Association between the geographic region and the risk of familial atrioventricular nodal reentrant tachycardia in the Polish population

INTRODUCTION Atrioventricular nodal reentrant tachycardia (AVNRT) is one of the most common regular supraventricular arrhythmias referred for catheter ablation (CA). In Poland, several families with familial AVNRT (FAVNRT) were reported in Podkarpacie Province (PP). OBJECTIVES We aimed to determine the frequency of FAVNRT in PP compared with other south‑eastern provinces of Poland. PATIENTS AND METHODS Clinical data of 1544 patients with AVNRT diagnosed by invasive electrophysi-ological study between 2010 and 2019 were screened for FAVNRT. From January 2017 to June 2019, patients were asked to provide details on family history and origin to obtain 3‑generation pedigrees. Families with at least 2 members with previous CA of AVNRT were divided into those from south‑eastern provinces (SEPs; including PP and bordering provinces [BPs]) and the remaining parts of Poland (RPP). RESULTS There were 932 patients from SEPs and 612 from RPP. FAVNRT was reported in 45 patients (2.91%) from 27 families, with a higher frequency in SEPs than RPP (4.02% vs 1.17%; P = 0.002) and the highest frequency in PP (6.33% vs 2.47% in BPs; P = 0.004). The risk of FAVNRT was higher in PP compared with BPs (odds ratio, 2.67; 95% CI, 1.36-5.23; P = 0.004) and similar in BPs compared with RPP (odds ratio, 2.14; 95% CI, 0.86-5.34; P = 0.1). CONCLUSIONS A relationship exists between the geographic region and frequency of FAVNRT. A greater distance from PP was associated with less frequent FAVNRT. International cooperation and genetic test-ing are needed to confirm the genetic impact of FAVNRT in this part of Central Europe.

Transgenic mouse model of ventricular preexcitation and atrioventricular reentrant tachycardia induced by an AMP-activated protein kinase loss-of-function mutation responsible for Wolff-Parkinson-White syndrome

BACKGROUND

We identified a gene (PRKAG2) that encodes the gamma-2 regulatory subunit of AMP-activated protein kinase (AMPK) with a mutation (Arg302Gln) responsible for familial Wolff-Parkinson-White (WPW) syndrome. The human phenotype consists of ventricular preexcitation, conduction abnormalities, and cardiac hypertrophy.

METHODS AND RESULTS

To elucidate the molecular basis for the phenotype, transgenic mice were generated by cardiac-restricted expression of the wild-type (TG(WT)) and mutant(TG(R302Q)) PRKAG2 gene with the cardiac-specific promoter alpha-myosin heavy chain. ECG recordings and intracardiac electrophysiology studies demonstrated the TG(R302Q) mice to have ventricular preexcitation (PR interval 10+/-2 versus 33+/-5 ms in TG(WT), P<0.05) and a prolonged QRS (20+/-5 versus 10+/-1 ms in TG(WT), P<0.05). A distinct AV accessory pathway was confirmed by electrical and pharmacological stimulation and substantiated by induction of orthodromic AV reentrant tachycardia. Enzymatic activity of AMPK in the mutant heart was significantly reduced (0.009+/-0.003 versus 0.025+/-0.001 nmol x min(-1) x g(-1) in nontransgenic mice), presumably owing to the mutation disrupting the AMP binding site. Excessive cardiac glycogen was observed. Hypertrophy was confirmed by increases in heart weight (296 versus 140 mg in TG(WT)) and ventricular wall thickness.

CONCLUSIONS

We have developed a genetic animal model of WPW that expresses a mutation responsible for a familial form of WPW syndrome with a phenotype identical to that of the human, including induction of supraventricular arrhythmia. The defect is due to loss of function of AMPK. Elucidation of the molecular basis should provide insight into development of the cardiac conduction system and accessory pathways.

Familial Atrioventricular Nodal Reentry Tachycardia

Dual atrioventricular nodal pathways, the substrate responsible for atrioventricular node reentry tachycardia (AVNRT), are thought to be randomly occurring congenital anomalies. This article describes 14 patients in six families, each with two or three first-degree relatives with paroxysmal supraventricular tachycardia. Electrophysiological evidence of dual atrioventricular nodal pathways was established in all 13 patients studied, AVNRT was induced in 12 (92%), and radiofrequency ablation of the slow pathway was curative in all cases. The data suggest a hereditary contribution to the development of atrioventricular nodal pathways and AVNRT. The pattern of inheritance appears to be autosomal dominant.

Recurrent syncope in a young patient with long QT syndrome: possible relationship of atrioventricular nodal re-entrant tachycardia with neurally mediated spells?

This is a case of a 15-year-old woman with long QT syndrome (LQTS) and a history of 14 events of syncope, demonstrating that the underlying mechanism for any symptomatic episode is not necessarily based on torsades de pointes. The need for careful distinction between true ventricular tachyarrhythmia and other forms of supraventricular tachycardia in the LQTS is the subject of the article. To the knowledge of the authors, this is the first reported case of an association of LQTS with AV nodal re-entrant tachycardia.

Paroxysmal supraventricular tachycardia in identical twins with the same left lateral accessory pathways and innocent dual atrioventricular pathways

We report on 16-year-old, female identical twins who both have atrioventricular reentrant tachycardia caused by the same left lateral atrioventricular accessory pathway. The Kent pathway in twin A was a unidirectional retrograde accessory pathway. A manifest Kent pathway was demonstrated in twin B. Both pathways were successfully ablated by radiofrequency (RF) energy and without recurrence. In addition, innocent dual AV nodal pathways were shown in both patients. These findings suggest that genetic factors may play a role in the pathogenesis of the formation of accessory atrioventricular pathways and dual AV nodal pathways.

Basic mechanisms of atrial fibrillation--very new insights into very old ideas

Atrial fibrillation (AF) was recognized and studied extensively in the early twentieth century, but many fundamental aspects of the arrhythmia were poorly understood until quite recently. It is now recognized that AF can be initiated by a variety of mechanisms that share the ability to cause extremely rapid, irregular atrial electrical activity. Once initiated, AF causes alterations in atrial electrical properties (electrical remodeling), including both rapid functional changes and slower alterations in ion channel gene expression, which promote the maintenance of AF and facilitate reinitiation of the arrhythmia should it terminate. Electrical remodeling decreases the atrial refractory period in a heterogeneous way, thus decreasing the size and stability of potential functional atrial reentry waves and promoting multiple-circuit reentry. Whatever the initial cause of AF, electrical remodeling is likely to be a final common pathway that ultimately supervenes. Recent advances in understanding ion channel function, regulation, and remodeling at the molecular level have allowed for a much more detailed appreciation of the basic determinants of AF. Improvements in the clinical management of AF will inevitably follow the recent advances in our understanding of its detailed pathophysiology.

The Brugada syndrome: clinical, electrophysiologic and genetic aspects

This review deals with the clinical, basic and genetic aspects of a recently highlighted form of idiopathic ventricular fibrillation known as the Brugada syndrome. Our primary objective in this review is to identify the full scope of the syndrome and attempt to correlate the electrocardiographic manifestations of the Brugada syndrome with cellular and ionic heterogeneity known to exist within the heart under normal and pathophysiologic conditions so as to identify the cellular basis and thus potential diagnostic and therapeutic approaches. The available data suggest that the Brugada syndrome is a primary electrical disease resulting in abnormal electrophysiologic activity in right ventricular epicardium. Recent genetic data linking the Brugada syndrome to an ion channel gene mutation (SCN5A) provides further support for the hypothesis. The electrocardiographic manifestations of the Brugada syndrome show transient normalization in many patients, but can be unmasked using sodium channel blockers such as flecainide, ajmaline or procainamide, thus identifying patients at risk. The available data suggest that loss of the action potential dome in right ventricular epicardium but not endocardium underlies the ST segment elevation seen in the Brugada syndrome and that electrical heterogeneity within right ventricular epicardium leads to the development of closely coupled premature ventricular contractions via a phase 2 reentrant mechanism that then precipitates ventricular tachycardia/ventricular fibrillation (VT/VF). Currently, implantable cardiac defibrillator implantation is the only proven effective therapy in preventing sudden death in patients with the Brugada syndrome and is indicated in symptomatic patients and should be considered in asymptomatic patients in whom VT/VF is inducible at time of electrophysiologic study.

Radiofrequency catheter ablation in familial paroxysmal supraventricular tachycardia due to accessory atrioventricular pathways

Radiofrequency catheter ablation (RF-CA) has been widely used to cure paroxysmal supraventricular tachycardia (PSVT). However, its use has never been reported in familial PSVT caused by an accessory atrioventricular pathway (AP), which is known as one of the typical familial cardiovascular diseases. Two cases of using RF-CA for familial PSVT due to APs are presented, in a brother and sister, supporting a potential genetic role in the developmental failure to lose the atrioventricular connection during fetal life. The sister, a 24-year-old woman, had intermittent episodes of palpitation accompanied by chest pain for 2 years. An electrophysiologic study (EPS) confirmed her clinical tachycardia was atrioventricular reentrant tachycardia (AVRT) due to a left lateral concealed AP, which was subsequently successfully ablated with RF-CA. The brother, a 22-year-old man, had a 5-year history of paroxysmal palpitation. A resting electrocardiogram showed a right bundle branch block and left axis deviation with a delta wave. During his EPS, AVRT was reproducibly induced and a manifest AP was localized and then ablated at the left posteroseptal site, resulting in disappearance of the delta wave. PSVT, however, recurred 1 month later and during a repeat EPS the tachycardia was proved to be AVRT due to a right anterior concealed AP. The right anterior AP was successfully ablated with RF-CA. Both patients remained asymptomatic for more than 3 years following the successful ablation procedures.

[Differences in the symptomatology of paroxysmal supraventricular tachycardias in relation to the different sites of localization of the arrhythmic reentry circuit. Clinical picture, semiologic and genetic aspects]

Transesophageal, electrophysiologic studies were conducted in 47 patients, with clinical and ECGgraphic diagnosis of paroxysmal reciprocating supraventricular tachycardia. After admission to hospital, the patients were enrolled in the study in accordance with the criterion concerning the exclusion of patients with signs and symptoms of severe heart pump failure (ie, NYHA III and IV class were excluded). The transesophageal study was performed during paroxysmal tachycardia in each patient to measure the V-A interval and to localize the site of reentry. Thereby, the patients could be grouped into 2 subsets, ie those with A-V nodal reentrant tachycardia (no. 30 patients) and those with accessory pathway reentrant tachycardia (no. 17 patients). Moreover, the prevalence in both subsets was evaluated in the following signs and symptoms: palpitations, dyspnoea, chest pain, pulsations in the neck, significant increase in urinary output, hypotension, dizziness, near-syncope, syncope, shock, focal brain injury. From the data analysis, significantly greater prevalence of palpitations in the neck resulted in the subset of patients with reentry confined to the A-V node (no. 20 cases) compared with those suffering from reentry via accessory pathway (no. 4 cases). Moreover the arterial pressure, in A-V nodal reentrant tachycardia, showed the lowest values and the best decreases, together with the finding of a more rapid trend to decline in comparison with the accessory pathway subset. On the other hand, no significant differences could be seen about the remaining symptoms. In an attempt to provide the reliable explanation for the differences found between the 2 subsets of study, concerning both the unpleasant pulsations in the neck and the pressure decrease, we postulated a remarkable role for the length of arrhythmic circle movement. The smaller dimensions of circuit limbs, in A-V nodal reentrant tachycardia, are likely to be the principle cause of the different clinical features of 2 types of reentry. We speculate actually that in susceptible patients the critical event is most likely to be A-V functional dissociation due to early and unphysiologic activation of atria by stimulus rapidly reentrant from the bottom portion of the AV node: the simultaneous occurrence, frequent in A-V node reentry, of both, atrial and ventricular mechanical activation, would result, however, in impairment of atrial haemodynamics due to development of cannon A waves, able either to activate a vasodepressor reflex from the atria or to stimulate instantaneous release of atrial natriuretic factor in the circulation. Further studies, however, are necessary to be performed on large cases-records, to confirm our hypothesis.(ABSTRACT TRUNCATED AT 400 WORDS)