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Mattesi G, Pergola V, Bariani R, Martini M, Motta R, Perazzolo Marra M, Rigato I, Bauce B. Multimodality imaging in arrhythmogenic cardiomyopathy - From diagnosis to management. Int J Cardiol 2024; 407:132023. [PMID: 38583594 DOI: 10.1016/j.ijcard.2024.132023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/03/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
Arrhythmogenic Cardiomyopathy (AC), an inherited cardiac disorder characterized by myocardial fibrofatty replacement, carries a significant risk of sudden cardiac death (SCD) due to ventricular arrhythmias. A comprehensive multimodality imaging approach, including echocardiography, cardiac magnetic resonance imaging (CMR), and cardiac computed tomography (CCT), allows for accurate diagnosis, effective risk stratification, vigilant monitoring, and appropriate intervention, leading to improved patient outcomes and the prevention of SCD. Echocardiography is primary tool ventricular morphology and function assessment, CMR provides detailed visualization, CCT is essential in early stages for excluding congenital anomalies and coronary artery disease. Echocardiography is preferred for follow-up, with CMR capturing changes over time. The strategic use of these imaging methods aids in confirming AC, differentiating it from other conditions, tracking its progression, managing complications, and addressing end-stage scenarios.
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Affiliation(s)
| | | | - Riccardo Bariani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Marika Martini
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
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Graziano F, Cipriani A, Balla D, Bondarev S, Marra MP, Bauce B, Vágó H, Corrado D, Zorzi A. Evolving spectrum of arrhythmogenic cardiomyopathy: Implications for Sports Cardiology. Clin Cardiol 2023; 46:1072-1081. [PMID: 37357443 PMCID: PMC10540004 DOI: 10.1002/clc.24069] [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: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/27/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a genetic heart muscle disease, structurally characterized by progressive fibro-fatty replacement of the normal myocardium and clinically by ventricular arrhythmias (VAs). Predominantly thanks to the use of cardiac magnetic resonance, we have learnt that the spectrum of the disease encompasses not only the classical right ventricular phenotype, but also biventricular and left dominant variants. Sport activity contributes to the phenotypic expression and progression of ACM and may trigger life-threatening VAs and sudden cardiac death (SCD). We conducted a review of the literature about ACM and its implications in Sport Cardiology and summarized the main findings in this topic. Early identification of affected athletes through preparticipation screening (PPS) is fundamental but, while classical right-ventricular or biventricular phenotypes are usually suspected because of electrocardiogram (ECG) and echocardiographic abnormalities, variants with predominant left ventricular involvement are often characterized by normal ECG and unremarkable echocardiography. Usually the only manifestations of such variants are exercise-induced VAs and for this reason exercise testing may empower the diagnostic yield of the PPS. Patients with ACM are not eligible to competitive sports activity, but low-to-moderate intensity physical activity under medical supervision is possible in most cases.
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Affiliation(s)
- Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Dorottya Balla
- Department of Sports MedicineSemmelweis UniversityBudapestHungary
| | - Sergei Bondarev
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Hajnalka Vágó
- Department of Sports MedicineSemmelweis UniversityBudapestHungary
- Heart and Vascular CenterSemmelweis UniversityBudapestHungary
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
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Todiere G, Barison A, Baritussio A, Cipriani A, Guaricci AI, Pica S, Indolfi C, Pontone G, Dellegrottaglie S. Acute clinical presentation of nonischemic cardiomyopathies: early detection by cardiovascular magnetic resonance. J Cardiovasc Med (Hagerstown) 2022; 24:e36-e46. [PMID: 36729634 DOI: 10.2459/jcm.0000000000001412] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Nonischemic cardiomyopathies include a wide range of dilated, hypertrophic and arrhythmogenic heart muscle disorders, not explained by coronary artery disease, hypertension, valvular or congenital heart disease. Advances in medical treatments and the availability of implantable cardioverter defibrillators to prevent sudden cardiac death have allowed a substantial increase in the survival of affected individuals, thus making early diagnosis and tailored treatment mandatory. The characterization of cardiomyopathies has received a great boost from the recent advances in cardiovascular magnetic resonance (CMR) imaging, which, to date, represents the gold standard for noninvasive assessment of cardiac morphology, function and myocardial tissue changes. An acute clinical presentation has been reported in a nonnegligible proportion of patients with nonischemic cardiomyopathies, usually complaining of acute chest pain, worsening dyspnoea or palpitations; 'hot phases' of cardiomyopathies are characterized by a dynamic rise in high-sensitivity troponin, myocardial oedema on CMR, arrhythmic instability, and by an increased long-term risk of adverse remodelling, progression of myocardial fibrosis, heart failure and malignant ventricular arrhythmias. Prompt recognition of 'hot phases' of nonischemic cardiomyopathies is of utmost importance to start an early, individualized treatment in these high-risk patients. On the one hand, CMR represents the gold standard imaging technique to detect early and typical signs of ongoing myocardial remodelling in patients presenting with a 'hot phase' nonischemic cardiomyopathy, including myocardial oedema, perfusion abnormalities and pathological mapping values. On the other hand, CMR allows the differential diagnosis of other acute heart conditions, such as acute coronary syndromes, takotsubo syndrome, myocarditis, pericarditis and sarcoidosis. This review provides a deep overview of standard and novel CMR techniques to detect 'hot phases' of cardiomyopathies, as well as their clinical and prognostic utility.
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Affiliation(s)
| | | | - Anna Baritussio
- Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padua, Padua
| | - Alberto Cipriani
- Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padua, Padua
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari
| | - Silvia Pica
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, Milan
| | - Ciro Indolfi
- Division of Cardiology, Magna Graecia University, Catanzaro
| | | | - Santo Dellegrottaglie
- Advanced Cardiovascular Imaging Unit, Clinica Villa dei Fiori, Acerra, Naples, Italy
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Cardiac magnetic resonance imaging of arrhythmogenic cardiomyopathy: evolving diagnostic perspectives. Eur Radiol 2022; 33:270-282. [PMID: 35788758 DOI: 10.1007/s00330-022-08958-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/30/2022] [Accepted: 06/08/2022] [Indexed: 01/09/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a genetically determined heart muscle disease characterized by fibro-fatty myocardial replacement, clinically associated with malignant ventricular arrhythmias and sudden cardiac death. Originally described a disease with a prevalent right ventricular (RV) involvement, subsequently two other phenotypes have been recognized, such as the left dominant and the biventricular phenotypes, for which a recent International Expert consensus document provided upgrade diagnostic criteria (the 2020 "Padua Criteria"). In this novel workup for the diagnosis of the entire spectrum of phenotypic variants of ACM, including left ventricular (LV) variants, cardiac magnetic resonance (CMR) has emerged as the cardiac imaging technique of choice, due to its capability of detailed morpho-functional and tissue characterization evaluation of both RV and LV. In this review, the key role of CMR in the diagnosis of ACM is outlined, including the supplemental value for the characterization of the disease variants. An ACM-specific CMR study protocol, as well as strengths and weaknesses of each imaging technique, is also provided. KEY POINTS: • Arrhythmogenic cardiomyopathy includes three different phenotypes: dominant right, biventricular, and dominant left. • In 2020, diagnostic criteria have been updated and cardiac magnetic resonance has emerged as the cardiac imaging technique of choice. • This aim of this review is to provide an update of the current state of art regarding the use of CMR in ACM, with a particular focus on novel diagnostic criteria, CMR protocols, and prognostic significance of CMR findings in ACM.
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Zorzi A, Bettella N, Tatangelo M, Del Monte A, Vessella T, Poscolieri B, Crescenzi C, Pegorin D, D'Ascenzi F, Pescatore V, Giada F, Sarto P, Calò L, Schiavon M, Gregori D, Hadley DM, Drezner JA, Pelliccia A, Corrado D. Prevalence and clinical significance of isolated low QRS voltages in young athletes. Europace 2022; 24:1484-1495. [PMID: 35243505 PMCID: PMC9559913 DOI: 10.1093/europace/euab330] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Indexed: 01/02/2023] Open
Abstract
AIMS Low QRS voltages (peak to peak <0.5 mV) in limb leads (LQRSV) on the athlete's electrocardiogram (ECG) may reflect an underlying cardiomyopathy, mostly arrhythmogenic cardiomyopathy (ACM) or non-ischaemic left ventricular scar (NILVS). We studied the prevalence and clinical meaning of isolated LQRSV in a large cohort of competitive athletes. METHODS AND RESULTS The index group included 2229 Italian competitive athletes [median age 18 years (16-25), 67% males, 97% Caucasian] without major ECG abnormalities at pre-participation screening. Three control groups included Black athletes (N = 1115), general population (N = 1115), and patients with ACM or NILVS (N = 58). Echocardiogram was performed in all athletes with isolated LQRSV and cardiac magnetic resonance (CMR) in those with ventricular arrhythmias or echocardiographic abnormalities. The isolated LQRSV pattern was found in 1.1% index athletes and was associated with increasing age (median age 28 vs. 18 years; P < 0.001), elite status (71% vs. 34%; P < 0.001), body surface area, and body mass index but not with sex, type of sport, and echocardiographic left ventricular mass. The prevalence of isolated LQRSV was 0.2% in Black athletes and 0.3% in young individuals from the general population. Cardiomyopathy patients had a significantly greater prevalence of isolated LQRSV (12%) than index athletes, Black athletes, and general population. Five index athletes with isolated LQSRV and exercise-induced ventricular arrhythmias underwent CMR showing biventricular ACM in 1 and idiopathic NILVS in 1. CONCLUSIONS Unlike cardiomyopathy patients, the ECG pattern of isolated LQRSV was rarely observed in athletes. This ECG sign should prompt clinical work-up for exclusion of an underlying cardiomyopathy.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - Natascia Bettella
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | | | - Alvise Del Monte
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | | | | | | | - Davide Pegorin
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy
| | | | - Franco Giada
- Sports Medicine Unit, ULSS3 Venezia, Venezia, Italy
| | | | | | | | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - David M Hadley
- Research & Development Department, Cardiac Insight Inc., Bellevue, WA, USA
| | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, WA, USA
| | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
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Brunetti G, Cipriani A, Perazzolo Marra M, De Lazzari M, Bauce B, Calore C, Rigato I, Graziano F, Vio R, Corrado D, Zorzi A. Role of Cardiac Magnetic Resonance Imaging in the Evaluation of Athletes with Premature Ventricular Beats. J Clin Med 2022; 11:426. [PMID: 35054118 PMCID: PMC8781801 DOI: 10.3390/jcm11020426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022] Open
Abstract
Premature ventricular beats (PVBs) in athletes are not rare. The risk of PVBs depends on the presence of an underlying pathological myocardial substrate predisposing the subject to sudden cardiac death. The standard diagnostic work-up of athletes with PVBs includes an examination of family and personal history, resting electrocardiogram (ECG), 24 h ambulatory ECG (possibly with a 12-lead configuration and including a training session), maximal exercise testing and echocardiography. Despite its fundamental role in the diagnostic assessment of athletes with PVBs, echocardiography has very limited sensitivity in detecting the presence of non-ischemic left ventricular scars, which can be revealed only through more in-depth studies, particularly with the use of contrast-enhanced cardiac magnetic resonance (CMR) imaging. The morphology, complexity and exercise inducibility of PVBs can help estimate the probability of an underlying heart disease. Based on these features, CMR imaging may be indicated even when echocardiography is normal. This review focuses on interpreting PVBs, and on the indication and role of CMR imaging in the diagnostic evaluation of athletes, with a special focus on non-ischemic left ventricular scars that are an emerging substrate of cardiac arrest during sport.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (G.B.); (A.C.); (M.P.M.); (M.D.L.); (B.B.); (C.C.); (I.R.); (F.G.); (R.V.); (A.Z.)
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Cicenia M, Silvetti MS, Drago F. When Should Premature Ventricular Contractions Be Considered as a Red Flag in Children with Cardiomyopathy? J Cardiovasc Dev Dis 2021; 8:jcdd8120176. [PMID: 34940531 PMCID: PMC8707971 DOI: 10.3390/jcdd8120176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
Premature ventricular contractions (PVCs) are common and generally benign in childhood and tend to resolve spontaneously in most cases. When PVCs occur frequently, an arrhythmia-induced cardiomyopathy may be present requiring medical or catheter ablation. PVCs are only rarely the manifestation of a cardiomyopathy. The purpose of this review is to provide some tips and tricks to raise the suspicion of a cardiac disease based on the presence and characteristics of PVCs in children.
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Mattesi G, Cipriani A, Bauce B, Rigato I, Zorzi A, Corrado D. Arrhythmogenic Left Ventricular Cardiomyopathy: Genotype-Phenotype Correlations and New Diagnostic Criteria. J Clin Med 2021; 10:jcm10102212. [PMID: 34065276 PMCID: PMC8160676 DOI: 10.3390/jcm10102212] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/06/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an inherited heart muscle disease characterized by loss of ventricular myocardium and fibrofatty replacement, which predisposes to scar-related ventricular arrhythmias and sudden cardiac death, particularly in the young and athletes. Although in its original description the disease was characterized by an exclusive or at least predominant right ventricle (RV) involvement, it has been demonstrated that the fibrofatty scar can also localize in the left ventricle (LV), with the LV lesion that can equalize or even overcome that of the RV. While the right-dominant form is typically associated with mutations in genes encoding for desmosomal proteins, other (non-desmosomal) mutations have been showed to cause the biventricular and left-dominant variants. This has led to a critical evaluation of the 2010 International Task Force criteria, which exclusively addressed the right phenotypic manifestations of ACM. An International Expert consensus document has been recently developed to provide upgraded criteria (“the Padua Criteria”) for the diagnosis of the whole spectrum of ACM phenotypes, particularly left-dominant forms, highlighting the use of cardiac magnetic resonance. This review aims to offer an overview of the current knowledge on the genetic basis, the phenotypic expressions, and the diagnosis of left-sided variants, both biventricular and left-dominant, of ACM.
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