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Seghetti P, Latrofa S, Biasi N, Giannoni A, Hartwig V, Rossi A, Tognetti A. Electrophysiological patterns and structural substrates of Brugada syndrome: Critical appraisal and computational analyses. J Cardiovasc Electrophysiol 2024; 35:1673-1687. [PMID: 38899376 DOI: 10.1111/jce.16341] [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: 02/29/2024] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
Brugada syndrome (BrS) is a cardiac electrophysiological disease with unknown etiology, associated with sudden cardiac death. Symptomatic patients are treated with implanted cardiac defibrillator, but no risk stratification strategy is effective in patients that are at low to medium arrhythmic risk. Cardiac computational modeling is an emerging tool that can be used to verify the hypotheses of pathogenesis and inspire new risk stratification strategies. However, to obtain reliable results computational models must be validated with consistent experimental data. We reviewed the main electrophysiological and structural variables from BrS clinical studies to assess which data could be used to validate a computational approach. Activation delay in the epicardial right ventricular outflow tract is a consistent finding, as well as increased fibrosis and subclinical alterations of right ventricular functional and morphological parameters. The comparison between other electrophysiological variables is hindered by methodological differences between studies, which we commented. We conclude by presenting a recent theory unifying electrophysiological and structural substrate in BrS and illustrate how computational modeling could help translation to risk stratification.
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Affiliation(s)
- Paolo Seghetti
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Sara Latrofa
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Niccolò Biasi
- Department of Information Engineering, Università di Pisa, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana 'G. Monasterio', Pisa, Italy
| | - Valentina Hartwig
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
- Fondazione Toscana 'G. Monasterio', Pisa, Italy
| | | | - Alessandro Tognetti
- Department of Information Engineering, Università di Pisa, Pisa, Italy
- Research Center 'Enrico Piaggio', Università di Pisa, Pisa, Italy
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Fogaça-da-Mata M, Martínez-Barrios E, Jiménez-Montañés L, Cruzalegui J, Chipa-Ccasani F, Greco A, Cesar S, Díez-Escuté N, Cerralbo P, Zschaeck I, Clavero Adell M, Ayerza-Casas A, Palanca-Arias D, López M, Campuzano O, Brugada J, Sarquella-Brugada G. Brugada Syndrome and Pulmonary Atresia with Intact Interventricular Septum: Fortuitous Finding or New Genetic Connection? Genes (Basel) 2024; 15:638. [PMID: 38790267 PMCID: PMC11121103 DOI: 10.3390/genes15050638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Brugada syndrome is a rare arrhythmogenic syndrome associated mainly with pathogenic variants in the SCN5A gene. Right ventricle outflow tract fibrosis has been reported in some cases of patients diagnosed with Brugada syndrome. Pulmonary atresia with an intact ventricular septum is characterized by the lack of a functional pulmonary valve, due to the underdevelopment of the right ventricle outflow tract. We report, for the first time, a 4-year-old boy with pulmonary atresia with an intact ventricular septum who harbored a pathogenic de novo variant in SCN5A, and the ajmaline test unmasked a type-1 Brugada pattern. We suggest that deleterious variants in the SCN5A gene could be implicated in pulmonary atresia with an intact ventricular septum embryogenesis, leading to overlapping phenotypes.
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Affiliation(s)
- Miguel Fogaça-da-Mata
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- Pediatric Cardiology Unit, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, 1449-005 Lisbon, Portugal
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
| | - Estefanía Martínez-Barrios
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
- Medical Science Department, School of Medicine, Universitat de Girona, 17003 Girona, Spain;
| | - Lorenzo Jiménez-Montañés
- Pediatric Cardiology Unit, University Hospital Miguel Servet, 50009 Zaragoza, Spain; (L.J.-M.); (M.C.A.); (A.A.-C.); (D.P.-A.); (M.L.)
| | - José Cruzalegui
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Fredy Chipa-Ccasani
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Andrea Greco
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Sergi Cesar
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Núria Díez-Escuté
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Patricia Cerralbo
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Irene Zschaeck
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
| | - Marcos Clavero Adell
- Pediatric Cardiology Unit, University Hospital Miguel Servet, 50009 Zaragoza, Spain; (L.J.-M.); (M.C.A.); (A.A.-C.); (D.P.-A.); (M.L.)
| | - Ariadna Ayerza-Casas
- Pediatric Cardiology Unit, University Hospital Miguel Servet, 50009 Zaragoza, Spain; (L.J.-M.); (M.C.A.); (A.A.-C.); (D.P.-A.); (M.L.)
| | - Daniel Palanca-Arias
- Pediatric Cardiology Unit, University Hospital Miguel Servet, 50009 Zaragoza, Spain; (L.J.-M.); (M.C.A.); (A.A.-C.); (D.P.-A.); (M.L.)
| | - Marta López
- Pediatric Cardiology Unit, University Hospital Miguel Servet, 50009 Zaragoza, Spain; (L.J.-M.); (M.C.A.); (A.A.-C.); (D.P.-A.); (M.L.)
| | - Oscar Campuzano
- Medical Science Department, School of Medicine, Universitat de Girona, 17003 Girona, Spain;
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, 28029 Madrid, Spain;
- Cardiovascular Genetics Center, University of Girona—IDIBGI, 17190 Girona, Spain
| | - Josep Brugada
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, 28029 Madrid, Spain;
- Arrhythmias Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Georgia Sarquella-Brugada
- Arrhythmia, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, 08950 Barcelona, Spain; (M.F.-d.-M.); (E.M.-B.); (J.C.); (F.C.-C.); (A.G.); (S.C.); (N.D.-E.); (P.C.); (I.Z.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), 1105 AZ Amsterdam, The Netherlands
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Institut de Recerca Sant Joan de Déu, Santa Rosa 39–57, Esplugues de Llobregat, 08950 Barcelona, Spain
- Medical Science Department, School of Medicine, Universitat de Girona, 17003 Girona, Spain;
- Department of Surgery and Medico-Surgical Specialties, School of Medicine and Health Sciences, Universitat de Barcelona, 08036 Barcelona, Spain
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Hoeksema WF, Amin AS, Bezzina CR, Wilde AAM, Postema PG. Novelties in Brugada Syndrome: Complex Genetics, Risk Stratification, and Catheter Ablation. Card Electrophysiol Clin 2023; 15:273-283. [PMID: 37558298 DOI: 10.1016/j.ccep.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Brugada syndrome (BrS) is an inherited arrhythmia syndrome with distinctive electrocardiographic abnormalities in the right precordial leads and predisposes to ventricular arrhythmias and sudden cardiac death in otherwise healthy patients. Its complex genetic architecture and pathophysiological mechanism are not yet completely understood, and risk stratification remains challenging, particularly in patients at intermediate risk of arrhythmic events. Further understanding of its complex genetic architecture may help improving future risk stratification, and advances in management may contribute to alternatives to implantable cardioverter-defibrillators. Here, the authors review the latest insights and developments in BrS.
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Affiliation(s)
- Wiert F Hoeksema
- Department of Clinical Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Meibergdreef 9, Amsterdam, the Netherlands
| | - Ahmad S Amin
- Department of Clinical Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Meibergdreef 9, Amsterdam, the Netherlands
| | - Connie R Bezzina
- Department of Experimental Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Meibergdreef 9, Amsterdam, the Netherlands
| | - Arthur A M Wilde
- Department of Clinical Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Meibergdreef 9, Amsterdam, the Netherlands
| | - Pieter G Postema
- Department of Clinical Cardiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Meibergdreef 9, Amsterdam, the Netherlands.
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Lu YY, Chen YC, Lin YK, Chen SA, Chen YJ. Electrical and Structural Insights into Right Ventricular Outflow Tract Arrhythmogenesis. Int J Mol Sci 2023; 24:11795. [PMID: 37511554 PMCID: PMC10380666 DOI: 10.3390/ijms241411795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
The right ventricular outflow tract (RVOT) is the major origin of ventricular arrhythmias, including premature ventricular contractions, idiopathic ventricular arrhythmias, Brugada syndrome, torsade de pointes, long QT syndrome, and arrhythmogenic right ventricular cardiomyopathy. The RVOT has distinct developmental origins and cellular characteristics and a complex myocardial architecture with high shear wall stress, which may lead to its high vulnerability to arrhythmogenesis. RVOT myocytes are vulnerable to intracellular sodium and calcium overload due to calcium handling protein modulation, enhanced CaMKII activity, ryanodine receptor phosphorylation, and a higher cAMP level activated by predisposing factors or pathological conditions. A reduction in Cx43 and Scn5a expression may lead to electrical uncoupling in RVOT. The purpose of this review is to update the current understanding of the cellular and molecular mechanisms of RVOT arrhythmogenesis.
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Affiliation(s)
- Yen-Yu Lu
- Division of Cardiology, Department of Internal Medicine, Sijhih Cathay General Hospital, New Taipei City 22174, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City 24257, Taiwan
| | - Yao-Chang Chen
- Department of Biomedical Engineering, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Cardiovacular Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Yi-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Cardiovacular Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11696, Taiwan
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Achmad C, Kamarullah W, Putra ICS, Firmansyah DK, Iqbal M, Karwiky G, Pramudyo M, Martha JW, Akbar MR. Investigation of High-Risk Electrocardiographic Markers as Predictors of Major Arrhythmic Events in Brugada Syndrome: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101727. [PMID: 36997139 DOI: 10.1016/j.cpcardiol.2023.101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Numerous studies have demonstrated that a type I Brugada electrocardiographic (ECG) pattern, history of syncope, prior sudden cardiac arrest, and previously documented ventricular tachyarrhythmias are still insufficient to stratify the risk of sudden cardiac death in Brugada syndrome (BrS). Several auxiliary risk stratification parameters are pursued to yield a better prognostic model. Our aim was to assess the association between several ECG markers (wide QRS, fragmented QRS, S-wave in lead I, aVR sign, early repolarization pattern in inferolateral leads, and repolarization dispersion pattern) with the risk of developing poor outcomes in BrS. METHODS A systematic literature search from several databases was conducted from database inception until August 17th, 2022. Studies were eligible if it investigated the relationship between the ECG markers with the likelihood of acquiring major arrhythmic events (MAE). RESULTS This meta-analysis comprised 27 studies with a total of 6552 participants. Our study revealed that wide QRS, fragmented QRS, S-wave in lead I, aVR sign, early repolarization pattern in inferolateral leads, and repolarization dispersion ECG pattern were associated with the incremental risk of syncope, ventricular tachyarrhythmias, implantable cardioverter-defibrillator shock, and sudden cardiac death in the future, with the risk ratios ranging from 1.41 to 2.00. Moreover, diagnostic test accuracy meta-analysis indicated that the repolarization dispersion ECG pattern had the highest overall area under curve (AUC) value amid other ECG markers regarding our outcomes of interest. CONCLUSION A multivariable risk assessment approach based on the prior mentioned ECG markers potentially improves the current risk stratification models in BrS patients.
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Affiliation(s)
- Chaerul Achmad
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia.
| | - William Kamarullah
- R. Syamsudin SH Regional Public Hospital, Sukabumi, West Java, Indonesia
| | - Iwan Cahyo Santosa Putra
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Dena Karina Firmansyah
- Department of Cardiology and Vascular Medicine, R. Syamsudin SH Regional Public Hospital, Sukabumi, West Java, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Giky Karwiky
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Padjadjaran, Bandung, Indonesia
| | - Miftah Pramudyo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Padjadjaran, Bandung, Indonesia
| | - Januar Wibawa Martha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Padjadjaran, Bandung, Indonesia
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Padjadjaran, Bandung, Indonesia
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Fir(e)ing the Rhythm. JACC Basic Transl Sci 2023. [DOI: 10.1016/j.jacbts.2022.12.004] [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: 02/17/2023]
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Isbister JC, Gray B, Offen S, Yeates L, Naoum C, Medi C, Raju H, Semsarian C, Puranik R, Sy RW. Longitudinal assessment of structural phenotype in Brugada syndrome using cardiac magnetic resonance imaging. Heart Rhythm O2 2023; 4:34-41. [PMID: 36713046 PMCID: PMC9877394 DOI: 10.1016/j.hroo.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Despite historically being considered a channelopathy, subtle structural changes have been reported in Brugada syndrome (BrS) on histopathology and cardiac magnetic resonance (CMR) imaging. It is not known if these structural changes progress over time. Objective The study sought to assess if structural changes in BrS evolve over time with serial CMR assessment and to investigate the utility of parametric mapping techniques to identify diffuse fibrosis in BrS. Methods Patients with a diagnosis of BrS based on international guidelines and normal CMR at least 3 years prior to the study period were invited to undergo repeat CMR. CMR images were analyzed de novo and compared at baseline and follow-up. Results Eighteen patients with BrS (72% men; mean age at follow-up 47.4 ± 8.9 years) underwent serial CMR with an average of 5.0 ± 1.7 years between scans. No patients had late gadolinium enhancement (LGE) on baseline CMR, but 4 (22%) developed LGE on follow-up, typically localized to the right ventricular (RV) side of the basal septum. RV end-systolic volume increased over time (P = .04) and was associated with a trend toward reduction in RV ejection fraction (P = .07). Four patients showed a reduction in RV ejection fraction >10%. There was no evidence of diffuse myocardial fibrosis observed on parametric mapping. Conclusions Structural changes may evolve over time with development of focal fibrosis, evidenced by LGE on CMR in a significant proportion of patients with BrS. These findings have implications for our understanding of the pathological substrate in BrS and the longitudinal evaluation of patients with BrS.
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Affiliation(s)
- Julia C. Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Belinda Gray
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sophie Offen
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Laura Yeates
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Centre for Population Genomics, Garvan Institute of Medical Research, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Chris Naoum
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Caroline Medi
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Hariharan Raju
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Rajesh Puranik
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Raymond W. Sy
- Faculty of Medicine and Heath, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Structural Heart Alterations in Brugada Syndrome: Is it Really a Channelopathy? A Systematic Review. J Clin Med 2022; 11:jcm11154406. [PMID: 35956023 PMCID: PMC9368908 DOI: 10.3390/jcm11154406] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Brugada syndrome (BrS) is classified as an inherited cardiac channelopathy attributed to dysfunctional ion channels and/or associated proteins in cardiomyocytes rather than to structural heart alterations. However, hearts of some BrS patients exhibit slight histologic abnormalities, suggesting that BrS could be a phenotypic variant of arrhythmogenic cardiomyopathy. We performed a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) criteria. Our comprehensive analysis of structural findings did not reveal enough definitive evidence for reclassification of BrS as a cardiomyopathy. The collection and comprehensive analysis of new cases with a definitive BrS diagnosis are needed to clarify whether some of these structural features may have key roles in the pathophysiological pathways associated with malignant arrhythmogenic episodes.
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9
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Blocking connexin 43 and its promotion of ATP release from renal tubular epithelial cells ameliorates renal fibrosis. Cell Death Dis 2022; 13:511. [PMID: 35641484 PMCID: PMC9156700 DOI: 10.1038/s41419-022-04910-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 02/08/2023]
Abstract
Whether metabolites derived from injured renal tubular epithelial cells (TECs) participate in renal fibrosis is poorly explored. After TEC injury, various metabolites are released and among the most potent is adenosine triphosphate (ATP), which is released via ATP-permeable channels. In these hemichannels, connexin 43 (Cx43) is the most common member. However, its role in renal interstitial fibrosis (RIF) has not been fully examined. We analyzed renal samples from patients with obstructive nephropathy and mice with unilateral ureteral obstruction (UUO). Cx43-KSP mice were generated to deplete Cx43 in TECs. Through transcriptomics, metabolomics, and single-cell sequencing multi-omics analysis, the relationship among tubular Cx43, ATP, and macrophages in renal fibrosis was explored. The expression of Cx43 in TECs was upregulated in both patients and mice with obstructive nephropathy. Knockdown of Cx43 in TECs or using Cx43-specific inhibitors reduced UUO-induced inflammation and fibrosis in mice. Single-cell RNA sequencing showed that ATP specific receptors, including P2rx4 and P2rx7, were distributed mainly on macrophages. We found that P2rx4- or P2rx7-positive macrophages underwent pyroptosis after UUO, and in vitro ATP directly induced pyroptosis by macrophages. The administration of P2 receptor or P2X7 receptor blockers to UUO mice inhibited macrophage pyroptosis and demonstrated a similar degree of renoprotection as Cx43 genetic depletion. Further, we found that GAP 26 (a Cx43 hemichannel inhibitor) and A-839977 (an inhibitor of the pyroptosis receptor) alleviated UUO-induced fibrosis, while BzATP (the agonist of pyroptosis receptor) exacerbated fibrosis. Single-cell sequencing demonstrated that the pyroptotic macrophages upregulated the release of CXCL10, which activated intrarenal fibroblasts. Cx43 mediates the release of ATP from TECs during renal injury, inducing peritubular macrophage pyroptosis, which subsequently leads to the release of CXCL10 and activation of intrarenal fibroblasts and acceleration of renal fibrosis.
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10
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Biventricular Myocardial Fibrosis and Sudden Death in Patients With Brugada Syndrome. J Am Coll Cardiol 2021; 78:1511-1521. [PMID: 34620408 PMCID: PMC8504200 DOI: 10.1016/j.jacc.2021.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Electrophysiological, imaging, and pathological studies have reported the presence of subtle structural abnormalities in hearts from patients with Brugada syndrome (BrS). However, data concerning disease involvement outside of the right ventricular outflow tract are limited. OBJECTIVES This study sought to characterize the presence and distribution of ventricular myocardial fibrosis in a cohort of decedents experiencing sudden cardiac death caused by BrS. METHODS The authors evaluated 28 whole hearts from consecutive sudden cardiac death cases attributed to BrS and 29 hearts from a comparator group comprised of noncardiac deaths (control subjects). Cardiac tissue from 6 regions across the right and left ventricle were stained with Picrosirius red for collagen and tissue composition was determined using image analysis software. Postmortem genetic testing was performed in cases with DNA retained for analysis. RESULTS Of 28 BrS decedents (75% men; median age of death 25 years), death occurred in sleep or at rest in 24 of 28 (86%). The highest proportion of collagen was observed in the epicardial right ventricular outflow tract of the BrS group (23.7%; 95% CI: 20.8%-26.9%). Ventricular myocardium from BrS decedents demonstrated a higher proportion of collagen compared with control subjects (ratio 1.45; 95% CI: 1.22-1.71; P < 0.001), with no significant interactions with respect to sampling location or tissue layer. There was insufficient evidence to support differences in collagen proportion in SCN5A-positive cases (n = 5) when compared with control subjects (ratio 1.23; 95% CI: 0.75-1.43; P = 0.27). CONCLUSIONS Brugada syndrome is associated with increased collagen content throughout right and left ventricular myocardium, irrespective of sampling location or myocardial layer.
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11
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Chaumont C, Suffee N, Gandjbakhch E, Balse E, Anselme F, Hatem SN. Epicardial origin of cardiac arrhythmias: clinical evidences and pathophysiology. Cardiovasc Res 2021; 118:1693-1702. [PMID: 34152392 PMCID: PMC9215195 DOI: 10.1093/cvr/cvab213] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022] Open
Abstract
Recent developments in imaging, mapping, and ablation techniques have shown that the epicardial region of the heart is a key player in the occurrence of ventricular arrhythmic events in several cardiac diseases, such as Brugada syndrome, arrhythmogenic cardiomyopathy, or dilated cardiomyopathy. At the atrial level as well, the epicardial region has emerged as an important determinant of the substrate of atrial fibrillation, pointing to common underlying pathophysiological mechanisms. Alteration in the gradient of repolarization between myocardial layers favouring the occurrence of re-entry circuits has largely been described. The fibro-fatty infiltration of the subepicardium is another shared substrate between ventricular and atrial arrhythmias. Recent data have emphasized the role of the epicardial reactivation in the formation of this arrhythmogenic substrate. There are new evidences supporting this structural remodelling process to be regulated by the recruitment of epicardial progenitor cells that can differentiate into adipocytes or fibroblasts under various stimuli. In addition, immune-inflammatory processes can also contribute to fibrosis of the subepicardial layer. A better understanding of such ‘electrical fragility’ of the epicardial area will open perspectives for novel biomarkers and therapeutic strategies. In this review article, a pathophysiological scheme of epicardial-driven arrhythmias will be proposed.
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Affiliation(s)
- Corentin Chaumont
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Nadine Suffee
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Estelle Gandjbakhch
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Elise Balse
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Anselme
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Stéphane N Hatem
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
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12
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Behr ER, Ben-Haim Y, Ackerman MJ, Krahn AD, Wilde AAM. Brugada syndrome and reduced right ventricular outflow tract conduction reserve: a final common pathway? Eur Heart J 2021; 42:1073-1081. [PMID: 33421051 DOI: 10.1093/eurheartj/ehaa1051] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/04/2020] [Accepted: 12/09/2020] [Indexed: 12/19/2022] Open
Abstract
Brugada syndrome (BrS) was first described as a primary electrical disorder predisposing to the risk of sudden cardiac death and characterized by right precordial lead ST elevation. Early description of right ventricular structural abnormalities and of right ventricular outflow tract (RVOT) conduction delay in BrS patients set the stage for the current controversy over the pathophysiology underlying the syndrome: channelopathy or cardiomyopathy; repolarization or depolarization. This review examines the current understanding of the BrS substrate, its genetic and non-genetic basis, theories of pathophysiology, and the clinical implications thereof. We propose that the final common pathway for BrS could be viewed as a disease of 'reduced RVOT conduction reserve'.
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Affiliation(s)
- Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, Cranmer Terrace, London SW17 0RE, UK.,St. George's University Hospitals NHS Foundation Trust, Cranmer Terrace, London SW17 0RE, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (ERN GUARDHEART http://guardheart.ern-net.eu).,European Cardiac Arrhythmia Genetics Focus Group (ECGen), EHRA
| | - Yael Ben-Haim
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, Cranmer Terrace, London SW17 0RE, UK.,St. George's University Hospitals NHS Foundation Trust, Cranmer Terrace, London SW17 0RE, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (ERN GUARDHEART http://guardheart.ern-net.eu)
| | - Michael J Ackerman
- Division of Heart Rhythm Services and the Windland Smith Rice Genetic Heart Rhythm Clinic, Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.,Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.,Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrew D Krahn
- Heart Rhythm Services, Division of Cardiology, Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (ERN GUARDHEART http://guardheart.ern-net.eu).,European Cardiac Arrhythmia Genetics Focus Group (ECGen), EHRA.,Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
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13
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Boukens BJ, Potse M, Coronel R. Fibrosis and Conduction Abnormalities as Basis for Overlap of Brugada Syndrome and Early Repolarization Syndrome. Int J Mol Sci 2021; 22:1570. [PMID: 33557237 PMCID: PMC7913989 DOI: 10.3390/ijms22041570] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
Brugada syndrome and early repolarization syndrome are both classified as J-wave syndromes, with a similar mechanism of arrhythmogenesis and with the same basis for genesis of the characteristic electrocardiographic features. The Brugada syndrome is now considered a conduction disorder based on subtle structural abnormalities in the right ventricular outflow tract. Recent evidence suggests structural substrate in patients with the early repolarization syndrome as well. We propose a unifying mechanism based on these structural abnormalities explaining both arrhythmogenesis and the electrocardiographic changes. In addition, we speculate that, with increasing technical advances in imaging techniques and their spatial resolution, these syndromes will be reclassified as structural heart diseases or cardiomyopathies.
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Affiliation(s)
- Bastiaan J. Boukens
- Department of Experimental Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
- Department of Medical Biology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Mark Potse
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Bordeaux, France;
- UMR5251, Institut de Mathématiques de Bordeaux, Université de Bordeaux, 33400 Talence, France
- Carmen Team, INRIA Bordeaux—Sud-Ouest, 33400 Talence, France
| | - Ruben Coronel
- Department of Experimental Cardiology, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
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14
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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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15
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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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16
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Blok M, Boukens BJ. Mechanisms of Arrhythmias in the Brugada Syndrome. Int J Mol Sci 2020; 21:ijms21197051. [PMID: 32992720 PMCID: PMC7582368 DOI: 10.3390/ijms21197051] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
Arrhythmias in Brugada syndrome patients originate in the right ventricular outflow tract (RVOT). Over the past few decades, the characterization of the unique anatomy and electrophysiology of the RVOT has revealed the arrhythmogenic nature of this region. However, the mechanisms that drive arrhythmias in Brugada syndrome patients remain debated as well as the exact site of their occurrence in the RVOT. Identifying the site of origin and mechanism of Brugada syndrome would greatly benefit the development of mechanism-driven treatment strategies.
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Affiliation(s)
- Michiel Blok
- Department of Medical Biology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Experimental Cardiology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Bastiaan J. Boukens
- Department of Medical Biology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Experimental Cardiology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-566-4659
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17
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Isbister JC, Krahn AD, Semsarian C, Sy RW. Brugada Syndrome: Clinical Care Amidst Pathophysiological Uncertainty. Heart Lung Circ 2020; 29:538-546. [PMID: 31959551 DOI: 10.1016/j.hlc.2019.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022]
Abstract
Brugada syndrome (BrS) is a complex clinical entity with ongoing conjecture regarding its genetic basis, underlying pathophysiology, and clinical management. Within this paradigm of uncertainty, clinicians are faced with the challenge of caring for patients with this uncommon but potentially fatal condition. This article reviews the current understanding of BrS and highlights the "known unknowns" to reinforce the need for flexible clinical practice in parallel with ongoing scientific discovery.
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Affiliation(s)
- Julia C Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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18
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Bhar-Amato J, Finlay M, Santos D, Orini M, Chaubey S, Vyas V, Taggart P, Grace AA, Huang CLH, Ben Simon R, Tinker A, Lambiase PD. Pharmacological Modulation of Right Ventricular Endocardial-Epicardial Gradients in Brugada Syndrome. Circ Arrhythm Electrophysiol 2019; 11:e006330. [PMID: 30354290 DOI: 10.1161/circep.118.006330] [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] [Indexed: 11/16/2022]
Abstract
Background We explored the hypothesis that increased cholinergic tone exerts its proarrhythmic effects in Brugada syndrome (BrS) through increasing dispersion of transmural repolarization in patients with spontaneous and drug-induced BrS. Methods BrS and supraventricular tachycardia patients were studied after deploying an Ensite Array in the right ventricular outflow tract and a Cardima catheter in the great cardiac vein to record endo and epicardial signals, respectively. S1-S2 restitution curves from the right ventricular apex were conducted at baseline and after edrophonium challenge to promote increased cholinergic tone. The local unipolar electrograms were then analyzed to study transmural conduction and repolarization dynamics. Results The study included 8 BrS patients (5 men:3 women; mean age, 56 years) and 8 controls patients with supraventricular tachycardia (5 men:3 women; mean age, 48 years). Electrophysiological studies in controls demonstrated shorter endocardial than epicardial right ventricular activation times (mean difference: 26 ms; P<0.001). In contrast, patients with BrS showed longer endocardial than epicardial activation time (mean difference: -15 ms; P=0.001). BrS hearts, compared with controls, showed significantly larger transmural gradients in their activation recovery intervals (mean intervals, 20.5 versus 3.5 ms; P<0.01), with longer endocardial than epicardial activation recovery intervals. Edrophonium challenge increased such gradients in both controls (to a mean of 16 ms [ P<0.001]) and BrS (to 29.7 ms; P<0.001). However, these were attributable to epicardial and endocardial activation recovery interval prolongations in control and BrS hearts, respectively. Dynamic changes in repolarization gradients were also observed across the BrS right ventricular wall in BrS. Conclusions Differential contributions of conduction and repolarization were identified in BrS which critically modulated transmural dispersion of repolarization with significant cholinergic effects only identified in the patients with BrS. This has important implications for explaining the proarrhythmic effects of increased vagal tone in BrS, as well as evaluating autonomic modulation and epicardial ablation as therapeutic strategies.
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Affiliation(s)
- Justine Bhar-Amato
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.)
| | - Malcolm Finlay
- Barts Heart Centre, London, United Kingdom (M.F., V.V., R.B.S., P.D.L.).,Queen Mary's College London, United Kingdom (M.F., A.T.)
| | - Diogo Santos
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.)
| | - Michele Orini
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.)
| | | | - Vishal Vyas
- Barts Heart Centre, London, United Kingdom (M.F., V.V., R.B.S., P.D.L.)
| | - Peter Taggart
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.)
| | - Andrew A Grace
- Cambridge University, United Kingdom (A.A.G., C.L.-H.H.)
| | | | - Ron Ben Simon
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.).,Barts Heart Centre, London, United Kingdom (M.F., V.V., R.B.S., P.D.L.)
| | - Andrew Tinker
- Queen Mary's College London, United Kingdom (M.F., A.T.)
| | - Pier D Lambiase
- University College London, United Kingdom (J.B.-A., D.S., M.O., P.T., P.D.L.).,Barts Heart Centre, London, United Kingdom (M.F., V.V., R.B.S., P.D.L.)
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19
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20
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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, 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. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
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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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 436] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Moncayo-Arlandi J, Brugada R. Unmasking the molecular link between arrhythmogenic cardiomyopathy and Brugada syndrome. Nat Rev Cardiol 2017; 14:744-756. [DOI: 10.1038/nrcardio.2017.103] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Juang JMJ, Lin JL. Brugada syndrome: Merely a ion channelopathy, a structural heart disease, or mixed? Heart Rhythm 2017; 14:590-591. [DOI: 10.1016/j.hrthm.2016.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Indexed: 11/28/2022]
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Martini B, Martini N, Dorantes Sánchez M, Márquez MF, Zhang L, Fontaine G, Nava A. [Clues of an underlying organic substrate in the Brugada Syndrome]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:49-60. [PMID: 28038951 DOI: 10.1016/j.acmx.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 10/06/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Bortolo Martini
- Unidad Cardiovascular, Hospital Alto Vicentino, Santorso, Italia.
| | - Nicolò Martini
- Colegio Médico, Universidad de Medicina de Ferrara, Ferrara, Italia
| | - Margarita Dorantes Sánchez
- Servicio de Arritmias y Estimulación Cardiaca, Instituto de Cardiología y Cirugía Cardiovascular, La Habana, Cuba
| | - Manlio F Márquez
- Servicio de Electrocardiología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Li Zhang
- Instituto Lankenau de Investigación Médica, Colegio Médico Jefferson, Filadelfia, Estados Unidos
| | - Guy Fontaine
- Unidad de Ritmología, Instituto de Cardiología, Hospital de La Pitié-Salpêtrière, París, Francia
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Corrado D, Zorzi A, Cerrone M, Rigato I, Mongillo M, Bauce B, Delmar M. Relationship Between Arrhythmogenic Right Ventricular Cardiomyopathy and Brugada Syndrome: New Insights From Molecular Biology and Clinical Implications. Circ Arrhythm Electrophysiol 2016; 9:e003631. [PMID: 26987567 PMCID: PMC4800833 DOI: 10.1161/circep.115.003631] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Domenico Corrado
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.).
| | - Alessandro Zorzi
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
| | - Marina Cerrone
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
| | - Ilaria Rigato
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
| | - Marco Mongillo
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
| | - Barbara Bauce
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
| | - Mario Delmar
- From the Departments of Cardiac, Thoracic, and Vascular Sciences (D.C., A.Z., I.R., B.B.) and Biomedical Sciences (M.M.), University of Padua, Padova, Italy; and The Leon H. Charney Division of Cardiology, New York University School of Medicine (M.C., M.D.)
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Nademanee K, Raju H, de Noronha SV, Papadakis M, Robinson L, Rothery S, Makita N, Kowase S, Boonmee N, Vitayakritsirikul V, Ratanarapee S, Sharma S, van der Wal AC, Christiansen M, Tan HL, Wilde AA, Nogami A, Sheppard MN, Veerakul G, Behr ER. Fibrosis, Connexin-43, and Conduction Abnormalities in the Brugada Syndrome. J Am Coll Cardiol 2016; 66:1976-1986. [PMID: 26516000 PMCID: PMC4631798 DOI: 10.1016/j.jacc.2015.08.862] [Citation(s) in RCA: 280] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/28/2015] [Accepted: 08/17/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The right ventricular outflow tract (RVOT) is acknowledged to be responsible for arrhythmogenesis in Brugada syndrome (BrS), but the pathophysiology remains controversial. OBJECTIVES This study assessed the substrate underlying BrS at post-mortem and in vivo, and the role for open thoracotomy ablation. METHODS Six whole hearts from male post-mortem cases of unexplained sudden death (mean age 23.2 years) with negative specialist cardiac autopsy and familial BrS were used and matched to 6 homograft control hearts by sex and age (within 3 years) by random risk set sampling. Cardiac autopsy sections from cases and control hearts were stained with picrosirius red for collagen. The RVOT was evaluated in detail, including immunofluorescent stain for connexin-43 (Cx43). Collagen and Cx43 were quantified digitally and compared. An in vivo study was undertaken on 6 consecutive BrS patients (mean age 39.8 years, all men) during epicardial RVOT ablation for arrhythmia via thoracotomy. Abnormal late and fractionated potentials indicative of slowed conduction were identified, and biopsies were taken before ablation. RESULTS Collagen was increased in BrS autopsy cases compared with control hearts (odds ratio [OR]: 1.42; p = 0.026). Fibrosis was greatest in the RVOT (OR: 1.98; p = 0.003) and the epicardium (OR: 2.00; p = 0.001). The Cx43 signal was reduced in BrS RVOT (OR: 0.59; p = 0.001). Autopsy and in vivo RVOT samples identified epicardial and interstitial fibrosis. This was collocated with abnormal potentials in vivo that, when ablated, abolished the type 1 Brugada electrocardiogram without ventricular arrhythmia over 24.6 ± 9.7 months. CONCLUSIONS BrS is associated with epicardial surface and interstitial fibrosis and reduced gap junction expression in the RVOT. This collocates to abnormal potentials, and their ablation abolishes the BrS phenotype and life-threatening arrhythmias. BrS is also associated with increased collagen throughout the heart. Abnormal myocardial structure and conduction are therefore responsible for BrS.
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Affiliation(s)
| | - Hariharan Raju
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | - Sofia V de Noronha
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | - Michael Papadakis
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | - Laurence Robinson
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | - Stephen Rothery
- Centre for Translational & Experimental Medicine, Imperial College London and Hammersmith Hospital, London, United Kingdom
| | - Naomasa Makita
- Department of Molecular Physiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinya Kowase
- Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama City, Japan
| | - Nakorn Boonmee
- Bhumibol Adulyadej Air Force Hospital, Royal Thai Air Force, Bangkok, Thailand
| | | | - Samrerng Ratanarapee
- Department of Pathology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sanjay Sharma
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | | | | | - Hanno L Tan
- Heart Centre, Academic Medical Centre, Amsterdam, the Netherlands
| | - Arthur A Wilde
- Heart Centre, Academic Medical Centre, Amsterdam, the Netherlands; Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Saudi Arabia
| | - Akihiko Nogami
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mary N Sheppard
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom
| | - Gumpanart Veerakul
- Bhumibol Adulyadej Air Force Hospital, Royal Thai Air Force, Bangkok, Thailand
| | - Elijah R Behr
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom.
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Basis for the Induction of Tissue-Level Phase-2 Reentry as a Repolarization Disorder in the Brugada Syndrome. BIOMED RESEARCH INTERNATIONAL 2015; 2015:197586. [PMID: 26583094 PMCID: PMC4637010 DOI: 10.1155/2015/197586] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/21/2015] [Accepted: 08/23/2015] [Indexed: 11/20/2022]
Abstract
Aims. Human action potentials in the Brugada syndrome have been characterized by delayed or even complete loss of dome formation, especially in the right ventricular epicardial layers. Such a repolarization pattern is believed to trigger phase-2 reentry (P2R); however, little is known about the conditions necessary for its initiation. This study aims to determine the specific mechanisms that facilitate P2R induction in Brugada-affected cardiac tissue in humans. Methods. Ionic models for Brugada syndrome in human epicardial cells were developed and used to study the induction of P2R in cables, sheets, and a three-dimensional model of the right ventricular free wall. Results. In one-dimensional cables, P2R can be induced by adjoining lost-dome and delayed-dome regions, as mediated by tissue excitability and transmembrane voltage profiles, and reduced coupling facilitates its induction. In two and three dimensions, sustained reentry can arise when three regions (delayed-dome, lost-dome, and normal epicardium) are present. Conclusions. Not only does P2R induction by Brugada syndrome require regions of action potential with delayed-dome and lost-dome, but in order to generate a sustained reentry from a triggered waveback multiple factors are necessary, including heterogeneity in action potential distribution, tissue coupling, direction of stimulation, the shape of the late plateau, the duration of lost-dome action potentials, and recovery of tissue excitability, which is predominantly modulated by tissue coupling.
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Zindler K, Klingel K, Kriebel T, Marschall C, Ormandy L, Grellner W. „Schweinegrippe“ vs. Brugada-Syndrom. Rechtsmedizin (Berl) 2015. [DOI: 10.1007/s00194-015-0003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Peters S. Is Brugada syndrome a variant of arrhythmogenic cardiomyopathy? Int J Cardiol 2015; 189:88-90. [PMID: 25889434 DOI: 10.1016/j.ijcard.2015.03.394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/19/2015] [Indexed: 12/28/2022]
Affiliation(s)
- S Peters
- St. Elisabeth Hospital Salzgitter, Germany.
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Spatial and transmural repolarization, and dispersion of repolarization and late potentials evaluated using signal-averaged vector-projected 187-channel high-resolution electrocardiogram in Brugada syndrome. J Arrhythm 2014. [DOI: 10.1016/j.joa.2013.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Pambrun T, Bortone A, Bois P, Degand B, Patri S, Mercier A, Chahine M, Chatelier A, Coisne D, Amiel A. Unmasked Brugada pattern by ajmaline challenge in patients with myotonic dystrophy type 1. Ann Noninvasive Electrocardiol 2014; 20:28-36. [PMID: 24943134 DOI: 10.1111/anec.12168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Myotonic dystrophy type 1 (DM1) generates missplicing of the SCN5A gene, encoding the cardiac sodium channel (Nav 1.5). Brugada syndrome, which partly results from Nav 1.5 dysfunction and causes increased VF occurrence, can be unmasked by ajmaline. We aimed to investigate the response to ajmaline challenge in DM1 patients and its potential impact on their sudden cardiac death risk stratification. METHODS Among 36 adult DM1 patients referred to our institution, electrophysiological study and ajmaline challenge were performed in 12 patients fulfilling the following criteria: (1) PR interval >200 ms or QRS duration >100 ms; (2) absence of complete left bundle branch block; (3) absence of permanent ventricular pacing; (4) absence of implantable cardioverter-defibrillator (ICD); (5) preserved left-ventricular ejection fraction >50%; and (6) absence of severe muscular impairment. Of note, DM1 patients with ajmaline-induced Brugada pattern (BrP) were screened for SCN5A. RESULTS In all the 12 patients studied, the HV interval was <70 ms. A BrP was unmasked in three patients but none carried an SCN5A mutation. Ajmaline-induced sustained ventricular tachycardia occurred in one patient with BrP, who finally received an ICD. The other patients did not present any cardiac event during the entire follow-up (15 ± 4 months). CONCLUSION Our study is the first to describe a high prevalence of ajmaline-induced BrP in DM1 patients. The indications, the safety, and the implications of ajmaline challenge in this particular setting need to be determined by larger prospective studies.
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Affiliation(s)
- Thomas Pambrun
- Cardiology Department, University Hospital of Poitiers, Poitiers, France; Cardiology Department, Les Franciscaines Private Hospital, Nîmes, France
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Myotonic dystrophy type 1 mimics and exacerbates Brugada phenotype induced by Nav1.5 sodium channel loss-of-function mutation. Heart Rhythm 2014; 11:1393-400. [PMID: 24768612 DOI: 10.1016/j.hrthm.2014.04.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Myotonic dystrophy type 1 (DM1), a muscular dystrophy due to CTG expansion in the DMPK gene, can cause cardiac conduction disorders and sudden death. These cardiac manifestations are similar to those observed in loss-of-function SCN5A mutations, which are also responsible for Brugada syndrome (BrS). OBJECTIVE The purpose of this study was to investigate DM1 effects on clinical expression of a loss-of-function SCN5A mutation causing BrS. METHODS We performed complete clinical evaluation, including ajmaline test, in 1 family combining DM1 and BrS. We screened the known BrS susceptibility genes. We characterized an SCN5A mutation using whole-cell patch-clamp experiments associated with cell surface biotinylation. RESULTS The proband, a 15-year-old female, was a survivor of out-of-hospital cardiac arrest with ventricular fibrillation. She combined a DMPK CTG expansion from the father's side and an SCN5A mutation (S910L) from the mother's side. S910L is a trafficking defective mutant inducing a dominant negative effect when transfected with wild-type Nav1.5. This loss-of-function SCN5A mutation caused a Brugada phenotype during the mother's ajmaline test. Surprisingly, in the father, a DM1 patient without SCN5A mutation, ajmaline also unmasked a Brugada phenotype. Furthermore, association of both genetic abnormalities in the proband exacerbated the response to ajmaline with a massive conduction defect. CONCLUSION Our study is the first to describe the deleterious effect of DM1 on clinical expression of a loss-of-function SCN5A mutation and to show a provoked BrS phenotype in a DM1 patient. The modification of the ECG pattern by ajmaline supports the hypothesis of a link between DM1 and Nav1.5 loss of -function.
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Gray B, Semsarian C, Sy RW. Brugada syndrome: a heterogeneous disease with a common ECG phenotype? J Cardiovasc Electrophysiol 2014; 25:450-456. [PMID: 24405173 DOI: 10.1111/jce.12366] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/05/2013] [Accepted: 12/31/2013] [Indexed: 12/19/2022]
Abstract
Our understanding of Brugada syndrome (BrS) has evolved since the syndrome was first described in 1992. BrS is considered to be a primary inherited channelopathy often involving the inward sodium current and the diagnosis has traditionally required the exclusion of overt structural heart disease. In view of recently published observations about BrS, we propose that the term BrS may actually encompass a heterogeneous group of disorders with a variety of genetic and clinical phenotypes. This disease has classically been described as a primary electrical disorder involving the sodium channel leading to the characteristic electrocardiogram (ECG) changes of BrS. We challenge the current understanding and propose that patients with structurally normal hearts, family history of sudden cardiac death, with associated genetic abnormalities only account for a subset of patients with the "Brugada pattern" ECG. There may also be some patients with a diagnosis of BrS who may also have features which overlap with arrhythmogenic right ventricular cardiomyopathy. In these patients there may be an underlying structural abnormality. In this context, it is possible that catheter ablation may abolish the "Brugada pattern" ECG changes as well as abolishing the risk of life threatening arrhythmias in these patients. Given the recent developments in the field, we propose a novel comprehensive multimodality model for risk stratification and assessment of patients with BrS. Identification of variations of diseases may facilitate more specific risk stratification models and management paradigms in patients with Brugada ECG pattern.
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Affiliation(s)
- Belinda Gray
- Department of Cardiology, Royal Prince Alfred Hospital.,Agnes Ginges Centre for Molecular Cardiology, Centenary Institute.,Sydney Medical School, University of Sydney, NSW, Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital.,Agnes Ginges Centre for Molecular Cardiology, Centenary Institute.,Sydney Medical School, University of Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital.,Sydney Medical School, University of Sydney, NSW, Australia
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Abstract
More than 20 years have passed since the description of Brugada syndrome as a clinical entity. The original case series depicted patients who all had coved ST-segment elevation in the right precordial leads, associated with a high risk of sudden death and no apparent structural heart disease. As subsequent registry data were published, it became apparent that the spectrum of risk is wide, with the majority of patients classified as low risk. Two consensus documents have been published that will continue to be updated. Despite intense research efforts, many controversies still exist over its pathophysiology and the risk stratification for sudden death. Management continues to be challenging with a lack of drug therapy and high complication rates from implantable cardioverter defibrillators. In this review, we highlight the current state-of-the-art therapies and their controversies.
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Affiliation(s)
- Anthony Li
- Cardiovascular Sciences Research Centre, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Papadakis M, Raju H, Behr ER, De Noronha SV, Spath N, Kouloubinis A, Sheppard MN, Sharma S. Sudden cardiac death with autopsy findings of uncertain significance: potential for erroneous interpretation. Circ Arrhythm Electrophysiol 2013; 6:588-96. [PMID: 23671135 DOI: 10.1161/circep.113.000111] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The sudden death of young individuals is commonly attributed to inherited cardiac disorders, and familial evaluation is advocated. The identification of pathognomonic histopathologic findings, or the absence of cardiac pathology (sudden arrhythmic death syndrome [SADS]) at postmortem, directs familial evaluation targeting structural disorders or primary arrhythmogenic syndromes, respectively. In a proportion of autopsies, structural abnormalities of uncertain significance are reported. We explored the hypothesis that such sudden cardiac deaths represent SADS. METHODS AND RESULTS Families (n=340) of index cases of sudden cardiac deaths who underwent postmortem evaluation were evaluated in specialist cardiogenetics clinics. Families in whom the deceased exhibited structural abnormalities of uncertain significance (n=41), such as ventricular hypertrophy, myocardial fibrosis, and minor coronary artery disease, were included in the study. Results were compared with 163 families with normal postmortem (SADS). Relatives underwent comprehensive cardiac evaluation. Twenty-one families (51%) with autopsy findings of uncertain significance received a diagnosis based on the identification of an inherited cardiac condition phenotype in ≥1 relatives: 14 Brugada syndrome; 4 long-QT syndrome; 1 catecholaminergic polymorphic ventricular tachycardia; and 2 cardiomyopathy. A similar proportion of families (47.2%) received a diagnosis in the SADS cohort (P=0.727). An arrhythmogenic syndrome was the predominant diagnosis in both cohorts (46% versus 45%; P=0.863). CONCLUSIONS Familial evaluation after sudden cardiac deaths with autopsy findings of uncertain significance identified a similar proportion of primary arrhythmogenic syndromes to a contemporary series of SADS. Our study highlights the need for accurate interpretation of autopsy findings to avoid erroneous diagnoses, with potentially devastating implications.
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Affiliation(s)
- Michael Papadakis
- Cardiovascular Sciences Research Centre, St George's University of London, UK
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Liu H, Chatel S, Simard C, Syam N, Salle L, Probst V, Morel J, Millat G, Lopez M, Abriel H, Schott JJ, Guinamard R, Bouvagnet P. Molecular genetics and functional anomalies in a series of 248 Brugada cases with 11 mutations in the TRPM4 channel. PLoS One 2013; 8:e54131. [PMID: 23382873 PMCID: PMC3559649 DOI: 10.1371/journal.pone.0054131] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 12/10/2012] [Indexed: 11/19/2022] Open
Abstract
Brugada syndrome (BrS) is a condition defined by ST-segment alteration in right precordial leads and a risk of sudden death. Because BrS is often associated with right bundle branch block and the TRPM4 gene is involved in conduction blocks, we screened TRPM4 for anomalies in BrS cases. The DNA of 248 BrS cases with no SCN5A mutations were screened for TRPM4 mutations. Among this cohort, 20 patients had 11 TRPM4 mutations. Two mutations were previously associated with cardiac conduction blocks and 9 were new mutations (5 absent from ∼14′000 control alleles and 4 statistically more prevalent in this BrS cohort than in control alleles). In addition to Brugada, three patients had a bifascicular block and 2 had a complete right bundle branch block. Functional and biochemical studies of 4 selected mutants revealed that these mutations resulted in either a decreased expression (p.Pro779Arg and p.Lys914X) or an increased expression (p.Thr873Ile and p.Leu1075Pro) of TRPM4 channel. TRPM4 mutations account for about 6% of BrS. Consequences of these mutations are diverse on channel electrophysiological and cellular expression. Because of its effect on the resting membrane potential, reduction or increase of TRPM4 channel function may both reduce the availability of sodium channel and thus lead to BrS.
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Affiliation(s)
- Hui Liu
- Laboratoire Cardiogénétique, Hospices Civils de Lyon, Groupe Hospitalier Est, Bron, France
- Laboratoire Cardiogénétique, Equipe d’Accueil 4173, Université Lyon 1, Lyon, France
| | - Stéphanie Chatel
- Unité Mixte de Recherche 915, Institut National de la Santé Et de la Recherche Médicale, l’institut du thorax, Nantes, France
- Equipe de Recherche Labellisée 3147, Centre National de la Recherche Scientifique, l’institut du thorax, Nantes, France
- Université de Nantes, l’institut du thorax, Nantes, France
| | - Christophe Simard
- Groupe Signalisation, Electrophysiologie et Imagerie des lésions d’ischémie- reperfusion myocardique, Equipe d’Accueil 4650, Université de Caen, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Ninda Syam
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Laurent Salle
- Groupe Signalisation, Electrophysiologie et Imagerie des lésions d’ischémie- reperfusion myocardique, Equipe d’Accueil 4650, Université de Caen, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Vincent Probst
- Unité Mixte de Recherche 915, Institut National de la Santé Et de la Recherche Médicale, l’institut du thorax, Nantes, France
- Equipe de Recherche Labellisée 3147, Centre National de la Recherche Scientifique, l’institut du thorax, Nantes, France
- Université de Nantes, l’institut du thorax, Nantes, France
- Service de Cardiologie, CHU Nantes, l’institut du thorax, Nantes, France
| | - Julie Morel
- Groupe Signalisation, Electrophysiologie et Imagerie des lésions d’ischémie- reperfusion myocardique, Equipe d’Accueil 4650, Université de Caen, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Gilles Millat
- Laboratoire Cardiogénétique, Hospices Civils de Lyon, Groupe Hospitalier Est, Bron, France
- Laboratoire Neurocardiologie, EA 4612, Université Lyon 1, Lyon, France
| | - Michel Lopez
- Service de Cardiologie, Hôpital Saint Luc, Saint Joseph, Lyon, France
| | - Hugues Abriel
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Jean-Jacques Schott
- Unité Mixte de Recherche 915, Institut National de la Santé Et de la Recherche Médicale, l’institut du thorax, Nantes, France
- Equipe de Recherche Labellisée 3147, Centre National de la Recherche Scientifique, l’institut du thorax, Nantes, France
- Université de Nantes, l’institut du thorax, Nantes, France
- Service de Cardiologie, CHU Nantes, l’institut du thorax, Nantes, France
| | - Romain Guinamard
- Groupe Signalisation, Electrophysiologie et Imagerie des lésions d’ischémie- reperfusion myocardique, Equipe d’Accueil 4650, Université de Caen, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Patrice Bouvagnet
- Laboratoire Cardiogénétique, Hospices Civils de Lyon, Groupe Hospitalier Est, Bron, France
- Laboratoire Cardiogénétique, Equipe d’Accueil 4173, Université Lyon 1, Lyon, France
- Service de Cardiologie Pédiatrique, Hospices Civils de Lyon, Groupe Hospitalier Est, Bron, France
- * E-mail:
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Jeevaratnam K, Rewbury R, Zhang Y, Guzadhur L, Grace AA, Lei M, Huang CLH. Frequency distribution analysis of activation times and regional fibrosis in murine Scn5a+/- hearts: the effects of ageing and sex. Mech Ageing Dev 2012; 133:591-9. [PMID: 22968175 PMCID: PMC3466423 DOI: 10.1016/j.mad.2012.07.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 07/17/2012] [Accepted: 07/31/2012] [Indexed: 12/21/2022]
Abstract
Both Brugada Syndrome (BrS) and progressive cardiac conduction defect (PCCD) are associated respectively with diffuse and discrete alterations in conduction pathways affected by ageing and sex. This study assessed for contributions of such processes to the mechanism of conduction changes in Scn5a+/− and WT hearts stratified by age (3 and 12 months) and sex. In vivo electrocardiographic chest-lead assessment demonstrated greater incidences of bundle branch block in all Scn5a+/− mice compared to WT. Frequency analysis of right ventricular (RV) epicardial activation obtained from a 64-channel multi-electrode array demonstrated greater prominence of late conducting components in Scn5a+/− compared to WT male, and in male compared to female Scn5a+/− following stratification by genotype and sex. Similar differences were observed between old male Scn5a+/− and young male Scn5a+/−, old female Scn5a+/−, and old male WT, following stratification by genotype, age and sex. These findings directly correlated with histomorphometric assessment of regional fibrosis in both septa and free walls preferentially involving the RV. We demonstrate complex alterations in conduction distributions suggesting a conversion of normal to slow-conducting tissue, modulated by ageing and sex, coupled with fibrosis in Scn5a+/− hearts. These features suggest an overlap between pathophysiological processes related to BrS and PCCD in Scn5a+/− hearts.
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Affiliation(s)
- Kamalan Jeevaratnam
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge CB2 3EG, United Kingdom.
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Hoogendijk MG. Diagnostic dilemmas: overlapping features of brugada syndrome and arrhythmogenic right ventricular cardiomyopathy. Front Physiol 2012; 3:144. [PMID: 22654761 PMCID: PMC3358709 DOI: 10.3389/fphys.2012.00144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 04/29/2012] [Indexed: 11/13/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) and Brugada syndrome are distinct clinical entities which diagnostic criteria exclude their coexistence in individual patients. ARVC is a myocardial disorder characterized by fibro-fatty replacement of the myocardium and ventricular arrhythmias. In contrast, the Brugada syndrome has long been considered a functional cardiac disorder: no gross structural abnormalities can be identified in the majority of patients and its electrocardiographic hallmark of coved-type ST-segment elevation in right precordial leads is dynamic. Nonetheless, a remarkable overlap in clinical features has been demonstrated between these conditions. This review focuses on this overlap and discusses its potential causes and consequences.
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Affiliation(s)
- Mark G Hoogendijk
- Experimental Cardiology Group, Heart Failure Research Center, Academic Medical Center, University of Amsterdam Amsterdam, Netherlands
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Merante A, Gareri P, Bonacci E, Russo G, Castagna A, Lacava R, Marigliano NM, Gualtieri U, Condito AM, Ruotolo G. Brugada syndrome (BS) and syncope: a complex therapeutic issue. Arch Gerontol Geriatr 2011; 55:706-8. [PMID: 22115873 DOI: 10.1016/j.archger.2011.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 10/24/2011] [Accepted: 10/26/2011] [Indexed: 10/15/2022]
Abstract
A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was "Syncope in patient affected with BS, hypertension". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions.
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Affiliation(s)
- Alfonso Merante
- SOC Geriatric Unit, Pugliese-Ciaccio Hospital, via Madonna dei Cieli, I-88100 Catanzaro, Italy.
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Kofune M, Watanabe I, Ohkubo K, Ashino S, Okumura Y, Nagashima K, Mano H, Nakai T, Kasamaki Y, Hirayama A. Clarifying the Arrhythmogenic Substrate for Brugada Syndrome Electroanatomic Mapping Study of the Right Ventricle. Int Heart J 2011; 52:290-4. [DOI: 10.1536/ihj.52.290] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sonoko Ashino
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yuji Kasamaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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