteria for ARVC were proposed by an expert consensus panel in 1996. Treatment is directed to preventing life-threatening cardiac arrhythmias with medications and the use of implantable defibrillators. This article will present in detail the etiology, clinical presentation, diagnosis and management of this condition.
Collapse
Affiliation(s)
- C Gemayel
- Hartford Hospital, Division of Cardiology, Hartford, Connecticut, USA
| | | | | |
Collapse
|
22
|
Fox PR, Maron BJ, Basso C, Liu SK, Thiene G. Spontaneously occurring arrhythmogenic right ventricular cardiomyopathy in the domestic cat: A new animal model similar to the human disease. Circulation 2000; 102:1863-70. [PMID: 11023944 DOI: 10.1161/01.cir.102.15.1863] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a primary myocardial disease of incompletely resolved pathogenesis and is a largely unappreciated cause of sudden death in the young. METHODS AND RESULTS Clinical features of 12 domestic cats with ARVC (7 male; 1 to 20 years old, mean 7.3+/-5.2 years) were right-sided congestive heart failure (n=8), supraventricular tachyarrhythmias (n=5), ventricular tachycardia (n=3), polymorphic ventricular arrhythmias (n=6), and right bundle-branch block (n=5). ARVC was suspected in all 8 cats examined with echocardiography by marked enlargement of the right ventricle (RV) and right atrium and tricuspid regurgitation. Eight died of cardiovascular disease and 4 died of noncardiac conditions. At autopsy, hearts of ARVC cats were characterized grossly by moderate-to-severe RV cavity enlargement and wall thinning (n=12) and apical aneurysm formation (n=6). Histology demonstrated pronounced RV lesions in all 12 ARVC cats, including marked myocardial injury (myocyte death and atrophy) and repair (fibrous and/or fatty replacement). Injury and repair were also evident in the left ventricle (LV) in 10 cats, and 2 had involvement of both atria. Myocarditis was present in 10 of the 12 ARVC cats. Apoptosis was detected in 9 ARVC cats (mean apoptotic index, 28+/-23% RV, 21+/-19% LV, and 17+/-15% ventricular septum) but not in controls. CONCLUSIONS In the common domestic cat, we identified a clinically relevant cardiomyopathy that closely mimics ARVC in humans. This unique feline model of human disease will be relevant to defining pathogenesis and investigating mechanisms responsible for disease progression in ARVC.
Collapse
Affiliation(s)
- P R Fox
- Caspary Research Institute of the Animal Medical Center, New York, NY 10021, USA.
| | | | | | | | | |
Collapse
|
23
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 20-2000. A 61-year-old man with a wide-complex tachycardia. N Engl J Med 2000; 342:1979-87. [PMID: 10874066 DOI: 10.1056/nejm200006293422608] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
24
|
Meurs KM, Fox PR, Magnon AL, Liu S, Towbin JA. Molecular screening by polymerase chain reaction detects panleukopenia virus DNA in formalin-fixed hearts from cats with idiopathic cardiomyopathy and myocarditis. Cardiovasc Pathol 2000; 9:119-26. [PMID: 10867362 PMCID: PMC7129092 DOI: 10.1016/s1054-8807(00)00031-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2000] [Revised: 02/17/2000] [Accepted: 03/08/2000] [Indexed: 01/18/2023] Open
Abstract
Viral myocarditis has been suggested as an etiology for cardiomyopathy in several mammalian species. Myocarditis and idiopathic cardiomyopathy have been reported in the domestic cat, although a viral etiology has not been demonstrated. Because of the continuing interest in the potential relationship between viral myocarditis and cardiomyopathy, we evaluated hearts from cats with spontaneous, idiopathic cardiomyopathy for viral genomic material within myocytes by polymerase chain reaction, and for the presence of myocarditis by light microscopy. Thirty-one (31) formalin-fixed hearts from domestic cats who died of idiopathic cardiomyopathy were randomly selected from pathology archives. Seventeen (17) formalin-fixed hearts from healthy cats were similarly selected as normal controls. The polymerase chain reaction (PCR) was used to evaluate myocardial tissue for the presence of viral genome from feline panleukopenia virus, herpes virus, calici virus, and corona virus. Hearts were examined using light microscopy for histologic evidence of myocarditis according to the Dallas criteria. Panleukopenia virus was identified by PCR in 10 of 31 cats with cardiomyopathy but in none of the controls. Neither cardiomyopathic or control cats tested positive by PCR for herpes virus, calici virus, and corona virus. Myocarditis was detected by histologic examination in 18 of 31 cardiomyopathic cats and in none of 17 control cats. Myocarditis and or feline panleukopenia virus genome was detected in felines with idiopathic hypertrophic, dilated, and restrictive cardiomyopathy, suggesting a possible role of viral infection and inflammation in the pathogenesis of cardiomyopathy in this species.
Collapse
Affiliation(s)
- K M Meurs
- Department of Veterinary Clinical Sciences, The Ohio State University College of Veterinary Medicine, Columbus, OH 43210, USA.
| | | | | | | | | |
Collapse
|
25
|
Sheppard M. Arrhythmogenic right ventricular dysplasia and arrhythmogenic right ventricular cardiomyopathy: do these entities exist and are they the same disease? ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s0968-6053(98)80023-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|