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Jain H, Marsool Marsool MD, Verma A, Irfan H, Nadeem A, Jain J, Goyal A, Passey S, Gole S, Khatib MN, Zahiruddin QS, Gaidhane AM, Rustagi S, Satapathy P. A Comprehensive Review on the Electrocardiographic Manifestations of Cardiac Sarcoidosis: Patterns and Prognosis. Curr Cardiol Rep 2024; 26:873-884. [PMID: 38954351 DOI: 10.1007/s11886-024-02088-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) refers to cardiac involvement in sarcoidosis and is usually associated with worse outcomes. This comprehensive review aims to elucidate the electrocardiographic (ECG) signs and features associated with CS, as well as examine modern techniques and their importance in CS evaluation. RECENT FINDINGS The exact pathogenesis of CS is still unclear, but it stems from an abnormal immunological response triggered by environmental factors in individuals with genetic predisposition. CS presents with non-cardiac symptoms; however, conduction system abnormalities are common in patients with CS. The most common electrocardiographic (ECG) signs include atrioventricular blocks and ventricular tachyarrhythmia. Distinct patterns, such as fragmented QRS complexes, T-wave alternans, and bundle branch blocks, are critical indicators of myocardial involvement. The application of advanced ECG techniques such as signal-averaged ECG, Holter monitoring, wavelet-transformed ECG, microvolt T-wave alternans, and artificial intelligence-supported analysis holds promising outcomes for opportune detection and monitoring of CS. Timely utilisation of inexpensive and readily available ECG possesses the potential to allow early detection and intervention for CS. The integration of artificial intelligence models into ECG analysis is a promising approach for improving the ECG diagnostic accuracy and further risk stratification of patients with CS.
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Affiliation(s)
- Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | | | - Amogh Verma
- Department of Internal Medicine, Rama Medical College Hospital and Research Center, Hapur, India.
| | - Hamza Irfan
- Department of Internal Medicine, Shaikh Khalifa Bin Zayed Al Nahyan Medical and Dental College, Lahore, Pakistan
| | - Abdullah Nadeem
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Jyoti Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College, KEM Hospital, Mumbai, India
| | - Siddhant Passey
- Department of Internal Medicine, University of Connecticut Health Center, Connecticut, USA
| | - Shrey Gole
- Department of Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Mahalaqua Nazli Khatib
- Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Quazi Syed Zahiruddin
- South Asia Infant Feeding Research Network (SAIFRN), Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Abhay M Gaidhane
- Global Health Academy, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education, Wardha, India
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Sarvesh Rustagi, Uttaranchal University, Dehradun, Uttarakhand, India
| | - Prakasini Satapathy
- Center for Global Health Research, Saveetha Institute of Medical and Technical Sciences, Saveetha Medical College and Hospital, Saveetha University, Chennai, 602117, India
- Medical Laboratories Techniques Department, AL-Mustaqbal University, Hillah, Babil, 51001, Iraq
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Carrick RT, Carruth ED, Gasperetti A, Murray B, Tichnell C, Gaine S, Sampognaro J, Muller SA, Asatryan B, Haggerty C, Thiemann D, Calkins H, James CA, Wu KC. Improved diagnosis of arrhythmogenic right ventricular cardiomyopathy using electrocardiographic deep learning. Heart Rhythm 2024:S1547-5271(24)03149-7. [PMID: 39168295 DOI: 10.1016/j.hrthm.2024.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/11/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare genetic heart disease associated with life-threatening ventricular arrhythmias. Diagnosis of ARVC is based on the 2010 Task Force Criteria (TFC), application of which often requires clinical expertise at specialized centers. OBJECTIVE The purpose of this study was to develop and validate an electrocardiogram (ECG) deep learning (DL) tool for ARVC diagnosis. METHODS ECGs of patients referred for ARVC evaluation were used to develop (n = 551 [80.1%]) and test (n = 137 [19.9%]) an ECG-DL model for prediction of TFC-defined ARVC diagnosis. The ARVC ECG-DL model was externally validated in a cohort of patients with pathogenic or likely pathogenic (P/LP) ARVC gene variants identified through the Geisinger MyCode Community Health Initiative (N = 167). RESULTS Of 688 patients evaluated at Johns Hopkins Hospital (JHH) (57.3% male, mean age 40.2 years), 329 (47.8%) were diagnosed with ARVC. Although ARVC diagnosis made by referring cardiologist ECG interpretation was unreliable (c-statistic 0.53; confidence interval [CI] 0.52-0.53), ECG-DL discrimination in the hold-out testing cohort was excellent (0.87; 0.86-0.89) and compared favorably to that of ECG interpretation by an ARVC expert (0.85; 0.84-0.86). In the Geisinger cohort, prevalence of ARVC was lower (n = 17 [10.2%]), but ECG-DL-based identification of ARVC phenotype remained reliable (0.80; 0.77-0.83). Discrimination was further increased when ECG-DL predictions were combined with non-ECG-derived TFC in the JHH testing (c-statistic 0.940; 95% CI 0.933-0.948) and Geisinger validation (0.897; 95% CI 0.883-0.912) cohorts. CONCLUSION ECG-DL augments diagnosis of ARVC to the level of an ARVC expert and can differentiate true ARVC diagnosis from phenotype-mimics and at-risk family members/genotype-positive individuals.
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Affiliation(s)
- Richard T Carrick
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Eric D Carruth
- Department of Genomic Health, Geisinger Medical Center, Danville, Pennsylvania
| | - Alessio Gasperetti
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Brittney Murray
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Crystal Tichnell
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sean Gaine
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - James Sampognaro
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Steven A Muller
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Babken Asatryan
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Chris Haggerty
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - David Thiemann
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Cynthia A James
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Katherine C Wu
- Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
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Kim BM, Bois MC, Del-Carpio Munoz F, Rosenbaum AN, Chang IC. An magnetic resonance imaging-pathology correlation case report of cardiac sarcoidosis mimicking arrhythmogenic biventricular cardiomyopathy. Eur Heart J Case Rep 2024; 8:ytae395. [PMID: 39156954 PMCID: PMC11328533 DOI: 10.1093/ehjcr/ytae395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/21/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
Background Cardiac sarcoidosis (CS) is a granulomatous disease that can manifest as conduction defects, ventricular arrhythmias, and heart failure. The diagnosis of CS is inherently difficult due to variable presentations; as such, endomyocardial biopsy is often required but lacks sensitivity due to patchy myocardial involvement. Moreover, the diagnostic criteria of CS and arrhythmogenic cardiomyopathy overlap, particularly in right-side dominant or biventricular presentations, which further complicates an already challenging differential diagnosis. Case summary A 53-year-old man with no prior chronic medical conditions presented with ventricular tachycardia (VT) and heart failure with reduced ejection fraction. He was found to have biventricular cardiomyopathy and late gadolinium enhancement on cardiac magnetic resonance imaging, resulting in an initial diagnosis of arrhythmogenic cardiomyopathy. Implantable cardioverter-defibrillator was placed, but he was readmitted for recurrent VT 2 months later. Despite an aggressive VT therapy (combination of antiarrhythmic drugs, epicardial and endocardial ablation, and stellate ganglion block), he continued with refractory VT and developed cardiogenic shock. Extra-corporeal membrane oxygenation was initiated as a bridge to heart transplantation. Pathology of the explanted heart revealed the underlying disease to be CS. Discussion Cardiac sarcoidosis can mimic arrhythmogenic biventricular cardiomyopathy and may be difficult to distinguish by the proposed diagnostic criteria. High clinical suspicion and thorough investigation are necessary for an earlier diagnosis and initiation of treatment.
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Affiliation(s)
- B Michelle Kim
- Mayo Clinic Alix School of Medicine, 200 First St SW, Rochester, MN 55905, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ian C Chang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Cheng RK, Kittleson MM, Beavers CJ, Birnie DH, Blankstein R, Bravo PE, Gilotra NA, Judson MA, Patton KK, Rose-Bovino L. Diagnosis and Management of Cardiac Sarcoidosis: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1197-e1216. [PMID: 38634276 DOI: 10.1161/cir.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Cardiac sarcoidosis is an infiltrative cardiomyopathy that results from granulomatous inflammation of the myocardium and may present with high-grade conduction disease, ventricular arrhythmias, and right or left ventricular dysfunction. Over the past several decades, the prevalence of cardiac sarcoidosis has increased. Definitive histological confirmation is often not possible, so clinicians frequently face uncertainty about the accuracy of diagnosis. Hence, the likelihood of cardiac sarcoidosis should be thought of as a continuum (definite, highly probable, probable, possible, low probability, unlikely) rather than in a binary fashion. Treatment should be initiated in individuals with clinical manifestations and active inflammation in a tiered approach, with corticosteroids as first-line treatment. The lack of randomized clinical trials in cardiac sarcoidosis has led to treatment decisions based on cohort studies and consensus opinions, with substantial variation observed across centers. This scientific statement is intended to guide clinical practice and to facilitate management conformity by providing a framework for the diagnosis and management of cardiac sarcoidosis.
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Malhi JK, Ibecheozor C, Chrispin J, Gilotra NA. Diagnostic and management strategies in cardiac sarcoidosis. Int J Cardiol 2024; 403:131853. [PMID: 38373681 DOI: 10.1016/j.ijcard.2024.131853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/11/2024] [Accepted: 02/10/2024] [Indexed: 02/21/2024]
Abstract
Cardiac sarcoidosis (CS) is increasingly recognized in the context of with otherwise unexplained electrical or structural heart disease due to improved diagnostic tools and awareness. Therefore, clinicians require improved understanding of this rare but fatal disease to care for these patients. The cardinal features of CS, include arrhythmias, atrio-ventricular conduction delay and cardiomyopathy. In addition to treatments tailored to these cardiac manifestations, immunosuppression plays a key role in active CS management. However, clinical trial and consensus guidelines are limited to guide the use of immunosuppression in these patients. This review aims to provide a practical overview to the current diagnostic challenges, treatment approach, and future opportunities in the field of CS.
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Affiliation(s)
- Jasmine K Malhi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chukwuka Ibecheozor
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Yamano M, Yamano T, Matoba S. Right ventricular dilatation: echocardiographic differential diagnosis. J Med Ultrason (2001) 2024; 51:275-282. [PMID: 38228943 DOI: 10.1007/s10396-023-01399-4] [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: 03/30/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024]
Abstract
The initial means of detecting right ventricular (RV) dilatation is often transthoracic echocardiography (TTE), and once the presence of RV dilatation is suspected, there is the possibility of RV volume overload, RV pressure overload, RV myocardial disease, and even nonpathological RV dilatation. With respect to congenital heart disease with RV volume overload, defects or valvular abnormalities can be easily detected with TTE, with the exception of some diseases. Volumetric assessment using three-dimensional echocardiography may be useful in determining the intervention timing in these diseases. When the disease progresses in patients with pulmonary hypertension as a result of RV pressure overload, RV dilatation becomes more prominent than hypertrophy, and RV functional parameters predict the prognosis at this stage of maladaptive remodeling. The differential diagnosis of cardiomyopathy or comparison with nonpathological RV dilatation may be difficult in the setting of RV myocardial disease. The characteristics of RV functional parameters such as two-dimensional speckle tracking may help differentiate RV cardiomyopathy from other conditions. We review the diseases presenting with RV dilatation, their characteristics, and echocardiographic findings and parameters that are significant in assessing their status or intervention timing.
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Affiliation(s)
- Michiyo Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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Galizia MS, Attili AK, Truesdell WR, Smith ED, Helms AS, Sulaiman AMA, Madamanchi C, Agarwal PP. Imaging Features of Arrhythmogenic Cardiomyopathies. Radiographics 2024; 44:e230154. [PMID: 38512728 PMCID: PMC10995833 DOI: 10.1148/rg.230154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/09/2023] [Accepted: 08/28/2023] [Indexed: 03/23/2024]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a genetic disease characterized by replacement of ventricular myocardium with fibrofatty tissue, predisposing the patient to ventricular arrhythmias and/or sudden cardiac death. Most cases of ACM are associated with pathogenic variants in genes that encode desmosomal proteins, an important cell-to-cell adhesion complex present in both the heart and skin tissue. Although ACM was first described as a disease predominantly of the right ventricle, it is now acknowledged that it can also primarily involve the left ventricle or both ventricles. The original right-dominant phenotype is traditionally diagnosed using the 2010 task force criteria, a multifactorial algorithm divided into major and minor criteria consisting of structural criteria based on two-dimensional echocardiographic, cardiac MRI, or right ventricular angiographic findings; tissue characterization based on endomyocardial biopsy results; repolarization and depolarization abnormalities based on electrocardiographic findings; arrhythmic features; and family history. Shortfalls in the task force criteria due to the modern understanding of the disease have led to development of the Padua criteria, which include updated criteria for diagnosis of the right-dominant phenotype and new criteria for diagnosis of the left-predominant and biventricular phenotypes. In addition to incorporating cardiac MRI findings of ventricular dilatation, systolic dysfunction, and regional wall motion abnormalities, the new Padua criteria emphasize late gadolinium enhancement at cardiac MRI as a key feature in diagnosis and imaging-based tissue characterization. Conditions to consider in the differential diagnosis of the right-dominant phenotype include various other causes of right ventricular dilatation such as left-to-right shunts and variants of normal right ventricular anatomy that can be misinterpreted as abnormalities. The left-dominant phenotype can mimic myocarditis at imaging and clinical examination. Additional considerations for the differential diagnosis of ACM, particularly for the left-dominant phenotype, include sarcoidosis and dilated cardiomyopathy. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Mauricio S. Galizia
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Anil K. Attili
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - William R. Truesdell
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Eric D. Smith
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Adam S. Helms
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Abdulbaset M. A. Sulaiman
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Chaitanya Madamanchi
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
| | - Prachi P. Agarwal
- From the Department of Radiology (M.S.G., A.K.A., W.R.T., P.P.A.) and
Division of Cardiovascular Medicine, Department of Internal Medicine (E.D.S.,
A.S.H., A.M.A.S., C.M.), Michigan Medicine, University of Michigan, 1500 E
Medical Center Dr, Ann Arbor, MI 48109
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Kodali M, Galazka P, Ghafoor A, Bhatia A, Allaqaband SQ. Biventricular Arrhythmogenic Cardiomyopathy Mimicking Cardiac Sarcoidosis. JACC Case Rep 2024; 29:102198. [PMID: 38379651 PMCID: PMC10874899 DOI: 10.1016/j.jaccas.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 02/22/2024]
Abstract
Noninvasive imaging is crucial for diagnosing and managing arrhythmogenic cardiomyopathy. Despite advanced multimodality imaging tools, challenges persist in differentiating it from other arrhythmogenic diseases (eg, cardiac sarcoidosis). We present a case of arrhythmogenic cardiomyopathy with an FLNC variant of uncertain significance exhibiting a phenocopy of cardiac sarcoidosis.
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Affiliation(s)
- Mouna Kodali
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin, USA
| | - Patrycja Galazka
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Asad Ghafoor
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Atul Bhatia
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Suhail Q. Allaqaband
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
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Sampognaro JR, Gaine SP, Sharma A, Tichnell C, Murray B, Shaik Z, Zimmerman SL, James CA, Gasperetti A, Calkins H. Diagnostic pitfalls in patients referred for arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2023; 20:1720-1726. [PMID: 37657721 DOI: 10.1016/j.hrthm.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging because of nonspecific clinical findings and lack of conclusive answers from genetic testing (ie, an ARVC-related variant is neither necessary nor sufficient for diagnosis). Despite the revised 2010 Task Force Criteria, patients are still misdiagnosed with ARVC. OBJECTIVE In patients referred for ARVC, we sought to identify the clinical characteristics and diagnostic confounders for those patients in whom ARVC was ultimately ruled out. METHODS Patients who were referred to our center with previously diagnosed or suspected ARVC (between January 2011 and September 2019; N = 726) were included in this analysis. RESULTS Among 726 patients, ARVC was ruled out in 365 (50.3%). The most common presenting symptoms in ruled-out patients were palpitations (n = 139, 38.1%), ventricular arrhythmias (n = 62, 17.0%), and chest pain (n = 53, 14.5%). On the basis of outside evaluation, 23.8% of these patients had received implantable cardioverter-defibrillators (ICDs) and device extraction was recommended in 9.0% after reevaluation. An additional 5.5% had received ICD recommendations, all of which were reversed on reevaluation. The most frequent final diagnoses were idiopathic premature ventricular contractions/ventricular tachycardia/ventricular fibrillation (46.6%), absence of disease (19.2%), and noncardiac presyncope/syncope (17.5%). The most common contributor to diagnostic error was cardiac magnetic resonance imaging, including mistaken right ventricular wall motion abnormalities (33.2%) and nonspecific fat (12.1%). CONCLUSION False suspicion or misdiagnosis was found in the majority of patients referred for ARVC, resulting in inappropriate ICD implantation or recommendation in 14.5% of these patients. Misdiagnosis or false suspicion was most commonly due to misinterpretation of cardiac magnetic resonance imaging.
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Affiliation(s)
- James R Sampognaro
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sean P Gaine
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Apurva Sharma
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zeba Shaik
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefan L Zimmerman
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alessio Gasperetti
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gasperetti A, James CA, Carrick RT, Protonotarios A, te Riele ASJM, Cadrin-Tourigny J, Compagnucci P, Duru F, van Tintelen P, Elliot PM, Calkins H. Arrhythmic risk stratification in arrhythmogenic right ventricular cardiomyopathy. Europace 2023; 25:euad312. [PMID: 37935403 PMCID: PMC10674106 DOI: 10.1093/europace/euad312] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable cardiomyopathy characterized by a predominantly arrhythmic presentation. It represents the leading cause of sudden cardiac death (SCD) among athletes and poses a significant morbidity threat in the general population. As a causative treatment for ARVC is still not available, the placement of an implantable cardioverter defibrillator represents the current cornerstone for SCD prevention in this setting. Thanks to international ARVC-dedicated efforts, significant steps have been achieved in recent years towards an individualized, patient-centred risk stratification approach. A novel risk calculator algorithm estimating the 5-year risk of arrhythmias of patients with ARVC has been introduced in clinical practice and subsequently validated. The purpose of this article is to summarize the body of evidence that has allowed the development of this tool and to discuss the best way to implement its use in the care of an individual patient.
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MESH Headings
- Humans
- Risk Factors
- Arrhythmogenic Right Ventricular Dysplasia/complications
- Arrhythmogenic Right Ventricular Dysplasia/diagnosis
- Arrhythmogenic Right Ventricular Dysplasia/therapy
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Death, Sudden, Cardiac/epidemiology
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/complications
- Defibrillators, Implantable/adverse effects
- Risk Assessment
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
- Department of Medicine, Division of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, Utrecht, The Netherlands
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Richard T Carrick
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | | | - Anneline S J M te Riele
- Department of Medicine, Division of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, Utrecht, The Netherlands
| | - Julia Cadrin-Tourigny
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Firat Duru
- Department of Cardiology, Arrhythmia Unit, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Peter van Tintelen
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Perry M Elliot
- Department of Cardiology, UCL Institute of Cardiovascular Science, London, UK
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
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11
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Zipse MM. Editorial commentary: Cardiac sarcoidosis in contemporary practice: Forward progress, but clinical quandaries persist. Trends Cardiovasc Med 2023; 33:456-457. [PMID: 35798173 DOI: 10.1016/j.tcm.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Matthew M Zipse
- From the Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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12
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Tan JL, Tan BEX, Cheung JW, Ortman M, Lee JZ. Update on cardiac sarcoidosis. Trends Cardiovasc Med 2023; 33:442-455. [PMID: 35504422 DOI: 10.1016/j.tcm.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 12/17/2022]
Abstract
Cardiac sarcoidosis is an inflammatory myocardial disease of unknown etiology. It is characterized by the deposition of non-caseating granulomas that may involve any part of the heart. Cardiac sarcoidosis is often under-diagnosed or recognized partly due to the heterogeneous clinical presentation of the disease. The three most frequent clinical manifestations of cardiac sarcoidosis are atrioventricular block, ventricular arrhythmias, and heart failure. A definitive diagnosis of cardiac sarcoidosis can be made with histology findings from an endomyocardial biopsy. However, the diagnosis in the majority of cases is based on findings from the clinical presentation and advanced imaging due to the low sensitivity of endomyocardial biopsy. The Heart Rhythm Society (HRS) 2014 expert consensus statement and the Japanese Ministry of Health and Welfare criteria are the two most commonly used diagnostic criteria sets. This review article summarizes the available evidence on cardiac sarcoidosis, focusing on the diagnostic criteria and stepwise approach to its management.
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Affiliation(s)
- Jian Liang Tan
- Division of Cardiovascular Disease, Cooper University Health Care/Cooper Medical School of Rowan University, Camden, New Jersey.
| | - Bryan E-Xin Tan
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Matthew Ortman
- Division of Cardiovascular Disease, Cooper University Health Care/Cooper Medical School of Rowan University, Camden, New Jersey
| | - Justin Z Lee
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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13
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Bobbio E, Eldhagen P, Polte CL, Hjalmarsson C, Karason K, Rawshani A, Darlington P, Kullberg S, Sörensson P, Bergh N, Bollano E. Clinical Outcomes and Predictors of Long-Term Survival in Patients With and Without Previously Known Extracardiac Sarcoidosis Using Machine Learning: A Swedish Multicenter Study. J Am Heart Assoc 2023; 12:e029481. [PMID: 37489729 PMCID: PMC10492974 DOI: 10.1161/jaha.123.029481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/27/2023] [Indexed: 07/26/2023]
Abstract
Background Cardiac involvement can be an initial manifestation in sarcoidosis. However, little is known about the association between various clinical phenotypes of cardiac sarcoidosis (CS) and outcomes. We aimed to analyze the relation of different clinical manifestations with outcomes of CS and to investigate the relative importance of clinical features influencing overall survival. Methods and Results A retrospective cohort of 141 patients with CS enrolled at 2 Swedish university hospitals was studied. Presentation, imaging studies, and outcomes of de novo CS and previously known extracardiac sarcoidosis were compared. Survival free of primary composite outcome (ventricular arrhythmias, heart transplantation, or death) was assessed. Machine learning algorithm was used to study the relative importance of clinical features in predicting outcome. Sixty-two patients with de novo CS and 79 with previously known extracardiac sarcoidosis were included. De novo CS showed more advanced New York Heart Association class (P=0.02), higher circulating levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide) (P<0.001), and troponins (P<0.001), as well as a higher prevalence of right ventricular dysfunction (P<0.001). During a median (interquartile range) follow-up of 61 (44-77) months, event-free survival was shorter in patients with de novo CS (P<0.001). The top 5 features predicting worse event-free survival in order of importance were as follows: impaired tricuspid annular plane systolic excursion, de novo CS, reduced right ventricular ejection fraction, absence of β-blockers, and lower left ventricular ejection fraction. Conclusions Patients with de novo CS displayed more severe disease and worse outcomes compared with patients with previously known extracardiac sarcoidosis. Using machine learning, right ventricular dysfunction and de novo CS stand out as strong overall predictors of impaired survival.
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Affiliation(s)
- Emanuele Bobbio
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Per Eldhagen
- Department of Medicine SolnaKarolinska InstitutetStockholmSweden
- Unit of Cardiology, Theme Cardiovascular and NeurologyKarolinska University HospitalStockholmSweden
| | - Christian L. Polte
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Departments of Clinical Physiology and RadiologySahlgrenska University HospitalGothenburgSweden
| | - Clara Hjalmarsson
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kristjan Karason
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of TransplantationSahlgrenska University HospitalGothenburgSweden
| | - Araz Rawshani
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Pernilla Darlington
- Department of Internal MedicineSödersjukhusetStockholmSweden
- Department of Clinical Science and EducationSödersjukhuset and Karolinska InstitutetStockholmSweden
| | - Susanna Kullberg
- Department of Respiratory Medicine, Theme Inflammation and AgeingKarolinska University HospitalStockholmSweden
- Respiratory Medicine Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Peder Sörensson
- Department of Respiratory Medicine, Theme Inflammation and AgeingKarolinska University HospitalStockholmSweden
- Respiratory Medicine Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Niklas Bergh
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Entela Bollano
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Institute of Medicine at Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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14
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Okafor J, Khattar R, Sharma R, Kouranos V. The Role of Echocardiography in the Contemporary Diagnosis and Prognosis of Cardiac Sarcoidosis: A Comprehensive Review. Life (Basel) 2023; 13:1653. [PMID: 37629510 PMCID: PMC10455750 DOI: 10.3390/life13081653] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiac sarcoidosis (CS) is a rare inflammatory disorder characterised by the presence of non-caseating granulomas within the myocardium. Contemporary studies have revealed that 25-30% of patients with systemic sarcoidosis have cardiac involvement, with detection rates increasing in the era of advanced cardiac imaging. The use of late gadolinium enhancement cardiac magnetic resonance and 18fluorodeoxy glucose positron emission tomography (FDG-PET) imaging has superseded endomyocardial biopsy for the diagnosis of CS. Echocardiography has historically been used as a screening tool with abnormalities triggering the need for advanced imaging, and as a tool to assess cardiac function. Regional wall thinning or aneurysm formation in a noncoronary distribution may indicate granuloma infiltration. Thinning of the basal septum in the setting of extracardiac sarcoidosis carries a high specificity for cardiac involvement. Abnormal myocardial echotexture and eccentric hypertrophy may be suggestive of active myocardial inflammation. The presence of right-ventricular involvement as indicated by free-wall aneurysms can mimic arrhythmogenic right-ventricular cardiomyopathy. More recently, the use of myocardial strain has increased the sensitivity of echocardiography in diagnosing cardiac involvement. Echocardiography is limited in prognostication, with impaired left-ventricular (LV) ejection fraction and LV dilatation being the only established independent predictors of mortality. More research is required to explore how advanced echocardiographic technologies can increase both the diagnostic sensitivity and prognostic ability of this modality in CS.
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Affiliation(s)
- Joseph Okafor
- Department of Echocardiography, Royal Brompton Hospital, London SW3 6NP, UK
- Cardiac Sarcoidosis Centre, Royal Brompton Hospital, London SW3 6NP, UK
| | - Rajdeep Khattar
- Department of Echocardiography, Royal Brompton Hospital, London SW3 6NP, UK
- Cardiac Sarcoidosis Centre, Royal Brompton Hospital, London SW3 6NP, UK
| | - Rakesh Sharma
- Cardiac Sarcoidosis Centre, Royal Brompton Hospital, London SW3 6NP, UK
| | - Vasilis Kouranos
- Cardiac Sarcoidosis Centre, Royal Brompton Hospital, London SW3 6NP, UK
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15
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Kurashima S, Kitai T, Xanthopoulos A, Skoularigis J, Triposkiadis F, Izumi C. Diagnosis of cardiac sarcoidosis: histological evidence vs. imaging. Expert Rev Cardiovasc Ther 2023; 21:693-702. [PMID: 37776232 DOI: 10.1080/14779072.2023.2266367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/29/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION The prognosis for cardiac sarcoidosis (CS) remains unfavorable. Although early and accurate diagnosis is crucial, the low detection rate of endomyocardial biopsy makes accurate diagnosis challenging. AREAS COVERED The Heart Rhythm Society (HRS) consensus statement and the Japanese Circulation Society (JCS) guidelines are two major diagnostic criteria for the diagnosis of CS. While the requirement of positive histology for the diagnosis in the HRS criteria can result in overlooked cases, the JCS guidelines advocate for a group of 'clinical' diagnoses based on advanced imaging, including cardiovascular magnetic resonance and 18F-fluorodeoxyglucose positron emission tomography, which do not require histological evidence. Recent studies have supported the usefulness of clinical diagnosis of CS. However, other evidence suggests that clinical CS may sometimes be inaccurate. This article describes the advantages and disadvantages of the current diagnostic criteria for CS, and typical imaging and clinical courses. EXPERT OPINION The diagnosis of clinical CS has been made possible by recent developments in multimodality imaging. However, it is still crucial to look for histological signs of sarcoidosis in other organs in addition to the endomyocardium. Additionally, phenotyping based on clinical manifestations such as heart failure, conduction abnormality or ventricular arrhythmia, and extracardiac abnormalities is clinically significant.
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Affiliation(s)
- Shinichi Kurashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - John Skoularigis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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16
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Mkoko P, Chin A. Diagnoses, management patterns, and outcomes of cardiac sarcoidosis in South Africa. Heart Rhythm O2 2023; 4:343-349. [PMID: 37361621 PMCID: PMC10288020 DOI: 10.1016/j.hroo.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background Sarcoidosis is an idiopathic multiorgan disease characterized by tissue infiltration by noncaseating granulomas. Clinical cardiac involvement is reported in approximately 5% of patients. However, the frequency of cardiac involvement is found to be higher on autopsy and in advanced imaging studies such as cardiac magnetic resonance imaging. Objective The purpose of this study was to determine contemporary diagnoses, management, and outcomes of cardiac sarcoidosis (CS) in South Africa. Methods Clinical records of patients diagnosed with CS between January 2000 and December 2021 were reviewed. Results Twenty-two patients were diagnosed with CS during the study period. The patients had a mean (± SD) age of 45.2 ± 12.3 years at the time of presentation. CS diagnostic rates increased from 4.5% in 2000-2005 to 45.5% in 2016-2021. Fifteen of the 22 patients (68.2%) were newly diagnosed with sarcoidosis at the time of CS diagnosis, and 9 of the 15 (60%) had pulmonary involvement. Of the 22 patients diagnosed with CS, 13 (59.1%) presented in combination with heart block, 10 (45.5%) with ventricular arrhythmias, and 4 (18.2%) with heart failure. Five endomyocardial biopsies were performed, and all were nondiagnostic. However, 8 of 8 endobronchial ultrasound (EBUS)-guided biopsies of thoracic lymph nodes were diagnostic of sarcoidosis and, notably, excluded tuberculosis. Fourteen patients (63.6%) were treated with corticosteroids, 7 (31.8%) with azathioprine, 9 (40.9%) with amiodarone, and 16 (72.7%) with a cardiac implantable electronic device. After a mean follow-up period of 64.5 ± 50.5 months, no deaths had occurred. Conclusion CS diagnostic rates have increased over time. Diagnostic endomyocardial biopsies have a low diagnostic yield, whereas EBUS-guided biopsy of thoracic lymph nodes is of crucial diagnostic utility.
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Affiliation(s)
- Philasande Mkoko
- Cardiac Clinic, Charlotte Maxeke Johannesburg Academic Hospital, Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ashley Chin
- E17 Cardiac Clinic, Groote Schuur Hospital, Division of Cardiology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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17
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Delasnerie H, Gandjbakhch E, Sauve R, Beneyto M, Domain G, Voglimacci-Stephanopoli Q, Mandel F, Badenco N, Waintraub X, Mondoly P, Fressart V, Rollin A, Maury P. Correlations Between Endocardial Voltage Mapping, Diagnosis, and Genetics in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy. Am J Cardiol 2023; 190:113-120. [PMID: 36621286 DOI: 10.1016/j.amjcard.2022.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/01/2022] [Accepted: 11/19/2022] [Indexed: 01/09/2023]
Abstract
The relations between endocardial voltage mapping and the genetic background of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) have not been investigated so far. A total of 97 patients with proved or suspected ARVC who underwent 3-dimensional endocardial mapping and genetic testing have been retrospectively included. Presence, localization, and size of scar areas were correlated to ARVC diagnosis and the presence of a pathogenic variant. A total of 78 patients (80%) presented with some bipolar or unipolar scar on endocardial voltage mapping, whereas 43 carried pathogenic variants (44%). Significant associations were observed between presence of endocardial scars on voltage mapping and previous or inducible ventricular tachycardia, right ventricular function and dimensions, or electrocardiogram features of ARVC. A total of 60 of the 78 patients (77%) with an endocardial scar fulfilled the criteria for a definitive arrhythmogenic right ventricular dysplasia diagnosis versus 8 of 19 patients (42%) without scar (p = 0.003). Patients with a definitive diagnosis of ARVC had more scars from any location and the scars were larger in patients with ARVC. In the 68 patients with a definitive diagnosis of ARVC, the presence of any endocardial scar was similar whether an ARVC-causal mutation was present or not. Only scar extent was significantly greater in patients with pathogenic variants. There was no difference in the presence and characteristics of scars in PKP2 mutated versus other mutated patients. The 3-dimensional endocardial mapping could have an important role for refining ARVC diagnosis and may be able to detect minor forms with otherwise insufficient criteria for diagnosis. The trend for larger scar extent were observed in mutated patients, without any difference according to the mutated genes.
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Affiliation(s)
- Hubert Delasnerie
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | - Estelle Gandjbakhch
- Department of Cardiology, Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Romain Sauve
- Biosense, Johnson & Johnson, Issy-les-Moulineaux, France
| | - Maxime Beneyto
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | - Guillaume Domain
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | | | - Franck Mandel
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | - Nicolas Badenco
- Department of Cardiology, Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Xavier Waintraub
- Department of Cardiology, Sorbonne Universités, AP-HP, Heart Institute, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Pierre Mondoly
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | - Véronique Fressart
- Service de Biochimie Métabolique, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Anne Rollin
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France
| | - Philippe Maury
- Department of Cardiology, Cardiology University Hospital Toulouse, Toulouse, France; I2MC, Inserm UMR 1297, Toulouse, France.
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18
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Monda E, Rubino M, Palmiero G, Verrillo F, Lioncino M, Diana G, Cirillo A, Fusco A, Dongiglio F, Caiazza M, Altobelli I, Mauriello A, Guarnaccia N, Scatteia A, Cesaro A, Pacileo G, Sarubbi B, Frisso G, Bauce B, D’Andrea A, Dellegrottaglie S, Russo MG, Calabrò P, Limongelli G. Multimodality Imaging in Arrhythmogenic Left Ventricular Cardiomyopathy. J Clin Med 2023; 12:jcm12041568. [PMID: 36836107 PMCID: PMC9966192 DOI: 10.3390/jcm12041568] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/31/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
The term arrhythmogenic cardiomyopathy (ACM) describes a large spectrum of myocardial diseases characterized by progressive fibrotic or fibrofatty replacement, which gives the substrate for the occurrence of ventricular tachyarrhythmias and the development of ventricular dysfunction. This condition may exclusively affect the left ventricle, leading to the introduction of the term arrhythmogenic left ventricular cardiomyopathy (ALVC). The clinical features of ALVC are progressive fibrotic replacement with the absence or mild dilation of the LV and the occurrence of ventricular arrhythmias within the left ventricle. In 2019, the diagnostic criteria for the diagnosis of ALVC, based on family history and clinical, electrocardiographic, and imaging features, have been proposed. However, since the significant clinical and imaging overlap with other cardiac diseases, genetic testing with the demonstration of a pathogenic variant in an ACM-related gene is required for diagnostic confirmation. In ALVC, the multimodality imaging approach comprises different imaging techniques, such as echocardiography, cardiac magnetic resonance, and cardiac nuclear imaging. It provides essential information for the diagnosis, differential diagnosis, sudden cardiac death risk stratification, and management purposes. This review aims to elucidate the current role of the different multimodality imaging techniques in patients with ALVC.
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Affiliation(s)
- Emanuele Monda
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
- Institute of Cardiovascular Sciences, University College of London and St. Bartholomew’s Hospital, London WC1E 6DD, UK
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Gaetano Diana
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Annapaola Cirillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Adelaide Fusco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Ippolita Altobelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Alfredo Mauriello
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Natale Guarnaccia
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | | | - Arturo Cesaro
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Berardo Sarubbi
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Giulia Frisso
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, University of Naples “Federico II”, 80138 Naples, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Antonello D’Andrea
- Department of Cardiology and Intensive Coronary Care, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | | | - Maria Giovanna Russo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Paolo Calabrò
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy
- Institute of Cardiovascular Sciences, University College of London and St. Bartholomew’s Hospital, London WC1E 6DD, UK
- Correspondence: ; Tel.: +39-0817062815
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19
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Gasperetti A, Tandri H. Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Cardiomyopathy. Card Electrophysiol Clin 2022; 14:679-683. [PMID: 36396184 DOI: 10.1016/j.ccep.2022.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy is an inherited desmosomal myopathy characterized by progressive fibrofatty replacement of the myocardium, right ventricular enlargement, and malignant ventricular arrhythmias. Ventricular tachycardias is one of the most common initial presentation of ARVC. This manuscript addresses invasive VT ablation options for the managmenet of VT in patients with ARVC.
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Affiliation(s)
- Alessio Gasperetti
- ARVC Program, Division of Cardiology, Johns Hopkins University School of Medicine, 600 Wolfe Street, Baltimore, MD 21287, USA
| | - Harikrishna Tandri
- ARVC Program, Division of Cardiology, Johns Hopkins University School of Medicine, 600 Wolfe Street, Baltimore, MD 21287, USA.
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20
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Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis. J Clin Med 2022; 11:jcm11226718. [PMID: 36431195 PMCID: PMC9694385 DOI: 10.3390/jcm11226718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.
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21
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Vereckei A, Katona G, Révész K, Vágó H, Müller V, Nagy B, Nagy P, Sepp R, Suvarna K. Cardiac sarcoidosis completely mimicking biventricular arrhythmogenic cardiomyopathy. ESC Heart Fail 2022; 9:4304-4314. [PMID: 36045019 PMCID: PMC9773774 DOI: 10.1002/ehf2.14123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/16/2022] [Accepted: 08/15/2022] [Indexed: 01/19/2023] Open
Abstract
Cardiac sarcoidosis (CS) is a chameleon of cardiology, and it can mimic different cardiac diseases; among them is arrhythmogenic cardiomyopathy (ACM). We admitted a 70-year-old female patient with heart failure symptoms in 2015, who fulfilled all major ECG and non-invasive imaging criteria of biventricular ACM. She was well with the recommended medications for 3 years, showing only isolated cardiac involvement, but in 2018, cervical and mediastinal lymphadenopathy appeared and cervical lymph node core biopsy histology, bronchoalveolar lavage flow cytometry strongly suggested extracardiac sarcoidosis. Therefore, our suspicion was that sarcoidosis is responsible for the cardiac involvement, which was not confirmed by PET-CT and gallium scintigraphy examinations. At the end of 2018, she died in septicaemia with multiorgan failure, and only autopsy verified her CS. A new ECG algorithm published in 2021 for the differential diagnosis of CS and biventricular ACM, when applied on her ECGs recorded in 2015, suggested the diagnosis of CS.
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Affiliation(s)
- András Vereckei
- Department of Medicine and HematologySemmelweis UniversityBudapestHungary
| | - Gábor Katona
- Department of Medicine and HematologySemmelweis UniversityBudapestHungary
| | - Katalin Révész
- Department of Medicine and HematologySemmelweis UniversityBudapestHungary
| | - Hajnalka Vágó
- Heart and Vascular CenterSemmelweis UniversityBudapestHungary
| | - Veronika Müller
- Department of PulmonologySemmelweis UniversityBudapestHungary
| | - Beáta Nagy
- 1st Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Péter Nagy
- 1st Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Róbert Sepp
- Department of Medicine, Division of Non‐Invasive CardiologyUniversity of SzegedSzegedHungary
| | - Kim Suvarna
- Department of HistopathologySheffield Teaching Hospitals, NHS Foundation Trust, Northern General HospitalSheffieldUK
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22
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Lukas Laws J, Lancaster MC, Ben Shoemaker M, Stevenson WG, Hung RR, Wells Q, Marshall Brinkley D, Hughes S, Anderson K, Roden D, Stevenson LW. Arrhythmias as Presentation of Genetic Cardiomyopathy. Circ Res 2022; 130:1698-1722. [PMID: 35617362 PMCID: PMC9205615 DOI: 10.1161/circresaha.122.319835] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
There is increasing evidence regarding the prevalence of genetic cardiomyopathies, for which arrhythmias may be the first presentation. Ventricular and atrial arrhythmias presenting in the absence of known myocardial disease are often labelled as idiopathic, or lone. While ventricular arrhythmias are well-recognized as presentation for arrhythmogenic cardiomyopathy in the right ventricle, the scope of arrhythmogenic cardiomyopathy has broadened to include those with dominant left ventricular involvement, usually with a phenotype of dilated cardiomyopathy. In addition, careful evaluation for genetic cardiomyopathy is also warranted for patients presenting with frequent premature ventricular contractions, conduction system disease, and early onset atrial fibrillation, in which most detected genes are in the cardiomyopathy panels. Sudden death can occur early in the course of these genetic cardiomyopathies, for which risk is not adequately tracked by left ventricular ejection fraction. Only a few of the cardiomyopathy genotypes implicated in early sudden death are recognized in current indications for implantable cardioverter defibrillators which otherwise rely upon a left ventricular ejection fraction ≤0.35 in dilated cardiomyopathy. The genetic diagnoses impact other aspects of clinical management such as exercise prescription and pharmacological therapy of arrhythmias, and new therapies are coming into clinical investigation for specific genetic cardiomyopathies. The expansion of available genetic information and implications raises new challenges for genetic counseling, particularly with the family member who has no evidence of a cardiomyopathy phenotype and may face a potentially negative impact of a genetic diagnosis. Discussions of risk for both probands and relatives need to be tailored to their numeric literacy during shared decision-making. For patients presenting with arrhythmias or cardiomyopathy, extension of genetic testing and its implications will enable cascade screening, intervention to change the trajectory for specific genotype-phenotype profiles, and enable further development and evaluation of emerging targeted therapies.
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Affiliation(s)
- J Lukas Laws
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Megan C Lancaster
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - M Ben Shoemaker
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Rebecca R Hung
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Quinn Wells
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - D Marshall Brinkley
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Sean Hughes
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Katherine Anderson
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Dan Roden
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
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23
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Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:533-553. [PMID: 35450611 DOI: 10.1016/j.jacep.2021.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/21/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) encompasses a group of conditions characterized by right ventricular fibrofatty infiltration, with a predominant arrhythmic presentation. First described in the late 1970s and early 1980s, it is now frequently recognized to have biventricular involvement. The prevalence is ∼1:2,000 to 1:5,000, depending on geographic location, and it has a slight male predominance. The diagnosis of ARVC is determined on the basis of fulfillment of task force criteria incorporating electrophysiological parameters, cardiac imaging findings, genetic factors, and histopathologic features. Risk stratification of patients with ARVC aims to identify those who are at increased risk of sudden cardiac death or sustained ventricular tachycardia. Factors including age, sex, electrophysiological features, and cardiac imaging investigations all contribute to risk stratification. The current management of ARVC includes exercise restriction, β-blocker therapy, consideration for implantable cardioverter-defibrillator insertion, and catheter ablation. This review summarizes our current understanding of ARVC and provides clinicians with a practical approach to diagnosis and management.
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24
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Limongelli G, Adorisio R, Baggio C, Bauce B, Biagini E, Castelletti S, Favilli S, Imazio M, Lioncino M, Merlo M, Monda E, Olivotto I, Parisi V, Pelliccia F, Basso C, Sinagra G, Indolfi C, Autore C. Diagnosis and Management of Rare Cardiomyopathies in Adult and Paediatric Patients. A Position Paper of the Italian Society of Cardiology (SIC) and Italian Society of Paediatric Cardiology (SICP). Int J Cardiol 2022; 357:55-71. [PMID: 35364138 DOI: 10.1016/j.ijcard.2022.03.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 12/20/2022]
Abstract
Cardiomyopathies (CMPs) are myocardial diseases in which the heart muscle is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease and congenital heart disease sufficient to cause the observed myocardial abnormality. Thought for a long time to be rare diseases, it is now clear that most of the CMPs can be easily observed in clinical practice. However, there is a group of specific heart muscle diseases that are rare in nature whose clinical/echocardiographic phenotypes resemble those of the four classical morphological subgroups of hypertrophic, dilated, restrictive, arrhythmogenic CMPs. These rare CMPs, often but not solely diagnosed in infants and paediatric patients, should be more properly labelled as specific CMPs. Emerging consensus exists that these conditions require tailored investigation and management. Indeed, an appropriate understanding of these conditions is mandatory for early treatment and counselling. At present, however, the multisystemic and heterogeneous presentation of these entities is a challenge for clinicians, and time delay in diagnosis is a significant concern. The aim of this paper is to define practical recommendations for diagnosis and management of the rare CMPs in paediatric or adult age. A modified Delphi method was adopted to grade the recommendations proposed by each member of the writing committee.
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Affiliation(s)
- Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy; Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu).
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Cardiocirculatory Support Unit, Department of Pediatric Cardiology and Cardiac Surgery, Heart Lung Transplantation, Bambino Gesù Hospital and Research Institute, Rome, Italy
| | - Chiara Baggio
- Cardiothoracovascular and Medical Surgical and Health Science Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, 34149 Trieste, Italy
| | - Barbara Bauce
- Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu); Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Elena Biagini
- Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu); Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Silvia Castelletti
- Cardiomyopathy Unit and Center for Cardiac Arrhythmias of Genetic Origin, Department of Cardiovascular, Neural and Metabolic Science, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Silvia Favilli
- Department of Pediatric Cardiology, Meyer Children's Hospital, Viale Gaetano Pieraccini, 24, 50139 Florence, Italy
| | - Massimo Imazio
- Head of Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", ASUFC, Piazzale Santa Maria della Misericordia 15, Udine 33100, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Marco Merlo
- Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu); Cardiothoracovascular and Medical Surgical and Health Science Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, 34149 Trieste, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi and the University of Florence, Florence, Italy
| | - Vanda Parisi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Cristina Basso
- Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu); Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health Azienda Ospedaliera, University of Padua Padova, Italy
| | - Gianfranco Sinagra
- Member of ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart; http://guardheart.ern-net.eu); Cardiothoracovascular and Medical Surgical and Health Science Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, 34149 Trieste, Italy
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Camillo Autore
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Division of Cardiology, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy
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25
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Molitor N, Duru F. Arrhythmogenic Right Ventricular Cardiomyopathy and Differential Diagnosis with Diseases Mimicking Its Phenotypes. J Clin Med 2022; 11:jcm11051230. [PMID: 35268321 PMCID: PMC8911116 DOI: 10.3390/jcm11051230] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 12/13/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease, which is characterized by fibro-fatty replacement of predominantly the right ventricle (RV). The disease can result in ventricular tachyarrhythmias and sudden cardiac death. Our understanding of the pathophysiology and clinical expressivity of ARVC has been continuously evolving. The diagnosis can be challenging due to its variable expressivity, incomplete penetrance and the lack of specific diagnostic criteria. Idiopathic RV outflow tract tachycardia, Brugada Syndrome, athlete’s heart, dilated cardiomyopathy, myocarditis, cardiac sarcoidosis, congenital aneurysms and diverticula may mimic clinical phenotypes of ARVC. This review aims to provide an update on the differential diagnosis of ARVC.
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Affiliation(s)
- Nadine Molitor
- Division of Arrhythmias and Electrophysiology, Clinic for Cardiology, University Heart Center Zurich, 8091 Zurich, Switzerland;
| | - Firat Duru
- Division of Arrhythmias and Electrophysiology, Clinic for Cardiology, University Heart Center Zurich, 8091 Zurich, Switzerland;
- Center for Integrative Human Physiology, University of Zurich, 8057 Zurich, Switzerland
- Correspondence: ; Tel.: +41-44-2553565
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26
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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.
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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
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27
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Fazelpour S, Nery PB, Birnie DH. When to suspect and investigate cardiac sarcoidosis. Can J Cardiol 2022; 38:549-551. [DOI: 10.1016/j.cjca.2022.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/19/2022] [Indexed: 11/02/2022] Open
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28
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Makhdumi M, Assar MD, Meyer DM, Roberts WC. Cardiac sarcoidosis diagnosed after orthotopic heart transplantation and clinically mimicking arrhythmogenic right ventricular cardiomyopathy. Cardiovasc Pathol 2021; 56:107390. [PMID: 34600147 DOI: 10.1016/j.carpath.2021.107390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/15/2022] Open
Abstract
Described herein is a 71-year-old man who underwent orthotopic heart transplant (OHT) for chronic severe heart failure secondary to cardiac sarcoidosis (CS) devoid of non-caseating granulomas but nevertheless characteristic of CS. Clinically, his heart disease had suggested the presence of arrhythmogenic right ventricular cardiomyopathy.
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Affiliation(s)
- Madiha Makhdumi
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, United States
| | - Manish D Assar
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, United States; Internal Medicine, Baylor University Medical Center, Dallas, Texas, United States
| | - Dan M Meyer
- Departments of Cardiac Surgery, Baylor University Medical Center, Dallas, Texas, United States; Internal Medicine, Baylor University Medical Center, Dallas, Texas, United States
| | - William C Roberts
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, United States; Internal Medicine, Baylor University Medical Center, Dallas, Texas, United States.
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29
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Abstract
Arrhythmogenic right ventricular cardiomyopathy, formerly called "arrhythmogenic right ventricular dysplasia," is an under-recognized clinical entity characterized by ventricular arrhythmias and a characteristic ventricular pathology. Diagnosis is often difficult due to the nonspecific nature of the disease and the broad spectrum of phenotypic variations. Therefore, consensus diagnostic criteria have been developed which combine electrocardiographic, echocardiographic, cardiac magnetic resonance imaging and histologic criteria. In 1994, an international task force first proposed the major and minor diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy based on family history, arrhythmias, electrocardiographic abnormalities, tissue characterization, and structural and functional right ventricular abnormalities. In 2010, the task force criteria were revised to include quantitative abnormalities. These diagnostic modalities and the most recent task force criteria are discussed in this review.
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30
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Affiliation(s)
- Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
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31
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Gilotra NA, Griffin JM, Pavlovic N, Houston BA, Chasler J, Goetz C, Chrispin J, Sharp M, Kasper EK, Chen ES, Blankstein R, Cooper LT, Joyce E, Sheikh FH. Sarcoidosis-Related Cardiomyopathy: Current Knowledge, Challenges, and Future Perspectives State-of-the-Art Review. J Card Fail 2021; 28:113-132. [PMID: 34260889 DOI: 10.1016/j.cardfail.2021.06.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022]
Abstract
The prevalence of sarcoidosis-related cardiomyopathy is increasing. Sarcoidosis impacts cardiac function through granulomatous infiltration of the heart, resulting in conduction disease, arrhythmia, and/or heart failure. The diagnosis of cardiac sarcoidosis (CS) can be challenging and requires clinician awareness as well as differentiation from overlapping diagnostic phenotypes, such as other forms of myocarditis and arrhythmogenic cardiomyopathy. Clinical manifestations, extracardiac involvement, histopathology, and advanced cardiac imaging can all lend support to a diagnosis of CS. The mainstay of therapy for CS is immunosuppression; however, no prospective clinical trials exist to guide management. Patients may progress to developing advanced heart failure or ventricular arrhythmia, for which ventricular assist device therapies or heart transplantation may be considered. The existing knowledge gaps in CS call for an interdisciplinary approach to both patient care and future investigation to improve mechanistic understanding and therapeutic strategies.
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Affiliation(s)
- Nisha A Gilotra
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jan M Griffin
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Columbia University School of Medicine, New York, New York
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Brian A Houston
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica Chasler
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Colleen Goetz
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Sharp
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward K Kasper
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward S Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Emer Joyce
- Department of Cardiology, Mater Misericordiae University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Farooq H Sheikh
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
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32
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Kupari M, Lehtonen J. POINT: Should Isolated Cardiac Sarcoidosis Be Considered a Significant Manifestation of Sarcoidosis? Yes. Chest 2021; 160:36-38. [PMID: 34246374 DOI: 10.1016/j.chest.2020.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/13/2020] [Indexed: 10/20/2022] Open
Affiliation(s)
- Markku Kupari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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33
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Hoogendoorn JC, Ninaber MK, Piers SRD, de Riva M, Grauss RW, Bogun FM, Zeppenfeld K. The harm of delayed diagnosis of arrhythmogenic cardiac sarcoidosis: a case series. Europace 2021; 22:1376-1383. [PMID: 32898252 PMCID: PMC7478317 DOI: 10.1093/europace/euaa115] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/17/2020] [Indexed: 01/18/2023] Open
Abstract
Aims Cardiac sarcoidosis (CS) is a known cause of ventricular tachycardia (VT). However, an arrhythmogenic presentation may not prompt immediate comprehensive evaluation. We aimed to assess the diagnostic and disease course of patients with arrhythmogenic cardiac sarcoidosis (ACS). Methods and results From the Leiden VT-ablation-registry, consecutive patients with CS as underlying aetiology were retrospectively included. Data on clinical presentation, time-to-diagnosis, cardiac function, and clinical outcomes were collected. Patients were divided in early (<6 months from first cardiac presentation) and late diagnosis. After exclusion of patients with known causes of non-ischaemic cardiomyopathy (NICM), 15 (12%) out of 129 patients with idiopathic NICM were ultimately diagnosed with CS and included. Five patients were diagnosed early; all had early presentation with VTs. Ten patients had a late diagnosis with a median delay of 24 (IQR 15–44) months, despite presentation with VT (n = 5) and atrioventricular block (n = 4). In 6 of 10 patients, reason for suspicion of ACS was the electroanatomical scar pattern. In patients with early diagnosis, immunosuppressive therapy was immediately initiated with stable cardiac function during follow-up. Adversely, in 7 of 10 patients with late diagnosis, cardiac function deteriorated before diagnosis, and in only one cardiac function recovered with immunosuppressive therapy. Six (40%) patients died (five of six with late diagnosis). Conclusion Arrhythmogenic cardiac sarcoidosis is an important differential diagnosis in NICM patients referred for VT ablation. Importantly, the diagnosis is frequently delayed, which leads to a severe disease course, including irreversible cardiac dysfunction and death. Early recognition, which can be facilitated by electroanatomical mapping, is crucial.
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Affiliation(s)
- Jarieke C Hoogendoorn
- Willem Einthoven Center for Cardiac Arrhythmia research and Management, Department of Cardiology, Leiden University Medical Center, (B4-P), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Willem Einthoven Center for Cardiac Arrhythmia research and Management, Department of Cardiology, Leiden University Medical Center, (B4-P), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Marta de Riva
- Willem Einthoven Center for Cardiac Arrhythmia research and Management, Department of Cardiology, Leiden University Medical Center, (B4-P), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Robert W Grauss
- Department of Cardiology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Frank M Bogun
- Department of Cardiology, Michigan Medicine, MI, USA
| | - Katja Zeppenfeld
- Willem Einthoven Center for Cardiac Arrhythmia research and Management, Department of Cardiology, Leiden University Medical Center, (B4-P), P.O. Box 9600, 2300 RC Leiden, The Netherlands
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34
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Lao N, Laiq Z, Courson J, Al-Quthami A. Left-dominant arrhythmogenic cardiomyopathy: an association with desmoglein-2 gene mutation-a case report. Eur Heart J Case Rep 2021; 5:ytab213. [PMID: 34263121 PMCID: PMC8274644 DOI: 10.1093/ehjcr/ytab213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/13/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Desmosomes are specialized intercellular adhesive junctions of cardiac and epithelial cells that provide intercellular mechanical coupling through glycoproteins, one of which is desmoglein (DSG). DSG-2 mutations are frequently associated with biventricular arrhythmogenic cardiomyopathy (ACM). We report a case of left-dominant ACM in a patient who initially was misclassified as dilated cardiomyopathy (DCM). CASE SUMMARY A 28-year-old-woman was found to have a moderately reduced left ventricular (LV) systolic function and frequent premature ventricular contractions (PVCs). Targeted genetic testing revealed a heterozygous likely pathogenic variant associated with ACM in exon 15 of the DSG-2 gene (c.3059_3062del; p.Glu1020Alafs*18). Subsequent cardiac magnetic resonance (CMR) imaging showed epicardial and mid-myocardial fatty infiltration involving multiple LV wall segments, multiple areas of mid-myocardial fibrosis/scar, regional dyskinesis involving both ventricles, and an overall reduced left ventricular ejection fraction. The patient's right ventricular (RV) cavity size and overall RV systolic function were normal. Based on the patient's frequent PVCs, family history, fibrofatty myocardial replacement in multiple LV segments, and dyskinetic motion of multiple ventricular wall segments (predominantly affecting the LV), the patient was diagnosed with left-dominant ACM. DISCUSSION Identifying a likely pathogenic mutation associated with ACM in a patient with ventricular arrhythmias and a family history of sudden cardiac death increased the possibility of ACM. Subsequent CMR imaging confirmed the diagnosis of left-dominant ACM by demonstrating regional biventricular dyskinesia and a characteristic pattern of fibrofatty myocardial replacement. Our case highlights the importance of targeted genetic testing and advanced cardiac imaging in distinguishing left-dominant ACM from DCM.
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Affiliation(s)
- Nicole Lao
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, 1 Akron General Ave, Akron, OH, USA 44307, USA
| | - Zenab Laiq
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Akron General, Akron, 1 Akron General Ave, Akron, OH, USA 44307, USA
| | - Jeffrey Courson
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Akron General, Akron, 1 Akron General Ave, Akron, OH, USA 44307, USA
| | - Adeeb Al-Quthami
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Akron General, Akron, 1 Akron General Ave, Akron, OH, USA 44307, USA
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Zghaib T, Te Riele ASJM, James CA, Rastegar N, Murray B, Tichnell C, Halushka MK, Bluemke DA, Tandri H, Calkins H, Kamel IR, Zimmerman SL. Left ventricular fibro-fatty replacement in arrhythmogenic right ventricular dysplasia/cardiomyopathy: prevalence, patterns, and association with arrhythmias. J Cardiovasc Magn Reson 2021; 23:58. [PMID: 34011348 PMCID: PMC8135158 DOI: 10.1186/s12968-020-00702-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Left ventricular (LV) fibrofatty infiltration in arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C) has been reported, however, detailed cardiovascular magnetic resonance (CMR) characteristics and association with outcomes are uncertain. We aim to describe LV findings on CMR in ARVD/C patients and their relationship with arrhythmic outcomes. METHODS CMR of 73 subjects with ARVD/C according to the 2010 Task Force Criteria (TFC) were analyzed for LV involvement, defined as ≥ 1 of the following features: LV wall motion abnormality, LV late gadolinium enhancement (LGE), LV fat infiltration, or LV ejection fraction (LVEF) < 50%. Ventricular volumes and function, regional wall motion abnormalities, and the presence of ventricular fat or fibrosis were recorded. Findings on CMR were correlated with arrhythmic outcomes. RESULTS Of the 73 subjects, 50.7% had CMR evidence for LV involvement. Proband status and advanced RV dysfunction were independently associated with LV abnormalities. The most common pattern of LV involvement was focal fatty infiltration in the sub-epicardium of the apicolateral LV with a "bite-like" pattern. LGE in the LV was found in the same distribution and most often had a linear appearance. LV involvement was more common with non-PKP2 genetic mutation variants, regardless of proband status. Only RV structural disease on CMR (HR 3.47, 95% CI 1.13-10.70) and prior arrhythmia (HR 2.85, 95% CI 1.33-6.10) were independently associated with arrhythmic events. CONCLUSION Among patients with 2010 TFC for ARVD/C, CMR evidence for LV abnormalities are seen in half of patients and typically manifest as fibrofatty infiltration in the subepicardium of the apicolateral wall and are not associated with arrhythmic outcomes.
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Affiliation(s)
- Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Cynthia A James
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Rastegar
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St.; Halsted B180, Baltimore, MD, USA
| | - Brittney Murray
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Crystal Tichnell
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marc K Halushka
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David A Bluemke
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St.; Halsted B180, Baltimore, MD, USA
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Harikrishna Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab R Kamel
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St.; Halsted B180, Baltimore, MD, USA
| | - Stefan Loy Zimmerman
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St.; Halsted B180, Baltimore, MD, USA.
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Mattesi G, Cipriani A, Bauce B, Rigato I, Zorzi A, Corrado D. Arrhythmogenic Left Ventricular Cardiomyopathy: Genotype-Phenotype Correlations and New Diagnostic Criteria. J Clin Med 2021; 10:jcm10102212. [PMID: 34065276 PMCID: PMC8160676 DOI: 10.3390/jcm10102212] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/06/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an inherited heart muscle disease characterized by loss of ventricular myocardium and fibrofatty replacement, which predisposes to scar-related ventricular arrhythmias and sudden cardiac death, particularly in the young and athletes. Although in its original description the disease was characterized by an exclusive or at least predominant right ventricle (RV) involvement, it has been demonstrated that the fibrofatty scar can also localize in the left ventricle (LV), with the LV lesion that can equalize or even overcome that of the RV. While the right-dominant form is typically associated with mutations in genes encoding for desmosomal proteins, other (non-desmosomal) mutations have been showed to cause the biventricular and left-dominant variants. This has led to a critical evaluation of the 2010 International Task Force criteria, which exclusively addressed the right phenotypic manifestations of ACM. An International Expert consensus document has been recently developed to provide upgraded criteria (“the Padua Criteria”) for the diagnosis of the whole spectrum of ACM phenotypes, particularly left-dominant forms, highlighting the use of cardiac magnetic resonance. This review aims to offer an overview of the current knowledge on the genetic basis, the phenotypic expressions, and the diagnosis of left-sided variants, both biventricular and left-dominant, of ACM.
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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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Rosenbaum AN, Kolluri N, Elwazir MY, Kapa S, Abou Ezzeddine OF, Bois JP, Chareonthaitawee P, Schmidt TJ, Cooper LT. Identification of a novel presumed cardiac sarcoidosis category for patients at high risk of disease. Int J Cardiol 2021; 335:66-72. [PMID: 33878372 DOI: 10.1016/j.ijcard.2021.04.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/19/2021] [Accepted: 04/12/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Histologic evidence is required for a definitive diagnosis of cardiac sarcoidosis (CS) by published guidelines; however, the sporadic nature of the disease may produce false negative biopsy results, causing CS to be underdiagnosed. We sought to establish a clinical category of CS absent histologic findings. METHODS Patients evaluated for CS were stratified into 3 groups: probable CS and definite CS based on Heart Rhythm Society (HRS) criteria and presumed CS, ie, patients without any histologic evidence of sarcoidosis, but with unexplained high-grade atrioventricular block or ventricular arrhythmia and findings suggestive of CS on either cardiac magnetic resonance imaging or positron emission tomography. The primary end point was hospitalization-free and overall survival at 10 years. RESULTS A total of 383 patients were included in the study: 59, definite CS; 223, probable CS; and 101, presumed CS (62, isolated CS and 39, systemic CS). Compared with patients meeting HRS criteria for CS, patients with presumed CS had lower odds of New York Heart Association class III or IV symptoms (odds ratio [OR], 0.44 [95% CI, 0.23-0.83]; P = .01) but greater odds of previous ventricular tachycardia (OR, 2.4 [95% CI, 1.4-4.0]; P = .001) or history of resuscitated sudden cardiac arrest (OR, 2.9 [95% CI, 1.0-8.6]; P = .05). Hospitalization-free and overall survival were similar among groups (P = .51 and P = .71, respectively). CONCLUSIONS Clinical categorization of patients with presumed CS identified a high-risk cohort comparable to patients with histologic evidence of disease, although caution should be exercised in reaching this diagnosis without paying due diligence to the differential diagnosis.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States.
| | - Nikhil Kolluri
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | | | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - Omar F Abou Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | | | - Tyler J Schmidt
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, United States
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Challenges in Cardiac and Pulmonary Sarcoidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:1878-1901. [PMID: 33059834 DOI: 10.1016/j.jacc.2020.08.042] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
Sarcoidosis is a complex disease with heterogeneous clinical presentations that can affect virtually any organ. Although the lung is typically the most common organ involved, combined pulmonary and cardiac sarcoidosis (CS) account for most of the morbidity and mortality associated with this disease. Pulmonary sarcoidosis can be asymptomatic or result in impairment in quality of life and end-stage, severe, and/or life-threatening disease. The latter outcome is seen almost exclusively in those with fibrotic pulmonary sarcoidosis, which accounts for 10% to 20% of pulmonary sarcoidosis patients. CS is problematic to diagnose and may cause significant morbidity and death from heart failure or ventricular arrhythmias. The diagnosis of CS usually requires surrogate cardiac imaging biomarkers, as endomyocardial biopsy has relatively low yield, even with directed electrophysiological mapping. Treatment of CS is often multifactorial, involving a combination of antigranulomatous therapy and pharmacotherapy for cardiac arrhythmias and/or heart failure in addition to device placement and cardiac transplantation.
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Sascău R, Anghel L, Clement A, Bostan M, Radu R, Stătescu C. The Importance of Multimodality Imaging in the Diagnosis and Management of Patients with Infiltrative Cardiomyopathies: An Update. Diagnostics (Basel) 2021; 11:diagnostics11020256. [PMID: 33562254 PMCID: PMC7915769 DOI: 10.3390/diagnostics11020256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 12/16/2022] Open
Abstract
Infiltrative cardiomyopathies (ICMs) comprise a broad spectrum of inherited and acquired conditions (mainly amyloidosis, sarcoidosis, and hemochromatosis), where the progressive buildup of abnormal substances within the myocardium results in left ventricular hypertrophy and manifests as restrictive physiology. Noninvasive multimodality imaging has gradually eliminated endomyocardial biopsy from the diagnostic workup of infiltrative cardiac deposition diseases. However, even with modern imaging techniques’ widespread availability, these pathologies persist in being largely under- or misdiagnosed. Considering the advent of novel, revolutionary pharmacotherapies for cardiac amyloidosis, the archetypal example of ICM, a standardized diagnostic approach is warranted. Therefore, this review aims to emphasize the importance of contemporary cardiac imaging in identifying specific ICM and improving outcomes via the prompt initiation of a targeted treatment.
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Affiliation(s)
- Radu Sascău
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (R.S.); (R.R.); (C.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
| | - Larisa Anghel
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (R.S.); (R.R.); (C.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
- Correspondence: (L.A.); (A.C.); (M.B.); Tel.: +40-0232-211834 (L.A.); +40-0232-211834 (A.C.); +40-0232-211834 (M.B.)
| | - Alexandra Clement
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
- Correspondence: (L.A.); (A.C.); (M.B.); Tel.: +40-0232-211834 (L.A.); +40-0232-211834 (A.C.); +40-0232-211834 (M.B.)
| | - Mădălina Bostan
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (R.S.); (R.R.); (C.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
- Correspondence: (L.A.); (A.C.); (M.B.); Tel.: +40-0232-211834 (L.A.); +40-0232-211834 (A.C.); +40-0232-211834 (M.B.)
| | - Rodica Radu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (R.S.); (R.R.); (C.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
| | - Cristian Stătescu
- Internal Medicine Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700503 Iași, Romania; (R.S.); (R.R.); (C.S.)
- Cardiology Department, Cardiovascular Diseases Institute “Prof. Dr. George I.M.Georgescu”, 700503 Iași, Romania
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Abstract
Sarcoidosis is an inflammatory granulomatous disease that can affect any organ. Up to one-quarter of patients with systemic sarcoidosis may have evidence of cardiac involvement. The clinical manifestations of cardiac sarcoidosis (CS) include heart block, atrial arrhythmias, ventricular arrhythmias and heart failure. The diagnosis of CS can be challenging given the patchy infiltration of the myocardium but, with the increased availability of advanced cardiac imaging, more cases of CS are being identified. Immunosuppression with corticosteroids remains the standard therapy for the acute inflammatory phase of CS, but there is an evolving role of steroid-sparing agents. In this article, the authors provide an update on the diagnosis of CS, including the role of imaging; review the clinical manifestations of CS, namely heart block, atrial and ventricular arrhythmias and heart failure; discuss updated management strategies, including immunosuppression, electrophysiological and heart failure therapies; and identify the current gaps in knowledge and future directions for cardiac sarcoidosis.
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Affiliation(s)
- Nisha Gilotra
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - David Okada
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Apurva Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, US
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Altmayer S, Nazarian S, Han Y. Left Ventricular Dysfunction in Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC): Can We Separate ARVC From Other Arrhythmogenic Cardiomyopathies? J Am Heart Assoc 2020; 9:e018866. [PMID: 33222587 PMCID: PMC7763763 DOI: 10.1161/jaha.120.018866] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy was first described as a right ventricular disease that is an important cause of death in young adults. However, with the advent of advanced imaging, arrhythmogenic right ventricular cardiomyopathy has been found to commonly have biventricular involvement, and a small portion of patients have left ventricular–dominant forms. On the other hand, a number of primarily left ventricular disease such as sarcoid and myocarditis can be arrhythmogenic and have right ventricular involvement. A few recent publications on arrhythmogenic right ventricular cardiomyopathy cohorts have average left ventricular functions that are comparable to sarcoid or myocarditis cohorts. We review the current literature and compare these cohorts of patients, and call for left ventricular functional criteria for arrhythmogenic right ventricular cardiomyopathy as inherited arrhythmogenic cardiomyopathy.
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Affiliation(s)
- Stephan Altmayer
- Department of Radiology Pontificia Universidade Catolica do Rio Grande do Sul Porto Alegre Brazil
| | - Saman Nazarian
- Cardiovascular Division Department of Medicine University of Pennsylvania Philadelphia PA
| | - Yuchi Han
- Cardiovascular Division Department of Medicine University of Pennsylvania Philadelphia PA
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Costa S, Medeiros-Domingo A, Gasperetti A, Akdis D, Berger W, James CA, Ruschitzka F, Brunckhorst CB, Duru F, Saguner AM. Impact of Genetic Variant Reassessment on the Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy Based on the 2010 Task Force Criteria. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 14:e003047. [PMID: 33232181 DOI: 10.1161/circgen.120.003047] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy, which is associated with life-threatening ventricular arrhythmias. Approximately 60% of patients carry a putative disease-causing genetic variant, but interpretation of genetic test results can be challenging. The aims of this study were to systematically reclassify genetic variants in patients with ARVC and to assess the impact on ARVC diagnosis. METHODS This study included patients from the Multicenter Zurich ARVC Registry who hosted a genetic variant deemed to be associated with the disease. Reclassification of pathogenicity was performed according to the modified 2015 American College of Medical Genetics criteria. ARVC diagnosis (categories: definite, borderline, possible) based on the 2010 Task Force Criteria was reclassified after genetic readjudication. RESULTS In 79 patients bearing 80 unique genetic variants, n=47 (58.8%) genetic variants were reclassified, and reclassification was judged to be clinically relevant in n=33 (41.3%). Variants in plakophilin-2 (PKP2) were shown to reclassify less frequently as compared with other genes (PKP2, n=1, 8.3%; desmosomal non-PKP2, n=20, 66.7%; nondesmosomal, n=26, 68.4%; P=0.001for overall comparison; PKP2 versus desmosomal non-PKP2, P=0.001; PKP2 versus nondesmosomal, P<0.001). Genetic reclassification impacted ARVC diagnosis. Eight patients (10.1%) were downgraded from definite to borderline/possible disease at the time of initial genetic testing as well as last follow-up, respectively. Separate genetic reclassification in family members led to downgrading of n=5 (38.5%) variants. CONCLUSIONS Given that approximately half of genetic variants were reclassified, with 10.1% of patients losing their definite disease status, accurate determination of variant pathogenicity is of utmost importance in the diagnosis of ARVC.
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Affiliation(s)
- Sarah Costa
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
| | | | - Alessio Gasperetti
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
| | - Deniz Akdis
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
| | - Wolfgang Berger
- Institute of Molecular Genetics, University of Zurich, Schlieren, Switzerland (W.B.)
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD (C.A.J.)
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
| | - Corinna B Brunckhorst
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
| | - Firat Duru
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.).,Zurich Center for Integrative Human Physiology (ZIHP), Switzerland (W.B., F.D.)
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (S.C., A.G., D.A., F.R., C.B.B., F.D., A.M.S.)
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Hauer RNW. Cardiac sarcoidosis mimicking definite arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2020; 18:239-240. [PMID: 33091604 DOI: 10.1016/j.hrthm.2020.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Richard N W Hauer
- Department of Cardiology, University Medical Center Utrecht, Netherlands Heart Institute, Utrecht, The Netherlands.
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Cavigli L, Focardi M, Cameli M, Mandoli GE, Mondillo S, D'Ascenzi F. The right ventricle in “Left-sided” cardiomyopathies: The dark side of the moon. Trends Cardiovasc Med 2020; 31:476-484. [DOI: 10.1016/j.tcm.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Differentiating hereditary arrhythmogenic right ventricular cardiomyopathy from cardiac sarcoidosis fulfilling 2010 ARVC Task Force Criteria. Heart Rhythm 2020; 18:231-238. [PMID: 32976989 DOI: 10.1016/j.hrthm.2020.09.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/16/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The clinical presentation of cardiac sarcoidosis (CS) may resemble that of arrhythmogenic right ventricular cardiomyopathy (ARVC). OBJECTIVE The purpose of this study was to identify clinical variables to better discriminate between patients with genetically determined ARVC and those with CS fulfilling definite 2010 ARVC Task Force Criteria (TFC). METHODS In this multicenter study, 10 patients with CS fulfilling definite 2010 ARVC TFC were age and gender matched with 10 genetically proven ARVC patients. A cardiac 18F-fluorodeoxyglucose positron emission tomographic (18F-FDG PET) scan was required for patients to be included in the study. RESULTS The 2010 ARVC TFC did not reliably differentiate between the 2 diseases. CS patients presented with longer PR intervals, advanced atrioventricular block (AVB), and longer QRS duration (P <.001 and P = .009, respectively), whereas T-wave inversions (TWIs) in the peripheral leads were more common in ARVC patients (P = .009). CS patients presented with more extensive left ventricular involvement and lower left ventricular ejection fraction (LVEF), whereas ARVC patients had a larger right ventricular outflow tract (RVOT) (P = .044). PET scan positivity was only present in CS patients (90% vs 0%). CONCLUSION The 2010 ARVC TFC do not reliably differentiate between CS patients fulfilling 2010 ARVC TFC and those with hereditary ARVC. Prolonged PR interval, advanced AVB, longer QRS duration, right ventricular apical involvement, reduced LVEF, and positive 18F-FDG PET scan should raise the suspicion of CS, whereas larger RVOT dimensions, subtricuspid involvement and peripheral TWI favor a diagnosis of hereditary ARVC.
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Abstract
BACKGROUND Prognostic factors are lacking in cardiac sarcoidosis (CS), and the effects of immunosuppressive treatments are unclear. OBJECTIVES To identify prognostic factors and to assess the effects of immunosuppressive drugs on relapse risk in patients presenting with CS. METHODS From a cohort of 157 patients with CS with a median follow-up of 7 years, we analysed all cardiac and extra-cardiac data and treatments, and assessed relapse-free and overall survival. RESULTS The 10-year survival rate was 90% (95% CI, 84-96). Baseline factors associated with mortality were the presence of high degree atrioventricular block (HR, 5.56, 95% CI 1.7-18.2, p = 0.005), left ventricular ejection fraction below 40% (HR, 4.88, 95% CI 1.26-18.9, p = 0.022), hypertension (HR, 4.79, 95% CI 1.06-21.7, p = 0.042), abnormal pulmonary function test (HR, 3.27, 95% CI 1.07-10.0, p = 0.038), areas of late gadolinium enhancement on cardiac magnetic resonance (HR, 2.26, 95% CI 0.25-20.4, p = 0.003), and older age (HR per 10 years 1.69, 95% CI 1.13-2.52, p = 0.01). The 10-year relapse-free survival rate for cardiac relapses was 53% (95% CI, 44-63). Baseline factors that were independently associated with cardiac relapse were kidney involvement (HR, 3.35, 95% CI 1.39-8.07, p = 0.007), wall motion abnormalities (HR, 2.30, 95% CI 1.22-4.32, p = 0.010), and left heart failure (HR 2.23, 95% CI 1.12-4.45, p = 0.023). After adjustment for cardiac involvement severity, treatment with intravenous cyclophosphamide was associated with a lower risk of cardiac relapse (HR 0.16, 95% CI 0.033-0.78, p = 0.024). CONCLUSIONS Our study identifies putative factors affecting morbidity and mortality in cardiac sarcoidosis patients. Intravenous cyclophosphamide is associated with lower relapse rates.
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Birnie DH, Nery PB. Debating the Definition and Incidence of Isolated Cardiac Sarcoidosis. JACC Clin Electrophysiol 2020; 6:1190-1191. [DOI: 10.1016/j.jacep.2020.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022]
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