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Pandozi C, Mariani MV, Chimenti C, Maestrini V, Filomena D, Magnocavallo M, Straito M, Piro A, Russo M, Galeazzi M, Ficili S, Colivicchi F, Severino P, Mancone M, Fedele F, Lavalle C. The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:27-38. [PMID: 35072829 PMCID: PMC9931863 DOI: 10.1007/s10840-021-01104-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias. METHODS Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD. RESULTS Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation. CONCLUSIONS Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.
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Affiliation(s)
- C. Pandozi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - C. Chimenti
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - V. Maestrini
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - D. Filomena
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Magnocavallo
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Straito
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - A. Piro
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Russo
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - M. Galeazzi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - S. Ficili
- ASP, Ragusa Maggiore Hospital, Modica, Italy
| | - F. Colivicchi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - P. Severino
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Mancone
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - F. Fedele
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - C. Lavalle
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Tarantino N, Della Rocca DG, De Leon De La Cruz NS, Manheimer ED, Magnocavallo M, Lavalle C, Gianni C, Mohanty S, Trivedi C, Al-Ahmad A, Horton RP, Bassiouny M, Burkhardt JD, Gallinghouse GJ, Forleo GB, Di Biase L, Natale A. Catheter Ablation of Life-Threatening Ventricular Arrhythmias in Athletes. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:205. [PMID: 33652714 PMCID: PMC7996951 DOI: 10.3390/medicina57030205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 12/22/2022]
Abstract
A recent surveillance analysis indicates that cardiac arrest/death occurs in ≈1:50,000 professional or semi-professional athletes, and the most common cause is attributable to life-threatening ventricular arrhythmias (VAs). It is critically important to diagnose any inherited/acquired cardiac disease, including coronary artery disease, since it frequently represents the arrhythmogenic substrate in a substantial part of the athletes presenting with major VAs. New insights indicate that athletes develop a specific electro-anatomical remodeling, with peculiar anatomic distribution and VAs patterns. However, because of the scarcity of clinical data concerning the natural history of VAs in sports performers, there are no dedicated recommendations for VA ablation. The treatment remains at the mercy of several individual factors, including the type of VA, the athlete's age, and the operator's expertise. With the present review, we aimed to illustrate the prevalence, electrocardiographic (ECG) features, and imaging correlations of the most common VAs in athletes, focusing on etiology, outcomes, and sports eligibility after catheter ablation.
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Affiliation(s)
- Nicola Tarantino
- Arrhythmia Service, Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY 10467, USA; (N.T.); (E.D.M.); (L.D.B.)
| | - Domenico G. Della Rocca
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | | | - Eric D. Manheimer
- Arrhythmia Service, Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY 10467, USA; (N.T.); (E.D.M.); (L.D.B.)
| | - Michele Magnocavallo
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.M.); (C.L.)
| | - Carlo Lavalle
- Department of Cardiovascular/Respiratory Diseases, Nephrology, Anesthesiology, and Geriatric Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.M.); (C.L.)
| | - Carola Gianni
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Sanghamitra Mohanty
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Chintan Trivedi
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Amin Al-Ahmad
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Rodney P. Horton
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Mohamed Bassiouny
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - J. David Burkhardt
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - G. Joseph Gallinghouse
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
| | - Giovanni B. Forleo
- Department of Cardiology, Azienda Ospedaliera-Universitaria “Luigi Sacco”, 20057 Milano, Italy;
| | - Luigi Di Biase
- Arrhythmia Service, Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY 10467, USA; (N.T.); (E.D.M.); (L.D.B.)
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
| | - Andrea Natale
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, 3000 N. IH-35, Suite 720, Austin, TX 78705, USA; (S.M.); (C.T.); (A.A.-A.); (R.P.H.); (M.B.); (J.D.B.); (G.J.G.); (A.N.)
- Interventional Electrophysiology, Scripps Clinic, La Jolla, CA 92037, USA
- Department of Cardiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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