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Changes in Exercise Capacity and Ventricular Function in Arrhythmogenic Right Ventricular Cardiomyopathy: The Impact of Sports Restriction during Follow-Up. J Clin Med 2022; 11:jcm11051150. [PMID: 35268241 PMCID: PMC8911196 DOI: 10.3390/jcm11051150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Physical exercise has been suggested to promote disease progression in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). We aimed to investigate the exercise performance and ventricular function of ARVC patients during follow-up, while taking into account their adherence to exercise restriction recommendations. (2) Methods: This retrospective study included 49 patients (33 male, 67%) who had an exercise test at baseline and after 4.2 ± 1.6 years. Of the 49 ARVC patients, 27 (55%) were athletes, while 22 (45%) were non-athletes. Of the athletes, 12 (44%) continued intensive sports activity (non-adherent), while 15 (56%) stopped intensive physical activity upon recommendation (adherent). The maximum workload in Watts (W), percentage of the target workload (W%), and double product (DP) factor were measured for all patients. (3) Results: The non-adherent cohort had a significant decrease in physical performance (W at baseline vs. follow-up, p = 0.012; W% at baseline vs. follow-up, p = 0.025; DP-factor at baseline vs. follow-up, p = 0.012) over time. Left ventricular (LV) function (LV ejection fraction at baseline vs. follow-up, p = 0.082) showed a decreasing trend in the non-adherent cohort, while the performance of the adherent cohort remained at a similar level. (4) Conclusions: If intensive sports activities are not discontinued, exercise capacity and left ventricular function of athletes with ARVC deteriorates during follow-up. All patients with ARVC need to strictly adhere to the recommendation to cease intense sports activity in order to halt disease progression.
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Giuliano K, Scheel P, Etchill E, Fraser CD, Suarez-Pierre A, Hsu S, Wittstein IS, Kasper EK, Florido R, Tandri H, Calkins H, Choi CW, Sharma K, Kilic A, Gilotra NA. Heart transplantation outcomes in arrhythmogenic right ventricular cardiomyopathy: a contemporary national analysis. ESC Heart Fail 2022; 9:988-997. [PMID: 35132806 PMCID: PMC8934952 DOI: 10.1002/ehf2.13687] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/27/2021] [Accepted: 10/09/2021] [Indexed: 01/06/2023] Open
Abstract
Aims Heart failure is an increasingly recognized later stage manifestation of arrhythmogenic right ventricular cardiomyopathy (ARVC) that can require heart transplantation (HT) to appropriately treat. We aimed to study contemporary ARVC HT outcomes in a national registry. Methods and results The United Network for Organ Sharing registry was queried for HT recipients from 1/1994 through 2/2020. ARVC patients were compared with non‐ARVC dilated, restrictive, and hypertrophic cardiomyopathy HT patients (HT for ischaemic and valvular disease was excluded from analysis). Post‐HT survival was assessed using Kaplan–Meier estimates. A total of 189 of 252 (75%) waitlisted ARVC patients (median age 48 years, 65% male) underwent HT, representing 0.3% of the total 65 559 HT during the study time period. Annual frequency of HT for ARVC increased significantly over time. ARVC patients had less diabetes (5% vs. 17%, P < 0.001), less cigarette use (15% vs. 23%, P < 0.001), lower pulmonary artery and pulmonary capillary wedge pressures, and lower cardiac output than the 33 659 non‐ARVC patients (P < 0.001). Ventricular assist device use was significantly lower in ARVC patients (8% vs. 32%, P < 0.001); 1 and 5 year post‐HT survival was 97% and 93% for ARVC vs. 95% and 82% for non‐ARVC HT recipients (P < 0.001). On adjusted multivariable Cox regression, ARVC had decreased risk of post‐HT death compared with non‐ARVC aetiologies (hazard ratio 0.48, 95% confidence interval 0.28–0.82, P = 0.008). Patients with ARVC also had lower risk of death or graft failure than non‐ARVC patients (hazard ratio 0.51, 95% confidence interval 0.32–0.81, P = 0.004). Conclusions In the largest series of HT in ARVC, we found that HT is increasingly performed in ARVC, with higher survival compared with other cardiomyopathy aetiologies. The right ventricular predominant pathophysiology may require unique considerations for heart failure management, including HT.
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Affiliation(s)
- Katherine Giuliano
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul Scheel
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric Etchill
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles D Fraser
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ilan S Wittstein
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward K Kasper
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Roberta Florido
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chun W Choi
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Kilic
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Denis A, Sacher F, Derval N, Lim HS, Cochet H, Shah AJ, Daly M, Pillois X, Ramoul K, Komatsu Y, Zemmoura A, Amraoui S, Ritter P, Ploux S, Bordachar P, Hocini M, Jaïs P, Haïssaguerre M. Diagnostic Value of Isoproterenol Testing in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Arrhythm Electrophysiol 2014; 7:590-7. [DOI: 10.1161/circep.113.001224] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arnaud Denis
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Frédéric Sacher
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Nicolas Derval
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Han. S. Lim
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Hubert Cochet
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Ashok J. Shah
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Matthew Daly
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Xavier Pillois
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Khaled Ramoul
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Yuki Komatsu
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Adlane Zemmoura
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Sana Amraoui
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Philippe Ritter
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Sylvain Ploux
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Pierre Bordachar
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Mélèze Hocini
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Pierre Jaïs
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
| | - Michel Haïssaguerre
- From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Victor Segalen, Bordeaux II, LIRYC Institute, Bordeaux, France
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Woźniewicz B, Czarnowska E, Kubicka K, Ziółkowska L, Cielecka-Kuszyk J, Zaleska T. Coexistence of arrhythmogenic right ventricular cardiomyopathy and chronic myocarditis in children. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s100570050003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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5
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Perrin MJ, Angaran P, Laksman Z, Zhang H, Porepa LF, Rutberg J, James C, Krahn AD, Judge DP, Calkins H, Gollob MH. Exercise Testing in Asymptomatic Gene Carriers Exposes a Latent Electrical Substrate of Arrhythmogenic Right Ventricular Cardiomyopathy. J Am Coll Cardiol 2013; 62:1772-9. [DOI: 10.1016/j.jacc.2013.04.084] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 04/03/2013] [Accepted: 04/16/2013] [Indexed: 11/30/2022]
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6
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McClaskey D, Lee D, Buch E. Outcomes among Athletes with Arrhythmias and Electrocardiographic Abnormalities: Implications for ECG Interpretation. Sports Med 2013; 43:979-91. [DOI: 10.1007/s40279-013-0074-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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7
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Philips B, Madhavan S, James C, Tichnell C, Murray B, Needleman M, Bhonsale A, Nazarian S, Laurita KR, Calkins H, Tandri H. High Prevalence of Catecholamine-facilitated Focal Ventricular Tachycardia in Patients With Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Circ Arrhythm Electrophysiol 2013; 6:160-6. [DOI: 10.1161/circep.112.975441] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Binu Philips
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Srinivasa Madhavan
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Cynthia James
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Crystal Tichnell
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Brittney Murray
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Matthew Needleman
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Aditya Bhonsale
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Saman Nazarian
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Kenneth R. Laurita
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Hugh Calkins
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
| | - Harikrishna Tandri
- From the Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (B.P., S.M., C.J., C.T., B.M., M.N., A.B., S.N., H.C., H.T.); and The Heart and Vascular Research Center, MetroHealth Campus, Case Western Reserve University, Cleveland, OH (K.R.L.)
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8
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Utility of exercise testing in children and teenagers with arrhythmogenic right ventricular cardiomyopathy. Am J Cardiol 2009; 104:411-3. [PMID: 19616676 DOI: 10.1016/j.amjcard.2009.03.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 03/23/2009] [Accepted: 03/23/2009] [Indexed: 11/24/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is increasingly recognized as an important cause of exertional sudden death in otherwise healthy young individuals and athletes. Graded exercise testing is routinely included in the evaluation of patients with suspected ARVC, but its diagnostic utility has not been systematically assessed. Using a single-center retrospective design, the rhythm response to graded exercise testing was examined in 33 tests performed in 16 young (aged <18 years) patients with established diagnosis of ARVC. Ventricular premature complexes (VPCs) were classified as absent (graded 0), as being isolated or in couplets (graded 1), or as comprising nonsustained ventricular tachycardia (graded 2) during pretest rest, at peak exercise, and during postexercise recovery. VPCs were absent at rest in 21 of 33 studies, subsequently appearing at peak exercise in 4 studies and during recovery in 2 studies. Isolated VPCs and couplets were present at rest in 9 of 33 studies, with subsequent exercise provoking higher grade ectopic activity in 2 instances at peak exercise and in 1 case during recovery, while VPCs decreased or remained unchanged in all other cases. In all 3 instances in which ventricular tachycardia was observed during pretest rest, there was either suppression (3 at peak exercise, 2 during recovery) or no change (1 case during recovery) in VPC grade. In conclusion, the exercise response of ventricular ectopic activity is highly variable in young patients with ARVC. The diagnostic utility of graded exercise testing is thus questionable in young patients with suspected ARVC, and the absence or suppression of VPCs during exercise should not be considered reassuring in terms of its diagnostic exclusion.
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9
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Montagnana M, Lippi G, Franchini M, Targher G, Cesare Guidi G. Sudden cardiac death: prevalence, pathogenesis, and prevention. Ann Med 2008; 40:360-75. [PMID: 18484348 DOI: 10.1080/07853890801964930] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Sudden cardiac death (SCD), also known as sudden arrest, is a major health problem worldwide. It is usually defined as an unexpected death from a cardiac cause occurring within a short time in a person with or without preexisting heart disease. The pathogenesis of SCD is complex and multifaceted. A dynamic triggering factor usually interacts with an underlying heart disease, either genetically determined or acquired, and the final outcome is the development of lethal tachyarrhythmias or, less frequently, bradycardia. It has increasingly been highlighted that a reliable clinical and diagnostic approach might be effective to unmask the most important genetic and environmental factors, allowing the construction of a rational personalized medicine framework that can be applied in both the preclinical and clinical settings of SCD. The aim of the present article is to provide a concise overview of prevalence, pathogenesis, clinical presentation, and diagnostic approach to this challenging disorder.
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Affiliation(s)
- Martina Montagnana
- Sezione di Chimica e Microscopia Clinica, Dipartimento di Scienze Morfologico-Biomediche, Universita degli Studi di Verona, Italy.
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10
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Maksimović R, Ekinci O, Reiner C, Bachmann GF, Seferović PM, Ristić AD, Hamm CW, Pitschner HF, Dill T. The value of magnetic resonance imaging for the diagnosis of arrhythmogenic right ventricular cardiomyopathy. Eur Radiol 2005; 16:560-8. [PMID: 16249865 DOI: 10.1007/s00330-005-0018-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2005] [Revised: 07/27/2005] [Accepted: 08/23/2005] [Indexed: 10/25/2022]
Abstract
This study evaluated the diagnostic significance of a magnetic resonance imaging (MRI) based scoring model for identification of arrhythmogenic right ventricular cardiomyopathy (ARVC) in patients with MRI evidence of RV abnormalities. Fifty-three patients with RV myocardial abnormalities on MRI were divided into a group with ARVC 1 (n=17) and a group with other RV arrhythmias (n=37). Decision tree learning (DTL) and linear classification (based on a modified ARVC scoring model of major and minor criteria) were used to identify and assess MRI criterion information value, and to induce ARVC diagnostic rules. All major ARVC criteria were more frequent in the ARVC group. Among minor criteria regional RV hypokinesia, mild segmental RV dilatation, and prominent trabeculae were more frequent in the ARVC group while mild global RV dilatation was more frequent in the non-ARVC group. RV aneurysm achieved highest importance in ARVC diagnosis (predictive accuracy 76.8%). Better diagnostic accuracy (sensitivity 93.3%, specificity 89.5%) was achieved when the MRI score for the major and minor criteria reached threshold value of four: two major criteria, or one major and two minor, or four minor criteria. Combinations between major and minor criteria contributed to a statistically valid model for ARVC diagnosis.
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Affiliation(s)
- Ruzica Maksimović
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany.
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11
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Bomma C, Dalal D, Tandri H, Prakasa K, Nasir K, Roguin A, Tichnell C, James C, Lima JAC, Calkins H, Bluemke DA. Regional differences in systolic and diastolic function in arrhythmogenic right ventricular dysplasia/cardiomyopathy using magnetic resonance imaging. Am J Cardiol 2005; 95:1507-11. [PMID: 15950585 DOI: 10.1016/j.amjcard.2005.02.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2004] [Revised: 02/10/2005] [Accepted: 02/08/2005] [Indexed: 11/26/2022]
Abstract
Global and regional biventricular functions were analyzed in 14 patients diagnosed with arrhythmogenic right ventricular dysplasia/cardiomyopathy using cine magnetic resonance imaging and compared with similar data from 18 age-matched controls. In this study, we report results of quantitative evaluation of biventricular global and regional function using peak ejection rate and peak filling rate as measures of systolic and diastolic function, respectively (volumetric method).
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Affiliation(s)
- Chandra Bomma
- Division of Cardiology (Department of Medicine), Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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12
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Abstract
MR imaging is helpful in the management of patients in whom the diagnosis of ARVD or RVOTT is suspected. Careful attention to cardiac rate control will minimize or eliminate ventricular extrasystolic beats during examination, which will improve image quality and confidence in diagnosis. Use of thin-section cine gradient echo acquisition provides a means of identifying regional wall motion abnormalities, characteristic of the regional dysfunction in these diseases. Furthermore, application of spin echo or double inversion recovery imaging may provide visualization of abnormally thin or fat-infiltrated regions of right ventricular free wall myocardium, providing additional diagnostic criteria for the diagnosis of these diseases.
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Affiliation(s)
- Lawrence M Boxt
- Department of Radiology, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003, USA.
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13
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Abstract
The athlete represents the healthiest segment of our society. Yet, there are still reports of sudden death occurring while on the athletic field. Any athlete who 'goes to ground' temporarily (syncope) warrants an immediate investigation. The differential diagnosis of syncope is wide-ranging. However, if a cardiac cause is the underlying etiology of an athlete with syncope, and that athlete participates and has another syncopal episode the likelihood of resuscitation may be quite low. This article reviews the most common causes of sudden death in athletes (hypertrophic cardiomyopathy, anomalous coronary arteries, arrhythmogenic right ventricular cardiomyopathy, myocarditis, and dilated cardiomyopathy). Important attention will be centered on the pathophysiology of each abnormality and how it contributes to symptoms of syncope and sudden death. Also, the ideal evaluation of each will be reviewed. Recommendations regarding eligibility for competition in sports with each underlying abnormality will be reviewed. In addition, this article will review the evaluation of children and young adults who wish to participate in athletics.
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Affiliation(s)
- S Cook
- Albert Einstein Hospital, Philadelphia, PA, USA
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Al-Sheikh T, Zipes DP. Guidelines for Competitive Athletes with Arrhythmias. DEVELOPMENTS IN CARDIOVASCULAR MEDICINE 2000. [DOI: 10.1007/978-94-017-0789-3_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sharma S, Whyte G, Elliott P, Padula M, Kaushal R, Mahon N, McKenna WJ. Electrocardiographic changes in 1000 highly trained junior elite athletes. Br J Sports Med 1999; 33:319-24. [PMID: 10522633 PMCID: PMC1756199 DOI: 10.1136/bjsm.33.5.319] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the spectrum of electrocardiographic (ECG) changes in 1000 junior (18 or under) elite athletes. METHODS A total of 1000 (73% male) junior elite athletes (mean (SD) age 15.7 (1.4) years (range 14-18); mean (SD) body surface area 1.73 (0.17) m2 (range 1.09-2.25)) and 300 non-athletic controls matched for gender, age, and body surface area had a 12 lead ECG examination. RESULTS Athletes had a significantly higher prevalence of sinus bradycardia (80% v 19%; p<0.0001) and sinus arrhythmia (52% v 9%; p<0.0001) than non-athletes. The PR interval, QRS, and QT duration were more prolonged in athletes than non-athletes (153 (20) v 140 (18) milliseconds (p<0.0001), 92 (12) v 89 (7) milliseconds (p<0.0001), and 391 (27) v 379 (29) milliseconds (p = 0.002) respectively). The Sokolow voltage criterion for left ventricular hypertrophy (LVH) and the Romhilt-Estes points score for LVH was more common in athletes (45% v 23% (p<0.0001) and 10% v 0% (p<0.0001) respectively), as were criteria for left and right atrial enlargement (14% v 1.2% and 16% v 2% respectively). None of the athletes with voltage criteria for LVH had left axis deviation, ST segment depression, deep T wave inversion, or pathological Q waves. ST segment elevation was more common in athletes than non-athletes (43% v 24%; p<0.0001). Minor T wave inversion (less than -0.2 mV) in V2 and V3 was present in 4% of athletes and non-athletes. Minor T wave inversion elsewhere was absent in non-athletes and present in 0.4% of athletes. CONCLUSIONS ECG changes in junior elite athletes are not dissimilar to those in senior athletes. Isolated Sokolow voltage criterion for LVH is common; however, associated abnormalities that indicate pathological hypertrophy are absent. Minor T wave inversions in leads other than V2 and V3 may be present in athletes and non-athletes less than 16 but should be an indication for further investigation in older athletes.
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Affiliation(s)
- S Sharma
- St George's Hospital Medical School, London, United Kingdom
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16
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Rodríguez Font E, Viñolas Prat X. Causas de muerte súbita. Problemas a la hora de establecer y clasificar los tipos de muerte. Rev Esp Cardiol 1999. [DOI: 10.1016/s0300-8932(99)75027-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ananthasubramaniam K, Khaja F. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: review for the clinician. Prog Cardiovasc Dis 1998; 41:237-46. [PMID: 9872609 DOI: 10.1016/s0033-0620(98)80058-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although hypertrophic obstructive cardiomyopathy remains the most common cause of sudden cardiac death in young people, rarer causes, such as arrhythmogenic right ventricular dysplasia (ARVD), are now being increasingly recognized to lead to sudden cardiac death in the younger population. Recent advances in the understanding of the genetic inheritance, etiopathogenesis, diagnosis, and treatment options of ARVD have prompted a lot of research in this form of right ventricular cardiomyopathy. The purpose of this report is to review the etiopathogenesis, clinical manifestations, diagnosis and treatment modalities for ARVD, and recent advances in the understanding of this disease entity.
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18
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Pathology of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia—An Autopsy Study of 20 Forensic Cases. J Forensic Sci 1998. [DOI: 10.1520/jfs14306j] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Abstract
The sudden unexpected death of an athlete is a disturbing and tragic event. Sudden cardiac death in the young athlete is caused primarily by cardiomyopathies and nonatherosclerotic coronary artery abnormalities; in the mature athlete, the most prevalent cause of sudden cardiac death is atherosclerotic coronary disease. The job of the emergency physician is to resuscitate those who succumb to ventricular dysrhythmias during exercise and to screen patients for potential risk of sudden cardiac death when they present with warning symptoms such as syncope.
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Affiliation(s)
- E J Reisdorff
- Michigan State University, Ingham Regional Medical Center, Lansing, USA
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20
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Furlanello F, Bertoldi A, Dallago M, Furlanello C, Fernando F, Inama G, Pappone C, Chierchia S. Cardiac arrest and sudden death in competitive athletes with arrhythmogenic right ventricular dysplasia. Pacing Clin Electrophysiol 1998; 21:331-5. [PMID: 9474700 DOI: 10.1111/j.1540-8159.1998.tb01116.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is a predisposing factor for sport-related cardiac arrest (CA), sudden cardiac death (SD), and life-threatening ventricular tachyarrhythmias (VT). The aim of this study was the assessment of athletes with ARVD, particularly the CA survivors. From 1974 to January 1996, 1642 competitive athletes (aver. 25.5 yr.), 136 of whom were top level athletes (TLA), were studied for important arrhythmic manifestations. All athletes underwent an individualised study protocol including a series of non invasive and invasive diagnostic techniques. One hundred and one athletes (90 males, 11 females, aver. 25.9 yr.) were diagnosed as being affected by ARVD on the basis of the WHO/ISFC criteria. The same percentage (about 6%) of ARVD is present in both the general arrhythmic athletes population and in the subgroup of TLA. Prevalence of ARVD among athletes with CA or SD is high (respectively 23% and 25%), confirming the observation that ARVD is one of the major causes of SD in Italian athletes. All CA were athletic activity related, indicating the potentiality of exercise as a cause of electrical destabilisation in subjects with ARVD. In athletes with documented ARVD intense sport activity has to be proscribed. In athletes at risk of CA or SD an aggressive treatment, ICD implantation and RF catheter ablation must be taken into consideration.
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Affiliation(s)
- F Furlanello
- S. Raffaele Scientific Institute, Milan, Rome, Italy
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21
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Basso C, Thiene G, Corrado D, Angelini A, Nava A, Valente M. Arrhythmogenic right ventricular cardiomyopathy. Dysplasia, dystrophy, or myocarditis? Circulation 1996; 94:983-91. [PMID: 8790036 DOI: 10.1161/01.cir.94.5.983] [Citation(s) in RCA: 537] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a frequent cause of sudden death in young individuals and athletes. Although familial occurrence has been documented and a gene defect was recently localized on chromosome 14q23-q24 the etiopathogenesis of the disease is still obscure. METHODS AND RESULTS A pathological study was conducted in 30 hearts with ARVC (age range, 15 to 65 years; mean, 28 years). In the 27 autopsy cases, the mode of death was sudden in 24 and congestive heart failure in 3. ECG, available in 19 cases, showed inverted T waves in the right precordial leads in 15 cases (79%) and ventricular arrhythmias in 15 (79%). Right ventricular aneurysms were present in 15 hearts (50%) and located in the inferior wall in 12. Left ventricle and ventricular septum were involved in 14 (47%) and 6 (20%) cases, respectively. Scattered foci of lymphocytes with myocardial death were observed in 20 cases (67%). Electron microscopy studies, although confirming the myocardial death and lymphocyte infiltrates, did not show any specific ultrastructural substrate. Two pathological patterns, fatty (40%) and fibrofatty (60%), were identified. The fibrofatty pattern was associated with a thinner right ventricular wall (P < .0001) and a higher occurrence of focal myocarditis (P < .001). In sections of right ventricular free wall with maximal fatty infiltration, the mean percentage area of fatty tissue was 35.9 +/- 11.1% in control versus 80.4 +/- 9.6% in the ARVC, fatty variety (P < .00001). Involvement of the left ventricle and/or ventricular septum, right ventricular aneurysms, and inflammation were found almost exclusively in the fibrofatty variety. CONCLUSIONS In the fibrofatty variety of ARVC, the myocardial atrophy appears to be the consequence of acquired injury (myocyte death) and repair (fibrofatty replacement), mediated by patchy myocarditis. Whether the inflammation is a primary event or a reaction to spontaneous cell death remains unclear.
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Affiliation(s)
- C Basso
- Department of Pathology, University of Padua Medical School, Italy
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22
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Abstract
The differential diagnosis of VTs with LBBB morphology includes several well-defined syndromes. Although the majority of cases are attributable to acquired structural heart disease, including ischemia, prior infarction, or dilated cardiomyopathy, consideration of specific right ventricular processes is essential to proper evaluation and treatment. The approach to older patients or those with evidence for heart disease should begin with an evaluation for coronary artery disease and an assessment of biventricular function. Careful evaluation for bundle branch reentry should be performed during electrophysiological study, especially when there is underlying conduction system disease. Younger patients, those without overt heart disease, or those with isolated right ventricular disease, should receive a complete noninvasive evaluation of right and left ventricular size and function. An abnormal SAECG or identification of intracardiac late potentials suggest right ventricular dysplasia or cardiomyopathy, whereas responsiveness to adenosine and absence of detectable heart disease support the diagnosis of idiopathic right VT. Newer techniques, including MRI, show promise in identifying subtle right ventricular disease not otherwise detectable even in the setting of presumed idiopathic right VT. Following surgical repair of selected congenital heart defects, particularly tetralogy of Fallot, symptoms of recurrent palpitations, near syncope, syncope, or aborted sudden death may be attributable to recurrent VT, and diagnostic electrophysiological study should be considered for these patients. Finally, SVTs with LBBB morphology, particularly cases associated with right-sided or septal accessory pathways, should always be considered in this differential diagnosis.
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Affiliation(s)
- C Nibley
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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23
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Jordaens L, Missault L, Pelleman G, Duprez D, De Backer G, Clement DL. Comparison of athletes with life-threatening ventricular arrhythmias with two groups of healthy athletes and a group of normal control subjects. Am J Cardiol 1994; 74:1124-8. [PMID: 7977071 DOI: 10.1016/0002-9149(94)90464-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Sudden cardiac death in well-trained athletes is most often superimposed on the presence of structural heart disease. However, some athletes die suddenly in the absence of overt heart disease. To improve identification of athletes at high risk for ventricular tachycardia (VT), ventricular repolarization, the signal-averaged electrocardiogram (ECG), and the echocardiogram from 13 male athletes with symptomatic VT and without evidence of manifest cardiac disease were compared with data obtained in 3 matched control groups (15 apparently healthy professional road cyclists, 10 professional basketball players, and 15 normal control subjects without any sports activity). All patients had apparently normal QRS duration on the routine ECG, and none were taking antiarrhythmic drugs. Echocardiography and signal-averaged electrocardiography were useful in distinguishing the group of athletes with tachyarrhythmias from the group of normal nonsporting controls, but not from both groups of normal athletes. The QT interval (V4) and the QT interval corrected with the cubic root were shorter for the nonsporting controls. Three parameters for QT dispersion showed significant differences (p < 0.003) between athletes with disease and all other groups. It is concluded that although significant differences were detected between normal subjects and the 3 groups of athletes by routine ECG, the signal-averaged ECG, and echocardiography, only an increased QT dispersion from the 12-lead ECG was helpful in distinguishing athletes with VT from other athletes.
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Affiliation(s)
- L Jordaens
- Department of Cardiology, University Hospital Ghent, University of Ghent, Belgium
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24
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Zipes DP, Garson A. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Task Force 6: arrhythmias. J Am Coll Cardiol 1994; 24:892-9. [PMID: 7523472 DOI: 10.1016/0735-1097(94)90847-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
In brief Athletes who have heart symptoms need the same type of evaluation as nonathletes who have such symptoms, except that the evaluation generally should include testing during exercise. In history taking, be aware that an athlete may try to minimize heart symptoms in an effort to avoid restrictions on participation. Syncope and related symptoms are Important in that they may reflect an arrhythmia caused by a potentially fatal condition. Syncope or near syncope also may be caused by cat- echolamine-dependent tachycardia, which usually responds to treatment with β-blockers.
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Gerlis LM, Schmidt-Ott SC, Ho SY, Anderson RH. Dysplastic conditions of the right ventricular myocardium: Uhl's anomaly vs arrhythmogenic right ventricular dysplasia. BRITISH HEART JOURNAL 1993; 69:142-50. [PMID: 8435240 PMCID: PMC1024941 DOI: 10.1136/hrt.69.2.142] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since 1905 there have been many reports of cases in which the right ventricle was deficient in myocardium. Several terms have been used to describe this condition. Of these, "Uhl's anomaly" and "arrhythmogenic right ventricular dysplasia" are most often used. Our study investigates the relation between these entities. METHOD Five cases with a primary deficiency of the right ventricular musculature were examined. The findings were compared with those published reports to evaluate the similarities and differences between Uhl's anomaly and arrhythmogenic dysplasia. RESULTS The five cases showed two patterns of myocardial deficiency in the right ventricle. On the one hand, the parietal wall was paper thin with complete absence of musculature and apposition of the endocardial and epicardial layers. On the other hand, patchy, localised fibrofatty tissue replacement was found within the parietal musculature. Evidence from our cases, combined with analysis of other publications, showed different modes and timing of clinical presentation of the patients with these two anatomical conditions, congestive heart failure or arrhythmia. CONCLUSIONS The conditions variously described as Uhl's anomaly and arrhythmogenic dysplasia are separate and distinct morphological entities.
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Affiliation(s)
- L M Gerlis
- Department of Paediatrics, National Heart and Lung Institute, London
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Wichter T, Borggrefe M, Haverkamp W, Chen X, Breithardt G. Efficacy of antiarrhythmic drugs in patients with arrhythmogenic right ventricular disease. Results in patients with inducible and noninducible ventricular tachycardia. Circulation 1992; 86:29-37. [PMID: 1617780 DOI: 10.1161/01.cir.86.1.29] [Citation(s) in RCA: 218] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ventricular tachyarrhythmias are the major clinical manifestation of arrhythmogenic right ventricular disease. Although antiarrhythmic therapy has been widely advocated, there is only limited information available on the efficacy of antiarrhythmic drugs in these patients. METHODS AND RESULTS The short- and long-term efficacies of various antiarrhythmic agents were retrospectively and prospectively analyzed in 81 patients (mean age, 39 +/- 14 years; range, 16-68 years; 61.7% males) with arrhythmogenic right ventricular disease. In 42 patients with inducible ventricular tachycardia during programmed ventricular stimulation, the following efficacy rates were obtained: class Ia and Ib drugs (n = 18), 5.6%; class Ic drugs (n = 25), 12%; beta-blockers (n = 8), 0%; sotalol (n = 38), 68.4%; amiodarone (n = 13), 15.4%; verapamil (n = 5), 0%; and drug combinations (n = 26), 15.4%. Only one of the 10 patients not responding to sotalol was treated effectively by amiodarone, whereas the remaining nine patients proved to be drug refractory toward all other drugs tested (3.8 +/- 2.3 drugs, including amiodarone in five cases) and underwent nonpharmacological therapy. During a follow-up of 34 +/- 25 months, three of the 31 patients (9.7%) discharged on pharmacological therapy had nonfatal recurrences of ventricular tachycardia after 0.5, 51, and 63 months, respectively. In 39 patients with noninducible ventricular tachycardia during programmed ventricular stimulation, the following efficacy rates were observed: class Ia and Ib drugs (n = 16), 0%; class Ic agents (n = 23), 17.4%; beta-blockers (n = 7), 28.6%; sotalol (n = 35), 82.8%; amiodarone (n = 4), 25%; verapamil (n = 24), 50%; and drug combinations (n = 11), 9.1%. During a follow-up of 14 +/- 13 months, four of 33 patients (12.1%) discharged on antiarrhythmic drugs had nonfatal relapses of their clinical ventricular arrhythmia. CONCLUSIONS Thus, in arrhythmogenic right ventricular disease, sotalol proved to be highly effective in patients with inducible as well as noninducible ventricular tachycardia. Patients with inducible ventricular tachycardia not responding to sotalol are likely to not respond to other antiarrhythmic drugs and should be considered for nonpharmacological therapy without further drug testing. Amiodarone did not prove to be more effective than sotalol and may not be an alternative because of frequent side effects during long-term therapy, especially in young patients. Verapamil and beta-blockers were effective in a considerable number of patients with noninducible ventricular tachycardia and may be a therapeutic alternative in this subgroup. Class I agents appear to be rarely effective in the treatment of both inducible and noninducible ventricular tachycardia in arrhythmogenic right ventricular disease.
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Affiliation(s)
- T Wichter
- Hospital of the Westfälische Wilhelms-University, Department of Cardiology and Angiology, Münster, Germany
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García-Rubira JC, López V, Rojas J, García-Martínez JT, Cruz JM. Thrombolytic therapy soon after left heart catheterization--is it safe? Intensive Care Med 1991; 17:501-3. [PMID: 1797897 DOI: 10.1007/bf01690777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Puncture of a femoral artery for left heart catheterization is considered a relative contraindication for thrombolytic therapy for some days. We treated 9 patients with systemic thrombolysis who had undergone left heart catheterization in the previous hours. Four patients developed a large hematoma, but only 1 required transfusion. We suggest that thrombolytic therapy can be administered soon after left heart catheterization by the femoral approach, provided that continuous care can be taken over the puncture site.
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