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Casella M, Dello Russo A, Bergonti M, Catto V, Conte E, Sommariva E, Gasperetti A, Vettor G, Tundo F, Sicuso R, Rizzo S, Mushtaq S, Della Rocca D, Pompilio G, Di Biase L, Andreini D, Natale A, Basso C, Tondo C. Diagnostic Yield of Electroanatomic Voltage Mapping in Guiding Endomyocardial Biopsies. Circulation 2020; 142:1249-1260. [PMID: 32791857 DOI: 10.1161/circulationaha.120.046900] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Electroanatomic voltage mapping (EVM) is a promising modality for guiding endomyocardial biopsies (EMBs). However, few data support its feasibility and safety. We now report the largest cohort of patients undergoing EVM-guided EMBs to show its diagnostic yield and to compare it with a cardiac magnetic resonance (CMR)-guided approach. METHODS We included 162 consecutive patients undergoing EMB at our institution from 2010 to 2019. EMB was performed in pathological areas identified at EVM and CMR. CMR and EVM sensitivity and specificity regarding the identification of pathological substrates of myocardium were evaluated according to EMB results. RESULTS Preoperative CMR showed late gadolinium enhancement in 70% of the patients, whereas EVM identified areas of low voltage in 61%. Right (73%), left (19%), or both ventricles (8%) underwent sampling. EVM proved to have sensitivity similar to CMR (74% versus 77%), with specificity being 70% and 47%, respectively. In 12 patients with EMB-proven cardiomyopathy, EVM identified pathological areas that had been undetected at CMR evaluation. Sensitivity of pooled EVM and CMR was as high as 95%. EMB analysis allowed us to reach a new diagnosis, different from the suspected clinical diagnosis, in 39% of patients. The complications rate was low, mostly related to vascular access, with no patients requiring urgent management. CONCLUSIONS EVM proved to be a promising tool for targeted EMB because of its sensitivity and specificity for identification of myocardial pathological substrates. EVM was demonstrated to have accuracy similar to CMR. EVM and CMR together conferred a positive predictive value of 89% on EMB.
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Affiliation(s)
- Michela Casella
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy.,Cardiology and Arrhythmology Clinic, Department of Clinical, Special and Dental Sciences(M.C.), University Hospital "Umberto I - Lancisi - Salesi," Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Department of Biomedical Sciences and Public Health(A.D.R.), University Hospital "Umberto I - Lancisi - Salesi," Marche Polytechnic University, Ancona, Italy
| | - Marco Bergonti
- Department of Clinical Sciences and Community Health, University of Milan, Italy(M.B., G.P., D.A., C.T.)
| | - Valentina Catto
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Edoardo Conte
- Cardiovascular Computed Tomography and Radiology Unit(E.C., S.M., D.A.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Elena Sommariva
- Unit of Vascular Biology and Regenerative Medicine(E.S., G.P.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Alessio Gasperetti
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Giulia Vettor
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Fabrizio Tundo
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Rita Sicuso
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | - Stefania Rizzo
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Azienda Ospedaliera-University of Padua, Padova, Italy(S.R., C.B.)
| | - Saima Mushtaq
- Cardiovascular Computed Tomography and Radiology Unit(E.C., S.M., D.A.), Centro Cardiologico Monzino IRCCS, Milano, Italy
| | | | - Giulio Pompilio
- Unit of Vascular Biology and Regenerative Medicine(E.S., G.P.), Centro Cardiologico Monzino IRCCS, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Italy(M.B., G.P., D.A., C.T.)
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York(L.D.B.)
| | - Daniele Andreini
- Cardiovascular Computed Tomography and Radiology Unit(E.C., S.M., D.A.), Centro Cardiologico Monzino IRCCS, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Italy(M.B., G.P., D.A., C.T.)
| | - Andrea Natale
- Texas Cardiac Arrhyhtmia Institute, St David's Hospital, Austin(D.D.R., A.N.)
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Azienda Ospedaliera-University of Padua, Padova, Italy(S.R., C.B.)
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Pacing(M.C., V.C., A.G., G.V., F.T., R.S., C.T.), Centro Cardiologico Monzino IRCCS, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Italy(M.B., G.P., D.A., C.T.)
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Belhassen B, Shmilovich H, Nof E, Milman A. A case report of arrhythmogenic ventricular cardiomyopathy presenting with sustained ventricular tachycardia arising from the right and the left ventricles before structural changes are documented. Eur Heart J Case Rep 2020; 4:1-7. [PMID: 32128479 PMCID: PMC7047046 DOI: 10.1093/ehjcr/ytz239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/19/2019] [Accepted: 12/13/2019] [Indexed: 12/29/2022]
Abstract
Background Arrhythmogenic ventricular cardiomyopathy (AC) is a genetic progressive disease characterized by fibro-fatty replacement of either ventricles in isolation or in combination. Arrhythmogenic ventricular cardiomyopathy is frequently associated with ventricular tachycardia (VT) having a left bundle branch block (LBBB) morphology and much more rarely with VT having right bundle branch block (RBBB) morphology even when the left ventricle is involved. Cardiac magnetic resonance (CMR) imaging plays a key role in the diagnosis of AC. Sustained VT in AC may occur in the concealed stage of the disease before the manifestation of morphological abnormalities on echocardiogram; however, they almost always are accompanied by structural abnormalities of the ventricles on CMR. Case summary A 54-year-old man presented with sustained VT of LBBB configuration consistent with the diagnosis of AC but with no right ventricular (RV) anomalies at repeat CMR. Ten years later, he developed sustained VT with RBBB morphology and structural changes at CMR compatible with RV involvement in the setting of AC. Two years later, he suffered from recurrent identical sustained RBBB-VT with typical CMR signs of left ventricular involvement. Genetic analysis was negative for any known mutation. Discussion In the present report, we describe a patient with AC who first exhibited LBBB- and 10 years later RBBB-sustained VT. Contrasting with what is usually observed in patients with AC, documentations of the VT's arising from either ventricle were found to precede the structural anomalies in the respective cardiac chambers. This case highlights that normal CMR does not exclude underlying AC contrary to the perceptions of many clinicians. In addition, it strongly encourages repeating CMR after 1-2 years when the diagnosis of AC is highly suspected.
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Affiliation(s)
- Bernard Belhassen
- Heart Institute, Hadassah University Hospital, Kiriat Hadassah, PO Box 12000, Jerusalem 91120, Israel.,Sackler School of Medicine, PO Box 39049, Ramat Aviv, Tel-Aviv 69978, Israel
| | - Haim Shmilovich
- Sackler School of Medicine, PO Box 39049, Ramat Aviv, Tel-Aviv 69978, Israel.,Department of Cardiology, Tel Aviv Sourasky Medical Center, Weizman Street 6, PO Box 6423906, Tel-Aviv, Israel.,Department of Radiology, Tel Aviv Sourasky Medical Center, Weizman Street 6, PO Box 6423906, Tel-Aviv, Israel
| | - Eyal Nof
- Sackler School of Medicine, PO Box 39049, Ramat Aviv, Tel-Aviv 69978, Israel.,Department of Cardiology, Leviev Heart Institute, The Chaim Sheba Medical Center, Derech Sheba 2, PO Box 52621, Ramat Gan,Tel Hashomer, Israel
| | - Anat Milman
- Sackler School of Medicine, PO Box 39049, Ramat Aviv, Tel-Aviv 69978, Israel.,Department of Cardiology, Leviev Heart Institute, The Chaim Sheba Medical Center, Derech Sheba 2, PO Box 52621, Ramat Gan,Tel Hashomer, Israel
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