Arrhythmic outcome of arrhythmogenic right ventricular cardiomyopathy patients without implantable defibrillators

The pivotal role of compelling high-risk electrocardiographic markers in prediction of ventricular arrhythmic risk in arrhythmogenic right ventricular cardiomyopathy: A systematic review and meta-analysis

INTRODUCTION

Several investigations have shown that existing risk stratification processes remain insufficient for stratifying sudden cardiac death risk in arrhythmogenic right ventricular cardiomyopathy (ARVC). Multiple auxiliary parameters are investigated to offer a more precise prognostic model. Our aim was to assess the association between several ECG markers (epsilon waves, prolonged terminal activation duration (TAD) of QRS, fragmented QRS (fQRS), late potentials on signal-averaged electrocardiogram (SA-ECG), T-wave inversion (TWI) in right precordial leads, and extension of TWI in inferior leads) with the risk of developing poor outcomes in ARVC.

METHODS

A systematic literature search from several databases was conducted until September 9th, 2023. Studies were eligible if it investigated the relationship between the ECG markers with the risk of developing ventricular arrhythmic events.

RESULTS

This meta-analysis encompassed 25 studies with a total of 3767 participants. Our study disclosed that epsilon waves, prolonged TAD of QRS, fQRS, late potentials on SA-ECG, TWI in right precordial leads, and extension of TWI in inferior leads were associated with the incremental risk of ventricular arrhythmias, implantable cardioverter-defibrillator shock, and sudden cardiac death, with the risk ratios ranging from 1.46 to 2.11. In addition, diagnostic test accuracy meta-analysis stipulated that the extension of TWI in inferior leads had the uppermost overall area under curve (AUC) value amidst other ECG markers apropos of our outcomes of interest.

CONCLUSION

A multivariable risk assessment strategy based on the previously stated ECG markers potentially enhances the current risk stratification models in ARVC patients, especially extension of TWI in inferior leads.

Prevention of Sudden Death and Management of Ventricular Arrhythmias in Arrhythmogenic Cardiomyopathy

Arrhythmogenic cardiomyopathy is an umbrella term for a group of inherited diseases of the cardiac muscle characterized by progressive fibro-fatty replacement of the myocardium. As suggested by the name, the disease confers electrical instability to the heart and increases the risk of the development of life-threatening arrhythmias, representing one of the leading causes of sudden cardiac death (SCD), especially in young athletes. In this review, the authors review the current knowledge of the disease, highlighting the state-of-the-art approaches to the prevention of the occurrence of SCD.

Natural History of Arrhythmogenic Cardiomyopathy

Arrhythmogenic cardiomyopathy (AC) is a heart muscle disease characterized by a scarred ventricular myocardium with a distinctive propensity to ventricular arrhythmias (VAs) and sudden cardiac death, especially in young athletes. Arrhythmogenic right ventricular cardiomyopathy (ARVC) represents the best characterized variant of AC, with a peculiar genetic background, established diagnostic criteria and management guidelines; however, the identification of nongenetic causes of the disease, combined with the common demonstration of biventricular and left-dominant forms, has led to coin the term of “arrhythmogenic cardiomyopathy”, to better define the broad spectrum of the disease phenotypic expressions. The genetic basis of AC are pathogenic mutations in genes encoding the cardiac desmosomes, but also non-desmosomal and nongenetic variants were reported in patients with AC, some of which showing overlapping phenotypes with other non-ischemic diseases. The natural history of AC is characterized by VAs and progressive deterioration of cardiac performance. Different phases of the disease are recognized, each characterized by pathological and clinical features. Arrhythmic manifestations are age-related: Ventricular fibrillation and SCD are more frequent in young people, while sustained ventricular tachycardia is more common in the elderly, depending on the different nature of the myocardial lesions. This review aims to address the genetic basis, the clinical course and the phenotypic variants of AC.

Left Ventricular Involvement in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Predicts Adverse Clinical Outcomes: A Cardiovascular Magnetic Resonance Feature Tracking Study

The aim of this study was to investigate left ventricular (LV) global myocardial strain and LV involvement characteristics in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and to evaluate their predictive value of adverse cardiac events. Sixty consecutive ARVD/C patients with a definite diagnosis of ARVD/C who underwent CMR examination and thirty-four healthy controls were enrolled retrospectively. The CMR images were analyzed for LV myocardial strain and the presence of LV involvement. The endpoint was defined as a composite of sustained ventricular tachycardia or fibrillation, cardiac death, resuscitated cardiac arrest, heart transplantation, and appropriate implantable cardioverter-defibrillator shock. LV global longitudinal (GLS), circumferential (GCS), and radial strain (GRS) were significantly impaired in ARVC/D patients compared to healthy controls (GLS: −13.89 ± 3.26% vs. −16.68 ± 2.74%, GCS: −15.65 ± 3.40% vs. −19.20 ± 2.23%, GRS: 34.57 ± 11.98% vs. 49.92 ± 12.59%; P < 0.001 for all). Even in ARVC/D patients with preserved LVEF, LV GLS, GCS and GRS were also significantly reduced than in controls. During a mean follow-up period of 4.10 ± 1.77 years, the endpoint was reached in 17 patients. LV GLS >−12.65% (HR, 3.58; 95%CI, 1.14 to 11.25; p = 0.029) and history of syncope (HR, 4.99; 95%CI, 1.88 to 13.24; p = 0.001) were the only independent predictors of cardiac outcomes. The LV myocardial deformation derived from FT CMR was significantly impaired in ARVD/C patients, and this alteration can occur before the impairment of LVEF. LV GLS >−12.65% and history of syncope were the only independent prognostic markers of adverse cardiac outcomes.

Ventricular Arrhythmias

Ventricular tachycardia is commonly seen in medical practice. It may be completely benign or portend high risk for sudden cardiac death. Therefore, it is important that clinicians be familiar with and able to promptly recognize and manage ventricular tachycardia when confronted with it clinically. In many cases, curative therapy for a given ventricular arrhythmia may be provided after a thorough understanding of the underlying substrate and mechanism. In this article, the authors broadly review the current classification of the different ventricular arrhythmias encountered in medical practice, provide brief background regarding the different mechanisms, and discuss practical diagnosis and management scenarios.

Risk stratification for ventricular arrhythmias and sudden cardiac death in arrhythmogenic right ventricular cardiomyopathy: an update

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically determined disease associated with a significant risk of ventricular arrhythmias and sudden cardiac death (SCD). Implantable cardioverter-defibrillators (ICDs) are the only effective preventive measure. Over the past 30 years, much effort has been invested in determining predictors of adverse arrhythmic events in these patients. Areas covered: This review summarizes available evidence on risk stratification for ARVC, with an emphasis on recent research findings. While efforts are ongoing to define risk predictors, several recent publications have synthetized and built on this knowledge base. A recently published meta-analysis has clarified the strongest predictors of ventricular arrhythmias in ARVC, which vary depending on the population included. Three management guidelines/expert consensus documents have integrated the previously described risk predictors into proposed ICD recommendations. Furthermore, a risk prediction model has allowed the integration of multiple risk factors to provide individualized risk prediction and to inform shared-decision making regarding ICD implantation. Expert opinion: Over the past few years, knowledge of risk prediction in ARVC has been consolidated and refined. Further improvements may be made by the considering additional predictors such as exercise and by targeting more specific surrogate outcomes for SCD.

2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy

Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.

Arrhythmogenic Right Ventricular Cardiomyopathy: Progress Toward Personalized Management

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart disease characterized by fibrofatty replacement of the ventricular myocardium, a high risk of ventricular arrhythmias, and progressive ventricular dysfunction. The clinical course is highly variable, and optimal approaches to management remain undefined. ARVC is associated with pathogenic variants in genes encoding the cardiac desmosome. Genetic testing facilitates identification of at-risk family members, but penetrance of ARVC in pathogenic variant carriers is difficult to predict. Participation in endurance exercise is a known key risk factor. However, there remains significant uncertainty about which family member will develop disease and how best to approach longitudinal screening. Our clinically focused review describes how new insights gained from natural history studies, improved understanding of pathogenic mechanisms, and appreciation of genetic and environmental modifiers have set the stage for developing personalized approaches to managing both ARVC patients and their at-risk family members.