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Quiroz JC, Brieger D, Jorm LR, Sy RW, Hsu B, Gallego B. Predicting Adverse Outcomes Following Catheter Ablation Treatment for Atrial Flutter/Fibrillation. Heart Lung Circ 2024; 33:470-478. [PMID: 38365498 DOI: 10.1016/j.hlc.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 11/06/2023] [Accepted: 12/19/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND & AIM To develop prognostic survival models for predicting adverse outcomes after catheter ablation treatment for non-valvular atrial fibrillation (AF) and/or atrial flutter (AFL). METHODS We used a linked dataset including hospital administrative data, prescription medicine claims, emergency department presentations, and death registrations of patients in New South Wales, Australia. The cohort included patients who received catheter ablation for AF and/or AFL. Traditional and deep survival models were trained to predict major bleeding events and a composite of heart failure, stroke, cardiac arrest, and death. RESULTS Out of a total of 3,285 patients in the cohort, 177 (5.3%) experienced the composite outcome-heart failure, stroke, cardiac arrest, death-and 167 (5.1%) experienced major bleeding events after catheter ablation treatment. Models predicting the composite outcome had high-risk discrimination accuracy, with the best model having a concordance index >0.79 at the evaluated time horizons. Models for predicting major bleeding events had poor risk discrimination performance, with all models having a concordance index <0.66. The most impactful features for the models predicting higher risk were comorbidities indicative of poor health, older age, and therapies commonly used in sicker patients to treat heart failure and AF and AFL. DISCUSSION Diagnosis and medication history did not contain sufficient information for precise risk prediction of experiencing major bleeding events. Predicting the composite outcome yielded promising results, but future research is needed to validate the usefulness of these models in clinical practice. CONCLUSIONS Machine learning models for predicting the composite outcome have the potential to enable clinicians to identify and manage high-risk patients following catheter ablation for AF and AFL proactively.
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Affiliation(s)
- Juan C Quiroz
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Benjumin Hsu
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Blanca Gallego
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
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2
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Cutler MJ, Eckhardt LL, Kaufman ES, Arbelo E, Behr ER, Brugada P, Cerrone M, Crotti L, deAsmundis C, Gollob MH, Horie M, Huang DT, Krahn AD, London B, Lubitz SA, Mackall JA, Nademanee K, Perez MV, Probst V, Roden DM, Sacher F, Sarquella-Brugada G, Scheinman MM, Shimizu W, Shoemaker B, Sy RW, Watanabe A, Wilde AAM. Clinical Management of Brugada Syndrome: Commentary From the Experts. Circ Arrhythm Electrophysiol 2024; 17:e012072. [PMID: 38099441 PMCID: PMC10824563 DOI: 10.1161/circep.123.012072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Although there is consensus on the management of patients with Brugada Syndrome with high risk for sudden cardiac arrest, asymptomatic or intermediate-risk patients present clinical management challenges. This document explores the management opinions of experts throughout the world for patients with Brugada Syndrome who do not fit guideline recommendations. Four real-world clinical scenarios were presented with commentary from small expert groups for each case. All authors voted on case-specific questions to evaluate the level of consensus among the entire group in nuanced diagnostic and management decisions relevant to each case. Points of agreement, points of controversy, and gaps in knowledge are highlighted.
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Affiliation(s)
- Michael J Cutler
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, UT (M.J.C.)
| | - Lee L Eckhardt
- Cellular and Molecular Arrhythmia Research Program, Division of CVM, Department of Medicine, University of Wisconsin-Madison (L.L.E.)
| | - Elizabeth S Kaufman
- Heart and Vascular Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (E.S.K.)
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona (E.A.)
- Centro de Investigacion Biomedica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid (E.A.)
- IDIBAPS, Institut d'Investigacio August Pi I Sunyer, Barcelona, Spain (E.A.)
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Cardiology Section, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust (E.R.B.)
- Mayo Clinic Healthcare, London, United Kingdom (E.R.B.)
| | - Pedro Brugada
- Cardiovascular Division, UZ Brussel-VUB, Belgium (P.B.)
- Arrhythmia Unit, Helicopteros Sanitarios Hospital (HSH), Puerto Banús, Marbella, Malaga, Spain (P.B.)
| | - Marina Cerrone
- New York Univ Grossman School of Medicine, Leon H. Charney Division of Cardiology (M.C.)
| | - Lia Crotti
- Department of Medicine and Surgery, University of Milano-Bicocca (L.C.)
- Istituto Auxologico Italiano IRCCS, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Milan, Italy (L.C.)
| | - Carlo deAsmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (C.D.)
| | - Michael H Gollob
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Canada (M.H.G.)
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Ohtsu, Japan (M.H.)
| | | | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, Canada (A.D.K.)
| | - Barry London
- Division of Cardiovascular Medicine, Department of Internal Medicine and Abboud Cardiovascular Research Center, University of Iowa Carver College of Medicine, Iowa City (B.L.)
| | - Steven A Lubitz
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston (S.A.L.)
| | - Judith A Mackall
- Department of Medicine, Division of Cardiology, University Hospitals Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH (J.A.M.)
| | - Koonlawee Nademanee
- Center of Excellence in Arrhythmia Research, Department of Medicine, Faculty of Medicine, Chulalongkorn University (K.N.)
- Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand (K.N.)
| | - Marco V Perez
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, CA (M.V.P.)
| | - Vincent Probst
- Université Nantes, CHU Nantes, CNRS, INSERM, Service de Cardiologie, l'institut du thorax, Nantes, France (V.P.)
| | - Dan M Roden
- Departments of Medicine, Pharmacology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (D.M.R.)
| | - Frederic Sacher
- Arrhythmia Department, Bordeaux University Hospital, IHU LIRYC, Pessac, France (F.S.)
| | - Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Universitat de Barcelona (G.S.-B.)
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain (G.S.-B.)
| | - Melvin M Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco (M.M.S.)
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (W.S.)
| | - Benjamin Shoemaker
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.S.)
| | - Raymond W Sy
- Faculty of Medicine and Heath, The University of Sydney (R.W.S.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (R.W.S.)
| | - Atsuyuki Watanabe
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Japan (A.W.)
| | - Arthur A M Wilde
- Department of Cardiology, University of Amsterdam (A.A.M.W.)
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands (A.A.M.W.)
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3
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Abrahams T, Davies B, Laksman Z, Sy RW, Postema PG, Wilde AAM, Krahn AD, Han HC. Provocation testing in congenital long QT syndrome: A practical guide. Heart Rhythm 2023; 20:1570-1582. [PMID: 37481219 DOI: 10.1016/j.hrthm.2023.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/01/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
Congenital long QT syndrome (LQTS) is a hereditary cardiac channelopathy with an estimated prevalence of 1 in 2500. A prolonged resting QT interval corrected for heart rate (QTc interval) remains a key diagnostic component; however, the QTc value may be normal in up to 40% of patients with genotype-positive LQTS and borderline in a further 30%. Provocation of QTc prolongation and T-wave changes may be pivotal to unmasking the diagnosis and useful in predicting genotype. LQTS provocation testing involves assessment of repolarization during and after exercise, in response to changes in heart rate or autonomic tone, with patients with LQTS exhibiting a maladaptive repolarization response. We review the utility and strengths and limitations of 4 forms of provocation testing-stand-up test, exercise stress test, epinephrine challenge, and mental stress test-in diagnosing LQTS and provide some practical guidance for performing provocation testing. Ultimately, exercise testing, when feasible, is the most useful form of provocation testing when considering diagnostic sensitivity and specificity.
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Affiliation(s)
- Timothy Abrahams
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia
| | - Brianna Davies
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure & Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hui-Chen Han
- Victorian Heart Institute & Monash Health Heart, Victorian Heart Hospital, Monash University, Melbourne, Victoria, Australia.
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4
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Leslie F, Avis SR, Bagnall RD, Bendall J, Briffa T, Brouwer I, Butters A, Figtree GA, La Gerche A, Gray B, Nedkoff L, Page G, Paratz E, Semsarian C, Sy RW, du Toit-Prinsloo L, Yeates L, Sweeting J, Ingles J. The New South Wales Sudden Cardiac Arrest Registry: A Data Linkage Cohort Study. Heart Lung Circ 2023; 32:1069-1075. [PMID: 37419791 DOI: 10.1016/j.hlc.2023.06.573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/04/2023] [Accepted: 06/18/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Sudden cardiac arrest (SCA) in young people aged 1 to 50 years often occurs with no presenting symptoms or risk factors prompting screening for cardiovascular disease prior to their cardiac arrest. Approximately 3,000 young Australians suffer from sudden cardiac death (SCD) each year, making this a major public health issue. However, there is significant variation in the way incidence is estimated resulting in discrepancy across reporting which impacts our ability to understand and prevent these devastating events. We describe the New South Wales (NSW) Sudden Cardiac Arrest Registry: a retrospective, data linkage study which will identify all SCAs in the young in NSW from 2009 through to June 2022. OBJECTIVE To determine the incidence, demographic characteristics and causes of SCA in young people. We will develop an NSW-based registry that will contribute to a greater understanding of SCA including risk factors and outcomes. METHODS The cohort will include all people who experience a SCA in the NSW community aged between 1 to 50 years. Cases will be identified using the following three datasets: the Out of Hospital Cardiac Arrest Register housed at NSW Ambulance, the NSW Emergency Department Data Collection, and the National Coronial Information System. Data from eight datasets will be collected, anonymised and linked for the entire cohort. Analysis will be undertaken and reported using descriptive statistics. CONCLUSIONS The NSW SCA registry will be an important resource for the improved understanding of SCA and inform the widespread impacts it has on individuals, their families and society.
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Affiliation(s)
- Felicity Leslie
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Suzanne R Avis
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia; Tasmanian School of Medicine, University of Tasmania, Hobart, Tas, Australia
| | - Richard D Bagnall
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Jason Bendall
- Clinical Systems, NSW Ambulance, Sydney, NSW, Australia; Department of Rural Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Isabel Brouwer
- Forensic Medicine, Forensic and Analytical Science Service, NSW Health Pathology, Sydney, NSW, Australia
| | - Alexandra Butters
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Cardiovascular Discovery Group, Kolling Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Belinda Gray
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | | | | | - Christopher Semsarian
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lorraine du Toit-Prinsloo
- Forensic Medicine, Forensic and Analytical Science Service, NSW Health Pathology, Sydney, NSW, Australia
| | - Laura Yeates
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Joanna Sweeting
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Jodie Ingles
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, NSW, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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5
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Foo FS, Sy RW, D'Ambrosio P, Quininir L, Irons J, Silberbauer J, Chan KH. Novel Epicardial Access Technique Facilitated by Carbon Dioxide Insufflation of the Pericardium for Ablation of Ventricular Arrhythmias: Lessons From the Early Experience From a Single Centre in Australia. Heart Lung Circ 2023; 32:197-204. [PMID: 36473791 DOI: 10.1016/j.hlc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/21/2022] [Accepted: 09/03/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Epicardial access for mapping and ablation of the epicardial substrate may be required in catheter ablation of ventricular tachycardias (VT). However, high complication rates are associated with the standard epicardial access approach. Recently, a novel method of intentional coronary vein (CV) exit with pericardial CO2 insufflation to facilitate epicardial access has been described. This study describes our initial experience with this technique. METHODS Patients undergoing epicardial VT ablation between 1 February 2021 to 31 May 2022 at the Royal Prince Alfred Hospital, Sydney, NSW, were included in this study. Via femoral venous access, a branch of the coronary sinus was sub-selected and intentional CV exit was performed with a high tip load coronary angioplasty wire. A microcatheter was then advanced over the wire into the pericardial space, followed by pericardial CO2 insufflation, facilitating subxiphoid pericardial puncture. RESULTS Five (5) patients underwent epicardial access for VT mapping and ablation. All patients had successful intentional CV exit and CO2 facilitated epicardial access. The mean time to successful epicardial access was 37.2±17.5 minutes. With increasing operator experience, there was improvement in epicardial access times, with the fifth case requiring only 13 minutes. There was one case of inadvertent right ventricular puncture (without haemodynamic or ventilatory compromise) due to inappropriate CO2 insufflation into the right ventricle. Epicardial access was successful on the second attempt. CONCLUSION This is the first case series of epicardial access facilitated by CO2 insufflation in Australia. This technique enabled successful epicardial access in all patients in our early experience, with no adverse outcomes from epicardial access. With increasing operator experience, this technique may allow for more widespread adoption of up-front epicardial access for the treatment of VT.
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Affiliation(s)
- Fang Shawn Foo
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Paolo D'Ambrosio
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Luis Quininir
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Joanne Irons
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Kim H Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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6
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Virk SA, Hyun K, Brieger D, Sy RW. Prognostic benefit of catheter ablation of atrial fibrillation in heart failure: An updated meta‐analysis of randomized controlled trials. J Arrhythm 2023; 39:129-141. [PMID: 37021020 PMCID: PMC10068943 DOI: 10.1002/joa3.12812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/30/2022] [Accepted: 12/24/2022] [Indexed: 01/19/2023] Open
Abstract
Background The prognostic role of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) remains uncertain, with guideline recommendations largely based on a single trial. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing the prognostic impact of AF ablation in patients with HF. Methods Electronic databases were searched for RCTs comparing 'AF ablation' versus 'other care' (medical therapy and/or atrioventricular node ablation with pacing) in patients with HF. Primary endpoints were ≥1-year mortality, HF hospitalization and change in left ventricular ejection fraction (LVEF). Meta-analyses were performed using random-effects modelling. Results Nine RCTs (n = 1462) met inclusion criteria. Compared to 'other care', AF ablation significantly reduced ≥1-year mortality (relative risk [RR] 0.65; 95% confidence intervals [CI], 0.49-0.87) and HF hospitalization (RR 0.64; 95% CI, 0.51-0.81). AF ablation demonstrated significantly greater improvement in LVEF (mean difference [MD] 5.4; 95% CI, 4.4-6.4), 6-min walk test distance (MD 21.5 meters; 95% CI, 4.6-38.4) and quality of life as measured by Minnesota Living with Heart Failure Questionnaire score (MD 7.2; 95% CI, 2.8-11.7). Meta-regression analyses showed the beneficial impact of AF ablation on LVEF was significantly blunted by higher prevalence of ischaemic cardiomyopathy. Conclusions Our meta-analysis demonstrates AF ablation is superior to 'other care' in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population.
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Affiliation(s)
- Sohaib A. Virk
- Department of Cardiology Concord Repatriation General Hospital Concord New South Wales Australia
| | - Karice Hyun
- Department of Cardiology Concord Repatriation General Hospital Concord New South Wales Australia
- Westmead Applied Research Centre University of Sydney New South Wales Australia
| | - David Brieger
- Department of Cardiology Concord Repatriation General Hospital Concord New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
| | - Raymond W. Sy
- Department of Cardiology Concord Repatriation General Hospital Concord New South Wales Australia
- Faculty of Medicine and Health The University of Sydney Sydney New South Wales Australia
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7
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Stafford F, Krishnan N, Richardson E, Butters A, Hespe S, Burns C, Gray B, Medi C, Nowak N, Isbister JC, Raju H, Richmond D, Ryan MP, Singer ES, Sy RW, Yeates L, Bagnall RD, Semsarian C, Ingles J. The role of genetic testing in diagnosis and care of inherited cardiac conditions in a specialised multidisciplinary clinic. Genome Med 2022; 14:145. [PMID: 36578016 PMCID: PMC9795753 DOI: 10.1186/s13073-022-01149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The diagnostic yield of genetic testing for inherited cardiac diseases is up to 40% and is primarily indicated for screening of at-risk relatives. Here, we evaluate the role of genomics in diagnosis and management among consecutive individuals attending a specialised clinic and identify those with the highest likelihood of having a monogenic disease. METHODS A retrospective audit of 1697 consecutive, unrelated probands referred to a specialised, multidisciplinary clinic between 2002 and 2020 was performed. A concordant clinical and genetic diagnosis was considered solved. Cases were classified as likely monogenic based on a score comprising a positive family history, young age at onset, and severe phenotype, whereas low-scoring cases were considered to have a likely complex aetiology. The impact of a genetic diagnosis was evaluated. RESULTS A total of 888 probands fulfilled the inclusion criteria, and genetic testing identified likely pathogenic or pathogenic (LP/P) variants in 330 individuals (37%) and suspicious variants of uncertain significance (VUS) in 73 (8%). Research-focused efforts identified 46 (5%) variants, missed by conventional genetic testing. Where a variant was identified, this changed or clarified the final diagnosis in a clinically useful way for 51 (13%). The yield of suspicious VUS across ancestry groups ranged from 15 to 20%, compared to only 10% among Europeans. Even when the clinical diagnosis was uncertain, those with the most monogenic disease features had the greatest diagnostic yield from genetic testing. CONCLUSIONS Research-focused efforts can increase the diagnostic yield by up to 5%. Where a variant is identified, this will have clinical utility beyond family screening in 13%. We demonstrate the value of genomics in reaching an overall diagnosis and highlight inequities based on ancestry. Acknowledging our incomplete understanding of disease phenotypes, we propose a framework for prioritising likely monogenic cases to solve their underlying cause of disease.
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Affiliation(s)
- Fergus Stafford
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Neesha Krishnan
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Ebony Richardson
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Alexandra Butters
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sophie Hespe
- grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Charlotte Burns
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Belinda Gray
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Caroline Medi
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Natalie Nowak
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Julia C. Isbister
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Hariharan Raju
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia ,grid.1004.50000 0001 2158 5405Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - David Richmond
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark P. Ryan
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Emma S. Singer
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Raymond W. Sy
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Laura Yeates
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richard D. Bagnall
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Christopher Semsarian
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jodie Ingles
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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8
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Isbister JC, Nowak N, Yeates L, Singer ES, Sy RW, Ingles J, Raju H, Bagnall RD, Semsarian C. Concealed Cardiomyopathy in Autopsy-Inconclusive Cases of Sudden Cardiac Death and Implications for Families. J Am Coll Cardiol 2022; 80:2057-2068. [PMID: 36423990 DOI: 10.1016/j.jacc.2022.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Genetic testing following sudden cardiac death (SCD) is currently guided by autopsy findings, despite the inherent challenges of autopsy examination and mounting evidence that malignant arrhythmia may occur before structural changes in inherited cardiomyopathy, so-called "concealed cardiomyopathy" (CCM). OBJECTIVES The authors sought to identify the spectrum of genes implicated in autopsy-inconclusive SCD and describe the impact of identifying CCM on the ongoing care of SCD families. METHODS Using a standardized framework for adjudication, autopsy-inconclusive SCD cases were identified as having a structurally normal heart or subdiagnostic findings of uncertain significance on autopsy. Genetic variants were classified for pathogenicity using the American College of Medical Genetics and Genomics guidelines. Family follow-up was performed where possible. RESULTS Twenty disease-causing variants were identified among 91 autopsy-inconclusive SCD cases (mean age 25.4 ± 10.7 years) with a similar rate regardless of the presence or absence of subdiagnostic findings (25.5% vs 18.2%; P = 0.398). Cardiomyopathy-associated genes harbored 70% of clinically actionable variants and were overrepresented in cases with subdiagnostic structural changes at autopsy (79% vs 21%; P = 0.038). Six of the 20 disease-causing variants identified were in genes implicated in arrhythmogenic cardiomyopathy. Nearly two-thirds of genotype-positive relatives had an observable phenotype either at initial assessment or subsequent follow-up, and 27 genotype-negative first-degree relatives were released from ongoing screening. CONCLUSIONS Phenotype-directed genetic testing following SCD risks under recognition of CCM. Comprehensive evaluation of the decedent should include assessment of genes implicated in cardiomyopathy in addition to primary arrhythmias to improve diagnosis of CCM and optimize care for families.
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Affiliation(s)
- Julia C Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Natalie Nowak
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The 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, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The 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, and UNSW Sydney, Sydney, New South Wales, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Emma S Singer
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jodie Ingles
- Faculty of Medicine and Health, The 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, and UNSW Sydney, Sydney, New South Wales, Australia; Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Hariharan Raju
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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9
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Isbister JC, Nowak N, Yeates L, Singer ES, Sy RW, Ingles J, Raju H, Bagnall R, Semsarian C. “Concealed cardiomyopathy” is an important cause of autopsy-inconclusive sudden cardiac death and diagnosis impacts care of surviving relatives. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Genetic testing following sudden cardiac death (SCD) is currently guided by autopsy findings, despite the inherent challenges of autopsy examination and mounting evidence that malignant arrhythmia may occur prior to structural changes in inherited cardiomyopathy, so-called “concealed cardiomyopathy” (CCM).
Purpose
To identify the spectrum of genes implicated in autopsy-inconclusive SCD and describe the importance of identifying CCM for the ongoing care of SCD families.
Methods
Using a standardised framework for adjudication, autopsy-inconclusive SCD cases were identified as having a structurally normal heart or sub-diagnostic findings of uncertain significance on autopsy. Genetic variants were classified for pathogenicity using the American College of Medical Genetics and Genomics guidelines. Family follow-up was performed where possible.
Results
Twenty disease-causing variants were identified among 91 autopsy-inconclusive SCD cases (mean age 25.4±10.7 years) with a similar rate regardless of the presence or absence of sub-diagnostic findings (25.5% vs 18.2%, p=0.40). Cardiomyopathy-associated genes harboured 70% of clinically-actionable variants and were overrepresented in cases with sub-diagnostic structural changes at autopsy, accounting for 11 out of 12 disease-causing variants in this group (79% vs 21%, p=0.038, Figure 1, panel A). Variants in arrhythmogenic cardiomyopathy genes were the most common cause of CCM (9/14 CCM cases, Figure 1, panel B). Nearly two-thirds of genotype-positive relatives had an observable phenotype either on initial assessment or during subsequent follow-up. Twenty-seven genotype-negative first-degree relatives were released from ongoing screening.
Conclusion
The current paradigm of phenotype-directed genetic testing following SCD risks under recognition of CCM. Comprehensive evaluation of the decedent should include assessment of genes implicated in both cardiomyopathy and primary arrhythmias to improve diagnosis of CCM and optimise care for families.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Foundation of Australia and National Health and Medical Research CouncilNew South Wales Health
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Affiliation(s)
- J C Isbister
- Centenary Institute, The University of Sydney , Sydney , Australia
| | - N Nowak
- Centenary Institute, The University of Sydney , Sydney , Australia
| | - L Yeates
- Garvan Institute , Sydney , Australia
| | - E S Singer
- Centenary Institute, The University of Sydney , Sydney , Australia
| | - R W Sy
- Royal Prince Alfred Hospital, Cardiology , Sydney , Australia
| | - J Ingles
- Garvan Institute , Sydney , Australia
| | - H Raju
- Macquarie University, Faculty of Medicine, Health and Human Sciences , Sydney , Australia
| | - R Bagnall
- Centenary Institute, The University of Sydney , Sydney , Australia
| | - C Semsarian
- Centenary Institute, The University of Sydney , Sydney , Australia
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10
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Quiroz JC, Brieger D, Jorm LR, Sy RW, Falster MO, Gallego B. An Observational Study of Clinical and Health System Factors Associated With Catheter Ablation and Early Ablation Treatment for Atrial Fibrillation in Australia. Heart Lung Circ 2022; 31:1269-1276. [PMID: 35623999 DOI: 10.1016/j.hlc.2022.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/20/2022] [Accepted: 04/18/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate clinical and health system factors associated with receiving catheter ablation (CA) and earlier ablation for non-valvular atrial fibrillation (AF). METHODS We used hospital administrative data linked with death registrations in New South Wales, Australia for patients with a primary diagnosis of AF between 2009 and 2017. Outcome measures included receipt of CA versus not receiving CA during follow-up (using Cox regression) and receipt of early ablation (using logistic regression). RESULTS Cardioversion during index admission (hazard ratio [HR] 1.96; 95% CI 1.75-2.19), year of index admission (HR 1.07; 1.07; 95% CI 1.05-1.10), private patient status (HR 2.65; 95% CI 2.35-2.97), and living in more advantaged areas (HR 1.18; 95% CI 1.13-1.22) were associated with a higher likelihood of receiving CA. A history of congestive heart failure, hypertension, diabetes, and myocardial infarction were associated with a lower likelihood of receiving CA. Private patient status (odds ratio [OR] 2.04; 95% CI 1.59-2.61), cardioversion during index admission (OR 1.25; 95% CI 1.0-1.57), and history of diabetes (OR 1.6; 95% CI 1.06-2.41) were associated with receiving early ablation. CONCLUSIONS Beyond clinical factors, private patients are more likely to receive CA and earlier ablation than their public counterparts. Whether the earlier access to ablation procedures in private patients is leading to differences in outcomes among patients with atrial fibrillation remains to be explored.
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Affiliation(s)
- Juan C Quiroz
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Blanca Gallego
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
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11
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Krahn AD, Laksman Z, Sy RW, Postema PG, Ackerman MJ, Wilde AAM, Han HC. Congenital Long QT Syndrome. JACC Clin Electrophysiol 2022; 8:687-706. [PMID: 35589186 DOI: 10.1016/j.jacep.2022.02.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 12/14/2022]
Abstract
Congenital long QT syndrome (LQTS) encompasses a group of heritable conditions that are associated with cardiac repolarization dysfunction. Since its initial description in 1957, our understanding of LQTS has increased dramatically. The prevalence of LQTS is estimated to be ∼1:2,000, with a slight female predominance. The diagnosis of LQTS is based on clinical, electrocardiogram, and genetic factors. Risk stratification of patients with LQTS aims to identify those who are at increased risk of cardiac arrest or sudden cardiac death. Factors including age, sex, QTc interval, and genetic background all contribute to current risk stratification paradigms. The management of LQTS involves conservative measures such as the avoidance of QT-prolonging drugs, pharmacologic measures with nonselective β-blockers, and interventional approaches such as device therapy or left cardiac sympathetic denervation. In general, most forms of exercise are considered safe in adequately treated patients, and implantable cardioverter-defibrillator therapy is reserved for those at the highest risk. This review summarizes our current understanding of LQTS and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Zachary Laksman
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pieter G Postema
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA; Departments of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart), Academic University Medical Center, Amsterdam, the Netherlands
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada; Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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12
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Al-Sinan A, Chan KH, Young GD, Martin A, Sepahpour A, Sy RW. Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava. J Cardiovasc Electrophysiol 2022; 33:1300-1311. [PMID: 35441755 PMCID: PMC9323496 DOI: 10.1111/jce.15505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022]
Abstract
AIMS The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction. METHODS We conducted a structured search to identify manuscripts reporting EP procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included seven local cases that met inclusion criteria. RESULTS The analysis included 142 patients (mean age 48.9 years; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure. CONCLUSION The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a "familiar approach" for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro-anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications.
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Affiliation(s)
- Ali Al-Sinan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
| | - Kim H Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Glenn D Young
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Andrew Martin
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Ali Sepahpour
- Department of Cardiology, St. George Hospital, Sydney, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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13
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Huynh R, Sy RW, Wong SJ, Wong CCY. A unique case report of relapsing eosinophilic myocarditis causing atrial myopathy and persistent sinus arrest. Eur Heart J Case Rep 2022; 6:ytac047. [PMID: 35233495 PMCID: PMC8874821 DOI: 10.1093/ehjcr/ytac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 01/26/2022] [Indexed: 11/12/2022]
Abstract
Background Eosinophilic myocarditis (EM) is a rare and devastating condition. The underlying cause of EM is unknown, and the natural history is not well understood. Case summary A 20-year-old male presented in cardiogenic shock with preceding 24-h history of pleuritic chest pain associated with nausea and vomiting. Electrocardiogram showed sinus tachycardia with widespread ST elevation, significantly raised high-sensitivity troponin T, and raised white cell count with eosinophilia. Transthoracic echocardiogram demonstrated severe left ventricular (LV) impairment and a moderate-sized pericardial effusion. Right ventricular (RV) endomyocardial biopsy and bone marrow biopsy were performed, with both demonstrating prominent eosinophilia. He was initiated on pulse methylprednisolone leading to rapid clinical improvement with normalization of LV function. Day 9 after discharge, he was readmitted to hospital with presyncope and right heart failure. Electrocardiogram revealed junctional escape rhythm, and cardiac magnetic resonance imaging showed scarring confined to the atria. The patient was treated with mepolizumab and underwent an electrophysiology study with electroanatomical mapping, demonstrating sinus arrest and the absence of electrical activity throughout the right atrium. After much deliberation, an implantable cardioverter-defibrillator was implanted with a deep septal RV pacing lead and an apical RV defibrillator lead. Discussion We present a unique case of EM with two distinct phases: the first marked by severe LV impairment resolving with immunosuppression; the second characterized by atrial cardiomyopathy leading to persistent symptomatic sinus arrest necessitating permanent pacing. Close follow-up of EM after initial remission is essential to monitor for further complications including heart failure and arrhythmias.
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Affiliation(s)
- Ronald Huynh
- Department of Cardiology, Concord Repatriation General Hospital, 1 Hospital Rd, Concord West, Sydney, New South Wales 2139, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, 1 Hospital Rd, Concord West, Sydney, New South Wales 2139, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown, Sydney, NSW 2050, Australia.,Faculty of Medicine and Health, University of Sydney, Science Rd, Camperdown, Sydney, NSW 2050, Australia
| | - Stephen J Wong
- Department of Pathology, St Vincent's Hospital, 390 Victoria St, Darlinghurst, Sydney, NSW 2010 Australia
| | - Christopher C Y Wong
- Department of Cardiology, Concord Repatriation General Hospital, 1 Hospital Rd, Concord West, Sydney, New South Wales 2139, Australia.,Faculty of Medicine and Health, University of Sydney, Science Rd, Camperdown, Sydney, NSW 2050, Australia
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14
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Rao ACA, Ng ACC, Sy RW, Chia KKM, Hansen PS, Chiha J, Kilian J, Kanagaratnam LB. Electrocardiographic QRS duration is influenced by body mass index and sex. Int J Cardiol Heart Vasc 2021; 37:100884. [PMID: 34660881 PMCID: PMC8503593 DOI: 10.1016/j.ijcha.2021.100884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/05/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022]
Abstract
In a large group of subjects without overt conduction system disease, there was a positive association between increasing BMI and electrocardiographic QRS duration that was independent of other covariates such as sex and age. Females had narrower QRS complex than the males at similar age and in the similar BMI category. Findings of this research should prompt further studies to explore the underlying mechanisms for these observations and potential reversibility of the conduction abnormality with weight loss
Background Electrocardiogram (ECG) measured QRS duration has been shown to influence cardiovascular outcomes. However, there is paucity of data on whether ECG QRS duration is influenced by obesity and sex in large populations. Methods All ECGs performed by a pathology provider over a 2-year period were included. ECGs with confounding factors and those not in sinus rhythm were excluded from the primary analysis. Results Of the 76,220 who met the inclusion criteria, 41,685 (55%) were females. The median age of the study cohort was 61 years (interquartile [IQR] range 48–71 years). The median QRS duration was 86 ms (IQR 80–94 ms). The median BMI was 27.6 kg/m2 (IQR 24.2–31.8 kg/m2). When stratified according to the World Health Organization classification of BMI < 18.50 kg/m2, 18.50–24.99 kg/m2, 25.00–29.99 kg/m2, and ≥ 30.00 kg/m2, the median QRS durations were 82 ms (IQR 76–88 ms), 86 ms (IQR 80–92 ms), 88 ms (IQR 80–94 ms) and 88 ms (IQR 82–94 ms), respectively (p < 0.001 for linear trend). Median QRS duration for females was 84 ms (IQR 78–88 ms); for males, it was 92 ms (IQR 86–98 ms), p < 0.001. Compared to males, females had narrower QRS complexes at similar age and similar BMI. In multiple linear regression analysis, BMI correlated positively with QRS duration (standardized beta 0.095, p < 0.001) independent of age, sex, and heart rate. Conclusions In this large cohort there was a positive association between increasing BMI and QRS duration. Females had narrower QRS duration than males at similar age and similar BMI.
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Key Words
- Age
- BMI
- BMI, Body Mass Index
- CRP, C Reactive Protein
- CRT, Cardiac Resynchronisation therapy
- Cx 43, Connexin 43
- ECG QRS duration
- ECG, Electrocardiogram
- EDV, End Diastolic Volume
- ESV, End Systolic Volume
- IQR, Interquartile range
- Population health
- QTc, Corrected QT interval
- Sex
- WHO, World Health Organisation
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Affiliation(s)
- Anupam C A Rao
- Department of Cardiology, Ryde Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia
| | - Austin C C Ng
- Department of Cardiology, Concord Repatriation General Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia
| | - Karin K M Chia
- Department of Cardiology, Royal North Shore Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia.,Douglas Hanly Moir Pathology, Australia
| | - Peter S Hansen
- Department of Cardiology, Royal North Shore Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia.,Douglas Hanly Moir Pathology, Australia
| | - Joseph Chiha
- Department of Cardiology, Bankstown Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia.,Douglas Hanly Moir Pathology, Australia
| | - Jens Kilian
- Department of Cardiology, Bankstown Hospital, Australia.,University of New South Wales, Australia.,Douglas Hanly Moir Pathology, Australia
| | - Logan B Kanagaratnam
- Department of Cardiology, Ryde Hospital, Australia.,Department of Cardiology, Royal North Shore Hospital, Australia.,Faculty of Medicine and Health, University of Sydney, Australia.,Douglas Hanly Moir Pathology, Australia
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15
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Kaufman ES, Eckhardt LL, Ackerman MJ, Aziz PF, Behr ER, Cerrone M, Chung MK, Cutler MJ, Etheridge SP, Krahn AD, Lubitz SA, Perez MV, Priori SG, Roberts JD, Roden DM, Schulze-Bahr E, Schwartz PJ, Shimizu W, Shoemaker MB, Sy RW, Towbin JA, Viskin S, Wilde AAM, Zareba W. Management of Congenital Long-QT Syndrome: Commentary From the Experts. Circ Arrhythm Electrophysiol 2021; 14:e009726. [PMID: 34238011 PMCID: PMC8301722 DOI: 10.1161/circep.120.009726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
While published guidelines are useful in the care of patients with long-QT syndrome, it can be difficult to decide how to apply the guidelines to individual patients, particularly those with intermediate risk. We explored the diversity of opinion among 24 clinicians with expertise in long-QT syndrome. Experts from various regions and institutions were presented with 4 challenging clinical scenarios and asked to provide commentary emphasizing why they would make their treatment recommendations. All 24 authors were asked to vote on case-specific questions so as to demonstrate the degree of consensus or divergence of opinion. Of 24 authors, 23 voted and 1 abstained. Details of voting results with commentary are presented. There was consensus on several key points, particularly on the importance of the diagnostic evaluation and of β-blocker use. There was diversity of opinion about the appropriate use of other therapeutic measures in intermediate-risk individuals. Significant gaps in knowledge were identified.
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Affiliation(s)
- Elizabeth S. Kaufman
- Heart & Vascular Center, MetroHealth Campus, Case Western Reserve Univ, Cleveland, OH
| | - Lee L. Eckhardt
- Cellular & Molecular Arrhythmia Research Program, Division of Cardiovascular Medicine, Dept of Medicine, Univ of Wisconsin, Madison, WI
| | - Michael J. Ackerman
- Departments of Cardiovascular Medicine, Pediatric & Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN
| | | | - Elijah R. Behr
- Cardiovascular Clinical Academic Group, Institute of Molecular & Clinical Sciences, St. George’s, Univ of London & St. George’s University Hospitals NHS Foundation Trust, London, UK
- ERN GUARDHEART member of the European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (http://guardheart.ern-net.eu)
| | - Marina Cerrone
- Inherited Arrhythmias Clinic, Leon H. Charney Division of Cardiology, New York Univ Grossman School of Medicine, New York, NY
| | - Mina K. Chung
- Heart, Vascular & Thoracic Dept, Dept of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Michael J. Cutler
- Intermountain Medical Center Heart Institute, Intermountain Medical Center, Murray, UT
| | - Susan P. Etheridge
- Department of Pediatrics, Division of Pediatric Cardiology, Univ of Utah, Salt Lake City, Utah
| | - Andrew D. Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, Univ of British Columbia, Vancouver, BC, Canada
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Marco V. Perez
- Stanford Center for Inherited Cardiovascular Diseases, Stanford Univ, Palo Alto, CA
| | - Silvia G. Priori
- Istituti Clinici Scientifici Maugeri, Pavia, Italy & Dept of Molecular Medicine, Univ of Pavia, Italy
- ERN GUARDHEART member of the European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (http://guardheart.ern-net.eu)
| | - Jason D. Roberts
- Population Health Research Institute, McMaster Univ & Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Dan M. Roden
- Senior Vice-President for Personalized Medicine, Vanderbilt Univ Medical Center, Nashville, TN
| | - Eric Schulze-Bahr
- Institute for Genetics of Heart Diseases, Univ Hospital Münster, Münster, Germany
- ERN GUARDHEART member of the European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (http://guardheart.ern-net.eu)
| | - Peter J. Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin & Laboratory of Cardiovascular Genetics, Milan, Italy
- ERN GUARDHEART member of the European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (http://guardheart.ern-net.eu)
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - M. Benjamin Shoemaker
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt Univ Medical Center, Nashville, TN
| | - Raymond W. Sy
- Department of Cardiology, Royal Prince Alfred Hospital Camperdown & Sydney Medical School, Univ of Sydney, NSW, Australia
| | - Jeffrey A. Towbin
- Le Bonheur Children’s Hospital, Univ of Tennessee Health Science Center, Memphis, TN
| | - Sami Viskin
- Tel Aviv Sourasky Medical Center & Sackler School of Medicine, Tel Aviv Univ, Tel Aviv, Israel
| | - Arthur AM Wilde
- Amsterdam UMC, Univ of Amsterdam, Heart Center; Dept of Clinical & Experimental Cardiology, Amsterdam, The Netherlands
- ERN GUARDHEART member of the European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (http://guardheart.ern-net.eu)
| | - Wojciech Zareba
- Clinical Cardiovascular Research Center, Univ of Rochester Medical Center, Rochester, NY
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Quininir L, Raju H, Chan K, Nalliah C, Toal E, Sy RW. Wide complex tachycardia with changing QRS‐axis on loop recorder. J Cardiovasc Electrophysiol 2020; 31:3356-3358. [DOI: 10.1111/jce.14786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/13/2020] [Accepted: 10/18/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Luis Quininir
- Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
| | - Hariharan Raju
- Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
- Department of Cardiology Concord Repatriation General Hospital Sydney Australia
- Macquarie University Sydney Australia
| | - Kim Chan
- Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
- Faculty of Medicine and Health, The University of Sydney Sydney Australia
| | | | - Edward Toal
- Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
| | - Raymond W. Sy
- Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
- Faculty of Medicine and Health, The University of Sydney Sydney Australia
- Department of Cardiology Concord Repatriation General Hospital Sydney Australia
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17
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Isbister JC, Sy RW, Semsarian C. Cardiac arrhythmias in epilepsy: Troublemaker, accomplice, or innocent bystander? Heart Rhythm 2020; 18:229-230. [PMID: 32950721 DOI: 10.1016/j.hrthm.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Julia C Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sidney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, The University of Sydney, Sidney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sidney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
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18
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Isbister JC, Nowak N, Butters A, Yeates L, Gray B, Sy RW, Ingles J, Bagnall RD, Semsarian C. "Concealed cardiomyopathy" as a cause of previously unexplained sudden cardiac arrest. Int J Cardiol 2020; 324:96-101. [PMID: 32931854 DOI: 10.1016/j.ijcard.2020.09.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/09/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Genetic heart disease is a common cause of sudden cardiac arrest (SCA) in the young and those without an ischaemic precipitant. Identifying a cause of SCA in these patients allows for targeted care and family screening. Current guidelines recommend limited, phenotype-guided genetic testing in SCA survivors where a specific genetic condition is suspected and genetic testing is not recommended in clinically-idiopathic SCA survivors. OBJECTIVE To investigate the diagnostic utility of broad, multi-phenotype genetic testing in clinically-idiopathic SCA survivors. METHODS Clinically-idiopathic SCA survivors underwent analysis of genes known to be associated with either cardiomyopathy or primary arrhythmia syndromes, following referral to a specialised genetic heart disease clinic in Sydney, Australia between 1997 and 2019. Comprehensive review of clinical records, investigations and re-appraisal of genetic data according to current variant classification criteria was performed. RESULTS In total, 22% (n = 8/36) of clinically-idiopathic SCA survivors (mean age 36.9 ± 16.9 years, 61% male) had a disease-causing variant identified on broad genetic testing. Of these, 7 (88%) variants resided in cardiomyopathy-associated genes (ACTN2, DES, DSP, MYBPC3, MYH7, PKP2) despite structurally normal hearts or sub-diagnostic structural changes at the time of arrest, so-called "concealed cardiomyopathy". Only one SCA survivor had a variant identified in a channelopathy associated gene (SCN5A). CONCLUSION Extended molecular analysis with multi-phenotype genetic testing can identify a "concealed cardiomyopathy", and increase the diagnosis rate for clinically-idiopathic SCA survivors.
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Affiliation(s)
- Julia C Isbister
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Natalie Nowak
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia
| | - Alexandra Butters
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia
| | - Laura Yeates
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Belinda Gray
- Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Raymond W Sy
- Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richard D Bagnall
- Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Heath, The University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
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19
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Lee S, Zhou J, Liu T, Letsas KP, Hothi SS, Vassiliou VS, Li G, Baranchuk A, Sy RW, Chang D, Zhang Q, Tse G. Temporal Variability in Electrocardiographic Indices in Subjects With Brugada Patterns. Front Physiol 2020; 11:953. [PMID: 33013434 PMCID: PMC7494959 DOI: 10.3389/fphys.2020.00953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Patients with Brugada electrocardiographic (ECG) patterns have differing levels of arrhythmic risk. We hypothesized that temporal variations in certain ECG markers may provide additional value for risk stratification. The present study evaluated the relationship between temporal variability of ECG markers and arrhythmic outcomes in patients with a Brugada pattern ECG. Comparisons were made between low-risk asymptomatic subjects versus high-risk symptomatic patients with a history of syncope, ventricular tachycardia (VT) or ventricular fibrillation (VF). Methods A total of 81 patients presenting with Brugada patterns were recruited. Serial ECGs and electronic health records from January 2004 to April 2019 were analyzed. Temporal variability of QRS interval, J point-Tpeak interval (JTp), Tpeak-Tend interval (Tp-e), and ST elevation (STe) in precordial leads V1-3, in addition to RR-interval from lead II, was assessed using standard deviation and difference between maximum and minimum values over the serial ECGs. Results Patients presenting with type 1 Brugada ECG pattern initially had significantly higher variability in JTp from lead V2 (SD: 33.5 ± 13.8 vs. 25.2 ± 11.5 ms, P = 0.009; max-min: 98.6 ± 46.2 vs. 78.3 ± 47.6 ms, P = 0.047) and ST elevation in lead V1 (0.117 ± 0.122 vs. 0.053 ± 0.030 mV; P = 0.004). Significantly higher variability in Tp-e interval measured from lead V3 was observed in the VT/VF group compared to the syncope and asymptomatic groups (SD: 20.5 ± 8.5 vs. 16.6 ± 7.3 and 14.7 ± 9.8 ms; P = 0.044; max-min: 70.2 ± 28.9 vs. 56.3 ± 29.0 and 43.5 ± 28.5 ms; P = 0.011). Conclusion Temporal variability in ECG indices may provide additional value for risk stratification in patients with Brugada pattern.
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Affiliation(s)
- Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Sandeep S Hothi
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Guoliang Li
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Raymond W Sy
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Dong Chang
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
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20
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Quininir L, Hodkinson E, Chan KH, Sy RW. "Atrial fibrillation and premature ventricular complexes": Is there a unifying diagnosis? J Cardiovasc Electrophysiol 2020; 31:2226-2229. [PMID: 32495398 DOI: 10.1111/jce.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Luis Quininir
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Emily Hodkinson
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kim H Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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21
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Li KHC, Lee S, Yin C, Liu T, Ngarmukos T, Conte G, Yan GX, Sy RW, Letsas KP, Tse G. Brugada syndrome: A comprehensive review of pathophysiological mechanisms and risk stratification strategies. Int J Cardiol Heart Vasc 2020; 26:100468. [PMID: 31993492 PMCID: PMC6974766 DOI: 10.1016/j.ijcha.2020.100468] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Abstract
Brugada syndrome (BrS) is an inherited ion channel channelopathy predisposing to ventricular arrhythmias and sudden cardiac death. Originally believed to be predominantly associated with mutations in SCN5A encoding for the cardiac sodium channel, mutations of 18 genes other than SCN5A have been implicated in the pathogenesis of BrS to date. Diagnosis is based on the presence of a spontaneous or drug-induced coved-type ST segment elevation. The predominant electrophysiological mechanism underlying BrS remains disputed, commonly revolving around the three main hypotheses based on abnormal repolarization, depolarization or current-load match. Evidence from computational modelling, pre-clinical and clinical studies illustrates that molecular abnormalities found in BrS lead to alterations in excitation wavelength (λ), which ultimately elevates arrhythmic risk. A major challenge for clinicians in managing this condition is the difficulty in predicting the subset of patients who will suffer from life-threatening ventricular arrhythmic events. Several repolarization risk markers have been used thus far, but these neglect the contributions of conduction abnormalities in the form of slowing and dispersion. Indices incorporating both repolarization and conduction based on the concept of λ have recently been proposed. These may have better predictive values than the existing markers. Current treatment options include pharmacological therapy to reduce the occurrence of arrhythmic events or to abort these episodes, and interventions such as implantable cardioverter-defibrillator insertion or radiofrequency ablation of abnormal arrhythmic substrate.
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Affiliation(s)
- Ka Hou Christien Li
- Faculty of Medicine, Newcastle University, Newcastle, United Kingdom.,Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, SAR, PR China
| | - Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, SAR, PR China
| | - Chengye Yin
- School of Biological and Chemical Sciences, Queen Mary University of London, London, United Kingdom
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, PR China
| | - Tachapong Ngarmukos
- Department of Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Giulio Conte
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical Center, Wynnewood, PA, USA
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, PR China.,Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
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Butters A, Isbister JC, Medi C, Raju H, Turner C, Sy RW, Semsarian C, Ingles J. Epidemiology and clinical characteristics of atrial fibrillation in patients with inherited heart diseases. J Cardiovasc Electrophysiol 2020; 31:465-473. [DOI: 10.1111/jce.14346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Alexandra Butters
- Agnes Ginges Centre for Molecular Cardiology at Centenary InstituteThe University of Sydney Sydney Australia
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
| | - Julia C. Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary InstituteThe University of Sydney Sydney Australia
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
| | - Caroline Medi
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
| | - Hariharan Raju
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
- Department of CardiologyConcord Repatriation General Hospital Sydney Australia
| | - Christian Turner
- Heart Centre for ChildrenSydney Children's Hospital Sydney Australia
| | - Raymond W. Sy
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
- Department of CardiologyConcord Repatriation General Hospital Sydney Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary InstituteThe University of Sydney Sydney Australia
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary InstituteThe University of Sydney Sydney Australia
- Faculty of Medicine and HealthThe University of Sydney Sydney Australia
- Department of CardiologyRoyal Prince Alfred Hospital Sydney Australia
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Femia G, Semsarian C, McGuire M, Sy RW, Puranik R. Long term CMR follow up of patients with right ventricular abnormality and clinically suspected arrhythmogenic right ventricular cardiomyopathy (ARVC). J Cardiovasc Magn Reson 2019; 21:76. [PMID: 31831077 PMCID: PMC6909455 DOI: 10.1186/s12968-019-0581-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/09/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Task Force Criteria (TFC) for arrhythmogenic right ventricular cardiomyopathy (ARVC) was updated in 2010 to improve specificity. There was concern however that the revised cardiovascular magnetic resonance (CMR) criteria was too restrictive and not sensitive enough to detect early forms of the condition. We previously described patients with clinically suspected ARVC who satisfied criteria from non-imaging TFC categories and fulfilled parameters from the original but not the revised CMR criteria; as a result, these patients were not confirmed as definite ARVC but may represent an early phenotype. METHODS Patients scanned between 2008 and 2015 who had either right ventricular (RV) dilatation or regional dyskinesia satisfying at least minor imaging parameters from the original criteria and without contra-indication underwent serial CMR scanning using a 1.5 T scanner. The aims were to assess the risk of progressive RV abnormalities, evaluate the accuracy of the revised CMR criteria and the need for guideline directed CMR surveillance in at-risk individuals. RESULTS Overall, 48 patients were re-scanned; 24 had a first-degree relative diagnosed with ARVC using the revised TFC or a first-degree relative with premature sudden death from suspected ARVC and 24 patients had either left bundle branch morphology ventricular tachycardia or > 500 ventricular extra-systoles in 24-h. Mean follow up was 69+/- 25 months. The indexed RV end-diastolic, end-systolic volumes and ejection fraction were calculated for both scans. There was significant reduction in RV volumes and improvement in RV ejection fraction (EF) irrespective of changes to body surface area; - 11.7+/- 15.2 mls/m2, - 6.4+/- 10.5 mls/m2 and + 3.3 +/- 7.9% (p = 0.01, 0.01 and 0.04). Applying the RV parameters to the revised CMR criteria, two patients from the family history group (one with confirmed ARVC and one with a premature death) had progressive RV abnormalities satisfying major criteria. The remaining patients (n = 46) did not satisfy the criteria and either had normal RV parameters with regression of structural abnormalities (27,56.3%) or stable abnormalities (19,43.7%). CONCLUSION The revised CMR criteria represents a robust tool in the evaluation of patients with clinical suspicion of ARVC, especially for those with ventricular arrhythmias without a family history for ARVC. For patients with RV abnormalities that do not fulfill the revised criteria but have a family history of ARVC or an ARVC associated gene mutation, a surveillance CMR scan should be considered as part of the clinical follow up protocol.
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Affiliation(s)
- Giuseppe Femia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW Australia
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, Australia
- Sydney Medical School Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Mark McGuire
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW Australia
| | - Raymond W. Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Affiliation(s)
- Ad W.G.J. Oomen
- Department of Cardiology, Amphia Ziekenhuis, Breda, The Netherlands
| | | | - Raymond W. Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
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26
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Moore BM, Chan KH, Sy RW. Catheter Ablation for Atrial Fibrillation in Heart Failure: Ready for Mainstream Adoption, or Is More Evidence Needed? Heart Lung Circ 2019; 28:665-666. [PMID: 30846417 DOI: 10.1016/j.hlc.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin M Moore
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kim H Chan
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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27
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Moore BM, Sy RW. Cryoballoon Versus Radiofrequency Ablation for Atrial Fibrillation - Is There a Role for Individualised Patient Selection? Heart Lung Circ 2018; 28:511-518. [PMID: 30528213 DOI: 10.1016/j.hlc.2018.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/09/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Benjamin M Moore
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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Moore BM, Sy RW, Chan KH. A wobbling tachycardia: What is the mechanism? Heart Rhythm 2018; 15:1583-1584. [PMID: 30274619 DOI: 10.1016/j.hrthm.2018.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Benjamin M Moore
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Kim H Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.
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Affiliation(s)
- A W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - R W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. .,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Affiliation(s)
- A W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - R W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. .,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Yeates L, Ingles J, Gray B, Singarayar S, Sy RW, Semsarian C, Bagnall RD. A balanced translocation disrupting SCN5A in a family with Brugada syndrome and sudden cardiac death. Heart Rhythm 2018; 16:231-238. [PMID: 30170230 DOI: 10.1016/j.hrthm.2018.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Brugada syndrome (BrS) is a primary arrhythmia syndrome affecting 1 in 2000 of the general population. Genetic testing identifies pathogenic variants in the sodium voltage-gated channel α-subunit 5 gene (SCN5A) in up to 25% of familial BrS. Balanced translocations, which involve the exchange of the ends of 2 different chromosomes, are found in approximately 1 in 500 people. They usually are benign and only rarely are reported to cause arrhythmogenic disorders. OBJECTIVE The purpose of this study was to identify the genetic mechanism underlying a family with BrS, sick sinus syndrome, cardiac hypertrophy, sudden cardiac death, and multiple miscarriages. METHODS We clinically evaluated family members with an electrocardiogram, 2-dimensional echocardiogram, and provocation testing with ajmaline challenge. Cytogenetic testing included karyotype and fluorescent in situ hybridization (FISH) analysis. We performed gene panel, exome, and genome sequencing analysis. RESULTS Sequencing of 128 cardiac genes and exome sequencing of a family with BrS, sick sinus syndrome, cardiac hypertrophy, sudden cardiac death, and multiple miscarriages did not reveal a pathogenic variant. Karyotype and FISH analysis identified a balanced translocation breaking the SCN5A gene on chromosome 3 and the multiple chromosome maintenance 10 gene (MCM10) on chromosome 10 t(3;10)(p22.2;p13). We characterized both translocation breakpoint junctions using genome sequencing and found no regions of sequence homology. CONCLUSION A balanced translocation breaking SCN5A is a novel mechanism underlying disease in a family with BrS, sick sinus syndrome, cardiac hypertrophy, and sudden cardiac death. Genome sequencing can identify rare chromosomal aberrations causing inherited diseases that may otherwise be missed using gene panel and exome sequencing-based approaches.
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Affiliation(s)
- Laura Yeates
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Belinda Gray
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Suresh Singarayar
- Prince of Wales Hospital and Eastern Heart Clinic, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Gray B, Hasdemir C, Ingles J, Aiba T, Makita N, Probst V, Wilde AAM, Newbury-Ecob R, Sheppard MN, Semsarian C, Sy RW, Behr ER. Lack of genotype-phenotype correlation in Brugada Syndrome and Sudden Arrhythmic Death Syndrome families with reported pathogenic SCN1B variants. Heart Rhythm 2018; 15:1051-1057. [PMID: 29758173 DOI: 10.1016/j.hrthm.2018.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is limited evidence that Brugada Syndrome (BrS) is due to SCN1B variants (BrS5). This gene may be inappropriately included in routine genetic testing panels for BrS or Sudden Arrhythmic Death Syndrome (SADS). OBJECTIVE We sought to characterize the genotype-phenotype correlation in families who had BrS and SADS with reportedly pathogenic SCN1B variants and to review their pathogenicity. METHODS Families with BrS and SADS were assessed from 6 inherited arrhythmia centers worldwide, and a comprehensive literature review was performed. Clinical characteristics including relevant history, electrocardiographic parameters and drug provocation testing results were studied. SCN1B genetic testing results were reclassified using American College of Medical Genetics criteria. RESULTS A total of 23 SCN1B genotype-positive individuals were identified from 8 families. Four probands (17%) experienced ventricular fibrillation or sudden cardiac death at the time of presentation. All family members were free from syncope or ventricular arrhythmias. Only 2 of 23 genotype-positive individuals (9%) demonstrated a spontaneous BrS electrocardiographic pattern. Drug challenge testing for BrS in 87% (13 of 15) was negative. There was no difference in PR interval (161 ± 7 ms vs 165 ± 9 ms; P = .83), QRS duration (101 ± 6 ms vs 89 ± 5 ms; P = .35), or corrected QT interval (414 ± 35 ms vs 405 ± 8 ms; P = .7) between genotype-positive and genotype-negative family members. The overall frequency of previously implicated SCN1B variants in the Genome Aggregation Database browser is 0.004%, exceeding the estimated prevalence of BrS owing to SCN1B (0.0005%), including 15 of 23 individuals (65%) who had the p.Trp179X variant. CONCLUSION The lack of genotype-phenotype concordance among families, combined with the high frequency of previously reported mutations in the Genome Aggregation Database browser, suggests that SCN1B is not a monogenic cause of BrS or SADS.
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Affiliation(s)
- Belinda Gray
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia; St George's University of London, London, United Kingdom
| | - Can Hasdemir
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
| | - Jodie Ingles
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Takeshi Aiba
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Vincent Probst
- l'institut du thorax, Cardiologic Department, University Nantes, Nantes, France
| | | | - Ruth Newbury-Ecob
- Department of Clinical Genetics, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | | | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Elijah R Behr
- St George's University of London, London, United Kingdom.
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Iyer NR, Oomen AWGJ, Sy RW. A challenging broad-complex tachycardia. Heart Asia 2018; 10:e011054. [DOI: 10.1136/heartasia-2018-011054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/09/2018] [Indexed: 11/03/2022]
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Oomen AWGJ, Semsarian C, Puranik R, Sy RW. Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy: Progress and Pitfalls. Heart Lung Circ 2018; 27:1310-1317. [PMID: 29705385 DOI: 10.1016/j.hlc.2018.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 01/20/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that predominantly affects the right ventricle. With a prevalence in the range of 1:5000 to 1:2000 persons, ARVC is one of the leading causes of sudden cardiac death in young people and in athletes. Although early detection and treatment is important, the diagnosis of ARVC remains challenging. There is no single pathognomonic diagnostic finding in ARVC; rather, current international task force criteria specify diagnostic major and minor criteria in six categories: right ventricular imaging (including echocardiography and cardiac magnetic resonance imaging (MRI)), histology, repolarisation abnormalities, depolarisation and conduction abnormalities, arrhythmias and family history (including genetic testing). Combining findings from differing diagnostic modalities can establish a "definite", "borderline" or "possible" diagnosis of ARVC. However, there are limitations inherent in the current task force criteria, including the lack of specificity for ARVC; future iterations may be improved, for example, by enhanced imaging protocols able to detect subtle changes in the structure and function of the right ventricle, incorporation of electro-anatomical data, response to adrenergic challenge, and validated criteria for interpreting genetic variants.
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Affiliation(s)
- Ad W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Ross SB, Bagnall RD, Yeates L, Sy RW, Semsarian C. Holt-Oram syndrome in two families diagnosed with left ventricular noncompaction and conduction disease. HeartRhythm Case Rep 2018; 4:146-151. [PMID: 29755943 PMCID: PMC5944048 DOI: 10.1016/j.hrcr.2017.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Samantha Barratt Ross
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Laura Yeates
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Abed HS, Kilborn MJ, Chen V, Sy RW. Reversal Agents in the Era of NOACs. J Atr Fibrillation 2017; 10:1634. [PMID: 29487678 DOI: 10.4022/jafib.1634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/19/2017] [Accepted: 10/14/2017] [Indexed: 12/31/2022]
Abstract
The incidence and prevalence of atrial fibrillation (AF) is expected to more than double between 2010 and 2030. Accordingly, the use of non-vitamin K oral anticoagulant (NOAC) agents for thromboembolic stroke prevention is anticipated to increase. The development of effective and safe antidotes is needed to address the unmet need for rapid anticoagulation reversal. The immediate role for these novel antidotes is for reversal of NOAC activity in life threatening bleeding and urgent surgical intervention. In addition, reversal agents may play an important role in simplifying bridging protocols in the peri-procedural period for catheter ablation of AF and elective surgery. Currently, novel reversal agents are either decoy drug receptors or small molecule non-specific anticoagulant activity inhibitors. These agents are at various stages of FDA investigation and approval, with emerging prospective data for safety and efficacy. The purpose of this review is to outline the currently developed NOAC molecular antagonists, their potential clinical roles and future directions.
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Affiliation(s)
- Hany S Abed
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
| | - Michael J Kilborn
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
| | - Vivien Chen
- Department of Haematology, Concord Repatriation General Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
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Lowres N, Neubeck L, Salkeld G, Krass I, McLachlan AJ, Redfern J, Bennett AA, Briffa T, Bauman A, Martinez C, Wallenhorst C, Lau JK, Brieger DB, Sy RW, Freedman SB. Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. Thromb Haemost 2017; 111:1167-76. [DOI: 10.1160/th14-03-0231] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/18/2014] [Indexed: 11/05/2022]
Abstract
SummaryAtrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy. Pharmacists performed pulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence. Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.Previous Presentation: This study was presented in part as an oral presentation at the Cardiac Society of Australia and New Zealand Conference; 9 August 2013; Sydney, Australia, abstract published in Heart Lung Circulation 2013;22:S223.Trial registration: Australian New Zealand clinical trials registry: ACTRN12612000406808.
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Kanawati J, Sy RW. Contemporary Review of Left Bundle Branch Block in the Failing Heart - Pathogenesis, Prognosis, and Therapy. Heart Lung Circ 2017; 27:291-300. [PMID: 29097067 DOI: 10.1016/j.hlc.2017.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/13/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Abstract
Cardiac resynchronisation therapy (CRT) is a cornerstone in the contemporary management of heart failure. The most effective way of predicting response to this therapy remains electrocardiographic (ECG) criteria of electromechanical dyssynchrony. The left bundle branch block (LBBB) pattern is currently the most robust ECG criterion in predicting improvement in symptoms and reduction in mortality. However, recent studies using three-dimensional (3D) mapping and cardiac magnetic resonance imaging (CMR) have demonstrated heterogeneous left ventricular activation patterns in patients with LBBB. This has led to intense debate on the activation pattern of "true LBBB" and resulted in the proposal of stricter criteria for defining LBBB. This review will focus on the definitions and implications of LBBB in the CRT era. At a minimum, the use of stricter ECG criteria appears warranted, and adjunctive pre-implant imaging or mapping may further identify patient-specific electrophysiological patterns that determine response to CRT.
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Affiliation(s)
- Juliana Kanawati
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Shakkottai P, Sy RW, McGuire MA. Cryoablation for Atrial Fibrillation in 2017: What Have We Learned? Heart Lung Circ 2017; 26:950-959. [DOI: 10.1016/j.hlc.2017.05.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/02/2017] [Indexed: 01/25/2023]
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Femia G, Sy RW, Puranik R. Systematic review: Impact of the new task force criteria in the diagnosis of arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2017; 241:311-317. [DOI: 10.1016/j.ijcard.2017.03.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 03/13/2017] [Indexed: 11/26/2022]
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Oomen AWGJ, Sy RW. A wolf in sheep's clothing: An unusual cause of atrio-ventricular Wenckebach phenomenon. J Cardiovasc Electrophysiol 2017; 28:1353-1354. [PMID: 28727194 DOI: 10.1111/jce.13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Ad W G J Oomen
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Gray B, Kirby A, Kabunga P, Freedman SB, Yeates L, Kanthan A, Medi C, Keech A, Semsarian C, Sy RW. Twelve-lead ambulatory electrocardiographic monitoring in Brugada syndrome: Potential diagnostic and prognostic implications. Heart Rhythm 2017; 14:866-874. [DOI: 10.1016/j.hrthm.2017.02.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Indexed: 02/08/2023]
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Chan KH, Sy RW. Catheter Ablation of Recurrent Ventricular Fibrillation: A Literature Review and Case Examples. Heart Lung Circ 2016; 25:784-90. [DOI: 10.1016/j.hlc.2016.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 02/02/2016] [Accepted: 02/09/2016] [Indexed: 11/24/2022]
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Hunyor I, Abed HS, Sy RW, Hodkinson EC, Santucci P, McGuire MA. Intermittent failure of pacing output caused by algorithm to prevent T-wave oversensing. HeartRhythm Case Rep 2016; 2:286-289. [PMID: 28491692 PMCID: PMC5419838 DOI: 10.1016/j.hrcr.2016.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abed HS, Chen V, Kilborn MJ, Sy RW. Periprocedural Management of Novel Oral Anticoagulants During Atrial Fibrillation Ablation: Controversies and Review of the Current Evidence. Heart Lung Circ 2016; 25:1164-1176. [PMID: 27425183 DOI: 10.1016/j.hlc.2016.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 04/05/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
Oral anticoagulation (OAC) has been the cornerstone for the prevention of thromboembolic complications in patients with atrial fibrillation (AF) at significant risk of stroke. Catheter ablation is an established efficacious technique for the treatment of AF. Ameliorating the risk of stroke or transient ischaemic attack (TIA) in patients with AF undergoing ablation requires meticulous planning of pharmacotherapy. The advent of non-vitamin K oral anticoagulants (NOACs) has broadened the therapeutic scope, representing a viable alternative to traditional vitamin K antagonists (VKA) in non-valvular AF. Potential advantages of NOACs include greater pharmacokinetic predictability, at least comparable efficacy as compared to VKA and a superior haemorrhagic complication profile. However, robust evidence for the safety and efficacy of periprocedural NOAC use for AF ablation remains uncertain with a non-uniform clinical approach between and within institutions. The following review will summarise the current and emerging evidence on periprocedural management of NOACs in patients undergoing catheter ablation of AF. An overview of NOAC pharmacology will provide a foundation for the review of reversal agents in the context of catheter ablation of AF. The purpose of the review is to outline key studies and identify key areas for further critical research with the ultimate aim of developing evidence-based guidelines for optimal care.
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Affiliation(s)
- Hany S Abed
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Vivien Chen
- Department of Haematology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Michael J Kilborn
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, NSW, Australia.
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Kabunga P, Phan K, Ha H, Sy RW. Meta-Analysis of Contemporary Atrial Fibrillation Ablation Strategies. JACC Clin Electrophysiol 2016; 2:377-390. [DOI: 10.1016/j.jacep.2015.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/01/2015] [Accepted: 12/27/2015] [Indexed: 12/21/2022]
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Gray B, Bagnall RD, Lam L, Ingles J, Turner C, Haan E, Davis A, Yang PC, Clancy CE, Sy RW, Semsarian C. A novel heterozygous mutation in cardiac calsequestrin causes autosomal dominant catecholaminergic polymorphic ventricular tachycardia. Heart Rhythm 2016; 13:1652-60. [PMID: 27157848 DOI: 10.1016/j.hrthm.2016.05.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a lethal inherited arrhythmia syndrome characterized by adrenergically stimulated ventricular tachycardia. Mutations in the cardiac ryanodine receptor gene (RYR2) cause an autosomal dominant form of CPVT, while mutations in the cardiac calsequestrin 2 gene (CASQ2) cause an autosomal recessive form. OBJECTIVE The aim of this study was to clinically and genetically evaluate a large family with severe autosomal dominant CPVT. METHODS Clinical evaluation of family members was performed, including detailed history, physical examination, electrocardiogram, exercise stress test, and autopsy review of decedents. We performed genome-wide linkage analysis in 12 family members and exome sequencing in 2 affected family members. In silico models of mouse and rabbit myocyte electrophysiology were used to predict potential disease mechanisms. RESULTS Severe CPVT with dominant inheritance in 6 members was diagnosed in a large family with 2 sudden deaths, 2 resuscitated cardiac arrests, and multiple appropriate implantable cardioverter-defibrillator shocks. A comprehensive analysis of cardiac arrhythmia genes did not reveal a pathogenic variant. Exome sequencing identified a novel heterozygous missense variant in CASQ2 (Lys180Arg) affecting a highly conserved residue, which cosegregated with disease and was absent in unaffected family members. Genome-wide linkage analysis confirmed a single linkage peak at the CASQ2 locus (logarithm of odds ratio score 3.01; θ = 0). Computer simulations predicted that haploinsufficiency was unlikely to cause the severe CPVT phenotype and suggested a dominant negative mechanism. CONCLUSION We show for the first time that a variant in CASQ2 causes autosomal dominant CPVT. Genetic testing in dominant CPVT should include screening for heterozygous CASQ2 variants.
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Affiliation(s)
- Belinda Gray
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, New South Wales, Australia
| | - Richard D Bagnall
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, New South Wales, Australia
| | - Lien Lam
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, New South Wales, Australia
| | - Jodie Ingles
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, New South Wales, Australia
| | - Christian Turner
- Department of Cardiology, Westmead Children's Hospital, Sydney, New South Wales, Australia
| | - Eric Haan
- Adult Genetics Unit, South Australian Clinical Genetics Service, SA Pathology and School of Medicine, University of Adelaide, Adelaide, New South Wales, Australia
| | - Andrew Davis
- Department of Cardiology, The Royal Children's Hospital Melbourne, Melbourne, New South Wales, Victoria, Australia
| | - Pei-Chi Yang
- Department of Pharmacology, University of California, Davis, California, USA
| | - Colleen E Clancy
- Department of Pharmacology, University of California, Davis, California, USA
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, New South Wales, Australia.
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48
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Phan K, Ha H, Kabunga P, Kilborn MJ, Toal E, Sy RW. Systematic Review of Defibrillation Threshold Testing at De Novo Implantation. Circ Arrhythm Electrophysiol 2016; 9:e003357. [DOI: 10.1161/circep.115.003357] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 03/14/2016] [Indexed: 11/16/2022]
Abstract
Background—
Recent results from the largest multicenter randomized trial (Shockless IMPLant Evaluation [SIMPLE]) on defibrillation threshold (DFT) testing suggest that while shock testing seems safe, it does not reduce the risk of failed shocks or prolong survival. A contemporary systematic review of DFT versus no-DFT testing at the time of implantable cardioverter–defibrillator implantation was performed to evaluate the current evidence and to assess the impact of the SIMPLE study.
Methods and Results—
Electronic searches were performed using 6 databases from their inception to March 2014. Relevant studies investigating implant DFT were identified. Data were extracted and analyzed according to predefined clinical end points. Predefined outcomes for interrogation were all-cause mortality, composite end point of implantable cardioverter–defibrillator efficacy (arrhythmic deaths and ineffective shocks), and composite safety end point (the sum of complications recorded at 30 days). Meta-analysis was performed including 13 studies and 9740 patients. No significant differences between DFT versus no-DFT cohorts were found in terms of all-cause mortality (risk ratio, 0.90; 95% confidence interval, 0.71–1.15;
P
=0.41), composite efficacy outcome (risk ratio, 1.24; 95% confidence interval, 0.65–3.37;
P
=0.51), and 30-day postimplant complications (risk ratio, 1.18; 95% confidence interval, 0.87–1.60;
P
=0.29). No significant difference was found in the trends observed when the results of the SIMPLE study were excluded or included.
Conclusions—
This systematic review of contemporary data suggests a modest average effect of DFT, if any, in terms of mortality, shock efficacy, or safety. Therefore, DFT testing should no longer be compulsory during de novo implantation. However, DFT testing may still be clinically relevant in specific patient populations.
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Affiliation(s)
- Kevin Phan
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
| | - Hakeem Ha
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
| | - Peter Kabunga
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
| | - Michael J. Kilborn
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
| | - Edward Toal
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
| | - Raymond W. Sy
- From the Faculty of Medicine, Sydney Medical School (K.P., M.J.K., R.W.S.), Department of Cardiology, Westmead Clinical School (K.P.), and Department of Cardiology, Royal Prince Alfred Hospital (P.K., M.J.K., E.T., R.W.S.), University of Sydney, Sydney, Australia; and Faculty of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia (H.H.)
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49
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Vaidya K, Arnott C, Russell A, Masson P, Sy RW, Patel S. Pulmonary Vein Isolation Compared to Rate Control in Patients with Atrial Fibrillation: A Systematic Review and Meta-analysis. Heart Lung Circ 2015; 24:744-52. [DOI: 10.1016/j.hlc.2015.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/22/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
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50
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Kabunga P, Lipton J, Sy RW. Adenosine-Sensitive Ventricular Tachycardia arising from the Middle Cardiac Vein. Heart Lung Circ 2015; 24:838-9. [PMID: 25911141 DOI: 10.1016/j.hlc.2015.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/14/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Peter Kabunga
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jonathan Lipton
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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