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Te Riele ASJM, James CA, Calkins H, Tsatsopoulou A. Arrhythmogenic Right Ventricular Cardiomyopathy in Pediatric Patients: An Important but Underrecognized Clinical Entity. Front Pediatr 2021; 9:750916. [PMID: 34926342 PMCID: PMC8678603 DOI: 10.3389/fped.2021.750916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/08/2021] [Indexed: 12/30/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by fibrofatty infiltration of predominantly the right ventricular (RV) myocardium. Affected patients typically present as young adults with hemodynamically stable ventricular tachycardia, although pediatric cases are increasingly recognized. These young subjects often have a more severe phenotype with a high risk of sudden cardiac death (SCD) and progression toward heart failure. Diagnosis of ARVC is made by combining multiple sources of information as prescribed by the consensus-based Task Force Criteria. The description of Naxos disease, a fully penetrant autosomal recessive disorder that is associated with ARVC and a cutaneous phenotype of palmoplantar keratoderma and wooly hair facilitated the identification of the genetic cause of ARVC. At present, approximately 60% of patients are found to carry a pathogenic variant in one of five genes associated with the cardiac desmosome. The incomplete penetrance and variable expressivity of these variants however implies an important role for environmental factors, of which participation in endurance exercise is a strong risk factor. Since there currently is no definite cure for ARVC, disease management is directed toward symptom reduction, delay of disease progression, and prevention of SCD. This clinically focused review describes the spectrum of ARVC among children and adolescents, the genetic architecture underlying this disease, the cardio-cutaneous syndromes that led to its identification, and current diagnostic and therapeutic strategies in pediatric ARVC subjects.
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Affiliation(s)
- Anneline S J M Te Riele
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Adalena Tsatsopoulou
- Unit of Inherited and Rare Cardiovascular Diseases, Onassis Cardiac Surgery Center, Athens, Greece
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Protonotarios A, Elliott PM. Arrhythmogenic cardiomyopathies (ACs): diagnosis, risk stratification and management. Heart 2019; 105:1117-1128. [PMID: 30792239 DOI: 10.1136/heartjnl-2017-311160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Alexandros Protonotarios
- UCL Institute of Cardiovascular Science, University College London, London, UK.,Inherited Cardiovascular Disease Unit, Barts Heart Centre, London, UK
| | - Perry M Elliott
- UCL Institute of Cardiovascular Science, University College London, London, UK.,Inherited Cardiovascular Disease Unit, Barts Heart Centre, London, UK
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Bicsák Á, Jellen A, Tuppy H, Poeschl WP. Sudden death after major head and neck cancer surgery due to undetected arrhythmogenic right ventricle cardiomyopathy (ARVC). Oral Maxillofac Surg 2016; 20:431-434. [PMID: 27357590 DOI: 10.1007/s10006-016-0567-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 06/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral squamous cell carcinoma is the sixth most frequent malignancy in Austria. The incidence of arrhythmogenic right ventricle dysplasia (ARVC), an important cause of sudden cardiac death, is estimated at 1:5000 to 1:1000. CASE REPORT We present a case of a 75-year-old woman who underwent major oncologic surgery for T4aN0M0 maxillary squamous cell carcinoma and reconstruction with a scapular-latissimus dorsi microvascular flap. The patient died suddenly during her postoperative care. Autopsy revealed pericardiac tamponade due to rupture of the right ventricular wall. Histologic examination showed ARVC in a sample taken directly from the ruptured area. Cause of death was secondary arrhythmia originating from the ARVC. The arrhythmia had led to rupture of the right ventricular wall and sudden cardiac death. DISCUSSION As per our current knowledge, no cases of maxillary cancer and ARVC as co-morbidities have been reported in the literature. The patient had been given anti-arrhythmia treatment for previously detected atrial fibrillation, which could have been why the arrhythmia was not apparent on the electrocardiogram. Thus, although the appropriate preoperative diagnostics were performed according to current oncologic and anesthesiology guidelines, the potentially lethal cardiac condition of the patient could not be detected.
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Affiliation(s)
- Ákos Bicsák
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria.
| | - Alice Jellen
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria
| | - Herwig Tuppy
- Department of Pathology, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, 4600, Austria
| | - Wolfgang Paul Poeschl
- Department of Oral and Maxillofacial Surgery, Klinikum Wels-Grieskirchen, 42 Grieskirchnerstrasse, Wels, Austria
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Tong LJ, Flach EJ, Sheppard MN, Pocknell A, Banerjee AA, Boswood A, Bouts T, Routh A, Feltrer Y. Fatal arrhythmogenic right ventricular cardiomyopathy in 2 related subadult chimpanzees (Pan troglodytes). Vet Pathol 2013; 51:858-67. [PMID: 23988399 DOI: 10.1177/0300985813501333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cardiovascular disease is increasingly recognized as an important cause of morbidity and mortality in captive chimpanzees (Pan troglodytes). This report records 2 cases of sudden cardiac death in closely related subadult captive chimpanzees with marked replacement fibrosis and adipocyte infiltration of the myocardium, which resemble specific atypical forms of the familial human disease arrhythmogenic right ventricular cardiomyopathy. Changes were consistent with left-dominant and biventricular subtypes, which are both phenotypic variants found within human families with familial arrhythmogenic right ventricular cardiomyopathy. Previously reported fibrosing cardiomyopathies in chimpanzees were characterized by nonspecific interstitial fibrosis, in contrast to the replacement fibrofatty infiltration with predilection for the outer myocardium seen in these 2 cases. To the authors' knowledge, this case report is the first to describe cardiomyopathy resembling arrhythmogenic right ventricular cardiomyopathy in nonhuman primates and the first to describe left-dominant arrhythmogenic cardiomyopathy-type lesions in an animal.
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Affiliation(s)
- L J Tong
- Zoological Society of London, Veterinary Department, London Zoo, Regents Park, London, UK Veterinary Pathology Diagnostic Services, Faculty of Veterinary Science, Sydney University, Australia
| | - E J Flach
- Zoological Society of London, Veterinary Department, London Zoo, Regents Park, London, UK
| | - M N Sheppard
- Cardiac Pathology Unit, Imperial College, London, UK
| | - A Pocknell
- Zoological Society of London, Veterinary Department, London Zoo, Regents Park, London, UK Finn Pathologists, One Eyed Lane, Weybread, Norfolk, UK
| | - A A Banerjee
- Royal Veterinary College, University of London, Hertfordshire, UK
| | - A Boswood
- Royal Veterinary College, University of London, Hertfordshire, UK
| | - T Bouts
- Whipsnade Zoo, Dunstable, Bedfordshire, UK Al Wabra Wildlife Preservation, Al Shahaniya, Qatar
| | - A Routh
- Zoological Society of London, Veterinary Department, London Zoo, Regents Park, London, UK Durrell Wildlife Conservation Trust, Jersey, Channel Islands
| | - Y Feltrer
- Zoological Society of London, Veterinary Department, London Zoo, Regents Park, London, UK
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Francés RJ. Arrhythmogenic right ventricular dysplasia/cardiomyopathy. A review and update. Int J Cardiol 2005; 110:279-87. [PMID: 16099519 DOI: 10.1016/j.ijcard.2005.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 05/19/2005] [Accepted: 07/04/2005] [Indexed: 12/16/2022]
Abstract
The arrhythmogenic right ventricular dysplasia/cardiomyopathy is an important cause of sudden arrhythmic death, often exertional, in young individuals and athletes. Although the aetiology remains partially unknown, genetic abnormalities have been demonstrated. Reported prevalence is 1 in 5000 individuals but it is considered there are many non-diagnosed cases. The characteristic pathologic finding is the progressive fibro-fatty replacement of the right ventricular myocardium. The clinical manifestations vary from asymptomatic patients with an episode of sudden cardiac death as first symptom to chronically symptomatic patients with recurrent palpitations and/or right or biventricular failure. Approximately a third of the patients show the characteristic Epsilon wave in the 12-lead ECG which is a useful screening test. Signal-averaged ECG frequently demonstrates late potentials. The two-dimensional echocardiography, magnetic resonance imaging, computerized tomography and right ventricular cineangiography show morphologic abnormalities in the right ventricle. Therapy is directed to prevent and/or treat malignant ventricular tachyarrhythmias with medications, implantable cardioverter defibrillator and radiofrequency ablation in selected cases.
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Affiliation(s)
- Raúl J Francés
- Section of Cardiac Electrophysiology and Pacing, Sanatorio Centro, Rosario, Argentina.
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Abstract
Arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) is a cardiomyopathy characterized pathologically by fibrofatty replacement primarily of the RV and clinically by life-threatening ventricular arrhythmias in apparently healthy young people. The prevalence of the disease has been estimated at 1 in 5,000 individuals, although this estimate will likely increase as awareness of the condition increases among physicians. Arrhythmogenic RV cardiomyopathy is recognized as a cause of sudden death during athletic activity because of its association with ventricular arrhythmias that are provoked by exercise-induced catecholamine discharge. Diagnosis may be difficult because many of the electrocardiographic abnormalities mimic patterns seen in normal children, and the disease often involves only patchy areas of the RV. For this reason, international diagnostic criteria for ARVC were proposed by an expert consensus panel in 1996. Treatment is directed to preventing life-threatening cardiac arrhythmias with medications and the use of implantable defibrillators. This article will present in detail the etiology, clinical presentation, diagnosis and management of this condition.
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Affiliation(s)
- C Gemayel
- Hartford Hospital, Division of Cardiology, Hartford, Connecticut, USA
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Affiliation(s)
- G Thiene
- Department of Pathology, University of Padua Medical School, Via A. Gabelli, 61, 35121, Padua, Italy.
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Patel VV, Ferrari VA, Narula N, Wiegers SE, St John Sutton MG. Right ventricular dysplasia in an asymptomatic young man: an uncommon case with biventricular involvement and no known family history. J Am Soc Echocardiogr 2001; 14:317-20. [PMID: 11287899 DOI: 10.1067/mje.2001.111531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 33-year-old man had cardiomegaly on a routine x-ray examination. He was asymptomatic with no history of infarction, syncope, or palpitations. There was no family history of congenital heart disease or sudden death. Two-dimensional transthoracic echocardiography demonstrated marked enlargement of the right atrium and ventricle with severely depressed right and left ventricular function that was consistent with right ventricular dysplasia. The patient was treated with an angiotensin-converting enzyme inhibitor and did well for 6 months, but then developed symptomatic left-sided congestive heart failure. Short-term improvement was obtained with intravenous inotropic therapy, but he continued to have progressive symptoms of heart failure. Approximately 7 months after his initial presentation, the patient underwent orthotopic heart transplantation for intractable congestive heart failure. Pathologic examination of the explanted heart established the diagnosis of right ventricular dysplasia with left ventricular involvement. This is an uncommon presentation of right ventricular dysplasia with biventricular involvement and no known family history.
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Affiliation(s)
- V V Patel
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, Department of Medicine, School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, USA
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Calabrese F, Angelini A, Thiene G, Basso C, Nava A, Valente M. No detection of enteroviral genome in the myocardium of patients with arrhythmogenic right ventricular cardiomyopathy. J Clin Pathol 2000; 53:382-7. [PMID: 10889821 PMCID: PMC1731194 DOI: 10.1136/jcp.53.5.382] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS Despite the evidence of familial occurrence, chromosomal gene mapping, and apoptosis as a mechanism of myocyte death, the aetiopathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC) remains speculative. Because of the frequent histological finding of focal inflammatory infiltrates, the hypothesis of an infective myocarditis aetiology has been put forward. The aim of this investigation was to test this hypothesis. The presence of enteroviruses was investigated by a highly sensitive and specific molecular technique. METHODS Endomyocardial tissue samples from 20 patients with ARVC (11 male, nine female; mean age, 40 years; SD, 16) and 20 control subjects with other cardiac diseases were analysed using reverse transcription and nested polymerase chain reaction (PCR). Myocardial samples obtained from four patients with enteroviral myocarditis and coxsackie B3 virus infected cells were used as positive controls. RESULTS Endomyocardial biopsy was diagnostic for ARVC in all patients: myocardial atrophy was seen, with less than 45% residual myocytes. Foci of inflammatory infiltrates were seen in four biopsies, and the cells were identified by immunohistochemistry as mainly T cells. All samples, from both patients with ARVC and subjects with other cardiac diseases, were negative for enteroviral genome by means of nested PCR. CONCLUSION These findings indicate that enteroviruses are not involved in the aetio-pathogenesis of ARVC. Future molecular studies should investigate the presence of other infective agents, as well as their possible role in triggering apoptosis.
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Affiliation(s)
- F Calabrese
- Institute of Pathological Anatomy, University of Padua, Padova, Italy
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d’Amati G, Fiore F, Giordano C, De Biase L, Laurenti A, Gallo P. Pathologic Evidence of Arrhythmogenic Cardiomyopathy and Myocarditis in Two Siblings. Cardiovasc Pathol 1998; 7:39-46. [DOI: 10.1016/s1054-8807(97)00063-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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