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Latrofa S, Hartwig V, Bachi L, Notarstefano P, Garibaldi S, Panchetti L, Nesti M, Seghetti P, Startari U, Mirizzi G, Morelli MS, Modena M, Mazzanti A, Emdin M, Giannoni A, Rossi A. Endocardial repolarization dispersion in BrS: A novel automatic algorithm for mapping activation recovery interval. J Cardiovasc Electrophysiol 2024; 35:965-974. [PMID: 38477371 DOI: 10.1111/jce.16244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Repolarization dispersion in the right ventricular outflow tract (RVOT) contributes to the type-1 electrocardiographic (ECG) phenotype of Brugada syndrome (BrS), while data on the significance and feasibility of mapping repolarization dispersion in BrS patients are scarce. Moreover, the role of endocardial repolarization dispersion in BrS is poorly investigated. We aimed to assess endocardial repolarization patterns through an automated calculation of activation recovery interval (ARI) estimated on unipolar electrograms (UEGs) in spontaneous type-1 BrS patients and controls; we also investigated the relation between ARI and right ventricle activation time (RVAT), and T-wave peak-to-end interval (Tpe) in BrS patients. METHODS Patients underwent endocardial high-density electroanatomical mapping (HDEAM); BrS showing an overt type-1 ECG were defined as OType1, while those without (latent type-1 ECG and LType1) received ajmaline infusion. BrS patients only underwent programmed ventricular stimulation (PVS). Data were elaborated to obtain ARI corrected with the Bazett formula (ARIc), while RVAT was derived from activation maps. RESULTS 39 BrS subjects (24 OType1 and 15 LTtype1) and 4 controls were enrolled. OType1 and post-ajmaline LType1 showed longer mean ARIc than controls (306 ± 27.3 ms and 333.3 ± 16.3 ms vs. 281.7 ± 10.3 ms, p = .05 and p < .001, respectively). Ajmaline induced a significant prolongation of ARIc compared to pre-ajmaline LTtype1 (333.3 ± 16.3 vs. 303.4 ± 20.7 ms, p < .001) and OType1 (306 ± 27.3 ms, p < .001). In patients with type-1 ECG (OTtype1 and post-ajmaline LType1) ARIc correlated with RVAT (r = .34, p = .04) and Tpec (r = .60, p < .001), especially in OType1 subjects (r = .55, p = .008 and r = .65 p < .001, respectively). CONCLUSION ARIc mapping demonstrates increased endocardial repolarization dispersion in RVOT in BrS. Endocardial ARIc positively correlates with RVAT and Tpec, especially in OType1.
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Affiliation(s)
- Sara Latrofa
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Lorenzo Bachi
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | | | - Paolo Seghetti
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Institute of Clinical Physiology, Pisa, Italy
| | | | | | | | - Martina Modena
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Andrea Mazzanti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Andrea Rossi
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Kawada S, Morita H, Miyamoto M, Asada S, Nakagawa K, Nishii N. Ventricular arrhythmias induced by phase 2 reentry in a patient with J-wave syndrome. HeartRhythm Case Rep 2023; 9:629-633. [PMID: 37746567 PMCID: PMC10511901 DOI: 10.1016/j.hrcr.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Affiliation(s)
- Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Saori Asada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Wei SJ, Du JL, Wang YB, Qu PF, Ma L, Sun ZC, Tang X, Liu K, Xi YM, Nie SJ, Jia PL, Long W, Qu YQ, Li YH, Lei PP. Whole exome sequencing with a focus on cardiac disease-associated genes in families of sudden unexplained deaths in Yunnan, southwest of China. BMC Genomics 2023; 24:57. [PMID: 36721086 PMCID: PMC9890689 DOI: 10.1186/s12864-022-09097-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/22/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To explore the causes of sudden unexpected death (SUD) and to search for high-risk people, whole exome sequencing (WES) was performed in families with SUDs. METHODS: Whole exome sequencing of 25 people from 14 SUD families were screened based on cardiac disease-associated gene variants, and their echocardiograms and electrocardiograms (ECG) were also examined. The protein function of mutated genes was predicted by SIFT, PolyPhen2 and Mutation Assessor. RESULTS In the group of 25 people from 14 SUD families, 49 single nucleotide variants (SNVs) of cardiac disease-associated genes were found and verified by Sanger sequencing. 29 SNVs of 14 cardiac disorder-related genes were predicted as pathogens by software. Among them, 7 SNVs carried by two or more members were found in 5 families, including SCN5A (c.3577C > T), IRX4 (c.230A > G), LDB3 (c.2104 T > G), MYH6 (c.3G > A), MYH6 (c.3928 T > C), TTN (c.80987C > T) and TTN (c.8069C > T). 25 ECGs were collected. In summary, 4 people had J-point elevation, 2 people had long QT syndrome (LQTS), 4 people had prolonged QT interval, 3 people had T-wave changes, 3 people had sinus tachycardia, 4 people had sinus bradycardia, 4 people had left side of QRS electrical axis, and 3 people had P wave broadening. Echocardiographic results showed that 1 person had atrial septal defect, 1 person had tricuspid regurgitation, and 2 people had left ventricular diastolic dysfunction. CONCLUSIONS Of the 14 heart disease-associated genes in 14 SUDs families, there are 7 possible pathological SNVS may be associated with SUDs. Our results indicate that people with ECG abnormalities, such as prolonged QT interval, ST segment changes, T-wave change and carrying the above 7 SNVs, should be the focus of prevention of sudden death.
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Affiliation(s)
- Si-Jie Wei
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Jin-Liang Du
- grid.449428.70000 0004 1797 7280Forensic Science Center of Jining Medical University, Jining, Shandong 272000 People’s Republic of China
| | - Yue-Bing Wang
- Yunnan Institute of Endemic Disease Control and Prevention, Dali, 671000 Yunnan Province China
| | - Peng-Fei Qu
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China ,grid.11135.370000 0001 2256 9319School of Basic Medicine, Peking University Health Science Center, Beijing, 100191 China
| | - Lin Ma
- Yunnan Institute of Endemic Disease Control and Prevention, Dali, 671000 Yunnan Province China
| | - Zhong-Chun Sun
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Xue Tang
- Yunnan Institute of Endemic Disease Control and Prevention, Dali, 671000 Yunnan Province China
| | - Kai Liu
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Yan-Mei Xi
- Yunnan Institute of Endemic Disease Control and Prevention, Dali, 671000 Yunnan Province China
| | - Sheng-Jie Nie
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Peng-Lin Jia
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Wu Long
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Yong-Qiang Qu
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Yu-Hua Li
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
| | - Pu-Ping Lei
- grid.285847.40000 0000 9588 0960Department of Forensic Medicine, Kunming Medical University, Kunming, 650500 Yunnan Province China
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Multisite conduction block in the epicardial substrate of Brugada syndrome. Heart Rhythm 2021; 19:417-426. [PMID: 34737095 DOI: 10.1016/j.hrthm.2021.10.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The Brugada pattern manifests as a spontaneous variability of the electrocardiographic marker, suggesting a variability of the underlying electrical substrate. OBJECTIVE The purpose of this study was to investigate the response of the epicardial substrate of Brugada syndrome (BrS) to programmed ventricular stimulation and to Na blocker infusion. METHODS We investigated 6 patients (all male; mean age 54 ± 14 years) with BrS and recurrent ventricular fibrillation. Five had no type 1 BrS electrocardiogram pattern at admission. They underwent combined epicardial-endocardial mapping using multielectrode catheters. Changes in epicardial electrograms were evaluated during single endocardial extrastimulation and after low-dose ajmaline infusion (0.5 mg/kg in 5 minutes). RESULTS All patients had a region in the anterior epicardial right ventricle with prolonged multicomponent electrograms. Single extrastimulation prolonged late epicardial components by 59 ± 31 ms and in 4 patients abolished epicardial components at some sites, without reactivation by surrounding activated sites. These localized blocks occurred at an initial coupling interval of 335 ± 58 ms and then expanded to other sites, being observed in up to 40% of epicardial sites. Ajmaline infusion prolonged electrogram duration in all and produced localized blocks in 62% of sites in the same patients as during extrastimulation. Epicardial conduction recovery after ajmaline occurred intermittently and at discontinuous sites and produced beat-to-beat changes in local repolarization, resulting in an area of marked electrical disparity. These changes were consistent with models based on microstructural alterations under critical propagation conditions. CONCLUSION In BrS, localized functional conduction blocks occur at multiple epicardial sites and with variable patterns, without being reactivated from the surrounding sites.
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Blok M, Boukens BJ. Mechanisms of Arrhythmias in the Brugada Syndrome. Int J Mol Sci 2020; 21:ijms21197051. [PMID: 32992720 PMCID: PMC7582368 DOI: 10.3390/ijms21197051] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
Arrhythmias in Brugada syndrome patients originate in the right ventricular outflow tract (RVOT). Over the past few decades, the characterization of the unique anatomy and electrophysiology of the RVOT has revealed the arrhythmogenic nature of this region. However, the mechanisms that drive arrhythmias in Brugada syndrome patients remain debated as well as the exact site of their occurrence in the RVOT. Identifying the site of origin and mechanism of Brugada syndrome would greatly benefit the development of mechanism-driven treatment strategies.
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Affiliation(s)
- Michiel Blok
- Department of Medical Biology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Experimental Cardiology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Bastiaan J. Boukens
- Department of Medical Biology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Experimental Cardiology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-566-4659
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Sattar Y, Ullah W, Zaidi SR, Almas T, Alraies MC. Brugada Pattern Type 2 Diagnosis Unmasked by Aspiration Pneumonia. Cureus 2020; 12:e8331. [PMID: 32617208 PMCID: PMC7325341 DOI: 10.7759/cureus.8331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brugada syndrome (BrS) is a rare autosomal dominant mutation affecting sodium channels. Electrocardiography can show two Brugada patterns (BrP). Type 1 BrP usually causes sudden cardiac arrest (SCA). Type 2 BrP can appear during circumstances that result in delayed sodium channel opening, such as fever, pneumonia, or use of sodium channel blockers. Patients with type 2 BrP often have underlying type 1 BrP; this can be confirmed by an ajmaline challenge test. We describe the case of a patient who presented with SCA. He later had an interval type 2 BrP secondary to aspiration pneumonia, followed by type 1 BrP pattern confirmed by an ajmaline challenge test. The patient ultimately underwent implantable cardiac defibrillator placement to prevent future SCA.
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Affiliation(s)
- Yasar Sattar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA
| | - Waqas Ullah
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, USA
| | | | - Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
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Wang S, Rodríguez-Mañero M, Ibarra-Cortez SH, Kreidieh B, Valderrábano L, Hemam M, Tavares L, Blanco E, Valderrábano M. NS5806 Induces Electromechanically Discordant Alternans and Arrhythmogenic Voltage-Calcium Dynamics in the Isolated Intact Rabbit Heart. Front Physiol 2020; 10:1509. [PMID: 31920713 PMCID: PMC6933003 DOI: 10.3389/fphys.2019.01509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/29/2019] [Indexed: 12/19/2022] Open
Abstract
Background: NS5806 activates the transient outward potassium current I to, and has been claimed to reproduce Brugada Syndrome (BrS) in ventricular wedge preparations. I to modulates excitation-contraction coupling, which is critical in alternans dynamics. We explored NS5806-arrhythmogenic effects in the intact whole heart and its impact on alternans. Methods: Langendorff-perfused rabbit hearts (n = 20) underwent optical AP and Ca mapping during pacing at decremental cycle lengths (CL). Spontaneous arrhythmias and pacing-induced alternans was characterized at baseline (BL), after perfusing with NS5806, before and after adding verapamil (VP), and SEA0400 (SEA, n = 5 each), to modulate Ca-current and Na-Ca exchange, the main AP-Ca coupling mechanisms. Results: NS5806 induced BrS-like ECG features in 6 out of 20 hearts. NS5806 prolonged steady-state (3 Hz) action potential duration (APD) by 16.8%, Ca decay constant by 34%, and decreased conduction velocity (CV) by 52.6%. After NS5806 infusion, spontaneous ventricular ectopy (VE) and AP/Ca alternans occurred. Pacing-induced alternans during NS5806 infusion occurred at longer CL and were AP/Ca discordant from its onset. Spatially discordant alternans after NS5806 infusion had non-propagation-driven nodal line distribution. No spontaneous phase-2 reentry occurred. Under NS5806 + VP, alternans became AP/Ca concordant and only induced in two out of five; NS5806 + SEA did not affect alternans but suppressed spontaneous ectopy. Conclusions: NS5806 disrupts AP-Ca coupling and leads to Ca-driven, AP/Ca-discordant alternans and VE. Despite BrS-like ECG features, no spontaneous sustained arrhythmias or phase-2 reentry occurred. NS5806 does not fully reproduce BrS in the intact rabbit heart.
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Affiliation(s)
- Sufen Wang
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Moisés Rodríguez-Mañero
- Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria (IDIS), Universidad de Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Sergio H Ibarra-Cortez
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Bahij Kreidieh
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Laura Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Majd Hemam
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Liliana Tavares
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
| | - Elvin Blanco
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States.,Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX, United States
| | - Miguel Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston Methodist Research Institute, Houston, TX, United States
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Boukens BJ, Remme CA. Intramural clefts and structural discontinuities in Brugada syndrome: the missing gap? Cardiovasc Res 2019; 114:638-640. [PMID: 29390049 DOI: 10.1093/cvr/cvy028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Bas J Boukens
- Department of Medical Biology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Carol Ann Remme
- Department of Clinical and Experimental Cardiology, Heart Center, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Leong KMW, Ng FS, Yao C, Roney C, Taraborrelli P, Linton NWF, Whinnett ZI, Lefroy DC, Davies DW, Boon Lim P, Harding SE, Peters NS, Kanagaratnam P, Varnava AM. ST-Elevation Magnitude Correlates With Right Ventricular Outflow Tract Conduction Delay in Type I Brugada ECG. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005107. [PMID: 29038102 DOI: 10.1161/circep.117.005107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 08/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The substrate location and underlying electrophysiological mechanisms that contribute to the characteristic ECG pattern of Brugada syndrome (BrS) are still debated. Using noninvasive electrocardiographical imaging, we studied whole heart conduction and repolarization patterns during ajmaline challenge in BrS individuals. METHODS AND RESULTS A total of 13 participants (mean age, 44±12 years; 8 men), 11 concealed patients with type I BrS and 2 healthy controls, underwent an ajmaline infusion with electrocardiographical imaging and ECG recordings. Electrocardiographical imaging activation recovery intervals and activation timings across the right ventricle (RV) body, outflow tract (RVOT), and left ventricle were calculated and analyzed at baseline and when type I BrS pattern manifested after ajmaline infusion. Peak J-ST point elevation was calculated from the surface ECG and compared with the electrocardiographical imaging-derived parameters at the same time point. After ajmaline infusion, the RVOT had the greatest increase in conduction delay (5.4±2.8 versus 2.0±2.8 versus 1.1±1.6 ms; P=0.007) and activation recovery intervals prolongation (69±32 versus 39±29 versus 21±12 ms; P=0.0005) compared with RV or left ventricle. In controls, there was minimal change in J-ST point elevation, conduction delay, or activation recovery intervals at all sites with ajmaline. In patients with BrS, conduction delay in RVOT, but not RV or left ventricle, correlated to the degree of J-ST point elevation (Pearson R, 0.81; P<0.001). No correlation was found between J-ST point elevation and activation recovery intervals prolongation in the RVOT, RV, or left ventricle. CONCLUSIONS Magnitude of ST (J point) elevation in the type I BrS pattern is attributed to degree of conduction delay in the RVOT and not prolongation in repolarization time.
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Affiliation(s)
- Kevin M W Leong
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.).
| | - Fu Siong Ng
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Cheng Yao
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Caroline Roney
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Patricia Taraborrelli
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Nicholas W F Linton
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Zachary I Whinnett
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - David C Lefroy
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - D Wyn Davies
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Phang Boon Lim
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Sian E Harding
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Nicholas S Peters
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Prapa Kanagaratnam
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.)
| | - Amanda M Varnava
- From the National Heart and Lung Institute, Imperial College London, United Kingdom (K.M.W.L., F.S.N., C.R., N.W.F.L., Z.I.W., P.B.L., S.E.H., N.S.P., P.K.); Imperial College Healthcare NHS Trust, London, United Kingdom (K.M.W.L., F.S.N., P.T., N.W.F.L., Z.I.W., D.C.L., D.W.D., P.B.L., N.S.P., P.K., A.M.V.); and Medtronic Ltd, Watford, United Kingdom (C.Y.).
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10
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Te Riele ASJM, Agullo-Pascual E, James CA, Leo-Macias A, Cerrone M, Zhang M, Lin X, Lin B, Sobreira NL, Amat-Alarcon N, Marsman RF, Murray B, Tichnell C, van der Heijden JF, Dooijes D, van Veen TAB, Tandri H, Fowler SJ, Hauer RNW, Tomaselli G, van den Berg MP, Taylor MRG, Brun F, Sinagra G, Wilde AAM, Mestroni L, Bezzina CR, Calkins H, Peter van Tintelen J, Bu L, Delmar M, Judge DP. Multilevel analyses of SCN5A mutations in arrhythmogenic right ventricular dysplasia/cardiomyopathy suggest non-canonical mechanisms for disease pathogenesis. Cardiovasc Res 2017; 113:102-111. [PMID: 28069705 DOI: 10.1093/cvr/cvw234] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/21/2016] [Accepted: 11/14/2016] [Indexed: 12/21/2022] Open
Abstract
AIMS Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) is often associated with desmosomal mutations. Recent studies suggest an interaction between the desmosome and sodium channel protein Nav1.5. We aimed to determine the prevalence and biophysical properties of mutations in SCN5A (the gene encoding Nav1.5) in ARVD/C. METHODS AND RESULTS We performed whole-exome sequencing in six ARVD/C patients (33% male, 38.2 ± 12.1 years) without a desmosomal mutation. We found a rare missense variant (p.Arg1898His; R1898H) in SCN5A in one patient. We generated induced pluripotent stem cell-derived cardiomyocytes (hIPSC-CMs) from the patient's peripheral blood mononuclear cells. The variant was then corrected (R1898R) using Clustered Regularly Interspaced Short Palindromic Repeats/Cas9 technology, allowing us to study the impact of the R1898H substitution in the same cellular background. Whole-cell patch clamping revealed a 36% reduction in peak sodium current (P = 0.002); super-resolution fluorescence microscopy showed reduced abundance of NaV1.5 (P = 0.005) and N-Cadherin (P = 0.026) clusters at the intercalated disc. Subsequently, we sequenced SCN5A in an additional 281 ARVD/C patients (60% male, 34.8 ± 13.7 years, 52% desmosomal mutation-carriers). Five (1.8%) subjects harboured a putatively pathogenic SCN5A variant (p.Tyr416Cys, p.Leu729del, p.Arg1623Ter, p.Ser1787Asn, and p.Val2016Met). SCN5A variants were associated with prolonged QRS duration (119 ± 15 vs. 94 ± 14 ms, P < 0.01) and all SCN5A variant carriers had major structural abnormalities on cardiac imaging. CONCLUSIONS Almost 2% of ARVD/C patients harbour rare SCN5A variants. For one of these variants, we demonstrated reduced sodium current, Nav1.5 and N-Cadherin clusters at junctional sites. This suggests that Nav1.5 is in a functional complex with adhesion molecules, and reveals potential non-canonical mechanisms by which Nav1.5 dysfunction causes cardiomyopathy.
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Affiliation(s)
- Anneline S J M Te Riele
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA.,Division of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands.,Netherlands Heart Institute, Moreelsepark 1, Utrecht, the Netherlands
| | - Esperanza Agullo-Pascual
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Cynthia A James
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Alejandra Leo-Macias
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Marina Cerrone
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Mingliang Zhang
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Xianming Lin
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Bin Lin
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Nara L Sobreira
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD, USA
| | - Nuria Amat-Alarcon
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Roos F Marsman
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Center, Meibergdreef 9, Amsterdam, the Netherlands
| | - Brittney Murray
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Crystal Tichnell
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Jeroen F van der Heijden
- Division of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands
| | - Dennis Dooijes
- Department of Medical Genetics, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands
| | - Toon A B van Veen
- Department of Medical Physiology, Division of Heart and Lungs, University Medical Center Utrecht, Yalelaan 50, Utrecht, the Netherlands
| | - Harikrishna Tandri
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Steven J Fowler
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA
| | - Richard N W Hauer
- Division of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands.,Netherlands Heart Institute, Moreelsepark 1, Utrecht, the Netherlands
| | - Gordon Tomaselli
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, the Netherlands
| | - Matthew R G Taylor
- Cardiovascular Institute and Adult Medical Genetics, University of Colorado Denver, 12605 E 16th Avenue, Aurora, CO, USA
| | - Francesca Brun
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Via Farneto 3, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Via Farneto 3, Trieste, Italy
| | - Arthur A M Wilde
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Center, Meibergdreef 9, Amsterdam, the Netherlands
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics, University of Colorado Denver, 12605 E 16th Avenue, Aurora, CO, USA
| | - Connie R Bezzina
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Center, Meibergdreef 9, Amsterdam, the Netherlands
| | - Hugh Calkins
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - J Peter van Tintelen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen, the Netherlands.,Department of Clinical Genetics, Academic Medical Center Amsterdam, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Department of Genetics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, the Netherlands
| | - Lei Bu
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Mario Delmar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, New York, NY, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA
| | - Daniel P Judge
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, USA;
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11
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Ragab AAY, Houck CA, van der Does LJME, Lanters EAH, Burghouwt DE, Muskens AJQM, de Groot NMS. Usefulness of the R-Wave Sign as a Predictor for Ventricular Tachyarrhythmia in Patients With Brugada Syndrome. Am J Cardiol 2017; 120:428-434. [PMID: 28583685 DOI: 10.1016/j.amjcard.2017.04.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/20/2017] [Accepted: 04/20/2017] [Indexed: 11/15/2022]
Abstract
Brugada syndrome (BrS) is an autosomal dominant channelopathy which is responsible for a large number of sudden cardiac deaths in young subjects without structural abnormalities. The most challenging step in management of patients with BrS is identifying who is at risk for developing malignant ventricular tachyarrhythmia (VTA). In patients with BrS, conduction delay in the right ventricular outflow tract (RVOT) causes a prominent R wave in lead aVR. This electrocardiographic parameter can be useful to detect these high-risk patients. The goal of this study was to test the significance of R-wave elevation in lead aVR as a predictor for VTA in patients with BrS. In this retrospective study, we included 132 patients with BrS (47 ± 15 years, 65% men) who visited the outpatient clinic for cardiogenetic screening. Patients' medical records were examined for the presence of a positive R-wave sign in lead aVR and VTA. A positive R-wave sign in lead aVR was observed in 41 patients (31%). This sign was more frequently observed in patients who experienced VTA (n = 24) before the initial diagnosis, during electrophysiological studies, or during follow-up (p <0.001). The positive R-wave sign occurred more frequently in symptomatic patients with a history of an out of hospital cardiac arrest, VTA, or syncope than asymptomatic patients (60% vs 26%; p = 0.002). During the follow-up period, this sign was more frequently detected in patients who developed either de novo (50%) or recurrent VTA (80%) (p = 0.017). Multivariable regression analysis showed that R-wave sign is an independent predictor for VTA development (odds ratio 4.8, 95% confidence interval 1.79 to 13.27). The presence of a positive R-wave sign in lead aVR is associated with the development of VTA. In conclusion, positive R-wave sign in lead aVR can be used to identify patients with BrS at risk for malignant VTA.
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Affiliation(s)
- Ahmed A Y Ragab
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Charlotte A Houck
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Agnes J Q M Muskens
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
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12
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Pappone C, Brugada J, Vicedomini G, Ciconte G, Manguso F, Saviano M, Vitale R, Cuko A, Giannelli L, Calovic Z, Conti M, Pozzi P, Natalizia A, Crisà S, Borrelli V, Brugada R, Sarquella-Brugada G, Guazzi M, Frigiola A, Menicanti L, Santinelli V. Electrical Substrate Elimination in 135 Consecutive Patients With Brugada Syndrome. Circ Arrhythm Electrophysiol 2017; 10:e005053. [DOI: 10.1161/circep.117.005053] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
Background—
There is emerging evidence that localization and elimination of abnormal electric activity in the epicardial right ventricular outflow tract may be beneficial in patients with Brugada syndrome.
Methods and Results—
A total of 135 symptomatic Brugada syndrome patients having implantable cardiac defibrillator were enrolled: 63 (group 1) having documented ventricular tachycardia (VT)/ventricular fibrillation (VF) and Brugada syndrome–related symptoms, and 72 (group 2) having inducible VT/VF without ECG documentation at the time of symptoms. About 27 patients of group 1 experienced multiple implantable cardiac defibrillator shocks for recurrent VT/VF episodes. Three-dimensional maps before and after ajmaline determined the arrhythmogenic electrophysiological substrate (AES) as characterized by prolonged fragmented ventricular potentials. Primary end point was identification and elimination of AES leading to ECG pattern normalization and VT/VF noninducibility. Extensive areas of AES were found in the right ventricle epicardium, which were wider in group 1 (
P
=0.007). AES increased after ajmaline in both groups (
P
<0.001) and was larger in men (
P
=0.008). The increase of type-1 ST-segment elevation correlated with AES expansion (
r
=0.682,
P
<0.001). Radiofrequency ablation eliminated AES leading to ECG normalization and VT/VF noninducibility in all patients. During a median follow-up of 10 months, the ECG remained normal even after ajmaline in all except 2 patients who underwent a repeated effective procedure for recurrent VF.
Conclusions—
In Brugada syndrome, AES is commonly located in the right ventricle epicardium and ajmaline exposes its extent and distribution, which is correlated with the degree of coved ST-elevation. AES elimination by radiofrequency ablation results in ECG normalization and VT/VF noninducibility. Substrate-based ablation is effective in potentially eliminating the arrhythmic consequences of this genetic disease.
Clinical Trial Registration—
URL:
https://clinicaltrials.gov
. Unique identifier: NCT02641431.
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Affiliation(s)
- Carlo Pappone
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Josep Brugada
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Gabriele Vicedomini
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Giuseppe Ciconte
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Francesco Manguso
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Massimo Saviano
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Raffaele Vitale
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Amarild Cuko
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Luigi Giannelli
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Zarko Calovic
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Manuel Conti
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Paolo Pozzi
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Andrea Natalizia
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Simonetta Crisà
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Valeria Borrelli
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Ramon Brugada
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Georgia Sarquella-Brugada
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Marco Guazzi
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Alessandro Frigiola
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Lorenzo Menicanti
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
| | - Vincenzo Santinelli
- From the Arrhythmology Department (C.P., G.V., G.C., F.M., M.S., R.V., A.C., L.G., Z.C., M.C., A.N., S.C., V.B., V.S.) and Cardiac Surgery Department (A.F., L.M.), IRCCS Policlinico San Donato, San Donato Milanese, Italy; Cardiology Department, Cardiovascular Institute, Hospital Clinic and IDIBAPS, Barcelona, Catalonia (J.B.); Cardiology Department, Hospital Trueta, Girona, Spain (R.B.); Department of Medical Sciences, University of Girona & IDIBGI, Spain ; Pediatric Arrhythmias,
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13
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Nagase S, Tanaka M, Morita H, Nakagawa K, Wada T, Murakami M, Nishii N, Nakamura K, Ito H, Ohe T, Kusano KF. Local Left Ventricular Epicardial J Waves and Late Potentials in Brugada Syndrome Patients with Inferolateral Early Repolarization Pattern. Front Physiol 2017; 8:14. [PMID: 28184198 PMCID: PMC5266732 DOI: 10.3389/fphys.2017.00014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/09/2017] [Indexed: 01/27/2023] Open
Abstract
Background: Brugada syndrome (BrS) is characterized by J-point or ST-segment elevation on electrocardiograms (ECGs) and increased risk of ventricular fibrillation (VF). In BrS, epicardial depolarization abnormality with delayed potential on the right ventricular outflow tract is reportedly the predominant mechanism underlying VF. Yet VF occurrence is also associated with early repolarization (ER) pattern in the inferolateral ECG leads, which may represent the inferior and/or left lateral ventricular myocardium. The aim of this study was to examine epicardial electrograms recorded directly at the left ventricle (LV) in BrS patients after VF episodes. Methods: In 12 BrS patients who had experienced VF episodes and 17 control subjects, a multipolar catheter was introduced into the left lateral coronary vein for unipolar and bipolar electrogram recordings at the LV epicardium. Both inferior and lateral ER patterns on ECG were observed in three BrS patients and six control subjects. Results: In the epicardium, prominent J waves were detected using unipolar recording, and potentials after the QRS complex were detected using bipolar recording in three of the 12 BrS patients. These three patients also showed both inferior and lateral ER patterns on ECG. Neither prominent J waves nor potentials after the QRS complex were recorded at the endocardium of the LV in any of these three patients; nor were they seen at the epicardium in any of the control subjects. These features were accentuated on pilsicainide administration (n = 2) but diminished on constant atrial pacing (n = 3) and isoproterenol administration (n = 1). The J waves observed through unipolar recording coincided with the potentials after QRS complex observed through bipolar recording and with the inferolateral ER patterns on ECG. Conclusions: We recorded prominent J waves in unipolar electrogram and potentials after QRS complex in bipolar electrogram at the LV epicardium in BrS patients with global ER pattern. The prominent J waves coincided with the potentials after QRS complex and the inferolateral ER pattern on ECG. The characteristics of the inferolateral ER pattern on ECG in these patients primarily represent depolarization feature.
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Affiliation(s)
- Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Osaka, Japan
| | - Masamichi Tanaka
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Hiroshi Morita
- Departments of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Koji Nakagawa
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Tadashi Wada
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Masato Murakami
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Nobuhiro Nishii
- Departments of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Kazufumi Nakamura
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Hiroshi Ito
- Departments of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences Okayama, Japan
| | - Tohru Ohe
- Department of Cardiovascular Medicine, Sakakibara Heart Institute of Okayama Okayama, Japan
| | - Kengo F Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Osaka, Japan
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14
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Pappone C, Santinelli V. Implantable cardioverter defibrillator and catheter ablation in Brugada syndrome. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e35-e39. [DOI: 10.2459/jcm.0000000000000449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Rudic B, Chaykovskaya M, Tsyganov A, Kalinin V, Tülümen E, Papavassiliu T, Dösch C, Liebe V, Kuschyk J, Röger S, El-Battrawy I, Akin I, Yakovleva M, Zaklyazminskaya E, Shestak A, Kim S, Chmelevsky M, Borggrefe M. Simultaneous Non-Invasive Epicardial and Endocardial Mapping in Patients With Brugada Syndrome: New Insights Into Arrhythmia Mechanisms. J Am Heart Assoc 2016; 5:JAHA.116.004095. [PMID: 27930354 PMCID: PMC5210320 DOI: 10.1161/jaha.116.004095] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background The underlying mechanisms of Brugada syndrome (BrS) are not completely understood. Recent studies provided evidence that the electrophysiological substrate, leading to electrocardiogram abnormalities and/or ventricular arrhythmias, is located in the right ventricular outflow tract (RVOT). The purpose of this study was to examine abnormalities of epicardial and endocardial local unipolar electrograms by simultaneous noninvasive mapping in patients with BrS. Methods and Results Local epicardial and endocardial unipolar electrograms were analyzed using a novel noninvasive epi‐ and endocardial electrophysiology system (NEEES) in 12 patients with BrS and 6 with right bundle branch block for comparison. Fifteen normal subjects composed the control group. Observed depolarization abnormalities included fragmented electrograms in the anatomical area of RVOT endocardially and epicardially, significantly prolonged activation time in the RVOT endocardium (65±20 vs 38±13 ms in controls; P=0.008), prolongation of the activation‐recovery interval in the RVOT epicardium (281±34 vs 247±26 ms in controls; P=0.002). Repolarization abnormalities included a larger area of ST‐segment elevation >2 mV and T‐wave inversions. Negative voltage gradient (−2.5 to −6.0 mV) between epicardium and endocardium of the RVOT was observed in 8 of 12 BrS patients, not present in patients with right bundle branch block or in controls. Conclusions Abnormalities of epicardial and endocardial electrograms associated with depolarization and repolarization properties were found using NEEES exclusively in the RVOT of BrS patients. These findings support both, depolarization and repolarization abnormalities, being operative at the same time in patients with BrS.
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Affiliation(s)
- Boris Rudic
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany .,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | | | - Alexey Tsyganov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | | | - Erol Tülümen
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Theano Papavassiliu
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Christina Dösch
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Volker Liebe
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jürgen Kuschyk
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Susanne Röger
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim El-Battrawy
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | | | - Elena Zaklyazminskaya
- Petrovsky National Research Center of Surgery, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anna Shestak
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - Stanislav Kim
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | | | - Martin Borggrefe
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Mannheim, Germany
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16
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Guillem MS, Climent AM, Millet J, Berne P, Ramos R, Brugada J, Brugada R. Spatiotemporal Characteristics of QRS Complexes Enable the Diagnosis of Brugada Syndrome Regardless of the Appearance of a Type 1 ECG. J Cardiovasc Electrophysiol 2016; 27:563-70. [PMID: 26799774 DOI: 10.1111/jce.12937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The diagnosis of Brugada syndrome based on the ECG is hampered by the dynamic nature of its ECG manifestations. Brugada syndrome patients are only 25% likely to present a type 1 ECG. The objective of this study is to provide an ECG diagnostic criterion for Brugada syndrome patients that can be applied consistently even in the absence of a type 1 ECG. METHODS AND RESULTS We recorded 67-lead body surface potential maps from 94 Brugada syndrome patients and 82 controls (including right bundle branch block patients and healthy individuals). The spatial propagation direction during the last r' wave and the slope at the end of the QRS complex were measured and compared between patients groups. Receiver-operating characteristic curves were constructed for half of the database to identify optimal cutoff values; sensitivity and specificity for these cutoff values were measured in the other half of the database. A spontaneous type 1 ECG was present in only 30% of BrS patients. An orientation in the sagittal plane < 101º during the last r' wave and a descending slope < 9.65 mV/s enables the diagnosis of the syndrome with a sensitivity of 69% and a specificity of 97% in non-type 1 Brugada syndrome patients. CONCLUSION Spatiotemporal characteristics of surface ECG recordings can enable a robust identification of BrS even without the presence of a type 1 ECG.
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Affiliation(s)
| | - Andreu M Climent
- ITACA, Universitat Politècnica de València, Valencia, Spain.,Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - José Millet
- ITACA, Universitat Politècnica de València, Valencia, Spain
| | - Paola Berne
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rafael Ramos
- Unitat de Recerca en Atenció Primaria-Girona, Institut Català de Salut, Girona, Spain
| | | | - Ramon Brugada
- Centre de Genètica Cardiovascular, Universitat de Girona and Hospital Trueta, Girona, Spain
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17
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Boukens BJ, Coronel R, Christoffels VM. Embryonic development of the right ventricular outflow tract and arrhythmias. Heart Rhythm 2016; 13:616-22. [DOI: 10.1016/j.hrthm.2015.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Indexed: 12/19/2022]
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18
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Basis for the Induction of Tissue-Level Phase-2 Reentry as a Repolarization Disorder in the Brugada Syndrome. BIOMED RESEARCH INTERNATIONAL 2015; 2015:197586. [PMID: 26583094 PMCID: PMC4637010 DOI: 10.1155/2015/197586] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/21/2015] [Accepted: 08/23/2015] [Indexed: 11/20/2022]
Abstract
Aims. Human action potentials in the Brugada syndrome have been characterized by delayed or even complete loss of dome formation, especially in the right ventricular epicardial layers. Such a repolarization pattern is believed to trigger phase-2 reentry (P2R); however, little is known about the conditions necessary for its initiation. This study aims to determine the specific mechanisms that facilitate P2R induction in Brugada-affected cardiac tissue in humans. Methods. Ionic models for Brugada syndrome in human epicardial cells were developed and used to study the induction of P2R in cables, sheets, and a three-dimensional model of the right ventricular free wall. Results. In one-dimensional cables, P2R can be induced by adjoining lost-dome and delayed-dome regions, as mediated by tissue excitability and transmembrane voltage profiles, and reduced coupling facilitates its induction. In two and three dimensions, sustained reentry can arise when three regions (delayed-dome, lost-dome, and normal epicardium) are present. Conclusions. Not only does P2R induction by Brugada syndrome require regions of action potential with delayed-dome and lost-dome, but in order to generate a sustained reentry from a triggered waveback multiple factors are necessary, including heterogeneity in action potential distribution, tissue coupling, direction of stimulation, the shape of the late plateau, the duration of lost-dome action potentials, and recovery of tissue excitability, which is predominantly modulated by tissue coupling.
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19
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Brugada J, Pappone C, Berruezo A, Vicedomini G, Manguso F, Ciconte G, Giannelli L, Santinelli V. Brugada Syndrome Phenotype Elimination by Epicardial Substrate Ablation. Circ Arrhythm Electrophysiol 2015; 8:1373-81. [PMID: 26291334 DOI: 10.1161/circep.115.003220] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 07/30/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Whether Brugada syndrome (BrS) depends on functional epicardial substrates, which may be definitively eliminated by radiofrequency ablation, remains unknown. METHODS AND RESULTS Patients with BrS underwent epicardial mapping to identify areas of abnormal electrograms as target for radiofrequency ablation. Substrate identification consisted in mapping right ventricle epicardial surface before and after flecainide (2 mg/kg per 10 minutes). After radiofrequency ablation, flecainide and remap confirmed elimination of abnormal substrate, BrS ECG pattern, and ventricular tachycardia/ventricular fibrillation inducibility. Flecainide testing was performed at each follow-up visits ≤6 months. Fourteen patients with BrS, median age 39 years (30.3-42.3) with implantable cardioverter-defibrillator were enrolled. Low-voltage areas (<1.5 mV) were commonly identified on the anterior right free wall and right ventricular outflow tract, which increased after flecainide from 17.6 cm(2) (12.1-24.2) to 28.5 cm(2) (21.6-30.2; P=0.001). Similarly, areas with abnormal electrograms increased after flecainide from 19.0 (17.5-23.6) to 27.3 cm(2) (24.0-31.2; P=0.001). After 23.8 minutes (18.1-28.5) of radiofrequency ablation, abnormal electrograms disappeared, whereas low-voltage areas were replaced by scar areas (<0.5 mV) of 25.9 cm(2) (19.6-31.0). Substrate elimination resulted in BrS ECG pattern disappearance and no ventricular tachycardia/ventricular fibrillation inducibility without complications. After a median follow-up of 5 months (3.8-5.3), ECG remained normal despite flecainide. CONCLUSIONS In patients with BrS, there is a relationship between abnormal ECG pattern, the extent of abnormal epicardial substrate, and ventricular tachycardia/ventricular fibrillation inducibility. Ablation of the substrate identified in the presence of flecainide can eliminate the BrS phenotype and warrants further study.
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Affiliation(s)
- Josep Brugada
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Carlo Pappone
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.).
| | - Antonio Berruezo
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Gabriele Vicedomini
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Francesco Manguso
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Giuseppe Ciconte
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Luigi Giannelli
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
| | - Vincenzo Santinelli
- From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain (J.B., A.B.); and Arrhythmology Department, Maria Cecilia Hospital, Cotignola and Policlinico San Donato, University of Milan, Milan, Italy (C.P., G.V., F.M., G.C., L.G., V.S.)
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20
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Chaykovskaya M, Rudic B, Tsyganov A, Zaklyazminskaya E, Yakovleva M, Borggrefe M. The use of noninvasive ECG imaging for examination of a patient with Brugada syndrome. HeartRhythm Case Rep 2015; 1:260-263. [PMID: 28491563 PMCID: PMC5419418 DOI: 10.1016/j.hrcr.2015.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Key Words
- BrS, Brugada syndrome
- Brugada syndrome
- CCW, counterclockwise
- CT, computed tomography
- CW, clockwise
- ECG, electrocardiography
- ECGI, electrocardiographic imaging
- EG, electrogram
- EP, electrophysiology
- LV, left ventricle
- Noninvasive ECG imaging
- RVOT, right ventricular outflow tract
- VF, ventricular fibrillation
- VT, ventricular tachycardia
- Ventricular tachycardia
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Affiliation(s)
- Maria Chaykovskaya
- Petrovsky National Research Center of Surgery, Moscow, Russia
- Address reprint requests and correspondence: Dr Maria Chaykovskaya, Cardiac Electrophysiology Department, Petrovsky Russian Research Center of Surgery, Abrikosovsky per. 2, 119991, Moscow, Russia
| | - Boris Rudic
- 1 Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Mannheim, Mannheim Germany
| | - Alexey Tsyganov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | | | | | - Martin Borggrefe
- 1 Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Mannheim, Mannheim Germany
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21
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Zhang J, Sacher F, Hoffmayer K, O'Hara T, Strom M, Cuculich P, Silva J, Cooper D, Faddis M, Hocini M, Haïssaguerre M, Scheinman M, Rudy Y. Cardiac electrophysiological substrate underlying the ECG phenotype and electrogram abnormalities in Brugada syndrome patients. Circulation 2015; 131:1950-9. [PMID: 25810336 DOI: 10.1161/circulationaha.114.013698] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 03/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Brugada syndrome (BrS) is a highly arrhythmogenic cardiac disorder, associated with an increased incidence of sudden death. Its arrhythmogenic substrate in the intact human heart remains ill-defined. METHODS AND RESULTS Using noninvasive ECG imaging, we studied 25 BrS patients to characterize the electrophysiological substrate and 6 patients with right bundle-branch block for comparison. Seven healthy subjects provided control data. Abnormal substrate was observed exclusively in the right ventricular outflow tract with the following properties (in comparison with healthy controls; P<0.005): (1) ST-segment elevation and inverted T wave of unipolar electrograms (2.21±0.67 versus 0 mV); (2) delayed right ventricular outflow tract activation (82±18 versus 37±11 ms); (3) low-amplitude (0.47±0.16 versus 3.74±1.60 mV) and fractionated electrograms, suggesting slow discontinuous conduction; (4) prolonged recovery time (381±30 versus 311±34 ms) and activation-recovery intervals (318±32 versus 241±27 ms), indicating delayed repolarization; (5) steep repolarization gradients (Δrecovery time/Δx=96±28 versus 7±6 ms/cm, Δactivation-recovery interval/Δx=105±24 versus 7±5 ms/cm) at right ventricular outflow tract borders. With increased heart rate in 6 BrS patients, reduced ST-segment elevation and increased fractionation were observed. Unlike BrS, right bundle-branch block had delayed activation in the entire right ventricle, without ST-segment elevation, fractionation, or repolarization abnormalities on electrograms. CONCLUSIONS The results indicate that both slow discontinuous conduction and steep dispersion of repolarization are present in the right ventricular outflow tract of BrS patients. ECG imaging could differentiate between BrS and right bundle-branch block.
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Affiliation(s)
- Junjie Zhang
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Frédéric Sacher
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Kurt Hoffmayer
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Thomas O'Hara
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Maria Strom
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Phillip Cuculich
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Jennifer Silva
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Daniel Cooper
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Mitchell Faddis
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Mélèze Hocini
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Michel Haïssaguerre
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Melvin Scheinman
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman)
| | - Yoram Rudy
- From Cardiac Bioelectricity and Arrhythmia Center (J.Z., P.C., J.S., D.C., M.F., Y.R.) and Department of Biomedical Engineering (J.Z., Y.R.), Washington University, St. Louis, MO; Bordeaux University Hospital, LIRYC Institute, Pessac, France (F.S., M. Hocini, M. Haïssaguerre); School of Medicine, University of Wisconsin, Madison (K.H.); Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD (T.O.); CardioInsight Technologies, Cleveland, OH (M. Strom); School of Medicine, Washington University, St. Louis, MO (P.C., J.S., D.C., M.F., Y.R.); and School of Medicine, University of California, San Francisco (M. Scheinman).
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Association of early repolarization with long-term mortality and major adverse cardiac events in patients with ST-segment elevation myocardial infarction. J Cardiol 2014; 64:162-3. [DOI: 10.1016/j.jjcc.2014.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 11/20/2022]
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Naseef A, Behr ER, Batchvarov VN. Electrocardiographic methods for diagnosis and risk stratification in the Brugada syndrome. J Saudi Heart Assoc 2014; 27:96-108. [PMID: 25870503 PMCID: PMC4392351 DOI: 10.1016/j.jsha.2014.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/02/2014] [Accepted: 06/26/2014] [Indexed: 12/19/2022] Open
Abstract
The Brugada syndrome (BrS) is a malignant, genetically-determined, arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals with structurally normal hearts. The diagnosis of the BrS is mainly based on the presence of a spontaneous or Na + channel blocker induced characteristic, electrocardiographic (ECG) pattern (type 1 or coved Brugada ECG pattern) typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal (i.c.) spaces. This pattern needs to be distinguished from similar ECG changes due to other causes (Brugada ECG phenocopies). This review focuses mainly on the ECG-based methods for diagnosis and arrhythmia risk assessment in the BrS. Presently, the main unresolved clinical problem is the identification of those patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD), which is the only therapy with proven efficacy. Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern, and either history of aborted cardiac arrest or documented sustained VT (class I), or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmic events (up to 10% or more annually for those with aborted cardiac arrest). The majority of BrS patients are asymptomatic when diagnosed and considered to have low risk (around 0.5% annually) and therefore not indicated for ICD. The majority of SCD victims in the BrS, however, had no symptoms prior to the fatal event and therefore were not protected with an ICD. While some ECG markers such as QRS fragmentation, infero-lateral early repolarisation, and abnormal late potentials on signal-averaged ECG are known to be linked to increased arrhythmic risk, they are not sufficiently sensitive or specific. Potential novel ECG-based strategies for risk stratification are discussed based on computerised methods for depolarisation and repolarisation analysis, a composite approach targeting several major components of ventricular arrhythmogenesis, and the collection of large digital ECG databases in genotyped BrS patients and their relatives.
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Key Words
- AP, action potential
- ARI, activation-recovery intervals
- BrS, Brugada syndrome
- Brugada syndrome
- ECG, electrocardiogram
- EPS, electrophysiology study
- Electrocardiogram
- Genetic arrhythmic syndromes
- ICD, implantable cardioverter-defibrillator
- IHD, ischaemic heart disease
- LBBB, left bundle branch block
- MAP, monophasic action potential
- MI, myocardial infarction
- PCA, principal component analysis
- RVOT, right ventricular outflow tract
- Risk stratification
- SAECG, signal-averaged electrocardiogram
- SCD, sudden cardiac death
- SNP, single-nucleotide polymorphism
- Sudden cardiac death
- VF, ventricular fibrillation
- VT, ventricular tachycardia
- WT, wavelet transform
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Affiliation(s)
- Abdulrahman Naseef
- Center for Health Studies, Prince Sultan Military Medical City, Riyadh, Saudi Arabia ; Cardiac and Vascular Sciences Research Centre, St. George's University of London, London, United Kingdom
| | - Elijah R Behr
- Cardiac and Vascular Sciences Research Centre, St. George's University of London, London, United Kingdom
| | - Velislav N Batchvarov
- Cardiac and Vascular Sciences Research Centre, St. George's University of London, London, United Kingdom
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Savastano S, Rordorf R, Vicentini A, Petracci B, Taravelli E, Castelletti S, D’Errico A, Torchio M, Dossena C, Novara P, Dagradi F, Landolina M, Spazzolini C, Crotti L, Schwartz PJ. A comprehensive electrocardiographic, molecular, and echocardiographic study of Brugada syndrome: Validation of the 2013 diagnostic criteria. Heart Rhythm 2014; 11:1176-83. [DOI: 10.1016/j.hrthm.2014.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Indexed: 12/19/2022]
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Batchvarov VN. The Brugada Syndrome - Diagnosis, Clinical Implications and Risk Stratification. Eur Cardiol 2014; 9:82-87. [PMID: 30310491 DOI: 10.15420/ecr.2014.9.2.82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Brugada syndrome (BrS) is a hereditary arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals without overt structural heart disease. Currently, its diagnosis is mainly based on the presence of a spontaneous or Na+-channel blocker induced so-called "type 1" Brugada electrocardiographic (ECG) pattern typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal spaces. Presently the main unresolved clinical problem in the BrS is the identification of patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD). Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern and either history of aborted cardiac arrest or documented sustained ventricular tachycardia (class I) or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmias. However, the majority of BrS patients are asymptomatic when diagnosed and have generally low risk (0.5 % annually or lower) and therefore are not indicated for ICD. Most of SCD victims in the BrS have had no symptoms prior to the fatal event and therefore were not protected with an ICD. Currently there are no reliable methods to identify these potential victims of SCD. Although some ECG markers such as QRS fragmentation and infero-lateral early repolarisation have been demonstrated to signify increased arrhythmic risk their value still needs to be confirmed in large prospective studies. Novel risk assessment strategies need to be developed based on computerised quantitative ECG analysis of large digital ECG databases in patients with BrS and their relatives, and combined assessment of the most important factors of ventricular arrhythmogenesis.
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Affiliation(s)
- Velislav N Batchvarov
- Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
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Nakagawa K, Nagase S, Morita H, Ito H. Left ventricular epicardial electrogram recordings in idiopathic ventricular fibrillation with inferior and lateral early repolarization. Heart Rhythm 2013; 11:314-7. [PMID: 24184784 DOI: 10.1016/j.hrthm.2013.10.057] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Affiliation(s)
- Noel G Boyle
- UCLA Cardiac Arrhythmia Center, 100 UCLA Medical Plaza, Suite 660, Westwood Blvd, Los Angeles CA 90095-7392, USA.
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SUNSANEEWITAYAKUL BUNCHA, YAO YAN, THAMAREE SUTHASINEE, ZHANG SHU. Endocardial Mapping and Catheter Ablation for Ventricular Fibrillation Prevention in Brugada Syndrome. J Cardiovasc Electrophysiol 2012; 23 Suppl 1:S10-6. [DOI: 10.1111/j.1540-8167.2012.02433.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Hoogendijk MG. Diagnostic dilemmas: overlapping features of brugada syndrome and arrhythmogenic right ventricular cardiomyopathy. Front Physiol 2012; 3:144. [PMID: 22654761 PMCID: PMC3358709 DOI: 10.3389/fphys.2012.00144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 04/29/2012] [Indexed: 11/13/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) and Brugada syndrome are distinct clinical entities which diagnostic criteria exclude their coexistence in individual patients. ARVC is a myocardial disorder characterized by fibro-fatty replacement of the myocardium and ventricular arrhythmias. In contrast, the Brugada syndrome has long been considered a functional cardiac disorder: no gross structural abnormalities can be identified in the majority of patients and its electrocardiographic hallmark of coved-type ST-segment elevation in right precordial leads is dynamic. Nonetheless, a remarkable overlap in clinical features has been demonstrated between these conditions. This review focuses on this overlap and discusses its potential causes and consequences.
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Affiliation(s)
- Mark G Hoogendijk
- Experimental Cardiology Group, Heart Failure Research Center, Academic Medical Center, University of Amsterdam Amsterdam, Netherlands
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Veltmann C, Papavassiliu T, Konrad T, Doesch C, Kuschyk J, Streitner F, Haghi D, Michaely HJ, Schoenberg SO, Borggrefe M, Wolpert C, Schimpf R. Insights into the location of type I ECG in patients with Brugada syndrome: correlation of ECG and cardiovascular magnetic resonance imaging. Heart Rhythm 2011; 9:414-21. [PMID: 22119454 DOI: 10.1016/j.hrthm.2011.10.032] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 10/26/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Brugada syndrome is characterized by ST-segment abnormalities in V1-V3. Electrocardiogram (ECG) leads placed in the 3rd and 2nd intercostal spaces (ICSs) increased the sensitivity for the detection of a type I ECG pattern. The anatomic explanation for this finding is pending. OBJECTIVE The purpose of the study was to correlate the location of the Brugada type I ECG with the anatomic location of the right ventricular outflow tract (RVOT). METHODS Twenty patients with positive ajmaline challenge and 10 patients with spontaneous Brugada type I ECG performed by using 12 right precordial leads underwent cardiovascular magnetic resonance imaging (CMRI). The craniocaudal and lateral extent of the RVOT and maximal RVOT area were determined. Type I ECG pattern and maximal ST-segment elevation were correlated to extent and maximal RVOT area, respectively. RESULTS In all patients, Brugada type I pattern was found in the 3rd ICS in sternal and left-parasternal positions. RVOT extent determined by using CMRI included the 3rd ICS in all patients. Maximal RVOT area was found in 3 patients in the 2nd ICS, in 5 patients in the 4th ICS, and in 22 patients in the 3rd ICS. CMRI predicted type I pattern with a sensitivity of 97.2%, specificity of 91.7%, positive predictive value of 88.6%, and negative predictive value of 98.0%. Maximal RVOT area coincided with maximal ST-segment elevation in 29 of 30 patients. CONCLUSION RVOT localization determined by using CMRI correlates highly with the type I Brugada pattern. Lead positioning according to RVOT location improves the diagnosis of Brugada syndrome.
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Affiliation(s)
- C Veltmann
- 1st Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany.
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Chevallier S, Forclaz A, Tenkorang J, Ahmad Y, Faouzi M, Graf D, Schlaepfer J, Pruvot E. New Electrocardiographic Criteria for Discriminating Between Brugada Types 2 and 3 Patterns and Incomplete Right Bundle Branch Block. J Am Coll Cardiol 2011; 58:2290-8. [DOI: 10.1016/j.jacc.2011.08.039] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 07/11/2011] [Accepted: 08/16/2011] [Indexed: 11/29/2022]
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Martin CA, Guzadhur L, Grace AA, Lei M, Huang CLH. Mapping of reentrant spontaneous polymorphic ventricular tachycardia in a Scn5a+/- mouse model. Am J Physiol Heart Circ Physiol 2011; 300:H1853-62. [PMID: 21378142 PMCID: PMC3094090 DOI: 10.1152/ajpheart.00034.2011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Two major mechanisms have been postulated for the arrhythmogenic tendency observed in Brugada Syndrome (BrS): delays in conduction or increased heterogeneities in repolarization. We use a contact mapping system to directly investigate the interacting roles of these two mechanisms in arrhythmogenesis using a genetic murine model for BrS for the first time. Electrograms were obtained from a multielectrode recording array placed against the left ventricle and right ventricle (RV) of spontaneously beating Langendorff-perfused wild type (WT) and Scn5a+/− mouse hearts. Scn5a+/− hearts showed activation waves arriving at the epicardial surface consistent with slowed conduction, which was exacerbated in the presence of flecainide. Lines of conduction block across the RV resulting from premature ventricular beats led to the formation of reentrant circuits and polymorphic ventricular tachycardia. WT hearts showed an inverse relationship between activation times and activation recovery intervals measured at the epicardial surface, which resulted in synchronicity of repolarization times. In contrast, Scn5a+/− hearts, despite having smaller mean activation recovery intervals, demonstrated a greater heterogeneity compared with WT. Isochronal maps showed that their normal activation recovery interval gradients at the epicardial surface were disrupted, leading to heterogeneity in repolarization times. We thus directly demonstrate the initiation of arrhythmia in the RV of Scn5a+/− hearts. This occurs as a result of the combination of repolarization heterogeneities leading to lines of conduction block and unidirectional conduction, with conduction slowing allowing the formation of reentrant circuits. The repolarization heterogeneities may also be responsible for the changing pattern of block, leading to the polymorphic character of the resulting ventricular tachycardia.
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Affiliation(s)
- Claire A Martin
- Physiological Laboratory, University of Cambridge, Cambridge, UK.
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Miyamoto A, Hayashi H, Makiyama T, Yoshino T, Mizusawa Y, Sugimoto Y, Ito M, Xue JQ, Murakami Y, Horie M. Risk Determinants in Individuals With a Spontaneous Type 1 Brugada ECG. Circ J 2011; 75:844-51. [DOI: 10.1253/circj.cj-10-0903] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akashi Miyamoto
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Hideki Hayashi
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tomohide Yoshino
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Yuka Mizusawa
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Yoshihisa Sugimoto
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | - Makoto Ito
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
| | | | | | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science
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Kusano KF. ECG Marker of High-Risk in Asymptomatic Patients With Brugada Syndrome. Circ J 2011; 75:777-8. [DOI: 10.1253/circj.cj-11-0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kengo F. Kusano
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Hoogendijk MG, Opthof T, Postema PG, Wilde AAM, de Bakker JMT, Coronel R. The Brugada ECG pattern: a marker of channelopathy, structural heart disease, or neither? Toward a unifying mechanism of the Brugada syndrome. Circ Arrhythm Electrophysiol 2010; 3:283-90. [PMID: 20551422 DOI: 10.1161/circep.110.937029] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Mark G Hoogendijk
- Heart Failure Research Center, Department of Cardiology and Experimental Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Batchvarov VN, Govindan M, Macfarlane P, Camm AJ, Behr ER. Diagnostic utility of bipolar precordial leads during ajmaline testing for suspected Brugada syndrome. Heart Rhythm 2010; 7:208-15. [DOI: 10.1016/j.hrthm.2009.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 10/05/2009] [Indexed: 11/28/2022]
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Nishii N, Nagase S, Morita H, Kusano KF, Namba T, Miura D, Miyaji K, Hiramatsu S, Tada T, Murakami M, Watanabe A, Banba K, Sakai Y, Nakamura K, Oka T, Ohe T. Abnormal restitution property of action potential duration and conduction delay in Brugada syndrome: both repolarization and depolarization abnormalities. Europace 2010; 12:544-52. [PMID: 20083482 DOI: 10.1093/europace/eup432] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
AIMS This study sought to examine the action potential duration restitution (APDR) property and conduction delay in Brugada syndrome (BrS) patients. A steeply sloped APDR curve and conduction delay are known to be important determinants for the occurrence of ventricular fibrillation (VF). METHODS AND RESULTS Endocardial monophasic action potential was obtained from 39 BrS patients and 9 control subjects using the contact electrode method. Maximum slopes of the APDR curve were obtained at both the right ventricular outflow tract (RVOT) and the right ventricular apex (RVA). The onset of activation delay (OAD) after premature stimulation was examined as a marker of conduction delay. Maximum slope of the APDR curve in BrS patients was significantly steeper than that in control subjects at both the RVOT and the RVA (0.77 +/- 0.21 vs. 058 +/- 0.14 at RVOT, P = 0.009; 0.98 +/- 0.23 vs. 0.62 +/- 0.16 at RVA, P = 0.001). The dispersion of maximum slope of the APDR curve between the RVOT and the RVA was also larger in BrS patients than in control subjects. The OAD was significantly longer in BrS patients than in control subjects from the RVOT to RVA and from the RVA to RVOT (from RVOT to RVA: 256 +/- 12 vs. 243 +/- 7 ms, P = 0.003; from RVA to RVOT: 252 +/- 11 vs. 241 +/- 9 ms, P = 0.01). CONCLUSIONS Abnormal APDR properties and conduction delay were observed in BrS patients. Both repolarization and depolarization abnormalities are thought to be related to the development of VF in BrS patients.
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Affiliation(s)
- Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama 700-8558, Japan.
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Zhou P, Yang X, Li C, Gao Y, Hu D. Quinidine depresses the transmural electrical heterogeneity of transient outward potassium current of the right ventricular outflow tract free wall. J Cardiovasc Dis Res 2010; 1:12-8. [PMID: 21188084 PMCID: PMC3004164 DOI: 10.4103/0975-3583.59979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND#ENTITYSTARTX02014;: Electrical heterogeneity of the right ventricular outflow tract (RVOT) is regarded as one of the main electrophysiological substrates for Brugada syndrome. Recently quinidine has shown efficacy in patients with Brugada syndrome due to its ability to inhibit potassium current especially 4-aminopyridine-sensitive, non-Ca(2+) -dependent transient outward potassium current (Ito). However, much less is known on how extent quinidine in clinical therapeutic concentration range can inhibit this kind of electrical heterogeneity of RVOT Ito. METHODS AND RESULTS#ENTITYSTARTX02014;: Single RVOT free wall epicardial (Epi) cell, midmyocardial (M) cell and endocarcial (Endo) cells were used for whole-cell voltage clamping and Ito was recorded at 37°C, 0.2 Hz depolarization pulse. Evident Ito tranmural heterogeneity existed in RVOT free wall. Under the condition of baseline, of 10 μM quinidine perfusion 5 minutes (mins), and of 10 μM quinidine perfusion 7-10 mins, from 0 mV to 70 mV the whole transmural average Ito values of RVOT free wall were 10.2 pA/pF, 5.5 pA/pF and 3.5 pA/pF, respectively (between groups, P< 0.01). The inhibitory percentage of 10 μM quinidine at 5 mins and 7-10 mins steady-state level on the the whole Ito transmural heterogeneity of RVOT free wall were 46.3%±6% and 66.5%±11%, respectively. CONCLUSIONS#ENTITYSTARTX02014;: There exists a robust Ito transmural electrical heterogeneity in RVOT free wall and quinidine in clinical therapeutic concentration can depress this kind of heterogeneity effectively.
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Affiliation(s)
- Peng Zhou
- Heart Center, Beijing Chaoyang Hospital Affiliated Capital Medical University, Beijing, PRC, China
- Current affiliation: Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Xinchun Yang
- Heart Center, Beijing Chaoyang Hospital Affiliated Capital Medical University, Beijing, PRC, China
| | - Cuilan Li
- Department of Cardiology, Peking University People’s Hospital, Beijing PRC, China
| | - Ying Gao
- Department of Cardiology, Tongren Hospital Affiliated Capital Medical University, Being, PRC, China
| | - Dayi Hu
- Department of Cardiology, Peking University People’s Hospital, Beijing PRC, China
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Morita H, Zipes DP, Wu J. Brugada syndrome: insights of ST elevation, arrhythmogenicity, and risk stratification from experimental observations. Heart Rhythm 2009; 6:S34-43. [PMID: 19880072 DOI: 10.1016/j.hrthm.2009.07.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Indexed: 11/25/2022]
Abstract
Brugada syndrome (BrS), caused by ion channel abnormalities, is characterized by ST segment elevation and negative T waves in the right precordial electrocardiographic (ECG) leads recorded over the right ventricular outflow tract (RVOT). BrS is sensitive to body temperature and can lead to T-wave alternans (TWA), ventricular tachycardia, and sudden death. Recent studies in an isolated canine RVOT model of BrS demonstrated that reversal of the transmural gradient of repolarization caused the ECG characteristics and that major intraepicardial and transmural dispersion of action potentials (APs) initiated phase 2 reentry, premature ventricular activations, and tachyarrhythmias. Hypothermia enhanced the heterogeneity of the AP and promoted the origination of phase 2 reentry in the epicardium of the RVOT, but the prolonged AP duration frequently blocked reentry. Hyperthermia abbreviated the AP and facilitated the maintenance of reentry and tachyarrhythmias. Bradycardia promoted alternans in the phase 2 dome of the AP within the epicardium of the RVOT, resulting in TWA. The above phenomena were localized in the epicardium of the RVOT. Blockade of the transient outward current, I(to), reduced AP heterogeneity and prevented arrhythmias in the BrS model. In addition, epicardial activation delay led to fragmented QRS, a risk marker of prognosis in BrS. Body surface mapping in patients with BrS supported these experimental findings. In conclusion, the AP heterogeneity within the epicardium of the RVOT contributes to the ECG characteristics, temperature sensitivity, TWA, and arrhythmias in BrS, and body surface mapping and fragmented QRS can be effective predictors of risk in patients with BrS.
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Affiliation(s)
- Hiroshi Morita
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Lambiase PD, Ahmed AK, Ciaccio EJ, Brugada R, Lizotte E, Chaubey S, Ben-Simon R, Chow AW, Lowe MD, McKenna WJ. High-density substrate mapping in Brugada syndrome: combined role of conduction and repolarization heterogeneities in arrhythmogenesis. Circulation 2009; 120:106-17, 1-4. [PMID: 19564561 DOI: 10.1161/circulationaha.108.771401] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Two principal mechanisms are thought to be responsible for Brugada syndrome (BS): (1) right ventricular (RV) conduction delay and (2) RV subepicardial action potential shortening. This in vivo high-density mapping study evaluated the conduction and repolarization properties of the RV in BS subjects. METHODS AND RESULTS A noncontact mapping array was positioned in the RV of 18 BS patients and 20 controls. Using a standard S(1)-S(2) protocol, restitution curves of local activation time and activation recovery interval were constructed to determine local maximal restitution slopes. Significant regional conduction delays in the anterolateral free wall of the RV outflow tract of BS patients were identified. The mean increase in delay was 3-fold greater in this region than in control (P=0<0.001). Local activation gradient was also maximally reduced in this area: 0.33+/-0.1 (mean+/-SD) mm/ms in BS patients versus 0.51+/-0.15 mm/ms in controls (P<0.0005). The uniformity of wavefront propagation as measured by the square of the correlation coefficient, r(2), was greater in BS patients versus controls (0.94+/-0.04 versus 0.89+/-0.09 [mean+/-SD]; P<0.05). The odds ratio of BS hearts having any RV segment with maximal restitution slope >1 was 3.86 versus controls. Five episodes of provoked ventricular tachycardia arose from wave breaks originating from RV outflow tract slow-conduction zones in 5 BS patients. CONCLUSIONS Marked regional endocardial conduction delay and heterogeneities in repolarization exist in BS. Wave break in areas of maximal conduction delay appears to be critical in the initiation and maintenance of ventricular tachycardia. These data indicate that further studies of mapping BS to identify slow-conduction zones should be considered to determine their role in spontaneous ventricular arrhythmias.
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Affiliation(s)
- P D Lambiase
- Heart Hospital, University College Hospital, University College London, London, UK.
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Sangawa M, Morita H, Nakatsu T, Nishii N, Miura D, Miura A, Tada T, Murakami M, Hiramatsu S, Nagase S, Nakamura K, Oka T, Toyonaga S, Mashima K, Kusachi S, Yamamoto K, Ohe T, Kusano KF. Abnormal transmural repolarization process in patients with Brugada syndrome. Heart Rhythm 2009; 6:1163-9. [PMID: 19632628 DOI: 10.1016/j.hrthm.2009.04.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 04/24/2009] [Indexed: 01/28/2023]
Abstract
BACKGROUND Repolarization abnormality, especially during bradycardia, might be critical for initiation of ventricular fibrillation (VF) in patients with Brugada syndrome (BrS), but the contribution of the rate-dependent repolarization dynamics to the occurrence of VF is still unknown. OBJECTIVE The aim of our study was to determine the differences in rate-dependent repolarization dynamics between BrS with and without spontaneous VF and between BrS with and without SCN5A mutation. METHODS The subjects were 37 BrS patients with VF (VF(+) group: 10 male subjects) and without VF (VF(-) group: 27 male subjects) and 20 control subjects. Genetic analysis of SCN5A was performed in all 37 BrS patients. The relationships between QT, QTp, Tp-e, and RR intervals were obtained from Holter recordings as first linear regression lines, and the slopes of QT/RR, QTp/RR, and Tp-e/RR linear regression lines as the sensitivity of rate-dependent repolarization dynamics were compared. RESULTS QT/RR and Tp-e/RR slopes showed loss of a rate-dependent property in the VF(+) group compared with those in the VF(-) and control groups. There was no significant difference in QTp/RR slope among the VF(+), VF(-) and control groups. The Tp-e interval had a negative correlation with the RR interval in the VF(+) group and a positive correlation with the RR interval in the VF(-) and control groups. There was no significant difference in QT/RR, QTp/RR, and Tp-e/RR slopes between BrS patients with SCN5A mutation and those without SCN5A mutation. CONCLUSIONS Loss of rate-dependent QT dynamics may be associated with occurrence of VF in BrS.
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Affiliation(s)
- Mutsuko Sangawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine and Dentistry, Okayama City, Okayama, Japan
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Current World Literature. Curr Opin Cardiol 2009; 24:95-101. [DOI: 10.1097/hco.0b013e32831fb366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Postema PG, van Dessel PFHM, de Bakker JMT, Dekker LRC, Linnenbank AC, Hoogendijk MG, Coronel R, Tijssen JGP, Wilde AAM, Tan HL. Slow and discontinuous conduction conspire in Brugada syndrome: a right ventricular mapping and stimulation study. Circ Arrhythm Electrophysiol 2008; 1:379-86. [PMID: 19808433 DOI: 10.1161/circep.108.790543] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Brugada syndrome (BrS) is associated with lethal arrhythmias, which are linked to specific ST-segment changes (type-1 BrS-ECG) and the right ventricle (RV). The pathophysiological basis of the arrhythmias and type-1 BrS-ECG is unresolved. We studied the electrophysiological characteristics of the RV endocardium in BrS. METHODS AND RESULTS RV endocardial electroanatomical mapping and stimulation studies were performed in controls (n=12) and BrS patients with a type-1 (BrS-1, n=10) or type-2 BrS-ECG (BrS-2, n=12) during the studies. BrS-1 patients had prominent impairment of RV endocardial impulse propagation when compared with controls, as represented by: (1) prolonged activation-duration during sinus rhythm (86+/-4 versus 65+/-3 ms), (2) increased electrogram fractionation (1.36+/-0.04 versus 1.15+/-0.01 deflections per electrogram), (3) longer electrogram duration (83+/-3 versus 63+/-2 ms), (4) activation delays on premature stimulation (longitudinal: 160+/-26 versus 86+/-9 ms; transversal: 112+/-5 versus 58+/-6 ms), and (5) abnormal transversal conduction velocity restitution (42+/-8 versus 18+/-2 ms increase in delay at shortest coupling intervals). Wider and more fractionated electrograms were also found in BrS-2 patients. Repolarization was not different between groups. CONCLUSIONS BrS-1 and BrS-2 patients are characterized by wide and fractionated electrograms at the RV endocardium. BrS-1 patients display additional conduction slowing during sinus rhythm and premature stimulation along with abnormal transversal conduction velocity restitution. These patients may thus exhibit a substrate for slow and discontinuous conduction caused by abnormal active membrane processes and electric coupling. Our findings support the emerging notion that BrS is not solely attributable to abnormal electrophysiological properties but requires the conspiring effects of conduction slowing and tissue discontinuities.
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Affiliation(s)
- Pieter G Postema
- Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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The Brugada syndrome: How many types? Heart Rhythm 2008; 5:1565-6. [DOI: 10.1016/j.hrthm.2008.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Indexed: 11/19/2022]
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Nagase S, Kusano KF, Morita H, Ohe T. Reply. J Am Coll Cardiol 2008. [DOI: 10.1016/j.jacc.2008.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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