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Haq KT, McLean K, Anderson-Barker GC, Berul CI, Shattock MJ, Posnack NG. Validation of a Demography-Based Adaptive QTc Formula using Pediatric and Adult Datasets Acquired from Humans and Guinea Pigs. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.10.602984. [PMID: 39071301 PMCID: PMC11275815 DOI: 10.1101/2024.07.10.602984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Introduction A variety of QT rate-correction (QTc) formulae have been utilized for both clinical and research purposes. However, these formulae are not universally effective, likely due to significant influences of demographic diversity on the QT-HR relationship. To address this limitation, we proposed an adaptive QTc (QTcAd) formula that adjusts to subject demographics (i.e., age). Further, we compared the efficacy and accuracy of the QTcAd formula to other widely used alternatives. Method Using age as a demographic parameter, we tested the QTcAd formula across diverse age groups with different heart rates (HR) in both humans and guinea pigs. Utilizing retrospective human (n=1360) and guinea pig electrocardiogram (ECG) data from in-vivo (n=55) and ex-vivo (n=66) settings, we evaluated the formula's effectiveness. Linear regression fit parameters of HR-QTc (slope and R²) were utilized for performance assessment. To evaluate the accuracy of the predicted QTc, we acquired epicardial electrical and optical voltage data from Langendorff-perfused guinea pig hearts. Results In both human subjects and guinea pigs, the QTcAd formula consistently outperformed other formulae across all age groups. For instance, in a 20-year-old human group (n=300), the QTcAd formula successfully nullified the inverse HR-QT relationship (R²=5.1E-09, slope=-3.5E-05), while the Bazett formula (QTcB) failed to achieve comparable effectiveness (R²= 0.20, slope=0.91). Moreover, the QTcAd formula exhibited better accuracy than the age-specific Benatar formula (QTcBe), which overcorrected QTc (1-week human QT: 263.8±14.8 ms, QTcAd: 263.8±7.3 ms, p=0.62; QTcBe: 422.5±7.3 ms, p<0.0001). The optically measured pseudo-QT interval (143±22.5 ms, n=44) was better approximated by QTcAd (180.6±17.0 ms) compared to all other formulae. Furthermore, we demonstrated that the QTcAd formula was not inferior to individual-specific QTc formulae. Conclusion The demography-based QTcAd formula showed superior performance across human and guinea pig age groups, which may enhance the efficacy of QTc for cardiovascular disease diagnosis, risk stratification, and drug safety testing. What is known Corrected QT (QTc) is a well-known ECG biomarker for cardiovascular disease risk stratification and drug safety testing. Various QT rate-correction formulae have been developed, but these formulae do not perform consistently across diverse datasets (e.g., sex, age, disease, species). What the study adds We introduce a novel QTc formula (QTcAd) that adapts to demographic variability, as the parameters can be modified based on the characteristics of the study population. The formula (QTcAd = QT + (|m|*(HR-HR mean )) - includes the absolute slope (m) of the linear regression of QT and heart rate (HR) and the mean HR of the population (HR mean ) as population characteristics parametersˍUsing datasets from both pediatric and adult human subjects and an animal model, we demonstrate that the QTcAd formula is more effective at eliminating the QT-HR inverse relationship, as compared to other commonly used correction formulae.
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Berger V, Bromée L, Lindam A, Hallin T, Reynisson B, Halldner Henriksson L, Naumburg E. Adolescents on psychotropic treatment displayed longer corrected QT intervals than unmedicated controls when they rose rapidly from the supine position. Acta Paediatr 2024; 113:1621-1629. [PMID: 38517107 DOI: 10.1111/apa.17206] [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: 11/13/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
AIM Psychotropic medication can contribute to arrhythmia and identifying individuals at risk is crucial. This Swedish study compared the corrected QT (QTc) intervals of adolescents on psychotropic medication with unmedicated controls, when supine and after rising rapidly. METHODS The study was carried out at Östersund County Hospital in March 2022 and February to March 2023. It comprised 16 cases, aged 10-17 years and 28 controls. QTc intervals were measured with electrocardiography and calculated using Bazett's and Fridericia's formulas. Univariate and multiple linear regressions were used to assess differences in QTc intervals between the cases and controls and across sex, age and body mass index. RESULTS The mean QTc interval when supine, calculated with Bazett's formula, was longer for the adolescents on psychotropic medication than the controls (p = 0.046). The same was true for the mean QTc interval after rising rapidly from the supine position, calculated with both Bazett's formula (p = 0.009) and Fridericia's formula (p = 0.007). Mean QTc intervals varied by sex and age groups. Psychotropic medication prolonged QTc intervals, particularly in girls. CONCLUSION Longer QTc intervals were found in adolescents on psychotropic medication, particularly after rising rapidly from the supine position.
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Affiliation(s)
- Vilma Berger
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå, Sweden
| | - Linn Bromée
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå, Sweden
| | - Anna Lindam
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Tove Hallin
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå, Sweden
| | - Björn Reynisson
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå, Sweden
| | - Linda Halldner Henriksson
- Department of Clinical Sciences, Unit of Child and Adolescent Psychiatry, Umeå University, Umeå, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Unit of Paediatrics, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development, Östersund Hospital, Umeå University, Umeå, Sweden
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Lundström A, Eliasson H, Karlsson M, Wiklund U, Rydberg A. Holter study of heart rate variability in children and adolescents with long QT syndrome. Ann Noninvasive Electrocardiol 2024; 29:e13132. [PMID: 38888254 PMCID: PMC11184570 DOI: 10.1111/anec.13132] [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: 12/13/2023] [Revised: 04/22/2024] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES This study aimed to retrospectively assess cardiac autonomic activity in children with LQTS, considering genotype, symptoms, sex, age, and beta-blocker therapy (BB) and compare it to healthy controls. METHODS Heart rate variability (HRV), using power spectrum analysis, was analyzed in 575 Holter recordings from 116 children with LQTS and in 69 healthy children. The data were categorized into four age-groups and four heart rate (HR) ranges. RESULTS In LQT1 and LQT2, increasing HR corresponded to significantly lower low (LF) and high frequency (HF) compared to controls. Total power (PTOT) was lower in all LQT1 age-groups compared to controls at HR 120-140 bpm (1-15 years: p < .01; 15-18 years: p = .03). At HR 80-100, LQT1 patients aged 1-10 years had lower HF than LQT2 patients (1-5 years: p = .05; 5-10 years: p = .02), and LQT2 patients aged 15-18 years had lower HF than LQT1 patients (p < .01). Symptomatic patients aged 10-15 years had lower PTOT at HR 100-120 bpm than asymptomatic patients (p = .04). LQT1 girls aged 10-15 and 15-18 years had a lower PTOT (10-15 years: p = .04; 15-18 years: p = .02) than boys. CONCLUSION This study shows a correlation between HR and changes in HRV parameters. At higher HRs, LQTS patients generally had lower HRV values than controls, suggesting an abnormal autonomic response. These results may strengthen the link between physical activity and arrhythmias in LQTS.
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Affiliation(s)
- Anna Lundström
- Department of Clinical SciencesUmeå UniversityUmeåSweden
| | - Håkan Eliasson
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Marcus Karlsson
- Department of Diagnostics and Intervention, Biomedical Engineering and Radiation PhysicsUmeå UniversityUmeåSweden
| | - Urban Wiklund
- Department of Diagnostics and Intervention, Biomedical Engineering and Radiation PhysicsUmeå UniversityUmeåSweden
| | - Annika Rydberg
- Department of Clinical SciencesUmeå UniversityUmeåSweden
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Bene Watts S, Gauthier B, Erickson AC, Morrison J, Sebastian M, Gillman L, McIntosh S, Ens C, Sherwin E, McCormick R, Sanatani S, Arbour L. A mild phenotype associated with KCNQ1 p.V205M mediated long QT syndrome in First Nations children of Northern British Columbia: effect of additional variants and considerations for management. Front Pediatr 2024; 12:1394105. [PMID: 38884101 PMCID: PMC11176454 DOI: 10.3389/fped.2024.1394105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Congenital Long QT Syndrome (LQTS) is common in a First Nations community in Northern British Columbia due to the founder variant KCNQ1 p.V205M. Although well characterized molecularly and clinically in adults, no data have been previously reported on the pediatric population. The phenotype in adults has been shown to be modified by a splice site variant in KCNQ1 (p.L353L). The CPT1A p.P479L metabolic variant, also common in Northern Indigenous populations, is associated with hypoglycemia and infant death. Since hypoglycemia can affect the corrected QT interval (QTc) and may confer risk for seizures (also associated with LQTS), we sought to determine the effect of all three variants on the LQTS phenotype in children within our First Nations cohort. Methods As part of a larger study assessing those with LQTS and their relatives in a Northern BC First Nation, we assessed those entering the study from birth to age 18 years. We compared the corrected peak QTc and potential cardiac events (syncope/seizures) of 186 children from birth to 18 years, with and without the KCNQ1 (p.V205M and p.L353L) and CPT1A variants, alone and in combination. Linear and logistic regression and student t-tests were applied as appropriate. Results Only the KCNQ1 p.V205M variant conferred a significant increase in peak QTc 23.8 ms (p < 0.001) above baseline, with females increased by 30.1 ms (p < 0.001) and males by 18.9 ms (p < 0.01). There was no evidence of interaction effects with the other two variants studied. Although the p.V205M variant was not significantly associated with syncope/seizures, the odds of having a seizure/syncope were significantly increased for those homozygous for CPT1A p.P479L compared to homozygous wild type (Odds Ratio [OR]3.0 [95% confidence interval (CI) 1.2-7.7]; p = 0.019). Conclusion While the KCNQ1 p.V205M variant prolongs the peak QTc, especially in females, the CPT1A p.P479L variant is more strongly associated with loss of consciousness events. These findings suggest that effect of the KCNQ1 p.V205M variant is mild in this cohort, which may have implications for standard management. Our findings also suggest the CPT1A p.P479L variant is a risk factor for seizures and possibly syncope, which may mimic a long QT phenotype.
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Affiliation(s)
- Simona Bene Watts
- Island Medical Program, University of British Columbia, Victoria, BC, Canada
| | - Barbara Gauthier
- Epidemiology and Surveillance Unit, Interior Health Authority, Kelowna, BC, Canada
| | | | | | | | - Lawrence Gillman
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Sarah McIntosh
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Connie Ens
- Department of Pediatrics, Division of Cardiology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Elizabeth Sherwin
- Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Rod McCormick
- Department of Education and Social Work, Thompson Rivers University, Kamloops, BC, Canada
| | - Shubhayan Sanatani
- Department of Pediatrics, Division of Cardiology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Laura Arbour
- Island Medical Program, University of British Columbia, Victoria, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
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Davies RA, Ladouceur VB, Green MS, Joza J, Juurlink DN, Krahn AD, McMurtry MS, Roberts JD, Roston TM, Sanatani S, Steinberg C, MacIntyre C. The 2023 Canadian Cardiovascular Society Clinical Practice Update on Management of the Patient With a Prolonged QT Interval. Can J Cardiol 2023; 39:1285-1301. [PMID: 37827588 DOI: 10.1016/j.cjca.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 10/14/2023] Open
Abstract
A prolonged QT interval on the electrocardiogram is associated with an increased risk of the torsades de pointes form of ventricular arrhythmia resulting in syncope, sudden cardiac arrest or death, or misdiagnosis as a seizure disorder. The cause of QT prolongation can be congenital and inherited as an autosomal dominant variant, or it can be transient and acquired, often because of QT-prolonging drugs or electrolyte abnormalities. Automated measurement of the QT interval can be inaccurate, especially when the baseline electrocardiogram is abnormal, and manual verification is recommended. In this clinical practice update we provide practical tips about measurement of the QT interval, diagnosis, and management of congenital long QT syndrome and acquired prolongation of the QT interval. For congenital long QT syndrome, certain β-adrenergic-blocking drugs are highly effective, and implantable defibrillators are infrequently required. Many commonly prescribed drugs such as antidepressants and antibiotics can prolong the QT interval, and recommendations are provided on their safe use.
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Affiliation(s)
- Ross A Davies
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | | | - Martin S Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - David N Juurlink
- University of Toronto, ICES, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jason D Roberts
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Thomas M Roston
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shubhayan Sanatani
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christian Steinberg
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec, Québec, Canada
| | - Ciorsti MacIntyre
- Dalhousie University, Halifax, Nova Scotia, Canada; Mayo Clinic, Rochester, Minnesota, USA
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Beach CM, Lampert R. Optimizing pre-participation screening to prevent tragedy in young athletes: moving from if to how. Eur Heart J 2023; 44:1093-1095. [PMID: 36760103 DOI: 10.1093/eurheartj/ehad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Affiliation(s)
- Cheyenne M Beach
- Section of Pediatric Cardiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA
| | - Rachel Lampert
- Yale University School of Medicine, 789 Howard Ave, Dana 319, New Haven, CT 06511, USA
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Lee W, Vandenberk B, Raj SR, Lee SS. Prolonged QT Interval in Cirrhosis: Twisting Time? Gut Liver 2022; 16:849-860. [PMID: 35864808 PMCID: PMC9668500 DOI: 10.5009/gnl210537] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/07/2021] [Indexed: 11/04/2022] Open
Abstract
Approximately 30% to 70% of patients with cirrhosis have QT interval prolongation. In patients without cirrhosis, QT prolongation is associated with an increased risk of ventricular arrhythmias, such as torsade de pointes (TdP). In cirrhotic patients, there is likely a significant association between the corrected QT (QTc) interval and the severity of liver disease, and possibly with increased mortality. We present a stepwise overview of the pathophysiology and management of acquired long QT syndrome in cirrhosis. The QT interval is mainly determined by ventricular repolarization. To compare the QT interval in time it should be corrected for heart rate (QTc), preferably by the Fridericia method. A QTc interval >450 ms in males and >470 ms in females is considered prolonged. The pathophysiological mechanism remains incompletely understood, but may include metabolic, autonomic or hormonal imbalances, cirrhotic heart failure and/or genetic predisposition. Additional external risk factors for QTc prolongation include medication (IKr blockade and altered cytochrome P450 activity), bradycardia, electrolyte abnormalities, underlying cardiomyopathy and acute illness. In patients with cirrhosis, multiple hits and cardiac-hepatic interactions are often required to sufficiently erode the repolarization reserve before long QT syndrome and TdP can occur. While some risk factors are unavoidable, overall risk can be mitigated by electrocardiogram monitoring and avoiding drug interactions and electrolyte and acidbase disturbances. In cirrhotic patients with prolonged QTc interval, a joint effort by cardiologists and hepatologists may be useful and significantly improve the clinical course and outcome.
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Affiliation(s)
- William Lee
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Satish R. Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samuel S. Lee
- Liver Unit, Snyder Institute for Chronic Disease, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Krahn AD, Laksman Z, Sy RW, Postema PG, Ackerman MJ, Wilde AAM, Han HC. Congenital Long QT Syndrome. JACC Clin Electrophysiol 2022; 8:687-706. [PMID: 35589186 DOI: 10.1016/j.jacep.2022.02.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 12/14/2022]
Abstract
Congenital long QT syndrome (LQTS) encompasses a group of heritable conditions that are associated with cardiac repolarization dysfunction. Since its initial description in 1957, our understanding of LQTS has increased dramatically. The prevalence of LQTS is estimated to be ∼1:2,000, with a slight female predominance. The diagnosis of LQTS is based on clinical, electrocardiogram, and genetic factors. Risk stratification of patients with LQTS aims to identify those who are at increased risk of cardiac arrest or sudden cardiac death. Factors including age, sex, QTc interval, and genetic background all contribute to current risk stratification paradigms. The management of LQTS involves conservative measures such as the avoidance of QT-prolonging drugs, pharmacologic measures with nonselective β-blockers, and interventional approaches such as device therapy or left cardiac sympathetic denervation. In general, most forms of exercise are considered safe in adequately treated patients, and implantable cardioverter-defibrillator therapy is reserved for those at the highest risk. This review summarizes our current understanding of LQTS and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Departments of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart), Academic University Medical Center, Amsterdam, the Netherlands
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada; Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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Martínez-Barrios E, Cesar S, Cruzalegui J, Hernandez C, Arbelo E, Fiol V, Brugada J, Brugada R, Campuzano O, Sarquella-Brugada G. Clinical Genetics of Inherited Arrhythmogenic Disease in the Pediatric Population. Biomedicines 2022; 10:106. [PMID: 35052786 PMCID: PMC8773373 DOI: 10.3390/biomedicines10010106] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/27/2021] [Accepted: 12/31/2021] [Indexed: 12/19/2022] Open
Abstract
Sudden death is a rare event in the pediatric population but with a social shock due to its presentation as the first symptom in previously healthy children. Comprehensive autopsy in pediatric cases identify an inconclusive cause in 40-50% of cases. In such cases, a diagnosis of sudden arrhythmic death syndrome is suggested as the main potential cause of death. Molecular autopsy identifies nearly 30% of cases under 16 years of age carrying a pathogenic/potentially pathogenic alteration in genes associated with any inherited arrhythmogenic disease. In the last few years, despite the increasing rate of post-mortem genetic diagnosis, many families still remain without a conclusive genetic cause of the unexpected death. Current challenges in genetic diagnosis are the establishment of a correct genotype-phenotype association between genes and inherited arrhythmogenic disease, as well as the classification of variants of uncertain significance. In this review, we provide an update on the state of the art in the genetic diagnosis of inherited arrhythmogenic disease in the pediatric population. We focus on emerging publications on gene curation for genotype-phenotype associations, cases of genetic overlap and advances in the classification of variants of uncertain significance. Our goal is to facilitate the translation of genetic diagnosis to the clinical area, helping risk stratification, treatment and the genetic counselling of families.
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Affiliation(s)
- Estefanía Martínez-Barrios
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
| | - Sergi Cesar
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
| | - José Cruzalegui
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
| | - Clara Hernandez
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
| | - Elena Arbelo
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (E.A.); (R.B.)
- Arrhythmias Unit, Hospital Clinic, University of Barcelona-IDIBAPS, 08036 Barcelona, Spain
| | - Victoria Fiol
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
| | - Josep Brugada
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (E.A.); (R.B.)
- Arrhythmias Unit, Hospital Clinic, University of Barcelona-IDIBAPS, 08036 Barcelona, Spain
| | - Ramon Brugada
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (E.A.); (R.B.)
- Medical Science Department, School of Medicine, University of Girona, 17004 Girona, Spain
- Cardiovascular Genetics Center, University of Girona-IDIBGI, 17190 Girona, Spain
- Cardiology Service, Hospital Josep Trueta, University of Girona, 17007 Girona, Spain
| | - Oscar Campuzano
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (E.A.); (R.B.)
- Medical Science Department, School of Medicine, University of Girona, 17004 Girona, Spain
- Cardiovascular Genetics Center, University of Girona-IDIBGI, 17190 Girona, Spain
| | - Georgia Sarquella-Brugada
- Arrhythmias Unit, Hospital Sant Joan de Déu, University of Barcelona, 08007 Barcelona, Spain; (E.M.-B.); (S.C.); (J.C.); (C.H.); (V.F.); (J.B.)
- Medical Science Department, School of Medicine, University of Girona, 17004 Girona, Spain
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10
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Harvey A, Curnier D, Dodin P, Abadir S, Jacquemet V, Caru M. OUP accepted manuscript. Eur J Prev Cardiol 2022; 29:1633-1677. [PMID: 35537006 DOI: 10.1093/eurjpc/zwac081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022]
Abstract
Current exercise recommendations make it difficult for long QT syndrome (LQTS) patients to adopt a physically active and/or athletic lifestyle. The purpose of this review is to summarize the current evidence, identify knowledge gaps, and discuss research perspectives in the field of exercise and LQTS. The first aim is to document the influence of exercise training, exercise stress, and postural change interventions on ventricular repolarization in LQTS patients, while the second aim is to describe electrophysiological measurements used to study the above. Studies examining the effects of exercise on congenital or acquired LQTS in human subjects of all ages were included. Systematic searches were performed on 1 October 2021, through PubMed (NLM), Ovid Medline, Ovid All EBM Reviews, Ovid Embase, and ISI Web of Science, and limited to articles written in English or French. A total of 1986 LQTS patients and 2560 controls were included in the 49 studies. Studies were mainly case-control studies (n = 41) and examined exercise stress and/or postural change interventions (n = 48). One study used a 3-month exercise training program. Results suggest that LQTS patients have subtype-specific repolarization responses to sympathetic stress. Measurement methods and quality were found to be very heterogeneous, which makes inter-study comparisons difficult. In the absence of randomized controlled trials, the current recommendations may have long-term risks for LQTS patients who are discouraged from performing physical activity, rendering its associated health benefits out of range. Future research should focus on discovering the most appropriate levels of exercise training that promote ventricular repolarization normalization in LQTS.
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Affiliation(s)
- Audrey Harvey
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Daniel Curnier
- Laboratory of Pathophysiology of EXercise (LPEX), School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, Canada
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Philippe Dodin
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
| | - Sylvia Abadir
- Department of Pediatric Cardiology, Sainte-Justine University Health Center, Montreal, Canada
| | - Vincent Jacquemet
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Maxime Caru
- Sainte-Justine University Health Center, Research Center, Montreal, Canada
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA, USA
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
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de Veld L, van der Lely N, Hermans BJM, van Hoof JJ, Wong L, Vink AS. QTc prolongation in adolescents with acute alcohol intoxication. Eur J Pediatr 2022; 181:2757-2770. [PMID: 35482092 PMCID: PMC9192465 DOI: 10.1007/s00431-022-04471-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/30/2022] [Accepted: 04/09/2022] [Indexed: 01/24/2023]
Abstract
In adults, alcohol intoxication is associated with prolongation of the QT interval corrected for heart rate (QTc). The QTc is influenced by age and sex. Although alcohol intoxication is increasingly common in adolescents, there are no data on the prevalence of QTc prolongation in adolescents with alcohol intoxication. This study aimed to determine the prevalence of QTc prolongation in adolescents with alcohol intoxication and identify at-risk adolescents. In this observational study including adolescents aged 10-18 years, heart rate and QT interval were automatically assessed from an electrocardiogram (ECG) at alcohol intoxication using a validated algorithm. The QTc was calculated using both the Bazett formula (QTcB) and Fridericia formula (QTcF). If present, an ECG recorded within 1 year of the date of admission to the emergency department was obtained as a reference ECG. A total of 317 adolescents were included; 13.3% had a QTcB and 7.9% a QTcF longer than the sex- and age-specific 95th-percentile. None of the adolescents had a QTcB or QTcF > 500 ms, but 11.8% of the adolescents with a reference ECG had a QTcB prolongation of > 60 ms, while no adolescents had a QTcF prolongation of > 60 ms. QTc prolongation was mainly attributable to an increase in heart rate rather than QT prolongation, which underlies the differences between QTcB and QTcF. Male sex and hypokalaemia increased the likelihood of QTc prolongation.Conclusion: QTc prolongation was seen in approximately 10% of the adolescents presenting with alcohol intoxication, and although no ventricular arrhythmias were observed in this cohort, QTc prolongation increases the potential for malignant QT-related arrhythmias. Clinicians must be aware of the possibility of QTc prolongation during alcohol intoxication and make an effort to obtain an ECG at presentation, measure the QT interval, and give an adequate assessment of the findings. We advocate admitting adolescents with alcohol intoxication and QTc prolongation. During hospital admission, we recommend limiting exposure to QTc-prolonging medication, increasing potassium levels to a high-normal range (4.5-5.0 mmol/L) and obtaining a reference ECG at discharge.
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Affiliation(s)
- Loes de Veld
- Erasmus School of Health Policy and Management, Erasmus University, Postbus 1738, 3000, Rotterdam, DR, Netherlands. .,Department of Pediatrics, Reinier de Graaf Hospital, Delft, Netherlands.
| | - Nico van der Lely
- Department of Pediatrics, Reinier de Graaf Hospital, Delft, Netherlands ,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Ben J. M. Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Joris J. van Hoof
- Department of Pediatrics, Reinier de Graaf Hospital, Delft, Netherlands
| | - Lichelle Wong
- Department of Pediatrics, Reinier de Graaf Hospital, Delft, Netherlands
| | - Arja Suzanne Vink
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands ,Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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12
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Patel TM, Kamande SM, Jarosz E, Bost JE, Hanumanthaiah S, Berul CI, Sherwin ED, Moak JP. Treadmill exercise testing improves diagnostic accuracy in children with concealed congenital long QT syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1521-1528. [PMID: 33020927 DOI: 10.1111/pace.14085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resting electrocardiogram (ECG) identification of long QT syndrome (LQTS) has limitations. Uncertainty exists on how to classify patients with borderline prolonged QT intervals. We tested if exercise testing could help serve to guide which children with borderline prolonged QT intervals may be gene positive for LQTS. METHODS Pediatric patients (n = 139) were divided into three groups: Controls (n = 76), gene positive LQTS with borderline QTc (n = 21), and gene negative patients with borderline QTc (n = 42). Borderline QTc was defined between 440-470 (male) and 440-480 (female) ms. ECGs were recorded supine, sitting, and standing. Patients then underwent treadmill stress testing with Bruce protocol followed by a 9-minute recovery phase. RESULTS Supine resting QTc, age, and Schwartz score for the three groups were: (a) gene positive: 446 ± 23 ms, 12.4 ± 3.4 years old, 3.2 ± 1.8; (b) gene negative: 445 ± 20 ms, 12.1 ± 2 years old, 2.0 ± 1.2; and (c) control: 400 ± 24 ms, 15.0 ± 3 years old. The three groups could be differentiated by their QTc response at two time points: standing and recovery phase at 6 minutes. Standing QTc ≥460 ms differentiated borderline prolonged QTc patients (gene positive and gene negative) from controls. Late recovery QTc ≥480 ms distinguished gene positive from gene negative patients. CONCLUSION Exercise stress testing can be useful to identify children who are gene positive borderline LQTS from a normal population and gene negative borderline QTc children, allowing for selective gene testing in a higher risk group of patients with borderline QTc intervals and intermediate Schwartz scores.
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Affiliation(s)
- Trisha M Patel
- Division of General Pediatrics, Children's National Health System, Washington, District of Columbia
| | - Stanley M Kamande
- School of Medicine, Georgetown University, Washington, District of Columbia
| | - Elizabeth Jarosz
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
| | - James E Bost
- Division of Biostatistics and Study Methodology, Children's National Health System, Washington, District of Columbia
| | - Sridhar Hanumanthaiah
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Charles I Berul
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Jeffrey P Moak
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
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13
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Extramiana F, Badilini F, Denjoy I, Vaglio M, Green CL, Kligfield P, Leenhardt A, Maison-Blanche P. Sex influences on ventricular repolarization duration in normal subjects and in type 1, 2 and 3 long QT syndrome patients: Different effect in acquired and congenital type 2 LQTS. J Electrocardiol 2020; 62:148-154. [PMID: 32905894 DOI: 10.1016/j.jelectrocard.2020.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 01/08/2023]
Abstract
AIM To evaluate the interaction between sex and rate corrected QT interval (QTc) duration in normal subjects after drug-induced QT prolongation and in LQTS patients. METHODS Semi-automated measurements were performed on 875 digital ECGs (200 normal subjects off drugs (100 females), 200 normal subjects on Moxifloxacin (100 females), 259 LQT1 patients (161 females), 183 LQT2 patients (100 females) and 33 LQT3 patients (15 females)). A sex specific coefficient was calculated in each group and was used to calculate group specific corrected QT intervals (QTci). RESULTS The mean sex difference (female minus male) in QTci interval duration was 17 ms 95%CI(12.7; 21.3) in normal subjects, 19 ms (14.5; 23.5) on Moxifloxacin, and 13 ms (4.8; 21.2) in LQT1 patients. The mean difference was 2 ms (-7.9; 11.9) in LQT2 and - 5 ms (-32.2; 22.2) in LQT3 patients (p = 0.0067 for the group and sex interaction). In the subgroup of patients above 15 years and without beta blocker treatment, the sex effect (female minus male) on QTci interval duration was 17 ms (4.1; 29.9) in LQT1 patients. QTc duration was not different between sex in LQT2 and in LQT3 patients (mean difference - 3 ms (-21.6; 15.6) and 12 ms (-28.4; 52.4), respectively) (p = 0.0191 for group and sex interaction). CONCLUSIONS The interaction between sex and QTc interval is preserved in type 1 LQTS and drug-induced QTc prolongation but blurred in type 2 LQTS. Further experimental studies are warranted to better understand the interaction of sexual hormones with malfunctioning KCNH2 encoded repolarizing potassium channel.
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Affiliation(s)
- Fabrice Extramiana
- Université de Paris, CNMR, Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, INSERMU1166, 75018 Paris, France.
| | | | - Isabelle Denjoy
- Université de Paris, CNMR, Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, INSERMU1166, 75018 Paris, France
| | | | - Cynthia L Green
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
| | - Paul Kligfield
- Division of Cardiology, Weill Cornell Medical College, New York, NY, United States of America
| | - Antoine Leenhardt
- Université de Paris, CNMR, Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, INSERMU1166, 75018 Paris, France
| | - Pierre Maison-Blanche
- Université de Paris, CNMR, Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, INSERMU1166, 75018 Paris, France
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15
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Tian XT, Xu YJ, Yang YQ. Gender Differences in Arrhythmias: Focused on Atrial Fibrillation. J Cardiovasc Transl Res 2019; 13:85-96. [PMID: 31637585 DOI: 10.1007/s12265-019-09918-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
There are significant differences in clinical presentation and treatment of atrial fibrillation (AF) between women and men. The primary goal of AF management is to restore sinus rhythm and to prevent various complications, including stroke and heart failure. In many areas of AF, such as prevalence, clinical manifestations, morbidity, risk factors, pathophysiology, treatment strategies, and complications, gender-specific variability is observed and needs to be further addressed by large-scale population researches or randomized clinical trials, which help to promote the customization of AF treatment programs, hence to maximize the success rate of AF therapy in both sexes. This review highlights our current understanding of these gender differences in AF and how these differences affect treatment decisions on AF.
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Affiliation(s)
- Xiao-Ting Tian
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China
| | - Ying-Jia Xu
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China
| | - Yi-Qing Yang
- Department of Cardiology, Cardiovascular Research Laboratory, and Center Laboratory, The Fifth People's Hospital of Shanghai, Fudan University, No. 801 Heqing Road, Shanghai, 200240, China.
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Abstract
The primary electrical disorders are a group of inherited cardiac ventricular arrhythmias that are a major cause of sudden cardiac death in young individuals. Inherited ventricular arrhythmias result from mutations in genes encoding cardiac ion channels or their modulatory subunits. Advances in genetic screening in the past three decades have led to the assembly of large patient cohorts with these disorders. Studies in these patients, as well as in the general population, have striven to define the prevalence of these inherited arrhythmias and the characteristics of patients with different genetic subtypes of the disease. In this Review, we provide a comprehensive update on the epidemiology of inherited ventricular arrhythmias, focusing on natural history, prevalence and patient demographics. In addition, we summarize the various founder populations (groups of individuals with a disease that is caused by a genetic defect inherited from a common ancestor) that have been identified for some of these disorders and which lead to increased prevalence in some geographical regions. To date, although numerous studies have markedly increased our understanding of the epidemiology of these disorders, demographic data, especially from non-Western countries, remain scarce. Furthermore, defining the true prevalence of these disorders remains challenging. International collaboration will undoubtedly accelerate the collection of demographic information and improve the accuracy of prevalence data.
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17
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Roberts JD, Gula LJ. QT-Interval Assessment in Left Bundle Branch Block: Deciphering Normal Within Abnormal. Can J Cardiol 2019; 35:802-804. [PMID: 31292074 DOI: 10.1016/j.cjca.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada.
| | - Lorne J Gula
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
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18
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Miyazaki A, Doi H. What Is the Best Age for Diagnostic Prediction of Pediatric Long-QT Syndrome With a Borderline QT Interval? Circ Arrhythm Electrophysiol 2019; 10:CIRCEP.117.005119. [PMID: 28356308 DOI: 10.1161/circep.117.005119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Aya Miyazaki
- From the Department of Pediatrics (A.M., H.D.) and Congenital Heart Disease Center (H.D.), Tenri Hospital, Nara, Japan.
| | - Hiraku Doi
- From the Department of Pediatrics (A.M., H.D.) and Congenital Heart Disease Center (H.D.), Tenri Hospital, Nara, Japan
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19
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Yoshinaga M, Kucho Y, Ushinohama H, Ishikawa Y, Ohno S, Ogata H. Autonomic Function and QT Interval During Night-Time Sleep in Infant Long QT Syndrome. Circ J 2018; 82:2152-2159. [PMID: 29952348 DOI: 10.1253/circj.cj-18-0048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sudden infant death syndrome mainly occurs during night-time sleep. Approximately 10% of cases are thought to involve infants with long QT syndrome (LQTS). Autonomic function and QT interval in night-time sleep in early infancy in LQTS infants, however, remain controversial.Methods and Results:Holter electrocardiography was performed in 11 LQTS infants before medication in early infancy, and in 11 age-matched control infants. Control infants were re-evaluated in late infancy. The power spectral density was calculated and parasympathetic activity and sympathovagal balance were obtained. Electrocardiograms of a representative hour during night-time sleep, daytime sleep, and daytime activity, were chosen and QT/RR intervals were manually measured. LQTS infants had significantly lower parasympathetic activity and higher sympathovagal balance during night-time sleep than control infants in early infancy. These autonomic conditions in early infancy were significantly depressed compared with late infancy. Corrected QT interval (QTc) during night-time sleep (490±20 ms) was significantly longer than that in daytime sleep (477±21 ms, P=0.04) or daytime activity (458±18 ms, P=0.003) in LQTS infants, and significantly longer than that during night-time sleep in controls. CONCLUSIONS A combination of the longest QTc and autonomic imbalance during night-time sleep in early infancy may be responsible for development of life-threatening arrhythmia in LQTS infants. Critical cases should be included in future studies.
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Affiliation(s)
- Masao Yoshinaga
- Department of Pediatrics, National Hospital Organization Kagoshima Medical Center
| | - Yu Kucho
- Department of Pediatrics, National Hospital Organization Kagoshima Medical Center
| | | | - Yuichi Ishikawa
- Department of the Cardiovascular System, Fukuoka Children's Hospital
| | - Seiko Ohno
- Center for Epidemiologic Research in Asia, Shiga University of Medical Science
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20
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Clur SAB, Vink AS, Etheridge SP, Robles de Medina PG, Rydberg A, Ackerman MJ, Wilde AA, Blom NA, Benson DW, Herberg U, Donofrio MT, Cuneo BF. Left Ventricular Isovolumetric Relaxation Time Is Prolonged in Fetal Long-QT Syndrome. Circ Arrhythm Electrophysiol 2018; 11:e005797. [PMID: 29654130 DOI: 10.1161/circep.117.005797] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-QT syndrome (LQTS), an inherited cardiac repolarization disorder, is an important cause of fetal and neonatal mortality. Detecting LQTS prenatally is challenging. A fetal heart rate (FHR) less than third percentile for gestational age is specific for LQTS, but the sensitivity is only ≈50%. Left ventricular isovolumetric relaxation time (LVIRT) was evaluated as a potential diagnostic marker for fetal LQTS. METHODS AND RESULTS LV isovolumetric contraction time, LV ejection time, LVIRT, cycle length, and FHR were measured using pulsed Doppler waveforms in fetuses. Time intervals were expressed as percentages of cycle length, and the LV myocardial performance index was calculated. Single measurements were stratified by gestational age and compared between LQTS fetuses and controls. Receiver-operator curves were performed for FHR and normalized LVIRT (N-LVIRT). A linear mixed-effect model including multiple measurements was used to analyze trends in FHR, N-LVIRT, and LV myocardial performance index. There were 33 LQTS fetuses and 469 controls included. In LQTS fetuses, the LVIRT was prolonged in all gestational age groups (P<0.001), as was the N-LVIRT. The best cutoff to diagnose LQTS was N-LVIRT ≥11.3 at ≤20 weeks (92% sensitivity, 70% specificity). Simultaneous analysis of N-LVIRT and FHR improved the sensitivity and specificity for LQTS (area under the curve=0.96; 95% confidence interval, 0.82-1.00 at 21-30 weeks). N-LVIRT, LV myocardial performance index, and FHR trends differed significantly between LQTS fetuses and controls through gestation. CONCLUSIONS The LVIRT is prolonged in LQTS fetuses. Findings of a prolonged N-LVIRT and sinus bradycardia can improve the prenatal detection of fetal LQTS.
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Affiliation(s)
- Sally-Ann B Clur
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.).
| | - Arja S Vink
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Susan P Etheridge
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Pascale G Robles de Medina
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Annika Rydberg
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Michael J Ackerman
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Arthur A Wilde
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Nico A Blom
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - D Woodrow Benson
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Ulrike Herberg
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Mary T Donofrio
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
| | - Bettina F Cuneo
- Departments of Pediatric Cardiology, Obstetrics and Gynecology, and Cardiology, Academic Medical Center, Amsterdam, The Netherlands (S.-A.B.C., A.S.V., P.G.R.d.M., A.A.W., N.A.B.). Department of Pediatric Cardiology, University of Utah & Primary Children's Hospital, Salt Lake City (S.P.E.). Department of Clinical Sciences, Pediatrics, Umeå University, Sweden (A.R.). Department of Cardiology, Mayo Clinic, Rochester, MN (M.J.A.). Department of Pediatrics, Medical College of Wisconsin, Milwaukee (D.W.B.). Department of Pediatric Cardiology, University of Bonn, Germany (U.H.). Pediatric Cardiology, Children's National Medical Center, Washington, DC (M.T.D.). The Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Denver (B.F.C.)
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Vink AS, Kuipers IM, De Bruin-Bon RHACM, Wilde AAM, Blom NA, Clur SAB. A Potential Diagnostic Approach for Foetal Long-QT Syndrome, Developed and Validated in Children. Pediatr Cardiol 2018; 39:1413-1422. [PMID: 29789915 PMCID: PMC6153877 DOI: 10.1007/s00246-018-1911-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/11/2018] [Indexed: 01/12/2023]
Abstract
In patients with Long-QT Syndrome (LQTS), mechanical abnormalities have been described. Recognition of these abnormalities could potentially be used in the diagnosis of LQTS, especially in the foetus where an ECG is not available and DNA-analysis is invasive. We aimed to develop and validate a marker for these mechanical abnormalities in children and to test its feasibility in foetuses as a proof of principle. We measured the myocardial contraction duration using colour Tissue Doppler Imaging (cTDI) in 41 LQTS children and age- and gender-matched controls. Children were chosen to develop and validate the measurement of the myocardial contraction duration, due to the availability of a simultaneously recorded ECG. Feasibility of this measurement in foetuses was tested in an additional pilot study among seven LQTS foetuses and eight controls. LQTS children had a longer myocardial contraction duration compared to controls, while there was no statistical difference in heart rate. Measuring the myocardial contraction duration in children had a high inter- and intra-observer validity and reliably correlated with the QT-interval. There was an area under the curve (AUC) of 0.71, and the optimal cut-off value showed an especially high specificity in diagnosing LQTS. Measuring the myocardial contraction duration was possible in all foetuses and had a high inter- and intra-observer validity (ICC = 0.71 and ICC = 0.88, respectively). LQTS foetuses seemed to have a longer myocardial contraction duration compared to controls. Therefore, a prolonged contraction duration may be a potential marker for the prenatal diagnosis of LQTS in the future. Further studies are required to support the measurement of the myocardial contraction duration as a diagnostic approach for foetal LQTS.
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Affiliation(s)
- Arja Suzanne Vink
- Heart Centre, Department of Cardiology, Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Department of Paediatric Cardiology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
| | - Irene M. Kuipers
- Department of Paediatric Cardiology, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Rianne H. A. C. M. De Bruin-Bon
- Heart Centre, Department of Cardiology, Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Arthur A. M. Wilde
- Heart Centre, Department of Cardiology, Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Nico A. Blom
- Department of Paediatric Cardiology, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, The Netherlands ,Department of Paediatric Cardiology, Willem-Alexander Children’s Hospital, University Medical Centre Leiden, Leiden, The Netherlands
| | - Sally-Ann B. Clur
- Department of Paediatric Cardiology, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, The Netherlands
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Effect of age and gender on the QTc-interval in healthy individuals and patients with long-QT syndrome. Trends Cardiovasc Med 2017; 28:64-75. [PMID: 28869094 DOI: 10.1016/j.tcm.2017.07.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/15/2022]
Abstract
Age- and gender-related differences in QTc-interval are most likely the result of changes in sex-specific hormones. Although the exact mechanisms and pathophysiology of sex hormones on the QTc-interval are not known, testosterone appears to shorten the QTc-interval. In females, however, there is a more complex interaction between progesterone and estrogen. In patients with an impaired repolarization, such as long-QT syndrome (LQTS), the effect of these sex hormones on the QTc-interval is more pronounced with a differing sensitivity between the LQTS genotypes.
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Touma M, Reemtsen B, Halnon N, Alejos J, Finn JP, Nelson SF, Wang Y. A Path to Implement Precision Child Health Cardiovascular Medicine. Front Cardiovasc Med 2017; 4:36. [PMID: 28620608 PMCID: PMC5451507 DOI: 10.3389/fcvm.2017.00036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022] Open
Abstract
Congenital heart defects (CHDs) affect approximately 1% of live births and are a major source of childhood morbidity and mortality even in countries with advanced healthcare systems. Along with phenotypic heterogeneity, the underlying etiology of CHDs is multifactorial, involving genetic, epigenetic, and/or environmental contributors. Clear dissection of the underlying mechanism is a powerful step to establish individualized therapies. However, the majority of CHDs are yet to be clearly diagnosed for the underlying genetic and environmental factors, and even less with effective therapies. Although the survival rate for CHDs is steadily improving, there is still a significant unmet need for refining diagnostic precision and establishing targeted therapies to optimize life quality and to minimize future complications. In particular, proper identification of disease associated genetic variants in humans has been challenging, and this greatly impedes our ability to delineate gene–environment interactions that contribute to the pathogenesis of CHDs. Implementing a systematic multileveled approach can establish a continuum from phenotypic characterization in the clinic to molecular dissection using combined next-generation sequencing platforms and validation studies in suitable models at the bench. Key elements necessary to advance the field are: first, proper delineation of the phenotypic spectrum of CHDs; second, defining the molecular genotype/phenotype by combining whole-exome sequencing and transcriptome analysis; third, integration of phenotypic, genotypic, and molecular datasets to identify molecular network contributing to CHDs; fourth, generation of relevant disease models and multileveled experimental investigations. In order to achieve all these goals, access to high-quality biological specimens from well-defined patient cohorts is a crucial step. Therefore, establishing a CHD BioCore is an essential infrastructure and a critical step on the path toward precision child health cardiovascular medicine.
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Affiliation(s)
- Marlin Touma
- Department of Pediatrics, Children's Discovery and Innovation Institute, University of California at Los Angeles, Los Angeles, CA, United States.,Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States
| | - Brian Reemtsen
- Department of Cardiothoracic Surgery, University of California at Los Angeles, Los Angeles, CA, United States
| | - Nancy Halnon
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Juan Alejos
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - J Paul Finn
- Department of Radiology, Cardiovascular Imaging, University of California at Los Angeles, Los Angeles, CA, United States
| | - Stanley F Nelson
- Department of Human Genetics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Yibin Wang
- Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States.,Department of Anesthesiology, Physiology and Medicine, University of California at Los Angeles, Los Angeles, CA, United States
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