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Amin A, Bailey N, Warren A, Reddy B. Non-sustained Ventricular Tachycardia as a Presentation of Arrhythmogenic Right Ventricular Cardiomyopathy. Cureus 2023; 15:e38620. [PMID: 37284396 PMCID: PMC10240442 DOI: 10.7759/cureus.38620] [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] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare disorder with familial (autosomal dominant) predisposition and can be challenging to diagnose. Non-sustained ventricular tachycardia (NSVT) is a relatively uncommon and short-lived arrhythmia when seen in the general, healthy population. NSVT with a left bundle branch block morphology is usually idiopathic but may also be seen in ARVC. It can also be associated with poorer prognosis and increased mortality. Repetitive monomorphic ventricular ectopic beats may suggest ARVC, but could also be idiopathic. Timely diagnosis is vital due to the unpredictability and progressive nature of ARVC. We present a case of a 40-year-old Caucasian female with heart palpitations and NSVT found on an outpatient Holter monitor, and later found to have clinical and radiological features consistent with ARVC.
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Affiliation(s)
- Adina Amin
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Nadian Bailey
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Amanda Warren
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Bharath Reddy
- Cardiac Electrophysiology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
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2
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Authors' Reply. J Am Soc Echocardiogr 2017; 30:1043-1045. [DOI: 10.1016/j.echo.2017.07.012] [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: 07/20/2017] [Indexed: 11/18/2022]
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3
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Femia G, Sy RW, Puranik R. Systematic review: Impact of the new task force criteria in the diagnosis of arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2017; 241:311-317. [DOI: 10.1016/j.ijcard.2017.03.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 03/13/2017] [Indexed: 11/26/2022]
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Abstract
Genetic variants contribute to several steps during heart failure pathophysiology. The mechanisms include frequent polymorphisms that increase the susceptibility to heart failure in the general population and rare variants as causes of an underlying cardiomyopathy. In this review, we highlight recent discoveries made by genetic approaches and provide an outlook onto the role of epigenetic modifiers of heart failure.
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Choudhary N, Tompkins C, Polonsky B, McNitt S, Calkins H, Mark Estes NA, Krahn AD, Link MS, Marcus FI, Towbin JA, Zareba W. Clinical Presentation and Outcomes by Sex in Arrhythmogenic Right Ventricular Cardiomyopathy: Findings from the North American ARVC Registry. J Cardiovasc Electrophysiol 2016; 27:555-62. [PMID: 26840461 DOI: 10.1111/jce.12947] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sex differences in clinical presentation and outcomes of hereditary arrhythmias are commonly reported. We aimed to compare clinical presentation and outcomes in men and women with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in the North American ARVC Registry. METHODS A total of 125 ARVC probands (55 females, mean age 38 ± 12; 70 males, mean age 41 ± 15) diagnosed, as either "affected" or "borderline" were included. Baseline clinical characteristics and time-dependent outcomes including syncope, ventricular tachycardia (VT), fast VT (>240 bpm), ventricular fibrillation (VF), and death were compared between males and females. RESULTS The percentage of ARVC subjects diagnosed as "affected" (84% vs. 89%; P = 0.424) or "borderline" (16% vs. 11%; P = 0.424) was similar between females and males. Among the baseline characteristics, inverted T-waves in V2 trended to be more common in women (P = 0.09), whereas abnormal signal-averaged ECGs (SAECGs; P < 0.001) and inducible VT/VF (P = 0.026) were more frequent in men. During a mean follow-up of 37 ± 20 months, the probability of ICD-recorded VT/VF or death was not significantly different between men and women (P = 0.456). However, there was a trend toward lower risk of fast VT/VF or death in women compared to men (hazard ratio 0.41, 95% CI 0.151-1.113, P = 0.066). Abnormal SAECG and evidence of intramyocardial fat by cardiac MRI was associated with adverse outcomes in men (P = 0.006 and 0.02 respectively). CONCLUSION In the North American ARVC Registry, we found similar frequency of "affected" and "borderline" subjects between men and women. Sex-related differences were observed in baseline ECG, SAECG, Holter-recorded ventricular arrhythmias, and VT inducibility. Men showed a trend toward greater risk of fast VT than women.
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Affiliation(s)
- Naila Choudhary
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Christine Tompkins
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Bronislava Polonsky
- Division of Cardiology, University of Rochester School of Medicine, Rochester, New York, USA
| | - Scott McNitt
- Division of Cardiology, University of Rochester School of Medicine, Rochester, New York, USA
| | - Hugh Calkins
- Division of Cardiology, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N A Mark Estes
- Division of Cardiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark S Link
- Division of Cardiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Frank I Marcus
- Division of Cardiology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jeffrey A Towbin
- Division of Pediatrics, University of Tennesse, Memphis, Tennessee, USA
| | - Wojciech Zareba
- Division of Cardiology, University of Rochester School of Medicine, Rochester, New York, USA
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Ruwald AC, Marcus F, Estes NAM, Link M, McNitt S, Polonsky B, Calkins H, Towbin JA, Moss AJ, Zareba W. Association of competitive and recreational sport participation with cardiac events in patients with arrhythmogenic right ventricular cardiomyopathy: results from the North American multidisciplinary study of arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2015; 36:1735-43. [PMID: 25896080 DOI: 10.1093/eurheartj/ehv110] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 03/17/2015] [Indexed: 12/26/2022] Open
Abstract
AIMS It has been proposed that competitive sport increases the risk of ventricular tachyarrhythmias (VTA) and death in patients with arrhythmogenic right-ventricular cardiomyopathy (ARVC). However, it is unknown whether this only applies to competitive sport or if recreational sports activity also increases the risk of VTA/death. METHODS AND RESULTS Probands diagnosed with ARVC according to the 2010 task force criteria for ARVC (n = 108) were included in the current analysis. At the time of enrolment, study participants were questioned about exercise level prior to and after ARVC diagnosis, within three categories of sports participation: competitive (n = 41), recreational (n = 48), and inactive (n = 19). Competitive sport was associated with a significantly higher risk of VTA/death when compared with both recreational sport [HR = 1.99 (1.21-3.28), P = 0.007] and inactive patients [HR = 2.05 (1.07-3.91), P = 0.030]. No increased risk of VTA/death was associated with recreational sport when compared with patients who were inactive [HR = 1.03 (0.54-1.97), P = 0.930]. Symptoms developed at an earlier age in patients who participated in competitive sport (30 ± 12 years), when compared with patients who participated in recreational sport (38 ± 17 years) (P = 0.015) and inactive patients (41 ± 11 years) (P = 0.002). No difference in age at first symptom was seen between patients who participated in recreational sport and inactive patients (P = 0.651). CONCLUSION Competitive sport was associated with a two-fold increased risk of VTA/death, and earlier presentation of symptoms, when compared with inactive patients, and to patients who participated in recreational sport. When compared with inactive patients, recreational sport was not associated with earlier onset of symptoms or increased risk of VTA/death. ClinicalTrials.gov Identifier: NCT00024505.
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Affiliation(s)
- Anne-Christine Ruwald
- Heart Research Follow-up Program, University of Rochester Medical Center, 265 Crittenden Blvd. CU 420653, Rochester, NY 14642, USA Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | - Frank Marcus
- University of Arizona Health Science Center, Tucson, AZ, USA
| | - N A Mark Estes
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, MA, USA
| | - Mark Link
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, MA, USA
| | - Scott McNitt
- Heart Research Follow-up Program, University of Rochester Medical Center, 265 Crittenden Blvd. CU 420653, Rochester, NY 14642, USA
| | - Bronislava Polonsky
- Heart Research Follow-up Program, University of Rochester Medical Center, 265 Crittenden Blvd. CU 420653, Rochester, NY 14642, USA
| | | | - Jeffrey A Towbin
- Pediatric Cardiology Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Arthur J Moss
- Heart Research Follow-up Program, University of Rochester Medical Center, 265 Crittenden Blvd. CU 420653, Rochester, NY 14642, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, University of Rochester Medical Center, 265 Crittenden Blvd. CU 420653, Rochester, NY 14642, USA
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Link MS, Laidlaw D, Polonsky B, Zareba W, McNitt S, Gear K, Marcus F, Estes NAM. Ventricular arrhythmias in the North American multidisciplinary study of ARVC: predictors, characteristics, and treatment. J Am Coll Cardiol 2014; 64:119-25. [PMID: 25011714 DOI: 10.1016/j.jacc.2014.04.035] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 04/21/2014] [Accepted: 04/21/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with sudden cardiac death. However, the selection of patients for implanted cardioverter-defibrillators (ICDs), as well as programming of the ICD, is unclear. OBJECTIVES The objective of this study was to identify predictors, characteristics, and treatment of ventricular arrhythmias in patients with ARVC. METHODS The Multidisciplinary Study of Right Ventricular Cardiomyopathy established the North American ARVC Registry and enrolled patients with a diagnosis of ARVC. Patients were followed prospectively. RESULTS Of 137 patients enrolled, 108 received ICDs. Forty-eight patients had 502 sustained episodes of ventricular arrhythmias, including 489 that were monomorphic and 13 that were polymorphic. In the patients with ICDs, independent predictors of ventricular arrhythmias in follow-up included spontaneous sustained ventricular arrhythmias before ICD implantation and T-wave inversions inferiorly. The only independent predictor for life-threatening arrhythmias, defined as sustained ventricular tachycardia (VT) ≥240 beats/min or ventricular fibrillation, was a younger age at enrollment. Anti-tachycardia pacing (ATP), independent of the cycle length of the VT, was successful in terminating 92% of VT episodes. CONCLUSIONS In the North American ARVC Registry, the majority of ventricular arrhythmias in follow-up are monomorphic. Risk factors for ventricular arrhythmias were spontaneous ventricular arrhythmias before enrollment and a younger age at ICD implantation. ATP is highly successful in terminating VT, and all ICDs should be programmed for ATP, even for rapid VT.
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MESH Headings
- Adult
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmogenic Right Ventricular Dysplasia/complications
- Arrhythmogenic Right Ventricular Dysplasia/physiopathology
- Arrhythmogenic Right Ventricular Dysplasia/therapy
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Echocardiography
- Electrocardiography, Ambulatory
- Female
- Follow-Up Studies
- Heart Rate
- Humans
- Incidence
- Male
- North America/epidemiology
- Prognosis
- Registries
- Survival Rate/trends
- Tachycardia, Ventricular/complications
- Tachycardia, Ventricular/epidemiology
- Tachycardia, Ventricular/therapy
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Affiliation(s)
- Mark S Link
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts.
| | - Douglas Laidlaw
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
| | - Bronislava Polonsky
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Rochester, New York
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Rochester, New York
| | - Scott McNitt
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Rochester, New York
| | - Kathleen Gear
- Section of Cardiology, University of Arizona, Tucson, Arizona
| | - Frank Marcus
- Section of Cardiology, University of Arizona, Tucson, Arizona
| | - N A Mark Estes
- Tufts Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts
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Sadjadieh G, Jabbari R, Risgaard B, Olesen MS, Haunsø S, Tfelt-Hansen J, Winkel BG. Nationwide (Denmark) study of symptoms preceding sudden death due to arrhythmogenic right ventricular cardiomyopathy. Am J Cardiol 2014; 113:1250-4. [PMID: 24513468 DOI: 10.1016/j.amjcard.2013.12.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/08/2013] [Accepted: 12/08/2013] [Indexed: 01/02/2023]
Abstract
In this study, we investigated medical history and symptoms before death in all subjects aged 1 to 35 years who died a sudden cardiac death (SCD) from arrhythmogenic right ventricular cardiomyopathy (ARVC) in Denmark in the years 2000 to 2006. All deaths (n=6,629) in subjects aged 1 to 35 years in Denmark in the period 2000 to 2006 were included. A total of 16 cases of SCD due to ARVC were identified based on histopathologic examination. Information on medical history was retrieved from The National Patient Registry, general practitioners, and hospitals. Symptoms before death were compared with 2 control groups in the same age group and time interval: one consisting of subjects who died in traffic accidents (n=74) and the other consisting of patients who died a SCD due to coronary artery disease (CAD; n=34). In the case group, 8 of the 16 patients with ARVC experienced antecedent cardiac symptoms and 7 of them sought medical attention. None were diagnosed with ARVC before death. Only 1 patient in the healthy control group and 31 of the 39 patients with CAD experienced cardiac symptoms before death. A total of 6 patients of the 16 with ARVC died during strenuous physical activity and 4 of the deaths were sports-related SCDs. In conclusion, antecedent cardiac symptoms before SCD in the young were seen in 1/2 of the patients who died because of ARVC, and this is significantly higher than in the healthy control group. When considering the ARVC and CAD groups collectively, antecedent cardiac symptoms are seen in the majority.
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Affiliation(s)
- Golnaz Sadjadieh
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Reza Jabbari
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Bjarke Risgaard
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten S Olesen
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stig Haunsø
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Medicine and Surgery, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Bo G Winkel
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark; Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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9
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Elmaghawry M, Alhashemi M, Zorzi A, Yacoub MH. A global perspective of arrhythmogenic right ventricular cardiomyopathy. Glob Cardiol Sci Pract 2013; 2012:81-92. [PMID: 24688993 PMCID: PMC3963715 DOI: 10.5339/gcsp.2012.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 11/12/2012] [Indexed: 01/19/2023] Open
Abstract
Abstract: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive inherited heart disease characterized by ventricular arrhythmias and sudden cardiac death especially in the young. ARVC has been traditionally associated with the Mediterranean basin, as many seminal studies on the disease have originated from research groups of this region. Today, however, numerous ARVC registries from all over the world emphasize that the disease does not have a specific racial or geographical predilection. This work provides a review on the global perspective of ARVC.
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Affiliation(s)
| | | | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Magdi H Yacoub
- Harefield Heart Science Centre, National Heart and Lung Institute, Imperial College, London, UK
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Romero J, Mejia-Lopez E, Manrique C, Lucariello R. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC/D): A Systematic Literature Review. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2013; 7:97-114. [PMID: 23761986 PMCID: PMC3667685 DOI: 10.4137/cmc.s10940] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic form of cardiomyopathy (CM) usually transmitted with an autosomal dominant pattern. It primary affects the right ventricle (RV), but may involve the left ventricle (LV) and culminate in biventricular heart failure (HF), life threatening ventricular arrhythmias and sudden cardiac death (SCD). It accounts for 11%-22% of cases of SCD in the young athlete population. Pathologically is characterized by myocardial atrophy, fibrofatty replacement and chamber dilation. Diagnosis is often difficult due to the nonspecific nature of the disease and the broad spectrum of phenotypic variations. Therefore consensus diagnostic criteria have been developed and combined electrocardiography, echocardiography, cardiac magnetic resonance imaging (CMRI) and myocardial biopsy. Early detection, family screening and risk stratification are the cornerstones in the diagnostic evaluation. Implantable cardioverter-defibrillator (ICD) implantation, ablative procedures and heart transplantation are currently the main therapeutic options.
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Affiliation(s)
- Jorge Romero
- Division of Cardiology, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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11
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Right ventricular morphology on catheter angiography: Variations and its implications for the diagnosis of arrhythmogenic right ventricular cardiomyopathy. Heart Lung Circ 2012; 21:700-5. [DOI: 10.1016/j.hlc.2012.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 06/03/2012] [Accepted: 06/14/2012] [Indexed: 11/22/2022]
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Paul M, Wichter T, Fabritz L, Waltenberger J, Schulze-Bahr E, Kirchhof P. Arrhythmogenic right ventricular cardiomyopathy: an update on pathophysiology, genetics, diagnosis, and risk stratification. Herzschrittmacherther Elektrophysiol 2012; 23:186-95. [PMID: 23011601 DOI: 10.1007/s00399-012-0233-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/20/2012] [Indexed: 12/17/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy accounting for life-threatening ventricular tachyarrhythmias and sudden death in young individuals and athletes. Over the past years, mutations in desmosomal genes have been identified as disease-causative. However, genetic heterogeneity and variable phenotypic expression alongside with diverse disease progression still render the evaluation of its prognostic implication difficult. ARVC was initially entered into the canon of cardiomyopathies of the World Health Organization in 1995, and international efforts have resulted in the 2010 modified diagnostic criteria for ARVC. Despite all additional insights into pathophysiology, clinical management, and modern risk stratification, under-/misdiagnosing of ARVC remains a problem and hampers reliable statements on the incidence, prevalence, and natural course of the disease.This review provides a comprehensive overview of the current literature on the pathogenesis, diagnosis, treatment, and prognosis of ARVC and sheds some light on potential new developments in these areas.
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Affiliation(s)
- M Paul
- Division of Cardiology, Department of Cardiovascular Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1 (Gebäude A1), 48149, Münster, Germany.
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13
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Thiene G. Arrhythmogenic cardiomyopathy: from autopsy to genes and transgenic mice (SCVP Achievement Award Lecture, San Antonio, TX, February 27, 2011). Cardiovasc Pathol 2012; 21:229-39. [DOI: 10.1016/j.carpath.2011.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 09/30/2011] [Indexed: 10/15/2022] Open
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Indik JH, Dallas WJ, Gear K, Tandri H, Bluemke DA, Moukabary T, Marcus FI. Right ventricular volume analysis by angiography in right ventricular cardiomyopathy. Int J Cardiovasc Imaging 2012; 28:995-1001. [PMID: 21706146 PMCID: PMC3488440 DOI: 10.1007/s10554-011-9915-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 06/15/2011] [Indexed: 10/18/2022]
Abstract
Imaging of the right ventricle (RV) for the diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is commonly performed by echocardiography or magnetic resonance imaging (MRI). Angiography is an alternative modality, particularly when MRI cannot be performed. We hypothesized that RV volume and ejection fraction computed by angiography would correlate with these quantities as computed by MRI. RV volumes and ejection fraction were computed for subjects enrolled in the North American ARVC/D Registry, with both RV angiography and MRI studies. Angiography was performed in the 30° right anterior oblique (RAO) and 60° left anterior oblique (LAO) views. Angiographic volumes were computed by RAO view and two-view (RAO and LAO) formulae. 17 subjects were analyzed (11 men and 6 women), with 15 subjects classified as affected, and two as unaffected by modified Task Force criteria. The correlation coefficient of MRI to the two-view angiographic analysis was 0.72 (P = 0.003) for end-diastolic volume and 0.68 (P = 0.005) for ejection fraction. Angiographically derived volumes were larger than MRI derived volume (P = 0.009) and with the slope in a linear relationship equal to 0.8 for end diastolic volume, and 0.9 for RV ejection fraction (P < 0.001), computed by the two view formula. End-diastolic volumes and ejection fractions of the RV obtained by dual view angiography correlate with these quantities by MRI. RV end-diastolic volumes are larger by RV angiography in comparison with MRI.
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Affiliation(s)
- Julia H Indik
- Sarver Heart Center, The University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ 85724-5037, USA.
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15
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Safety of Endomyocardial Biopsy in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Cardiovasc Interv 2011; 4:1142-8. [DOI: 10.1016/j.jcin.2011.06.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/20/2011] [Accepted: 06/23/2011] [Indexed: 11/23/2022]
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Behera SK, Pattnaik T, Luke A. Practical Recommendations and Perspectives on Cardiac Screening for Healthy Pediatric Athletes. Curr Sports Med Rep 2011; 10:90-8. [DOI: 10.1249/jsr.0b013e3182141c1e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Huttin O, Mandry D, Brembilla-Perrot B. Arrhythmogenic right ventricular cardiomyopathy: Magnetic resonance imaging does not detect early stages of the disease. Int J Cardiol 2011; 147:167-9. [DOI: 10.1016/j.ijcard.2010.10.003] [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: 07/27/2010] [Accepted: 10/02/2010] [Indexed: 11/26/2022]
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Kamath GS, Zareba W, Delaney J, Koneru JN, McKenna W, Gear K, Polonsky S, Sherrill D, Bluemke D, Marcus F, Steinberg JS. Value of the signal-averaged electrocardiogram in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Heart Rhythm 2010; 8:256-62. [PMID: 20933608 DOI: 10.1016/j.hrthm.2010.10.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 10/03/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited disease that causes structural and functional abnormalities of the right ventricle (RV). The presence of late potentials as assessed by the signal-averaged electrocardiogram (SAECG) is a minor task force criterion. OBJECTIVE The purpose of this study was to examine the diagnostic and clinical value of the SAECG in a large population of genotyped ARVC/D probands. METHODS We compared the SAECGs of 87 ARVC/D probands (age 37 ± 13 years, 47 males) diagnosed as affected or borderline by task force criteria without using the SAECG criterion with 103 control subjects. The association of SAECG abnormalities was also correlated with clinical presentation, surface ECG, ventricular tachycardia (VT) inducibility at electrophysiologic testing, implantable cardioverter-defibrillator therapy for VT, and RV abnormalities as assessed by cardiac magnetic resonance imaging (cMRI). RESULTS Compared with controls, all three components of the SAECG were highly associated with the diagnosis of ARVC/D (P <.001). They include the filtered QRS duration (97.8 ± 8.7 ms vs 119.6 ± 23.8 ms), low-amplitude signal (24.4 ± 9.2 ms vs 46.2 ± 23.7 ms), and root mean square amplitude of the last 40 ms of the QRS (50.4 ± 26.9 μV vs 27.9 ± 36.3 μV). The sensitivity of using SAECG for diagnosis of ARVC/D was increased from 47% using the established 2 of 3 criteria (i.e., late potentials) to 69% by using a modified criterion of any 1 of 3 criteria, while maintaining a high specificity of 95%. Abnormal SAECG as defined by this modified criterion was associated with a dilated RV volume and decreased RV ejection fraction detected by cMRI (P <.05). SAECG abnormalities did not vary with clinical presentation or reliably predict spontaneous or inducible VT and had limited correlation with ECG findings. CONCLUSION Using 1 of 3 SAECG criteria contributed to increased sensitivity and specificity for the diagnosis of ARVC/D. This finding is incorporated in the recent modification of the task force criteria.
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Affiliation(s)
- Ganesh S Kamath
- Al-Sabah Arrhythmia Institute, St. Luke's and Roosevelt Hospitals, and Columbia University College of Physicians & Surgeons, New York, New York 10025, USA
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Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) originally emerged as a pathologic diagnosis based on distinctive autopsy findings in cases of premature sudden death. Subsequently these characteristic pathologic features were associated with ventricular tachycardia of right ventricular origin and syncope. ARVC is a rare condition and our understanding of the disorder has been confounded by multiple small, highly selected series. Driven by both family studies and improved non-invasive imaging tools the clinical diagnosis of ARVC has broadened, in some instances extending far beyond the original limits of the syndrome. In recent years false-positive diagnoses have increased, thus stimulating investigators to move toward more rigorous clinical criteria. Despite the efforts of a Task Force to establish a baseline for subsequent empiric testing, these criteria have often inadvertently been used as a definitive diagnostic tool in the absence of prospective data. Recent genetic studies have revealed substantial etiologic heterogeneity, and ARVC is emerging as a syndrome consisting of multiple discrete disease entities, in part explaining the tremendous variation in clinical features and natural history seen in prior reports.
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Affiliation(s)
- Patrick T Ellinor
- Cardiovascular Research Center and Cardiology Division, Massachusetts General Hospital, Charlestown, Boston, MA, USA
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Comparison between electroanatomic and pathologic findings in a patient with arrhythmogenic right ventricular cardiomyopathy/dysplasia treated with orthotopic cardiac transplant. Heart Rhythm 2010; 7:828-31. [DOI: 10.1016/j.hrthm.2010.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 01/12/2010] [Indexed: 11/23/2022]
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21
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Xu T, Yang Z, Vatta M, Rampazzo A, Beffagna G, Pillichou K, Scherer SE, Saffitz J, Kravitz J, Zareba W, Danieli GA, Lorenzon A, Nava A, Bauce B, Thiene G, Basso C, Calkins H, Gear K, Marcus F, Towbin JA. Compound and digenic heterozygosity contributes to arrhythmogenic right ventricular cardiomyopathy. J Am Coll Cardiol 2010; 55:587-97. [PMID: 20152563 PMCID: PMC2852685 DOI: 10.1016/j.jacc.2009.11.020] [Citation(s) in RCA: 249] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Revised: 10/13/2009] [Accepted: 11/10/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this study was to define the genetic basis of arrhythmogenic right ventricular cardiomyopathy (ARVC). BACKGROUND Arrhythmogenic right ventricular cardiomyopathy, characterized by right ventricular fibrofatty replacement and arrhythmias, causes sudden death. Autosomal dominant inheritance, reduced penetrance, and 7 desmosome-encoding causative genes are known. The basis of low penetrance is poorly understood. METHODS Arrhythmogenic right ventricular cardiomyopathy probands and family members were enrolled, blood was obtained, lymphoblastoid cell lines were immortalized, deoxyribonucleic acid was extracted, polymerase chain reaction (PCR) amplification of desmosome-encoding genes was performed, PCR products were sequenced, and diseased tissue samples were studied for intercellular junction protein distribution with confocal immunofluorescence microscopy and antibodies against key proteins. RESULTS We identified 21 variants in plakophilin-2 (PKP2) in 38 of 198 probands (19%), including missense, nonsense, splice site, and deletion/insertion mutations. Pedigrees showed wide intra-familial variability (severe early-onset disease to asymptomatic individuals). In 9 of 38 probands, PKP2 variants were identified that were encoded in trans (compound heterozygosity). The 38 probands hosting PKP2 variants were screened for other desmosomal genes mutations; second variants (digenic heterozygosity) were identified in 16 of 38 subjects with PKP2 variants (42%), including desmoplakin (DSP) (n = 6), desmoglein-2 (DSG2) (n = 5), plakophilin-4 (PKP4) (n = 1), and desmocollin-2 (DSC2) (n = 1). Heterozygous mutations in non-PKP 2 desmosomal genes occurred in 14 of 198 subjects (7%), including DSP (n = 4), DSG2 (n = 5), DSC2 (n = 3), and junctional plakoglobin (JUP) (n = 2). All variants occurred in conserved regions; none was identified in 700 ethnic-matched control subjects. Immunohistochemical analysis demonstrated abnormalities of protein architecture. CONCLUSIONS These data suggest that the genetic basis of ARVC includes reduced penetrance with compound and digenic heterozygosity. Disturbed junctional cytoarchitecture in subjects with desmosomal mutations confirms that ARVC is a disease of the desmosome and cell junction.
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Affiliation(s)
- Tianhong Xu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Zhao Yang
- Department of Medicine (Cardiovascular Sciences), Baylor College of Medicine, Houston, TX
- Department of Pediatrics (Section of Cardiology), Baylor College of Medicine, Houston, TX
| | - Matteo Vatta
- Department of Pediatrics (Section of Cardiology), Baylor College of Medicine, Houston, TX
| | | | - Giorgia Beffagna
- Department of Pediatrics (Section of Cardiology), Baylor College of Medicine, Houston, TX
- Department of Biology, University of Padua Medical School, Padua, Italy
| | | | - Steven E. Scherer
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Jeffrey Saffitz
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - Joshua Kravitz
- Department of Pediatrics (Section of Cardiology), Baylor College of Medicine, Houston, TX
| | - Wojciech Zareba
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | | | | | - Andrea Nava
- Department of Cardiothoracic-Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Barbara Bauce
- Department of Cardiothoracic-Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Gaetano Thiene
- Department of Medico-Diagnostic Sciences, University of Padua Medical School, Padua, Italy
| | - Cristina Basso
- Department of Medico-Diagnostic Sciences, University of Padua Medical School, Padua, Italy
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins School of Medicine and ARVD Program, Baltimore, MD
| | - Kathy Gear
- Department of Medicine, University of Arizona, Tucson, AZ
| | - Frank Marcus
- Department of Medicine, University of Arizona, Tucson, AZ
| | - Jeffrey A. Towbin
- The Heart Institute and Department of Pediatrics (Pediatric Cardiology), Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Abstract
Arrhythmogenic right ventricular cardiomyopathy is a rare inherited heart-muscle disease that is a cause of sudden death in young people and athletes. Causative mutations in genes encoding desmosomal proteins have been identified and the disease is nowadays regarded as a genetically determined myocardial dystrophy. The left ventricle is so frequently involved as to support the adoption of the broad term arrhythmogenic cardiomyopathy. Clinical diagnosis can be achieved by demonstrating function and structure changes of the right ventricle, electrocardiogram depolarisation and repolarisation abnormalities, ventricular arrhythmias, and fibrofatty replacement through endomyocardial biopsy. Although specific, the standardised diagnostic criteria lack sensitivity for early disease and their primary application remains in establishing the diagnosis in probands. However, the main clinical targets are early detection of concealed forms and risk stratification for preventive strategies, which include physical exercise restriction, antiarrhythmic drugs, and implantable cardioverter-defibrillator therapy. Cascade genetic screening of family members of gene-positive probands allows the identification of asymptomatic carriers who would require lifelong follow-up due to the age-related penetrance.
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Asimaki A, Tandri H, Huang H, Halushka MK, Gautam S, Basso C, Thiene G, Tsatsopoulou A, Protonotarios N, McKenna WJ, Calkins H, Saffitz JE. A new diagnostic test for arrhythmogenic right ventricular cardiomyopathy. N Engl J Med 2009; 360:1075-84. [PMID: 19279339 DOI: 10.1056/nejmoa0808138] [Citation(s) in RCA: 367] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) can be challenging because the clinical presentation is highly variable and genetic penetrance is often low. METHODS To determine whether a change in the distribution of desmosomal proteins can be used as a sensitive and specific diagnostic test for ARVC, we performed immunohistochemical analysis of human myocardial samples. RESULTS We first tested myocardium from 11 subjects with ARVC; of these samples, 8 had desmosomal gene mutations. We also tested myocardium obtained at autopsy from 10 subjects with no clinical or pathological evidence of heart disease as control samples. All ARVC samples but no control samples showed a marked reduction in immunoreactive signal levels for plakoglobin (also known as gamma-catenin), a protein that links adhesion molecules at the intercalated disk to the cytoskeleton. Other desmosomal proteins showed variable changes, but signal levels for the nondesmosomal adhesion molecule N-cadherin were normal in all subjects with ARVC. To determine whether a diminished plakoglobin signal level was specific for ARVC, we analyzed myocardium from 15 subjects with hypertrophic, dilated, or ischemic cardiomyopathies. In every sample, levels of N-cadherin and plakoglobin signals at junctions were indistinguishable from those in control samples. Finally, we performed blinded immunohistochemical analysis of heart-biopsy samples from the Johns Hopkins ARVC registry. We made the correct diagnosis in 10 of 11 subjects with definite ARVC on the basis of clinical criteria and correctly ruled out ARVC in 10 of 11 subjects without ARVC, for a sensitivity of 91%, a specificity of 82%, a positive predictive value of 83%, and a negative predictive value of 90%. The plakoglobin signal level was reduced diffusely in ARVC samples, including those obtained in the left ventricle and the interventricular septum. CONCLUSIONS Routine immunohistochemical analysis of a conventional endomyocardial-biopsy sample appears to be a highly sensitive and specific diagnostic test for ARVC.
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Affiliation(s)
- Angeliki Asimaki
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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Marcus FI, Zareba W, Calkins H, Towbin JA, Basso C, Bluemke DA, Estes NAM, Picard MH, Sanborn D, Thiene G, Wichter T, Cannom D, Wilber DJ, Scheinman M, Duff H, Daubert J, Talajic M, Krahn A, Sweeney M, Garan H, Sakaguchi S, Lerman BB, Kerr C, Kron J, Steinberg JS, Sherrill D, Gear K, Brown M, Severski P, Polonsky S, McNitt S. Arrhythmogenic right ventricular cardiomyopathy/dysplasia clinical presentation and diagnostic evaluation: results from the North American Multidisciplinary Study. Heart Rhythm 2009; 6:984-92. [PMID: 19560088 DOI: 10.1016/j.hrthm.2009.03.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 03/06/2009] [Indexed: 01/28/2023]
Abstract
BACKGROUND Prior reports on patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) focused on individuals with advanced forms of the disease. Data on the diagnostic performance of various testing modalities in newly identified individuals suspected of having ARVC/D are limited. OBJECTIVE The purpose of the Multidisciplinary Study of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia was to study the clinical characteristics and diagnostic evaluation of a large group of patients newly identified with ARVC/D. METHODS A total of 108 newly diagnosed patients with suspected ARVC/D were prospectively enrolled in the United States and Canada. The patients underwent noninvasive and invasive tests using standardized protocols that initially were interpreted by the enrolling center and adjudicated by blind analysis in six core laboratories. Patients were followed for a mean of 27 +/- 16 months (range 0.2-63 months). RESULTS The clinical profile of these newly diagnosed patients differs from the profile of reported patients with more advanced disease. There was considerable difference in the initial and final classification of the presence of ARVC/D after the diagnostic tests were evaluated by the core laboratories. Final clinical diagnosis was 73 affected, 28 borderline, and 7 unaffected. Individual tests agreed with the final diagnosis in 50% to 70% of the 73 patients with a final classification of affected. CONCLUSION The clinical profile of 108 newly diagnosed probands with suspected ARVC/D indicates that a combination of diagnostic tests is needed to evaluate the presence of right ventricular structural, functional, and electrical abnormalities. Echocardiography, right ventricular angiography, signal-averaged ECG, and Holter monitoring provide optimal clinical evaluation of patients suspected of ARVC/D.
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Affiliation(s)
- Frank I Marcus
- Section of Cardiology, University of Arizona, 1501 N. Campbell Avenue, Tucson, Arizona 85724-0001, USA.
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Cardiac imaging in right ventricular cardiomyopathy/dysplasia—how does cardiac imaging assist in understanding the morphologic, functional, and electrical changes of the heart in this disease? J Electrocardiol 2009; 42:137.e1-10. [DOI: 10.1016/j.jelectrocard.2008.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Indexed: 12/13/2022]
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Herren T, Gerber PA, Duru F. Arrhythmogenic right ventricular cardiomyopathy/dysplasia: a not so rare "disease of the desmosome" with multiple clinical presentations. Clin Res Cardiol 2009; 98:141-58. [PMID: 19205777 DOI: 10.1007/s00392-009-0751-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 01/08/2009] [Indexed: 02/07/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a rare but increasingly recognized form of a cardiomyopathy, involving primarily the right ventricle. Mutations in seven candidate genes coding for five desmosomal proteins (plakoglobin, plakophilin-2, desmoplakin, desmoglein-2, desmocollin-2), for the cardiac ryanodine receptor-2, for the transforming growth factor beta-3, and for the transmembrane protein 43, respectively, are pathogenetically important. A typical feature of the disease is the replacement of the right ventricular myocardium by fibrofatty infiltrates, leading to electrical instability including ventricular arrhythmias in the early stages, and reduced contractility and heart failure later on. The left ventricle may also be involved. Unfortunately, the disease is often diagnosed post mortem only, especially in young adults dying suddenly during exercise. Since the disease is inherited in up to 50% of cases, the screening of relatives is important. The implantable cardioverter defibrillator is an important therapeutic tool. Nevertheless, the mortality of the disease remains to be 2%-4% per year. Several clinical, electrocardiographic, and imaging parameters were identified as risk predictors for an adverse outcome. In this paper, we describe distinct clinical presentations of ARVC/D, review the genetic background of the disease, and discuss its diagnosis and treatment.
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Affiliation(s)
- Thomas Herren
- Department of Medicine, Limmattal Hospital, Schlieren, Switzerland.
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H Fischer A, van der Loo B, M Shär G, Zbinden R, Duru F, Brunckhorst C, Rousson V, Delacrétaz Y E, Stuber T, Oechslin EN, Follath F, Jenni R. Serological evidence for the association of Bartonella henselae infection with arrhythmogenic right ventricular cardiomyopathy. Clin Cardiol 2009; 31:469-71. [PMID: 18666174 DOI: 10.1002/clc.20269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an important cause of sudden death in young adults. On the basis of histopathological findings its pathogenesis may involve both a genetic origin and an inflammatory process. Bartonella henselae may cause endomyocarditis and was detected in myocardium from a young male who succumbed to sudden cardiac death. HYPOTHESIS We hypothesized that chronic infection with Bartonella henselae could contribute to the pathogenesis of ARVC. METHODS We investigated sera from 49 patients with ARVC for IgG antibodies to Bartonella henselae. In this study, 58 Swiss blood donors tested by the same method served as controls. RESULTS Six patients with ARVC (12%) had positive (>1:256) IgG titres in the immunofluorescence test with Bartonella henselae. In contrast, only 1 elevated titre was found in 58 controls (p < or = 0.05). Interestingly, all patients with increased titres had no familial occurrence of ARVC. CONCLUSIONS Further studies in larger patient cohorts seem justified to investigate a possible causal link between chronic Bartonella henselae and ARVC, in particular its sporadic (nonfamilial) form.
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Affiliation(s)
- Andreas H Fischer
- Clinic of Cardiology, University Hospital Zurich, Zurich, Switzerland
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28
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Vasaiwala SC, Finn C, Delpriore J, Leya F, Gagermeier J, Akar JG, Santucci P, Dajani K, Bova D, Picken MM, Basso C, Marcus F, Wilber DJ. Prospective study of cardiac sarcoid mimicking arrhythmogenic right ventricular dysplasia. J Cardiovasc Electrophysiol 2008; 20:473-6. [PMID: 19017339 DOI: 10.1111/j.1540-8167.2008.01351.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Case studies indicate that cardiac sarcoid may mimic the clinical presentation of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C); however, the incidence and clinical predictors to diagnose cardiac sarcoid in patients who meet International Task Force criteria for ARVD/C are unknown. METHODS AND RESULTS Patients referred for evaluation of left bundle branch block (LBBB)-type ventricular arrhythmia and suspected ARVD/C were prospectively evaluated by a standardized protocol including right ventricle (RV) cineangiography-guided myocardial biopsy. Sixteen patients had definite ARVD/C and four had probable ARVD/C. Three patients were found to have noncaseating granulomas on biopsy consistent with sarcoid. Age, systemic symptoms, findings on chest X-ray or magnetic resonance imaging (MRI), type of ventricular arrhythmia, RV function, ECG abnormalities, and the presence or duration of late potentials did not discriminate between sarcoid and ARVD/C. Left ventricular dysfunction (ejection fraction <50%) was present in 3/3 patients with cardiac sarcoid, but only 2/17 remaining patients with definite or probable ARVD/C (P = 0.01). CONCLUSIONS In this prospective study of consecutive patients with suspected ARVD/C evaluated by a standard protocol including biopsy, the incidence of cardiac sarcoid was surprisingly high (15%). Clinical features, with the exception of left ventricular dysfunction and histological findings, did not discriminate between the two entities.
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Affiliation(s)
- Smit C Vasaiwala
- Cardiovascular Institute, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Abstract
Cardiomyopathies account for a significant portion of morbidity and mortality in patients with heart disease. The diagnosis and identification of the underlying disorder are essential for directing appropriate life-saving therapy. Cardiac magnetic resonance imaging (CMR) is an ideal method for the noninvasive evaluation of cardiomyopathies of unknown etiology. In addition, there is increasing prognostic evidence to support the use of this technology in patient risk stratification. CMR is not limited by anatomic barriers and is able to characterize tissue abnormalities that previously could often be identified only through biopsy. This review discusses the utility of CMR in the assessment of cardiomyopathies, including specific imaging techniques and their application in ischemic and nonischemic settings.
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Basso C, Ronco F, Marcus F, Abudureheman A, Rizzo S, Frigo AC, Bauce B, Maddalena F, Nava A, Corrado D, Grigoletto F, Thiene G. Quantitative assessment of endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy/dysplasia: an in vitro validation of diagnostic criteria. Eur Heart J 2008; 29:2760-71. [PMID: 18819962 DOI: 10.1093/eurheartj/ehn415] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
AIMS To provide a standardized endomyocardial biopsy (EMB) protocol and diagnostic quantitative parameters for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). The Task Force criteria for the in vivo diagnosis of ARVC/D include tissue characterization by EMB as a major criterion. METHODS AND RESULTS EMBs were simulated in vitro with a Cordis bioptome in explanted hearts from six groups: diffuse (n = 10) and segmental (n = 10) ARVC/D, dilated cardiomyopathy (DC) (n = 10), controls (n = 10), adipositas cordis (n = 10), elderly >80 years (n = 10). Sampling sites were the RV inferior-subtricuspid, antero-apical, and mid-outflow tract (RVOT), the septum, and the left ventricle (LV). Histomorphometry was performed to evaluate the amount of myocardium and fibrous and fatty tissues. Myocyte diameters and abnormalities were also assessed. By selecting a 95% specificity, the ARVC/D diagnostic cut-offs on cumulative RV EMB samples are myocardium <59%, fibrosis >31% and fat >22% (80, 50, and 50% sensitivity, respectively). By excluding elderly and obese people groups a lower cut-off for fat was found (>9%). A high variability between different RV sampling sites was observed; the antero-apical was the most informative region although fat at this level is non-specific. No useful diagnostic cut-off for fatty tissue was identified at the antero-apical and RVOT area. No significant difference was found for any tissue parameter either in septal or in LV EMB. Increased RV myocyte diameters and cytological changes were detected in ARVC/D and DC. CONCLUSION The residual myocardium is the main diagnostic morphometric parameter in ARVC/D, whereas fat at the apex is non-specific. Sensitivity and specificity vary according to the RV region. Target sampling of the triangle of dysplasia is required, although only a single region is often informative, emphasizing the usefulness of imaging-guided EMB. There is no diagnostic value of either septal or LV EMB. Cardiomyopathic changes of the myocytes also appear important for establishing a pathological diagnosis.
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Affiliation(s)
- Cristina Basso
- Pathological Anatomy, Department of Medico-Diagnostic Sciences and Special Therapies, University of Padua Medical School, Padua, Italy
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Jain A, Tandri H, Calkins H, Bluemke DA. Role of cardiovascular magnetic resonance imaging in arrhythmogenic right ventricular dysplasia. J Cardiovasc Magn Reson 2008; 10:32. [PMID: 18570661 PMCID: PMC2483704 DOI: 10.1186/1532-429x-10-32] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 06/20/2008] [Indexed: 12/25/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is a genetic cardiomyopathy characterized clinically by ventricular arrhythmias and progressive right ventricular (RV) dysfunction. The histopathologic hallmark is fibro-fatty replacement of RV myocardium. It is inherited in an autosomal pattern with variable penetrance. ARVD is unique in that it most commonly presents in young, otherwise healthy and highly athletic individuals. The cause of ARVD is not well-known but recent evidence suggests strongly that it is a disease of desmosomal dysfunction. The disease involvement is not limited only to the RV as left ventricle (LV) has also been reportedly affected. Diagnosis of ARVD is challenging and is currently based upon a multi-disciplinary work-up of the patient as defined by the Task Force. Currently, implanted cardioverter defibrillators (ICD) are routinely used to prevent sudden death in patients with ARVD. Cardiovascular MR is an important non-invasive diagnostic modality that allows both qualitative and quantitative evaluation of RV. This article reviews the genetics of ARVD, current status and role of CMR in the diagnosis of ARVD and LV involvement in ARVD.
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Affiliation(s)
- Aditya Jain
- Russell H. Morgan Department of Radiology and Radiological Science, 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
| | - David A Bluemke
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
- Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy: Clinical Profile of Four Patients and Review. South Med J 2008; 101:309-16. [DOI: 10.1097/01.smj.0000308364.02545.f2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Callans DJ. Diagnosing Subtle Forms of Potentially Life-Threatening Diseases⁎⁎Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. J Am Coll Cardiol 2008; 51:740-1. [DOI: 10.1016/j.jacc.2007.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Accepted: 11/08/2007] [Indexed: 12/31/2022]
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Basso C, Corrado D, Thiene G. Arrhythmogenic right ventricular cardiomyopathy in athletes: diagnosis, management, and recommendations for sport activity. Cardiol Clin 2008; 25:415-22, vi. [PMID: 17961795 DOI: 10.1016/j.ccl.2007.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This article examines the role of arrhythmogenic right ventricular cardiomyopathy/dysplasia in causing sudden death in young competitive athletes and suggests a prevention strategy based on identification of affected athletes at preparticipation screening. Systematic cardiovascular screening (including 12-lead ECG) of all subjects embarking on sports activity has the potential to identify those athletes at risk and to reduce mortality.
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Affiliation(s)
- Cristina Basso
- Department of Medical-Diagnostic Sciences and Special Therapies, University of Padua Medical School, Via A. Gabelli 61, 35121 Padova, Italy
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Tandri H, Macedo R, Calkins H, Marcus F, Cannom D, Scheinman M, Daubert J, Estes M, Wilber D, Talajic M, Duff H, Krahn A, Sweeney M, Garan H, Bluemke DA. Role of magnetic resonance imaging in arrhythmogenic right ventricular dysplasia: insights from the North American arrhythmogenic right ventricular dysplasia (ARVD/C) study. Am Heart J 2008; 155:147-53. [PMID: 18082506 DOI: 10.1016/j.ahj.2007.08.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Accepted: 08/12/2007] [Indexed: 12/18/2022]
Abstract
BACKGROUND Prior reports describing magnetic resonance (MR) imaging abnormalities in arrhythmogenic right ventricular dysplasia (ARVD/C) were limited by nonuniform inclusion criteria. The aim of our study was to define the prevalence, sensitivity, and specificity of quantitative MR imaging findings in the probands of multidisciplinary study of right ventricular dysplasia. METHODS Individuals with ventricular arrhythmias of left bundle-branch block morphology meeting the Task Force criteria for ARVD/C underwent MR imaging. The MR images were compared with 10 patients with idiopathic ventricular tachycardia (VT) and 25 controls. Of the 42 study probands, 40 met the Task Force criteria exclusive of MR imaging findings. All MR images were interpreted in a blinded fashion. RESULTS Right ventricle fat infiltration was reported in 24 (60%) probands and none of the patients with idiopathic VT or controls. Six patients (15%) had fat infiltration of the left ventricle. Right ventricle regional dysfunction was observed in 32 probands (80%) and none of the patients with idiopathic VT or controls. Qualitative RV function was abnormal in 26 probands (60%); however, quantitative RV ejection fraction was abnormal in 85% (24/28) of the probands. An RV ejection fraction <50% had a sensitivity of 73% and a specificity of 95% in diagnosis of ARVD/C. CONCLUSIONS Fat infiltration is seldom the only MR imaging abnormality and is less sensitive for ARVD/C diagnosis compared with RV regional dysfunction. Qualitative estimates of RV function may underestimate the prevalence of RV dysfunction in ARVD/C. Quantitative evaluation of RV by MR imaging may have a high sensitivity and specificity for ARVD/C diagnosis.
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Affiliation(s)
- Harikrishna Tandri
- Department of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Thiene G, Corrado D, Basso C. Arrhythmogenic right ventricular cardiomyopathy/dysplasia. Orphanet J Rare Dis 2007; 2:45. [PMID: 18001465 PMCID: PMC2222049 DOI: 10.1186/1750-1172-2-45] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 11/14/2007] [Indexed: 11/29/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a heart muscle disease clinically characterized by life-threatening ventricular arrhythmias. Its prevalence has been estimated to vary from 1:2,500 to 1:5,000. ARVC/D is a major cause of sudden death in the young and athletes. The pathology consists of a genetically determined dystrophy of the right ventricular myocardium with fibro-fatty replacement to such an extent that it leads to right ventricular aneurysms. The clinical picture may include: a subclinical phase without symptoms and with ventricular fibrillation being the first presentation; an electrical disorder with palpitations and syncope, due to tachyarrhythmias of right ventricular origin; right ventricular or biventricular pump failure, so severe as to require transplantation. The causative genes encode proteins of mechanical cell junctions (plakoglobin, plakophilin, desmoglein, desmocollin, desmoplakin) and account for intercalated disk remodeling. Familiar occurrence with an autosomal dominant pattern of inheritance and variable penetrance has been proven. Recessive variants associated with palmoplantar keratoderma and woolly hair have been also reported. Clinical diagnosis may be achieved by demonstrating functional and structural alterations of the right ventricle, depolarization and repolarization abnormalities, arrhythmias with the left bundle branch block morphology and fibro-fatty replacement through endomyocardial biopsy. Two dimensional echo, angiography and magnetic resonance are the imaging tools for visualizing structural-functional abnormalities. Electroanatomic mapping is able to detect areas of low voltage corresponding to myocardial atrophy with fibro-fatty replacement. The main differential diagnoses are idiopathic right ventricular outflow tract tachycardia, myocarditis, dialted cardiomyopathy and sarcoidosis. Only palliative therapy is available and consists of antiarrhythmic drugs, catheter ablation and implantable cardioverter defibrillator. Young age, family history of juvenile sudden death, QRS dispersion ≥ 40 ms, T-wave inversion, left ventricular involvement, ventricular tachycardia, syncope and previous cardiac arrest are the major risk factors for adverse prognosis. Preparticipation screening for sport eligibility has been proven to be effective in detecting asymptomatic patients and sport disqualification has been life-saving, substantially declining sudden death in young athletes.
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Affiliation(s)
- Gaetano Thiene
- Pathological Anatomy, Department of Medical-Diagnostic Sciences and Special Therapies, University of Padua Medical School, Padua, Italy.
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Indik JH, Wichter T, Gear K, Dallas WJ, Marcus FI. Quantitative assessment of angiographic right ventricular wall motion in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). J Cardiovasc Electrophysiol 2007; 19:39-45. [PMID: 17900252 DOI: 10.1111/j.1540-8167.2007.00974.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Angiography of the right ventricle (RV) is a standard, reference technique to diagnose wall motion abnormalities in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). RV wall motion is usually assessed by qualitative, visual impression, and has lacked a quantitative basis for defining abnormalities. Since the normal RV has a markedly asymmetric movement, angiographic interpretation can differ, even among experienced clinicians. The purpose of this study was to quantify RV wall motion based on contrast ventriculography in patients with ARVD/C and to specify the severity and location of wall motion abnormalities, as compared with normal subjects. METHODS AND RESULTS We analyzed the angiographic contours of the RV in three views from 19 normal subjects and 23 subjects with ARVD/C. Contour area movement during contraction was calculated circumferentially and further analyzed in nine zones. RV ejection fraction was also computed. Wall motion in ARVD/C was depressed by more than 30% at the tricuspid valve and inferior wall regions (P < 0.001) and significantly reduced at the apex (P = 0.003). However, the RVOT and anterior wall motion were not significantly reduced. RV ejection fraction was depressed from 60 +/- 11% in normal subjects to 41 +/- 12% in ARVD/C patients (P < 0.001). CONCLUSION Wall motion abnormalities in ARVD/C can be quantified and compared with normal controls, showing primarily reduced movement in the tricuspid and inferior wall regions. This study delineates objective measurements that can be used to aid in the diagnosis of ARVD/C. In addition, they may be incorporated in future refinements of criteria to diagnose ARVD/C.
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Affiliation(s)
- Julia H Indik
- Section of Cardiology, Sarver Heart Center, University of Arizona, Tucson, Arizona 85724-5037, USA.
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Rey C, Rodríguez-Nuñez A, Medina A, Mayordomo J. Life-saving automated external defibrillation in a teenager: a case report. J Med Case Rep 2007; 1:76. [PMID: 17767706 PMCID: PMC2018713 DOI: 10.1186/1752-1947-1-76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Accepted: 09/03/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescent sudden death during sport participation is commonly due to cardiac causes. Survival is more likely when an automated external defibrillator (AED) is used soon after collapse. CASE PRESENTATION We describe a case of sudden death in a 14 year old boy with two remarkable points, successful resuscitation at school using an AED and diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). Bystander cardiopulmonary resuscitation (CPR) was immediately started by a witness and 5 minutes after the event the child was placed on an AED monitor that determined he was in a non shockable rhythm, therefore CPR was continued. Two minutes later, the AED monitor detected a shockable rhythm and recommended a shock, which was then administered. One minute after the shock, a palpable pulse was detected and the child began to breathe by himself. Four days after cardiac arrest, the boy was conversing and self-caring. Cardiac magnetic resonance imaging was suggestive of ARVC. CONCLUSION Ventricular fibrillation secondary to ARVC may be a devastating event and places young patients and athletes at high risk of sudden death. Immediate CPR and AED have been demonstrated to be lifesaving in such events. Therefore, we suggest that schools should have teachers skilled in CPR and accessible AEDs.
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Affiliation(s)
- Corsino Rey
- Paediatric Intensive Care Unit. Department of Paediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Antonio Rodríguez-Nuñez
- Pediatric Emergency and Critical Care Division, Department of Paediatrics, Hospital Clínico Universitario de Santiago de Compostela, Servicio Galego de Saúde (SERGAS) and University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Medina
- Paediatric Intensive Care Unit. Department of Paediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Juan Mayordomo
- Paediatric Intensive Care Unit. Department of Paediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
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Wingenfeld L, Freislederer A, Schulze-Bahr E, Paul M, Bajanowski T. Life-threatening hobbies in the youth? Forensic Sci Int 2007; 171:e1-4. [PMID: 17544237 DOI: 10.1016/j.forsciint.2007.04.199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 04/16/2007] [Indexed: 11/19/2022]
Abstract
Determining the cause for the sudden death in young adults tends to be complex and difficult. Two cases of death of young people were autoptically investigated who died suddenly while carrying out their hobbies (a 22-year-old male musician and a 20-year-old female dancer). In both cases neither the police investigation, the autopsy, nor the toxicological investigations gave any relevant results. However, when investigating the histology fatty and fibrotic tissue in the right ventricle of the myocardium were found, whereas the myocytes proved to be degenerated--typical for arrhythmogenic right ventricular cardiomyopathy (ARVC). It is important to consider the possibility of heart rhythm failure if a clear reason for sudden death in young adults cannot be detected. Heart rhythm failure often involves the genetic background of the case, which suggests that genetic analysis should be carried out as a supportive means of diagnostics.
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Affiliation(s)
- Lisa Wingenfeld
- Institute of Legal Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
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Marcus FI, Zareba W, Sherrill D. Evaluation of the normal values for signal-averaged electrocardiogram. J Cardiovasc Electrophysiol 2007; 18:231-3. [PMID: 17338774 DOI: 10.1111/j.1540-8167.2006.00685.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Frank I Marcus
- Sarver Heart Center, University of Arizona, Tucson, Arizona 85724, USA.
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Bomma C, Dalal D, Tandri H, Prakasa K, Nasir K, Roguin A, Piccini J, Dong J, Mahadevappa M, Tichnell C, James C, Lima JAC, Fishman E, Calkins H, Bluemke DA. Evolving role of multidetector computed tomography in evaluation of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Am J Cardiol 2007; 100:99-105. [PMID: 17599449 DOI: 10.1016/j.amjcard.2007.02.064] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 02/06/2007] [Accepted: 02/06/2007] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to report 1 center's experience with multidetector computed tomography (MDCT) in the evaluation of patients suspected to have arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C). RV dilatation/dysfunction is 1 of the most important criteria for establishing the diagnosis of ARVD/C. Cardiac magnetic resonance imaging (MRI) is the most preferred imaging modality for the diagnosis of ARVD/C. However, many patients with suspected ARVD/C have implantable cardioverter-defibrillators, prohibiting the use of MRI. Thirty-one patients (19 men; mean age 41 +/- 12 years) referred for evaluation of known or suspected ARVD/C had a complete reevaluation including contrast-enhanced cardiac MDCT at the center. Two patients underwent both cardiac MRI and MDCT. Seventeen of 31 patients met Task Force criteria for ARVD/C and were confirmed to have ARVD/C. Multidetector computed tomographic images were analyzed for qualitative and quantitative characteristic findings of ARVD/C. Increased RV trabeculation (p <0.001), RV intramyocardial fat (p <0.001), and scalloping (p <0.001) were significantly associated with the final diagnosis of ARVD/C. RV volumes, RV inlet dimensions, and RV outflow tract surface area were increased in patients with ARVD/C compared with patients who did not meet the criteria. RV and left ventricular functional analysis was performed in 2 patients. In conclusion, cardiac MDCT has a strong potential to detect many qualitative and quantitative abnormalities of the right ventricle in patients with ARVD/C. Limitations include implantable cardioverter-defibrillators and motion artifacts, along with well-known radiation and contrast-induced reaction.
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Affiliation(s)
- Chandra Bomma
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fornès P. Mort subite cardiaque non ischémique — biologie moléculaire et génétique des cardiomyopathies et canalopathies. Ann Pathol 2006. [DOI: 10.1016/s0242-6498(06)78382-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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45
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW Arrhythmogenic right-ventricular dysplasia is a rare inherited disease characterized by right-ventricular dysfunction and ventricular arrhythmias. The purpose of this article is to review recent developments concerning the diagnosis, genetics, and management of patients with this disease. RECENT FINDINGS In the past few years important new information has emerged regarding the role of magnetic resonance imaging in the diagnosis of arrhythmogenic right-ventricular dysplasia. Although magnetic resonance imaging is a very sensitive tool, it is also the most common reason for over diagnosis of this condition. There have also been important new breakthroughs in the genetic basis of arrhythmogenic right-ventricular dysplasia; it now appears that most forms result from mutations in genes encoding desmosomal junction proteins. This may explain why arrhythmogenic right-ventricular dysplasia preferentially impacts the thin right ventricle. Other studies have demonstrated the important role of implantable cardioverter defibrillator therapy in the management of patients with arrhythmogenic right-ventricular dysplasia. In the USA, most patients who meet the Task Force criteria for the disease undergo placement of an implantable cardioverter defibrillator for prevention of sudden cardiac death. SUMMARY Arrhythmogenic right-ventricular dysplasia is a rare disease. Recent new findings concerning the diagnosis and management of these patients should have direct implications regarding the evaluation and management of patients with this rare, but potentially life-threatening, disorder.
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Affiliation(s)
- Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Kiès P, Bootsma M, Bax J, Schalij MJ, van der Wall EE. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: screening, diagnosis, and treatment. Heart Rhythm 2006; 3:225-34. [PMID: 16443541 DOI: 10.1016/j.hrthm.2005.10.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Accepted: 10/14/2005] [Indexed: 02/07/2023]
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a heart muscle disorder characterized pathologically by fatty or fibrofatty replacement and electrical instability of the right ventricular myocardium. Clinical manifestations include structural and functional malformations (fatty infiltration, dilatation, aneurysms) of the right ventricle, ECG abnormalities, and presentation with ventricular tachycardias with left bundle branch block pattern or sudden death. The disease often is familial with an autosomal inheritance. The typical hallmarks of ARVD/C are distributed in the so-called "triangle of dysplasia." The functional and morphologic characteristics are relevant to clinical imaging approaches such as contrast angiography, echocardiography, radionuclide angiography, ultrafast computed tomography, and cardiovascular magnetic resonance imaging. Evident forms of the disease are straightforward to diagnose based on a series of diagnostic criteria proposed by the International Task Force for Cardiomyopathy. However, the diagnosis of early and mild forms of the disease often is difficult. Treatment is directed toward preventing life-threatening ventricular arrhythmias in which radiofrequency ablation and implantable defibrillators play an increasing role. Despite new diagnostic and therapeutic approaches in ARVD/C, uncertainties about the etiology of the disease, the genetic basis, the appropriate diagnosis and therapy, and the clinical course of patients with ARVD/C have resulted in several registries to increase our knowledge of this intriguing disease.
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Affiliation(s)
- Philippine Kiès
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
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Meurs KM, Lacombe VA, Dryburgh K, Fox PR, Reiser PR, Kittleson MD. Differential expression of the cardiac ryanodine receptor in normal and arrhythmogenic right ventricular cardiomyopathy canine hearts. Hum Genet 2006; 120:111-8. [PMID: 16733711 DOI: 10.1007/s00439-006-0193-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 04/18/2006] [Indexed: 11/24/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a form of cardiomyopathy characterized by ventricular tachyarrhythmias and a fibrofatty infiltrate that is believed to preferentially affect the right ventricle. Mutations in the cardiac ryanodine receptor (RyR2) gene have been identified in some human families with a unique form of ARVC, ARVC2. Although the RyR2 has significant importance in excitation-contraction coupling across the ventricles, mutations in the gene encoding for it appear to have the greatest impact on the right ventricle in ARVC2. Using a canine model (boxer), the RyR2 protein and message RNA in the right ventricle, left ventricle and interventricular septum from normal dogs and dogs with ARVC were investigated by immunoblotting and real time PCR. The cardiac RyR2 message and protein expression were differentially expressed across the cardiac walls in the normal heart, with the lowest concentration expressed in the right ventricle (P < 0.05). The message and protein expression of the RyR2 were reduced in all chambers in the canine model of ARVC. We propose that the increased susceptibility of the right ventricle to ARVC may be associated with the lower baseline protein concentration of RyR2 in the normal right ventricle compared to the left ventricle and interventricular septum and that all three areas are equally affected in this canine model of ARVC. Using this naturally occurring model of canine ARVC, we may have provided new insights into the pathogenesis of this cardiomyopathy.
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Affiliation(s)
- Kathryn M Meurs
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, USA.
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Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart muscle disease in which the pathological substrate is a fibro-fatty replacement of the right ventricular myocardium. The major clinical features are different types of arrhythmias with a left branch block pattern. ARVC shows autosomal dominant inheritance with incomplete penetrance. Recessive forms were also described, although in association with skin disorders. Ten genetic loci have been discovered so far and mutations were reported in five different genes. ARVD1 was associated with regulatory mutations of transforming growth factor beta-3 (TGFβ3), whereas ARVD2, characterized by effort-induced polymorphic arrhythmias, was associated with mutations in cardiac ryanodine receptor-2 (RYR2). All other mutations identified to date have been detected in genes encoding desmosomal proteins: plakoglobin (JUP) which causes Naxos disease (a recessive form of ARVC associated with palmoplantar keratosis and woolly hair); desmoplakin (DSP) which causes the autosomal dominant ARVD8 and plakophilin-2 (PKP2) involved in ARVD9. Desmosomes are important cell-to-cell adhesion junctions predominantly found in epidermis and heart; they are believed to couple cytoskeletal elements to plasma membrane in cell-to-cell or cell-to-substrate adhesions.
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