Impact of new electrocardiographic criteria in arrhythmogenic cardiomyopathy

Varied Presentation of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C): A Case Series

Arrhythmogenic right ventricular dysplasia (ARVD) is a genetically predisposed form of cardiomyopathy that mainly affects young individuals resulting in fatal ventricular arrhythmias leading to sudden cardiac death. ARVD has 50% of cases that involve both the right ventricle (RV) and left ventricle (LV), but only a small number of cases involve an isolated left ventricle. In this case series, five patients (four males and one female) with a diagnosis of ARVD presented to our center with varied clinical presentations across a wide range of age groups. The MRI of all five cases showed dilated right atrium (RA)/RV with right ventricular free wall dyskinesia. Two-dimensional (2D) MRI showed aneurysmal outpouching with diffuse free wall enhancement. Automated implantable cardioverter defibrillator (AICD) was implanted uneventfully in all five patients, and the patients were discharged with oral medications such as low-dose diuretics, beta-blockers, spironolactone, angiotensin-converting enzymes (ACE) inhibitors, amiodarone, and anxiolytics. Until now, the patients were doing well on follow-up visits. The therapeutic management of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) has evolved over the years and continues to be an important challenge. To further improve risk stratification and treatment of patients, more information is needed on natural history, long-term prognosis, and risk assessment. Special attention should be focused on the identification of patients who would benefit from implantable cardioverter-defibrillator (ICD) implantation in comparison to pharmacological and other nonpharmacological approaches.

Prognostic value of late gadolinium enhancement in arrhythmogenic right ventricular cardiomyopathy: a meta-analysis

AIM

To assess systematically the prognostic value of cardiac magnetic resonance imaging (CMRI) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC).

MATERIALS AND METHODS

The full text of studies of the clinical efficacy of late gadolinium enhancement (LGE) in ARVC was retrieved in multiple databases. Stata 14 was adopted for meta-analysis and bias analysis. Heterogeneity was assessed with the I² statistic.

RESULTS

After exclusions, 561 patients were included in five studies, and the eligibility criteria were met. The meta-analysis suggested that there was a significant difference between LGE positive and negative patients with ARVC in all-cause mortality (relative risk [RR] = 4.78, 95% confidence interval [CI] = 1.41, 16.23, p=0.012; p for heterogeneity = 0.692, I² = 0%); major adverse cardiovascular events (MACE) (RR=2.48, 95% CI = 1.24, 4.96, p=0.010; p for heterogeneity = 0.596, I² = 0%); ventricular tachycardia (RR=3.13, 95% CI = 1.69, 5.78, p<0.001; p for heterogeneity = 0.825, I² = 0%); implanted cardiac defibrillators (RR=3.15, 95% CI = 1.69, 5.87], p<0.001; p for heterogeneity = 0.353, I² = 9.4%).

CONCLUSION

LGE in ARVC patients is a predictor of all-cause mortality and MACE.

Usefulness of the Electrocardiogram in Establishing the Diagnosis and Prognosis of Arrhythmogenic Right Ventricular Cardiomyopathy

A middle-aged man had repeat hospitalizations and interventions over several years for ventricular tachyarrhythmias and then, a 2-year history of progressive heart failure. Twelve-lead electrocardiogram recorded 10 months apart established the most likely cause and prognosis of the heart failure, and predicted its definitive treatment.

Usefulness of Total 12-Lead QRS Voltage for Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy in Patients With Heart Failure Severe Enough to Warrant Orthotopic Heart Transplantation and Morphologic Illustration of Its Cardiac Diversity

Although several electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) (also called dysplasia) have been described, total 12-lead QRS voltage is not one of them. This report describes total 12-lead QRS voltage in 11 patients with ARVC who underwent orthotopic heart transplantation (OHT) because of progressively severe heart failure. Additionally, it illustrates the varied morphologic features of ARVC. The total 12-lead nonpaced QRS voltages before OHT ranged from 28 to 118 mm (mean 74 ± 32), and those in the paced tracings, from 33 to 129 mm (62 ± 32). The voltages are the lowest we have encountered among 12 previously reported cardiovascular conditions. The heart weights among the 11 ARVC patients ranged from 285 to 670 g (mean 448 ± 125). Very low 12-lead QRS voltage is characteristic of patients with ARVC with heart failure severe enough to warrant OHT, and thus may serve as a clue to its diagnosis.

Left ventricular involvement in arrhythmogenic right ventricular cardiomyopathy - a cardiac magnetic resonance imaging study

BACKGROUND

Few studies evaluated left ventricular (LV) involvement in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). The aim of this study is to determine the frequency, clinical presentation, and pattern of LV involvement in ARVD/C (LV-ARVD/C).

METHODS

We retrospectively evaluated the cardiac magnetic resonance (CMR) in 202 patients referred between 2008 and 2012 to our institution, and we determined the presence or the absence of CMR criteria in the revised task force criteria 2010 for the diagnosis of ARVD/C. A total of 21 patients were diagnosed with ARVD/C according to the revised task force criteria 2010. All included patients had no previous history of myocarditis, acute coronary syndrome, or any other cardiac disease that could interfere with the interpretations of structural abnormalities. The LV involvement in ARVD/C was defined by the presence of one or more of the following criteria: LV end-diastolic volume (LVEDV; >95 mL/m²), LV ejection fraction (LVEF; <55%), LV late enhancement of gadolinium (LVLE) in a non-ischemic pattern, and LV wall motion abnormalities (WMAs). In the follow-up for the occurrence of cardiac death, ventricular tachycardia (VT) was obtained at a mean of 31 ± 20.6 months.

RESULTS

A total of 21 patients had ARVD/C. The median age was 48 (33–63) years. In all, 11 patients (52.4%) had LV-ARVD/C. The demographic characteristics of patients with or without LV were similar. There was a higher frequency of left bundle-branch block (LBBB) VT morphology in ARVD/C (P = 0.04). In CMR, regional WMAs of right ventricle (RV) and RV ejection fraction (RVEF; <45%) were strongly correlated with LV-WMAs (r = 0.72, P = 0.02, r = 0.75, P = 0.02, respectively). RV late enhancement of gadolinium (RVLE) was associated with LV-WMs and LVLE (r = 0.7, P = 0.03; r = 0.8, P = 0.006). LVLE was associated with LV-WMAs, LVEF, and LVEDV (r = 0.9, P = 0.001; r = 0.8, P = 0.001; r = 0.8, P = 0.01).

CONCLUSION

LV involvement in ARVD/C is common and frequently associated with moderate to severe right ventricular (RV) abnormalities. The impact of LV involvement in ARVD/C on the prognosis needs further investigations.