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Hakimi M, Burnham T, Ramsay J, Cheung JW, Goyal NA, Jefferies JL, Donaldson D. Electrophysiologic and cardiovascular manifestations of Duchenne and Becker muscular dystrophies. Heart Rhythm 2024:S1547-5271(24)02882-0. [PMID: 38997055 DOI: 10.1016/j.hrthm.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024]
Abstract
There have been significant advances in the diagnosis and management of the hereditary muscular disorders Duchenne and Becker muscular dystrophy (DMD and BMD). Cardiac electrophysiologic and cardiovascular involvement has long been important in the surveillance, care, and prognosis of patients with both BMD and DMD and is the leading cause of mortality in patients with DMD. With improved long-term prognosis, rhythm disorders and progressive cardiomyopathy with resultant heart failure are increasingly common. This review aimed to provide an overview to electrophysiologists and cardiologists of the cardiac electrophysiologic phenotypes and genetics of BMD and DMD and to highlight the recent discoveries that have advanced clinical course and management. A systematic review was performed of the diagnosis and management of DMD and BMD. The Cochrane Library, PubMed, MEDLINE, Europe PubMed Central, AMED, and Embase databases were accessed for available evidence. The research reported in this paper adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence from randomized controlled trials and studies cited in expert consensus and practice guidelines are examined. Advanced imaging techniques and a spectrum of rhythm disorders associated with the progressive cardiomyopathy are presented. Early initiation of heart failure therapies, the role of cardiac implantable devices, and novel gene therapies approved for use with the potential to alter the disease course are discussed. When profound cardiac and cardiac electrophysiologic involvement is diagnosed and treated earlier, outcomes for DMD and BMD patients may be improved.
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Affiliation(s)
- Matthew Hakimi
- Division of Cardiology, Weill Cornell Medical, New York, New York
| | - Tyson Burnham
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California.
| | - Jay Ramsay
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California
| | - Jim W Cheung
- Division of Cardiology, Weill Cornell Medical, New York, New York
| | - Namita A Goyal
- Department of Neurology, University of California at Irvine, Irvine Medical Center, Orange, California
| | | | - David Donaldson
- Division of Cardiology, Department of Medicine, University of California at Irvine, Irvine Medical Center, Orange, California
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2
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Amador AF, Pinho T, Martins da Costa C, Madureira AJ, Martins E. Cardiovascular magnetic resonance in muscular dystrophies: looking ahead. Monaldi Arch Chest Dis 2024. [PMID: 38305807 DOI: 10.4081/monaldi.2024.2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/25/2024] [Indexed: 02/03/2024] Open
Abstract
Cardiac magnetic resonance (CMR) is an established tool for risk stratification in several cardiomyopathies, and its role in muscular dystrophies (MuD) looks promising. We sought to assess how CMR performs in predicting cardiac events in a real cohort of MuD patients. A prospective single-center study with the enrollment of consecutive adult MuD patients referred to cardiac screening from 2012 to 2018 with the collection of clinical and CMR data. During follow-up (FUP), major adverse cardiac events were considered a composite of device implantation, ventricular tachycardia (VT), hospitalization due to heart failure, and death. Sixty-five patients were included (mean age of 32±16, 51% female); the majority had myotonic dystrophy (34; 52.3%); most were asymptomatic (60; 92.3%) and at sinus rhythm (64; 98.5%). CMR was abnormal in 23 (43.3%) patients: left ventricle ejection fraction (LVEF) <55% was found in 7 patients, and late gadolinium enhancement (LGE) was present in 23 patients, mainly intra-myocardial or subepicardial (10 and 8 patients, respectively). During a median FUP of 77 months (interquartile range: 33), there were 7 deaths, 8 implanted devices, and one sustained VT. LVEF<55% and the presence of LGE were associated with the occurrence of all events (log rank test, p=0.002 and p=0.045, respectively). LVEF<55% was associated with a 6-fold higher risk of events (crude hazard ratio of 6.15; 95% confidence interval of 1.65-22.93), that remained significant after adjusting for LGE presence (adjusted hazard ratio of 4.81, 95% confidence interval of 1.07-15.9). In our cohort, CMR LVEF<55% and the presence of LGE were significantly associated with adverse events during follow-up, reinforcing the role of this technique on risk stratification of MuD populations.
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Affiliation(s)
- Ana Filipa Amador
- Department of Cardiology,São João University Hospital Center, Porto; Faculty of Medicine, University of Porto.
| | - Teresa Pinho
- Department of Cardiology,São João University Hospital Center, Porto; Faculty of Medicine, University of Porto.
| | - Catarina Martins da Costa
- Department of Cardiology,São João University Hospital Center, Porto; Faculty of Medicine, University of Porto.
| | - António José Madureira
- Faculty of Medicine, University of Porto; Department of Radiology, São João University Hospital Center, Porto.
| | - Elisabete Martins
- Department of Cardiology,São João University Hospital Center, Porto; Faculty of Medicine, University of Porto.
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3
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Goebel J, Schult K, Schara U, Neudorf U, Forsting M, Schlosser T, Nassenstein K. Patterns of cardiac involvement in different muscular dystrophies assessed by magnetic resonance imaging. Acta Radiol 2023; 64:605-611. [PMID: 35147046 DOI: 10.1177/02841851221077402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In muscular dystrophies, it is not only skeletal muscles that can be affected, but also the myocardium. This cardiac involvement can represent a major cause of morbidity and mortality. PURPOSE To investigate cardiac involvement in Duchenne (DMD), Becker (BMD), and limb girdle muscular dystrophy (LGMD) patients, and carriers of DMD/BMD by cardiac magnetic resonance (CMR) imaging and to search for differences in the pattern of cardiac involvement. MATERIAL AND METHODS All patients with genetically or histologically proven DMD, BMD, and LGMD, or confirmed carriers of DMD/BMD who had undergone CMR at our clinic between January 2008 and November 2018 were retrospectively included and re-evaluated for regional and global left ventricular function, increased trabecularization, and late enhancement. RESULTS A total of 26 DMD, 10 BMD, 11 LGMD, and seven DMD/BMD carriers were included. Only one carrier of DMD presented with normal CMR results; all other participants showed cardiac abnormalities. Regional wall motion abnormalities (RWMA; prevalence in LGMD patients: 55%) and late enhancement (prevalence in LGMD patients: 82%) were frequent. RWMA were accentuated basal inferolateral in DMD/BMD carriers, while in LGMD they were accentuated apical. In all groups late enhancement was located mainly subepicardial/midmyocardial with a basal inferolateral accentuation. Apart from the different RWMA distribution, no further group-specific differences were found. CONCLUSION We found a high rate of cardiac involvement not only in DMD/BMD, but also in LGMD and DMD/BMD carriers with a different RWMA accentuation (apical in LGMD and basal inferolateral in DMD/BMD) as a single group-specific difference.
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Affiliation(s)
- Juliane Goebel
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Karolin Schult
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Ulrike Schara
- Department of Pediatric Neurology, 39081University Hospital Essen, Essen, Germany
| | - Ulrich Neudorf
- Department of Pediatric Cardiology, 39081University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Thomas Schlosser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
| | - Kai Nassenstein
- Department of Diagnostic and Interventional Radiology and Neuroradiology, 39081University Hospital Essen, Essen, Germany
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Del Rio-Pertuz G, Morataya C, Ratheal K, Rios SR, Sethi P, Argueta-Sosa E. Heart Failure as the Initial Clinical Manifestation of Becker Muscular Dystrophy in an Adult. Tex Heart Inst J 2022; 49:488992. [PMID: 36472918 PMCID: PMC9809096 DOI: 10.14503/thij-21-7634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congestive heart failure is an uncommon initial presentation for dystrophin-deficient muscular dystrophies. Cardiac manifestations may appear in late disease stages, although they classically present after musculoskeletal symptoms develop. This case report describes a patient who presented with heart failure and was newly diagnosed with Becker muscular dystrophy. The objective is to recognize Becker muscular dystrophy as a potential cause of dilated cardiomyopathy in young patients, even in the absence of clinically overt musculoskeletal symptoms.
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Affiliation(s)
- Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Cristina Morataya
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Kelly Ratheal
- Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Steven R. Rios
- Department of Cardiopulmonary Rehabilitation, University Medical Center, Lubbock, Texas
| | - Pooja Sethi
- Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Erwin Argueta-Sosa
- Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, Texas
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Diversity of Dystrophin Gene Mutations and Disease Progression in a Contemporary Cohort of Duchenne Muscular Dystrophy. Pediatr Cardiol 2022; 43:855-867. [PMID: 35064276 DOI: 10.1007/s00246-021-02797-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 11/24/2021] [Indexed: 01/14/2023]
Abstract
Abnormal dystrophin production due to mutations in the dystrophin gene causes Duchenne Muscular Dystrophy (DMD). Cases demonstrate considerable genetic and disease progression variability. It is unclear if specific gene mutations are prognostic of outcomes in this population. We conducted a retrospective cohort study of DMD patients followed at 17 centers across the USA and Canada from 2005 to 2015 with goal of understanding the genetic variability of DMD and its impact on clinical outcomes. Cumulative incidence of clinically relevant outcomes was stratified by genetic mutation type, exon mutation location, and extent of exon deletion. Of 436 males with DMD, 324 (74.3%) underwent genetic testing. Deletions were the most common mutation type (256, 79%), followed by point mutations (45, 13.9%) and duplications (23, 7.1%). There were 131 combinations of mutations with most mutations located along exons 45 to 52. The number of exons deleted varied between 1 and 52 with a median of 3 exons deleted (IQR 1-6). Subjects with mutations starting at exon positions 40-54 had a later onset of arrhythmias occurring at median age 25 years (95% CI 18-∞), p = 0.01. Loss of ambulation occurred later at median age of 13 years (95% CI 12-15) in subjects with mutations that started between exons 55-79, p = 0.01. There was no association between mutation type or location and onset of cardiac dysfunction. We report the genetic variability in DMD and its association with timing of clinical outcomes. Genetic modifiers may explain some phenotypic variability.
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Touma AM, Nijjar PS, Manousakis GE, Kamdar F. A rare case report of severe cardiomyopathy associated with myotonic dystrophy type 2. Eur Heart J Case Rep 2022; 6:ytac015. [PMID: 35350724 PMCID: PMC8942102 DOI: 10.1093/ehjcr/ytac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/21/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
Background Myotonic dystrophies (DM) are multi-systemic diseases characterized by muscle
weakness and myotonia. Despite a growing appreciation for the cardiovascular
manifestations in myotonic dystrophy type 1 (DM1), cardiac involvement in
myotonic dystrophy type 2 (DM2) has been less well characterized. In
patients with DM2, cardiomyopathy has rarely been described. Case summary This case report describes a rare case of DM2 associated cardiomyopathy. A
56-year-old male with DM2 who presented with palpitations and fatigue.
Cardiac magnetic resonance (CMR) imaging confirmed a severely enlarged left
ventricular cavity with a left ventricular ejection fraction of 28%
consistent with severely reduced global systolic function. The lateral wall
epicardium exhibited late gadolinium enhancement in a pattern seen in
myotonic dystrophy-related cardiomyopathy. Discussion This case highlights the potential for significant cardiovascular involvement
in DM2, as well as the importance of screening, including CMR imaging, and
therapy in the myotonic dystrophy patient population.
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Affiliation(s)
- Anja M Touma
- Medical School, Medical Scientist Training Program (MSTP), University of Minnesota Medical School, Twin Cities, Minneapolis, MN 55455, USA
| | - Prabhjot S Nijjar
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Twin Cities, Minneapolis, MN, 55455, USA
| | - Georgios E Manousakis
- Department of Neurology, University of Minnesota Medical School, Twin Cities, 420 Delaware St. SE, MMC 508 Cardiology, Minneapolis, MN USA
| | - Forum Kamdar
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Twin Cities, Minneapolis, MN, 55455, USA
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Gossios TD, Providencia R, Creta A, Segal OR, Nikolenko N, Turner C, Lopes LR, Wahbi K, Savvatis K. An overview of heart rhythm disorders and management in myotonic dystrophy type 1. Heart Rhythm 2021; 19:497-504. [PMID: 34843968 DOI: 10.1016/j.hrthm.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 11/07/2021] [Accepted: 11/22/2021] [Indexed: 11/04/2022]
Abstract
Myotonic dystrophy type 1 (DM1) is the most common adult form of muscular dystrophy, presenting with a constellation of systemic findings secondary to a CTG triplet expansion of the noncoding region of the DMPK gene. Cardiac involvement is frequent, with conduction disease and supraventricular and ventricular arrhythmias being the most prevalent cardiac manifestations, often developing from a young age. The development of cardiac arrhythmias has been linked to increased morbidity and mortality, with sudden cardiac death well described. Strategies to mitigate risk of arrhythmic death have been developed. In this review, we outline the current knowledge on the pathophysiology of rhythm abnormalities in patients with myotonic dystrophy and summarize available knowledge on arrhythmic risk stratification. We also review management strategies from an electrophysiological perspective, attempting to underline the substantial unmet need to address residual arrhythmic risks for this population.
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Affiliation(s)
- Thomas D Gossios
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.
| | - Rui Providencia
- Department of Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Antonio Creta
- Department of Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Oliver R Segal
- Department of Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Nikoletta Nikolenko
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - Chris Turner
- National Hospital for Neurology and Neurosurgery, University College London Hospital, London, United Kingdom
| | - Luis R Lopes
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London Hospital, London, United Kingdom
| | - Karim Wahbi
- APHP, Cochin Hospital, Cardiology Department, FILNEMUS, Paris-Descartes, Sorbonne Paris Cité University, Paris, France
| | - Konstantinos Savvatis
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
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Tan SML, Ong CC, Tan KB, Chin HL, Paliwal PR, Ng KWP, Lin W. Subclinical Cardiomyopathy in Miyoshi Myopathy Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance Imaging. Int Heart J 2021; 62:186-192. [PMID: 33518658 DOI: 10.1536/ihj.20-354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dysferlin is a sarcolemmal protein present in muscle cells. It is responsible for muscle membrane repair. Dysferlin gene (DYSF) mutation, resulting in deficiency in this protein, is termed dysferlinopathy. Clinically, it manifests as early adulthood onset of muscle weakness with markedly elevated creatine kinase levels. The main phenotypes are limb-girdle muscular dystrophy type 2B (LGMD2B), affecting proximal muscles, and Miyoshi myopathy (MM), affecting distal muscles. Dysferlin is also present in cardiomyocytes, and case reports have emerged of cardiac abnormalities in dysferlinopathy. While routine methods of cardiac screening, namely, electrocardiography or echocardiography, are convenient and noninvasive, they often exhibit insufficient diagnostic sensitivity for detecting subclinical cardiac remodeling during early stages of cardiomyopathy. Cardiac magnetic resonance imaging though can provide accurate assessment of cardiac chamber sizes and function. With gadolinium administration, it can also detect areas of myocardial scarring and fibrosis. Early diagnosis of neuromuscular disease-related cardiomyopathy is of clinical significance, as appropriate treatment can retard myocardial fibrosis, delaying cardiomyopathy progression. We present a case of a patient with MM incidentally diagnosed with concomitant cardiomyopathy.
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Affiliation(s)
| | - Ching Ching Ong
- Department of Diagnostic Imaging, National University Hospital.,Yong Loo Lin School of Medicine, National University of Singapore
| | - Kong Bing Tan
- Yong Loo Lin School of Medicine, National University of Singapore.,Department of Pathology, National University Hospital
| | - Hui-Lin Chin
- Yong Loo Lin School of Medicine, National University of Singapore.,Division of Paediatric Genetics & Metabolism, Department of Paediatrics, Khoo Teck Puat - National University Children's Medical Institute
| | - Prakash R Paliwal
- Yong Loo Lin School of Medicine, National University of Singapore.,Division of Neurology, Department of Medicine, National University Hospital
| | - Kay Wei Ping Ng
- Yong Loo Lin School of Medicine, National University of Singapore.,Division of Neurology, Department of Medicine, National University Hospital
| | - Weiqin Lin
- Yong Loo Lin School of Medicine, National University of Singapore.,Department of Cardiology, National University Heart Centre
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Sanchez F, Weitz C, Gutierrez JM, Mestroni L, Hanneman K, Vargas D. Cardiac MR Imaging of Muscular Dystrophies. Curr Probl Diagn Radiol 2021; 51:225-234. [PMID: 33551194 DOI: 10.1067/j.cpradiol.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/27/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
Muscular dystrophies (MDs) are a group of inherited disorders caused by mutations that interfere with muscular structure, contraction, or relaxation. As the cardiac sarcomeric unit shares multiple proteins with the skeletal muscle unit, the heart is affected in several MDs, sometimes without apparent musculoskeletal involvement. Early detection of MD-related cardiomyopathy is crucial as timely initiation of cardioprotective therapy can slow adverse cardiac remodeling. Although transthoracic echocardiography is widely used for the evaluation of cardiac morphology and function, it has limitations in terms of reproducibility and image quality. The need for an optimal acoustic window may be particularly challenging to obtain in patients with MDs given their body habitus and position. Cardiac magnetic resonance (CMR) imaging has emerged as a useful tool in the evaluation of patients with MDs. Its superb tissue characterization capability through late gadolinium enhancement, T1 mapping, extracellular volume fraction quantification, and edema imaging detects early cardiac involvement, even when echocardiography and electrocardiogram are unremarkable. MDs that frequently present with cardiac involvement include Duchenne MD, Becker MD, Emery Dreifuss MD, Limb-Girdle MDs, and myotonic dystrophy. The purpose of this review article is to briefly describe the pathophysiology of these entities, discuss their clinical presentation and expected evolution, explain the role of CMR in the diagnosis and follow-up of these patients, and portray the different CMR findings present in MD patients.
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Affiliation(s)
- Felipe Sanchez
- Department of Medical Imaging, University of Toronto - University Health Network, Toronto General Hospital, Toronto, ON, Canada.
| | - Carolina Weitz
- Department of Medical Imaging, Hospital Clinico Felix Bulnes Cerda, Santiago, Chile
| | - Jose M Gutierrez
- Department of Medical Imaging, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Luisa Mestroni
- University of Colorado - Anschutz Medical Campus, Molecular Genetics, Cardiovascular Institute, Aurora, CO
| | - Kate Hanneman
- Department of Medical Imaging, University of Toronto - University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Daniel Vargas
- Department of Radiology, University of Colorado - Anschutz Medical Campus, Aurora, CO
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Renella P, Lai WW. When Ejection Fraction Is Not Enough: The Search for Early Signs of Cardiomyopathy in Duchenne Muscular Dystrophy. Circ Cardiovasc Imaging 2020; 13:e012003. [PMID: 33190535 DOI: 10.1161/circimaging.120.012003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pierangelo Renella
- Department of Cardiology, CHOC Children's Hospital, Orange, CA and University of California Irvine School of Medicine, Irvine, CA
| | - Wyman W Lai
- Department of Cardiology, CHOC Children's Hospital, Orange, CA and University of California Irvine School of Medicine, Irvine, CA
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