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Engel M, Shiel EA, Chelko SP. Basic and translational mechanisms in inflammatory arrhythmogenic cardiomyopathy. Int J Cardiol 2024; 397:131602. [PMID: 37979796 DOI: 10.1016/j.ijcard.2023.131602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/24/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a familial, nonischemic heart disease typically inherited via an autosomal dominant pattern (Nava et al., [1]; Wlodarska et al., [2]). Often affecting the young and athletes, early diagnosis of ACM can be complicated as incomplete penetrance with variable expressivity are common characteristics (Wlodarska et al., [2]; Corrado et al., [3]). That said, of the five desmosomal genes implicated in ACM, pathogenic variants in desmocollin-2 (DSC2) and desmoglein-2 (DSG2) have been discovered in both an autosomal-recessive and autosomal-dominant pattern (Wong et al., [4]; Qadri et al., [5]; Chen et al., [6]). Originally known as arrhythmogenic right ventricular dysplasia (ARVD), due to its RV prevalence and manifesting in the young, the disease was first described in 1736 by Giovanni Maria Lancisi in his book "De Motu Cordis et Aneurysmatibus" (Lancisi [7]). However, the first comprehensive clinical description and recognition of this dreadful disease was by Guy Fontaine and Frank Marcus in 1982 (Marcus et al., [8]). These two esteemed pathologists evaluated twenty-two (n = 22/24) young adult patients with recurrent ventricular tachycardia (VT) and RV dysplasia (Marcus et al., [8]). Initially, ARVD was thought to be the result of partial or complete congenital absence of ventricular myocardium during embryonic development (Nava et al., [9]). However, further research into the clinical and pathological manifestations revealed acquired progressive fibrofatty replacement of the myocardium (McKenna et al., [10]); and, in 1995, ARVD was classified as a primary cardiomyopathy by the World Health Organization (Richardson et al., [11]). Thus, now classifying ACM as a cardiomyopathy (i.e., ARVC) rather than a dysplasia (i.e., ARVD). Even more recently, ARVC has shifted from its recognition as a primarily RV disease (i.e., ARVC) to include left-dominant (i.e., ALVC) and biventricular subtypes (i.e., ACM) as well (Saguner et al., [12]), prompting the use of the more general term arrhythmogenic cardiomyopathy (ACM). This review aims to discuss pathogenesis, clinical and pathological phenotypes, basic and translational research on the role of inflammation, and clinical trials aimed to prevent disease onset and progression.
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Affiliation(s)
- Morgan Engel
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL, United States of America; Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, United States of America
| | - Emily A Shiel
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL, United States of America
| | - Stephen P Chelko
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL, United States of America; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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Saguner AM, Lunk D, Mohsen M, Knecht S, Akdis D, Costa S, Gasperetti A, Duru F, Rossi VA, Brunckhorst CB. Electroanatomical voltage mapping with contact force sensing for diagnosis of arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2023; 392:131289. [PMID: 37619879 DOI: 10.1016/j.ijcard.2023.131289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Three-dimensional electroanatomical mapping (EAM) can be helpful to diagnose arrhythmogenic right ventricular cardiomyopathy (ARVC). Yet, previous studies utilizing EAM have not systematically used contact-force sensing catheters (CFSC) to characterize the substrate in ARVC, which is the current gold standard to assure adequate tissue contact. OBJECTIVE To investigate reference values for endocardial right ventricular (RV) EAM as well as substrate characterization in patients with ARVC by using CFSC. METHODS Endocardial RV EAM during sinus rhythm was performed with CFSC in 12 patients with definite ARVC and 5 matched controls without structural heart disease. A subanalysis for the RV outflow tract (RVOT), septum, free-wall, subtricuspid region, and apex was performed. Endocardial bipolar and unipolar voltage amplitudes (BVA, UVA), signal characteristics and duration as well as the impact of catheter orientation on endocardial signals were also investigated. RESULTS ARVC patients showed lower BVA vs. controls (p = 0.018), particularly in the subtricuspid region (1.4, IQR:0.5-3.1 vs. 3.8, IQR:2.5-5 mV, p = 0.037) and RV apex (2.5, IQR:1.5-4 vs. 4.3,IQR:2.9-6.1 mV, p = 0.019). BVA in all RV regions yielded a high sensitivity and specificity for ARVC diagnosis (AUC 59-78%, p < 0.05 for all), with the highest performance for the subtricuspid region (AUC 78%, 95% CI:0.75-0.81, p < 0.001, negative predictive value 100%). A positive correlation between BVA and an orthogonal catheter orientation (46°-90°:r = 0.106, p < 0.001), and a negative correlation between BVA and EGM duration (r = -0.370, p < 0.001) was found. CONCLUSIONS EAM using CFSC validates previous bipolar cut-off values for normal endocardial RV voltage amplitudes. RV voltages are generally lower in ARVC as compared to controls, with the subtricuspid area being commonly affected and having the highest discriminatory power to differentiate between ARVC and healthy controls. Therefore, EAM using CFSC constitutes a promising tool for diagnosis of ARVC.
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Affiliation(s)
- A M Saguner
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital, University of Zurich, 8952 Schlieren, Switzerland.
| | - D Lunk
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - M Mohsen
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, Qatar Heart Hospital 7GR5+RW4, Doha, Qatar
| | - Sven Knecht
- Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Deniz Akdis
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Costa
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - A Gasperetti
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Carnegie 568D, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - F Duru
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital, University of Zurich, 8952 Schlieren, Switzerland
| | - V A Rossi
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C B Brunckhorst
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
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Lazzeroni D, Crocamo A, Ziveri V, Notarangelo MF, Rizzello D, Spoladori M, Donelli D, Cacciola G, Ardissino D, Niccoli G, Peretto G. Personalized Management of Sudden Death Risk in Primary Cardiomyopathies: From Clinical Evaluation and Multimodality Imaging to Ablation and Cardioverter-Defibrillator Implant. J Pers Med 2023; 13:jpm13050877. [PMID: 37241047 DOI: 10.3390/jpm13050877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Sudden cardiac death represents the leading cause of death worldwide; although the majority of sudden deaths occur in an elderly population with coronary artery disease, some occur in young and otherwise healthy individuals, as is the case of cardiomyopathies. The aim of the present review is to provide a stepwise hierarchical approach for the global sudden death risk estimation in primary cardiomyopathies. Each individual risk factor is analyzed for its contribution to the overall risk of sudden death for each specific cardiomyopathy as well as across all primary myocardial diseases. This stepwise hierarchical and personalized approach starts from the clinical evaluation, subsequently passes through the role of electrocardiographic monitoring and multimodality imaging, and finally concludes with genetic evaluation and electro-anatomical mapping. In fact, the sudden cardiac death risk assessment in cardiomyopathies depends on a multiparametric approach. Moreover, current indications for ventricular arrhythmia ablation and defibrillator implantation are discussed.
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Affiliation(s)
- Davide Lazzeroni
- Prevention and Rehabilitation Unit of Parma, IRCCS Fondazione Don Gnocchi, 43100 Parma, Italy
| | - Antonio Crocamo
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Valentina Ziveri
- Prevention and Rehabilitation Unit of Parma, IRCCS Fondazione Don Gnocchi, 43100 Parma, Italy
| | | | - Davide Rizzello
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Matteo Spoladori
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Davide Donelli
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Giovanna Cacciola
- Prevention and Rehabilitation Unit of Parma, IRCCS Fondazione Don Gnocchi, 43100 Parma, Italy
| | - Diego Ardissino
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Giampaolo Niccoli
- U.O.C. di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, 43100 Parma, Italy
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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Kommata V, Sciaraffia E, Blomström-Lundqvist C. Epicardial conduction abnormalities in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) and mutation positive healthy family members - A study using electrocardiographic imaging. PLoS One 2023; 18:e0280111. [PMID: 36603020 PMCID: PMC9815642 DOI: 10.1371/journal.pone.0280111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) in early stages is challenging. The aim of this study was therefore to investigate whether electrocardiographic imaging (ECGI) can detect epicardial conduction changes in ARVC patients and healthy mutation-carriers (M-carriers). METHOD Twelve ARVC patients, 20 M-carriers and 8 controls underwent 12-lead ECG, signal-averaged ECG, 2-dimensional echocardiography, 24-hours Holter monitoring and ECGI (body surface mapping and computer tomography with offline analysis of reconstructed epicardial signals). Total and Right Ventricular Activation Time (tVAT and RVAT respectively), area of Ventricular Activation during the terminal 20 milliseconds (aVAte20) and the activation patterns were compared between groups. RESULTS In ARVC patients the locations of aVAte20 were scattered or limited to smaller parts of the right ventricle (RV) versus in controls, in whom aVAte20 was confined to right ventricular outflow tract (RVOT) and left ventricle (LV) base (+/- RV base). ARVC patients had smaller aVAte20 (35cm2 vs 87cm2, p<0.05), longer tVAT (99msec vs 58msec, p<0.05) and longer RVAT (66msec vs 43msec, p<0.05) versus controls. In 10 M-carriers (50%), the locations of aVAte20 were also eccentric. This sub-group presented smaller aVAte20 (53cm2 vs 87cm2, p = 0.009), longer RVAT (55msec vs 48msec, p = 0.043), but similar tVAT (65msec vs 60msec, p = 0.529) compared with the M-carriers with normal activation pattern. CONCLUSIONS ECGI can detect epicardial conduction abnormalities in ARVC patients. Moreover, the observation of localized delayed RV epicardial conduction in M-carriers suggests an early stage of ARVC and may be a useful diagnostic marker enhancing an early detection of the disease.
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Affiliation(s)
- Varvara Kommata
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Elena Sciaraffia
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Carina Blomström-Lundqvist
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Bandorski D, Heibel S, Höltgen R, Bogossian H, Ghofrani HA, Zarse M, Gall H. Incidence and prognostic significance of malignant arrhythmias during (repetitive) Holter electrocardiograms in patients with pulmonary hypertension. Front Cardiovasc Med 2023; 10:1084051. [PMID: 37139131 PMCID: PMC10150006 DOI: 10.3389/fcvm.2023.1084051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
Background In patients with pulmonary hypertension (PH), increased pulmonary vascular resistance (PVR) may lead to increased right ventricular afterload and cardiac remodelling, potentially providing the substrate for ventricular arrhythmias. Studies dealing with long term monitoring of patients with PH are rare. The present study evaluated the incidence and the types of arrhythmias retrospectively recorded by Holter ECG in patients with newly detected PH during a long-term Holter ECG follow-up. Moreover, their impact on patient survival was evaluated. Patients and methods Medical records were screened for demographic data, aetiology of PH, incidence of coronary heart disease, level of brain natriuretic peptide (BNP), results from Holter ECG monitoring, 6-minute walk test distance, echocardiographic data and hemodynamic data derived from right heart catheterization. Two subgroups were analyzed: 1. patients (n = 65) with PH (group 1 + 4) and derivation of at least 1 Holter ECG within 12 months from initial detection of PH and 2. patients (all PH etiologies, n = 59) with 3 follow-up Holter ECGs. The frequency and complexity of premature ventricular contractions (PVC) was classified into "lower" and "higher" (=non sustained ventricular tachycardia, nsVT) burden. Results Holter ECG revealed sinus rhythm (SR) in most of the patients (n = 60). Incidence of atrial fibrillation (AFib) was low (n = 4). Patients with premature atrial contractions (PAC) tend to have a shorter period of survival (p = 0.098), PVC were not correlated with significant survival differences. During follow-up PAC and PVC were common in all PH groups. Holter ECG revealed non sustained ventricular tachycardia in 19/59 patients [(32.2%); n = 6 during first Holter-ECG, n = 13 during second/third Holter-ECG]. In all patients suffering from nsVT during follow-up previous Holter ECG revealed multiform/repetitive PVC. PVC burden was not linked to differences in systolic pulmonary arterial pressure, right atrial pressure, brain natriuretic peptide and results of six-minute walk test. Conclusion Patients with PAC tend to have a shortened survival. None of the evaluated parameters (BNP, TAPSE, sPAP) was correlated with the development of arrhythmias. Patients with multiform/repetitive PVC seem to be at risk for ventricular arrhythmias.
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Affiliation(s)
- Dirk Bandorski
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Correspondence: Dirk Bandorski
| | - Sebastian Heibel
- Medical Clinic III, Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Reinhard Höltgen
- Klinikum Westmünsterland, St. Agnes-Hospital Bocholt-Rhede, Bocholt, Germany
| | | | - Hossein Ardeschir Ghofrani
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Markus Zarse
- Cardiology Department, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Henning Gall
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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Crooks AV, Hsue W, Tschabrunn CM, Gelzer AR. Feasibility of electroanatomic mapping and radiofrequency catheter ablation in Boxer dogs with symptomatic ventricular tachycardia. J Vet Intern Med 2022; 36:886-896. [PMID: 35307868 PMCID: PMC9151449 DOI: 10.1111/jvim.16412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background Treatment for Boxers with ventricular tachycardia (VT) is limited. Electroanatomic mapping (EAM) facilitates identification of arrhythmogenic substrate for radiofrequency catheter ablation (RFCA). Objective Describe the use of EAM to guide RFCA in Boxers with VT. Animals Five client‐owned Boxers with symptomatic VT or persistent VT despite antiarrhythmic medications. Methods Case series evaluating clinical, EAM, and before and after RFCA Holter data. Results Sustained VT was inducible in 3 dogs, but required aggressive stimulation protocols. Low‐voltage areas consistent with electroanatomic scar were found in 2 dogs, located at the right ventricular (RV) outflow tract and cranial RV. Two dogs had a focal activation pattern of VT and 1 dog had a reentrant mechanism. After RFCA, all dogs no longer collapsed and had fewer runs of VT, 3 of which had 0 runs of VT. Number of ventricular premature beats increased in 3 dogs and decreased in 2 dogs, 1 of which had nearly complete resolution of all arrhythmias. Procedural complications included ventricular fibrillation (n = 2) with successful defibrillation, bruising or hemorrhage at the vascular access site (n = 4), retroperitoneal hemorrhage (n = 1), aortic and mitral regurgitation (n = 1), onset of frequent supraventricular tachycardia (n = 1), and persistent right pelvic limb lameness (n = 1). Conclusions and Clinical Importance Electroanatomic mapping and RFCA are feasible in Boxers with VT. Based on this small cohort, RFCA may help decrease runs of VT and improve clinical signs. The anatomic substrate and electrophysiologic mechanisms are variable and require further study.
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Affiliation(s)
- Alexandra V. Crooks
- Department of Clinical Sciences and Advanced Medicine School of Veterinary Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Weihow Hsue
- Department of Clinical Sciences and Advanced Medicine School of Veterinary Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Cory M. Tschabrunn
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Anna R. Gelzer
- Department of Clinical Sciences and Advanced Medicine School of Veterinary Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
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Abstract
Arrhythmogenic right ventricular cardiomyopathy, formerly called "arrhythmogenic right ventricular dysplasia," is an under-recognized clinical entity characterized by ventricular arrhythmias and a characteristic ventricular pathology. 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 which combine electrocardiographic, echocardiographic, cardiac magnetic resonance imaging and histologic criteria. In 1994, an international task force first proposed the major and minor diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy based on family history, arrhythmias, electrocardiographic abnormalities, tissue characterization, and structural and functional right ventricular abnormalities. In 2010, the task force criteria were revised to include quantitative abnormalities. These diagnostic modalities and the most recent task force criteria are discussed in this review.
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping for tissue characterization beyond arrhythmia definition: A systematic review. Pacing Clin Electrophysiol 2021; 44:1432-1448. [PMID: 34096635 DOI: 10.1111/pace.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits, which can be identified by means of dynamic (activation and propagation) and static (voltage) color-coded maps. However, besides this conventional use, EAM may offer helpful anatomical and functional information for tissue characterisation in several clinical settings. Today, data regarding electromechanical myocardial viability, scar detection in ischaemic and nonischaemic cardiomyopathy and arrhythmogenic right ventricle dysplasia (ARVC/D) definition are mostly consolidated, while emerging results are becoming available in contexts such as Brugada syndrome and cardiac resynchronisation therapy (CRT) implant procedures. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the data in the current literature regarding the use of 3D EAM systems beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giulia Gagno
- Dipartimento di Cardiologia, Azienda Sanitaria Universitaria Giuliano Isontina, ed Università degli Studi di Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Kommata V, Elshafie M, Sciaraffia E, Perez M, Augustine R, Blomström-Lundqvist C. QRS dispersion detected in ARVC patients and healthy gene carriers using 252-leads body surface mapping: an explorative study of a potential diagnostic tool for arrhythmogenic right ventricular cardiomyopathy. Pacing Clin Electrophysiol 2021; 44:1355-1364. [PMID: 34109638 DOI: 10.1111/pace.14295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/26/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers. METHODS ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12-lead resting ECG, signal-averaged ECG, echocardiographic examination, 24-hours Holter monitoring, and BSM with electrocardiographic imaging. All 252-leads BSM recordings and 12-leads ECG recordings were manually analyzed for QRS durations and QRS dispersion. RESULTS Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG-QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM-derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut-off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes. CONCLUSIONS QRS dispersion, when assessed by BSM versus 12-lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM-QRS dispersion in this respect.
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Affiliation(s)
- Varvara Kommata
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Marwa Elshafie
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Elena Sciaraffia
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Mauricio Perez
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
| | - Robin Augustine
- Microwaves in Medical Engineering Group, Solid State Electronics, Department of Engineering Sciences, Angstrom Laboratory, Uppsala University, Box 534, Uppsala, Sweden
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping and characterisation imaging for "right ventricle arrhythmic syndromes" beyond the arrhythmia definition: a comprehensive review. Int J Cardiovasc Imaging 2021; 37:2347-2357. [PMID: 33761057 DOI: 10.1007/s10554-021-02221-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits along with pacing techniques. However, besides this conventional use, EAM may offer helpful anatomical and functional information. Data regarding electromechanical scar detection in ischaemic (and nonischaemic) cardiomyopathy are mostly consolidated, while emerging results are becoming available in contexts such as arrhythmogenic right ventricular dysplasia (ARVC/D) definition and Brugada syndrome. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the current literature regarding the use of 3D EAM systems for right ventricle (RV) functional characterisation beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy.
| | - Giulia Gagno
- Azienda Sanitaria Universitaria Giuliano Isontina - Dipartimento di Cardiologia Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 208] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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12
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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13
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Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease characterized by progressive fibrofatty replacement of the myocardium, right ventricular enlargement, and malignant ventricular arrhythmias. Ventricular tachycardia (VT) may be seen in all stages of the disease and is associated with sudden cardiac death. In patients who failed anti-arrhythmic medical therapy, catheter ablation has become an attractive therapeutic option to reduce VT burden and implantable cardioverter-defibrillator interventions. In this article, the authors aim to address the overall concepts of epicardial catheter ablation in ARVC, focusing on substrate characterization and ablation strategies.
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Affiliation(s)
- Fabrizio R Assis
- ARVC Program, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Harikrishna Tandri
- ARVC Program, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Samanta R, Kumar S, Chik W, Qian P, Barry MA, Al Raisi S, Bhaskaran A, Farraha M, Nadri F, Kizana E, Thiagalingam A, Kovoor P, Pouliopoulos J. Influence of Intramyocardial Adipose Tissue on the Accuracy of Endocardial Contact Mapping of the Chronic Myocardial Infarction Substrate. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004998. [PMID: 29038101 DOI: 10.1161/circep.116.004998] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 08/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies have demonstrated that intramyocardial adipose tissue (IMAT) may contribute to ventricular electrophysiological remodeling in patients with chronic myocardial infarction. Using an ovine model of myocardial infarction, we aimed to determine the influence of IMAT on scar tissue identification during endocardial contact mapping and optimal voltage-based mapping criteria for defining IMAT dense regions. METHOD AND RESULTS In 7 sheep, left ventricular endocardial and transmural mapping was performed 84 weeks (15-111 weeks) post-myocardial infarction. Spearman rank correlation coefficient was used to assess the relationship between endocardial contact electrogram amplitude and histological composition of myocardium. Receiver operator characteristic curves were used to derive optimal electrogram thresholds for IMAT delineation during endocardial mapping and to describe the use of endocardial mapping for delineation of IMAT dense regions within scar. Endocardial electrogram amplitude correlated significantly with IMAT (unipolar r=-0.48±0.12, P<0.001; bipolar r=-0.45±0.22, P=0.04) but not collagen (unipolar r=-0.36±0.24, P=0.13; bipolar r=-0.43±0.31, P=0.16). IMAT dense regions of myocardium reliably identified using endocardial mapping with thresholds of <3.7 and <0.6 mV, respectively, for unipolar, bipolar, and combined modalities (single modality area under the curve=0.80, P<0.001; combined modality area under the curve=0.84, P<0.001). Unipolar mapping using optimal thresholding remained significantly reliable (area under the curve=0.76, P<0.001) during mapping of IMAT, confined to putative scar border zones (bipolar amplitude, 0.5-1.5 mV). CONCLUSIONS These novel findings enhance our understanding of the confounding influence of IMAT on endocardial scar mapping. Combined bipolar and unipolar voltage mapping using optimal thresholds may be useful for delineating IMAT dense regions of myocardium, in postinfarct cardiomyopathy.
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Affiliation(s)
- Rahul Samanta
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Saurabh Kumar
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - William Chik
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pierre Qian
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Michael A Barry
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Sara Al Raisi
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Abhishek Bhaskaran
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Melad Farraha
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Fazlur Nadri
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Eddy Kizana
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Aravinda Thiagalingam
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pramesh Kovoor
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Jim Pouliopoulos
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.).
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16
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Hsieh WH, Lin CY, Te ALD, Lo MT, Wu CI, Chung FP, Chang YC, Chang SL, Lin C, Lo LW, Hu YF, Liao JN, Chen YY, Jhuo SJ, Raharjo SB, Lin YJ, Chen SA. A novel noninvasive surface ECG analysis using interlead QRS dispersion in arrhythmogenic right ventricular cardiomyopathy. PLoS One 2017; 12:e0182364. [PMID: 28771538 PMCID: PMC5542590 DOI: 10.1371/journal.pone.0182364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/17/2017] [Indexed: 11/19/2022] Open
Abstract
Background This study investigated the feasibility of using the precordial surface ECG lead interlead QRS dispersion (IQRSD) in the identification of abnormal ventricular substrate in arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods Seventy-one consecutive patients were enrolled and reclassified into 4 groups: definite ARVC with epicardial ablation (Group 1), ARVC with ventricular tachycardia (VT, Group 2), idiopathic right ventricular outflow tract VT without ARVC (Group 3), and controls without VT (Group 4). IQRSD was quantified by the angular difference between the reconstruction vectors obtained from the QRS-loop decomposition, based on a principal component analysis (PCA). Electroanatomic mapping and simulated ECGs were used to investigate the relationship between QRS dispersion and abnormal substrate. Results The percentage of the QRS loop area in the Group 1–2 was smaller than the controls (P = 0.01). The IQRSD between V1-V2 could differentiate all VTs from control (P<0.01). Group 1–2 had a greater IQRSD than the Group 3–4 (V4-V5,P = 0.001), and Group 1 had a greater IQRSD than Group 3–4 (V6-Lead I, P<0.001). Both real and simulated data had a positive correlation between the maximal IQRSD (γ = 0.62) and the extent of corresponding abnormal substrate (γ = 0.71, both P<0.001). Conclusions The IQRSD of the surface ECG precordial leads successfully differentiated ARVC from controls, and could be used as a noninvasive marker to identify the abnormal substrate and the status of ARVC patients who can benefit from epicardial ablation.
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Affiliation(s)
- Wan-Hsin Hsieh
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, Taipei Veterans General Hospital, Yuan-Shan Branch, I-Lan, Taiwan
| | - Abigail Louise D. Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- HB Calleja Heart and Vascular Institute, St. Luke’s Medical Center, Quezon City, Philippines
| | - Men-Tzung Lo
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Cheng-I Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Chung Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chen Lin
- Institute of Translational and Interdisciplinary Medicine and Department of Biomedical Sciences and Engineering, National Central University, Chung-Li, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jie Jhuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sunu Budhi Raharjo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (YJL); (SAC)
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail: (YJL); (SAC)
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17
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Chen X, Chen L, Chen Z, Chen X, Song J. Remodelling of myocardial intercalated disc protein connexin 43 causes increased susceptibility to malignant arrhythmias in ARVC/D patients. Forensic Sci Int 2017; 275:14-22. [DOI: 10.1016/j.forsciint.2017.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/25/2017] [Accepted: 02/18/2017] [Indexed: 10/20/2022]
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18
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Castro SA, Pathak RK, Muser D, Santangeli P, Owens A, Marchlinski F, Garcia FC. Incremental value of electroanatomical mapping for the diagnosis of arrhythmogenic right ventricular cardiomyopathy in a patient with sustained ventricular tachycardia. HeartRhythm Case Rep 2017; 2:469-472. [PMID: 28491739 PMCID: PMC5419974 DOI: 10.1016/j.hrcr.2016.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Simon A Castro
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajeev K Pathak
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniele Muser
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anjali Owens
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Latt H, Tun Aung T, Roongsritong C, Smith D. A classic case of arrhythmogenic right ventricular cardiomyopathy (ARVC) and literature review. J Community Hosp Intern Med Perspect 2017. [PMID: 28638576 PMCID: PMC5473197 DOI: 10.1080/20009666.2017.1302703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a relatively under-recognized hereditary cardiomyopathy. It is characterized pathologically by fibro-fatty infiltration of right ventricular (RV) myocardium and clinically by consequences of RV electrical instability. Timely intervention with device therapy and pharmacotherapy may help reduce the risk of arrhythmic events or sudden cardiac death. Here, we describe a classic case of a young adult with ARVC and a brief literature review. The patient presented with exertional palpitations and ARVC was suspected after his routine electrocardiogram (EKG) revealed symmetric T wave inversions and possible epsilon waves in right precordial leads. Subsequent work up showed fatty infiltration of RV myocardium on cardiac magnetic resonance imaging and inducible ventricular tachycardia from the right ventricle during electrophysiologic study. Those findings confirmed the diagnosis of ARVC and warranted treatment with implantable cardioverter defibrillator. It is always exciting to encounter rare pathological entities with classic clinical findings, especially when they present as a diagnostic challenge.We were able to provide correct diagnosis and management, thereby preventing the potentially lethal consequences. Therefore, it is important to recognize the possible EKG findings of ARVC and to know when to pursue further investigations and to implement therapies.
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Affiliation(s)
- Htun Latt
- Department of Internal Medicine, University of Nevada, Reno, NV, USA
| | - Thein Tun Aung
- Department of Cardiology, Good Samaritan Hospital, Dayton, OH, USA
| | - Chanwit Roongsritong
- Department of Heart and Vascular Health, Renown Regional Medical Center, Reno, NV, USA
| | - David Smith
- Department of Heart and Vascular Health, Renown Regional Medical Center, Reno, NV, USA
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Abstract
PURPOSE OF REVIEW This review will discuss the recent advances in the diagnosis and management of arrhythmogenic right ventricular cardiomyopathy (ARVC). RECENT FINDINGS Since the first detailed clinical description of the disease in 1982, we have learned much about the genetics, pathophysiology, diagnosis, and management of ARVC. We now appreciate that pathogenic mutations in desmosomal genes are the most common genetic finding. Although the right ventricle is mostly affected, left ventricular involvement is being increasingly recognized. Electrical instability precipitating sudden cardiac death often presents before structural abnormalities, and therefore early accurate diagnosis is of utmost importance. The broad spectrum of phenotypic variation, age-related penetrance, and lack of a definitive diagnostic test make the clinical diagnosis challenging. The diagnosis is made by fulfilling the 2010 Task Force criteria. Today, genetic testing and cardiac MRI play an important role in the diagnosis. Implantable cardioverter defibrillator implantation is the only lifesaving therapy available today for a subset of patients. In patients with recurrent ventricular arrhythmias, epicardial catheter ablation has demonstrated improved outcomes compared with endocardial ablation. Exercise restriction may delay the progression of disease. SUMMARY ARVC is predominantly associated with mutations in desmosomal genes with incomplete penetrance and variable expressivity. Ventricular electrical instability is the hallmark of ARVC, often occurring before structural abnormalities. Goals in the evaluation and management of ARVC are early diagnosis, risk stratification for sudden cardiac death, minimizing ventricular arrhythmias, and delaying the progression of disease.
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Abstract
Myocardial involvement in patients with sarcoidosis can be difficult to diagnose, and requires a high index of suspicion and low threshold for screening. The presentation of cardiac sarcoidosis is variable, and can range from asymptomatic electrocardiographic changes to sudden cardiac death. This review provides an overview of the arrhythmic consequences of cardiac sarcoidosis, with emphasis on the electrophysiologist's role in recognition, diagnostic testing, and management of this rare disease.
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Affiliation(s)
- Matthew M Zipse
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, 12401 East 17th Avenue, B132, Aurora, CO 80045, USA
| | - William H Sauer
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, 12401 East 17th Avenue, B132, Aurora, CO 80045, USA.
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Lin T, Conti S, Cipolletta L, Marino V, Zucchetti M, Russo E, Pizzamiglio F, AlMohani G, Pala S, Catto V, Biase LD, Natale A, Tondo C, Carbucicchio C. Right Ventricular Outflow Tract Arrhythmias: Benign Or Early Stage Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia? J Atr Fibrillation 2014; 7:1161. [PMID: 27957137 DOI: 10.4022/jafib.1161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 10/24/2014] [Accepted: 10/24/2014] [Indexed: 01/01/2023]
Abstract
Ventricular arrhythmias (VAs) arising from the right ventricular outflow tract (RVOT) are a common and heterogeneous entity. Idiopathic right ventricular arrhythmias (IdioVAs) are generally benign, with excellent ablation outcomes and long-term arrhythmia-free survival, and must be distinguished from other conditions associated with VAs arising from the right ventricle: the differential diagnosis with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is therefore crucial because VAs are one of the most important causes of sudden cardiac death (SCD) in young individuals even with early stage of the disease. Radiofrequency catheter ablation (RFCA) is a current option for the treatment of VAs but important differences must be considered in terms of indication, purposes and procedural strategies in the treatment of the two conditions. In this review, we comprehensively discuss clinical and electrophysiological features, diagnostic and therapeutic techniques in a compared analysis of these two entities.
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Affiliation(s)
- Tina Lin
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Sergio Conti
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Laura Cipolletta
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Vittoria Marino
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Martina Zucchetti
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Eleonora Russo
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Ghaliah AlMohani
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Salvatore Pala
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Valentina Catto
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Luigi Di Biase
- Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA
| | - Andrea Natale
- Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA; Texas Cardiac Arrhytmia Institute at St David's Medical Centre, Austin , TX, USA
| | - Claudio Tondo
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Corrado Carbucicchio
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino IRCCS, Milan, Italy
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Zorzi A, Migliore F, Elmaghawry M, Silvano M, Marra MP, Niero A, Nguyen K, Rigato I, Bauce B, Basso C, Thiene G, Iliceto S, Corrado D. Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification. J Cardiovasc Electrophysiol 2013; 24:1321-7. [PMID: 24016194 DOI: 10.1111/jce.12246] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/09/2013] [Accepted: 07/12/2013] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The extent of right ventricular (RV) electroanatomic scar (EAS) detected by endocardial voltage mapping (EVM) is a powerful invasive predictor of arrhythmic outcome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Electrocardiogram (ECG) and signal-averaged ECG are noninvasive tools of established clinical value for the diagnosis of electrical abnormalities in ARVC. This study was designed to assess the role of ECG and SAECG abnormalities for noninvasive estimation of the extent and regional distribution of RV-EAS and prediction of scar-related arrhythmic risk. METHODS AND RESULTS The study population included 49 consecutive patients (38 males, median age 35 years) with a definite diagnosis of ARVC and an abnormal EVM by CARTO system. At univariate analysis, the presence of epsilon waves, the degree of RV dilation, the severity of RV dysfunction, and the extent of negative T waves correlated with RV-EAS% area. Normal T-waves were associated with a median RV-EAS% area of 4.9% (4.5-6.4), negative T waves in V1-V3 of 22.0% (8.5-30.6), negative T waves in V1-V3 extending to lateral precordial leads (V4-V6) of 26.8% (11.5-35.2), and negative T waves in both precordial (V2-V6) and inferior leads of 30.2% (24.8-33.0) (P < 0.001). At multivariate analysis, the extent of negative T waves remained the only independent predictor of RV-EAS% area (B = 4.4, 95%CI 1.3-7.4, P = 0.006) and correlated with the arrhythmic event-rate during follow-up (P = 0.03). CONCLUSIONS In patients with ARVC, the extent of negative T-waves across 12-lead ECG allows noninvasive estimation of the amount of RV-EAS and prediction of EAS-related arrhythmic risk.
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Affiliation(s)
- Alessandro Zorzi
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
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Migliore F, Zorzi A, Silvano M, Bevilacqua M, Leoni L, Marra MP, Elmaghawry M, Brugnaro L, Dal Lin C, Bauce B, Rigato I, Tarantini G, Basso C, Buja G, Thiene G, Iliceto S, Corrado D. Prognostic value of endocardial voltage mapping in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circ Arrhythm Electrophysiol 2013; 6:167-76. [PMID: 23392584 DOI: 10.1161/circep.111.974881] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Endocardial voltage mapping (EVM) identifies low-voltage right ventricular (RV) areas, which may represent the electroanatomic scar substrate of life-threatening tachyarrhythmias. We prospectively assessed the prognostic value of EVM in a consecutive series of patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). METHODS AND RESULTS We studied 69 consecutive ARVC/D patients (47 males; median age 35 years [28-45]) who underwent electrophysiological study and both bipolar and unipolar EVM. The extent of confluent bipolar (<1.5 mV) and unipolar (<6.0 mV) low-voltage electrograms was estimated using the CARTO-incorporated area calculation software. Fifty-three patients (77%) showed ≥1 RV electroanatomic scars with an estimated burden of bipolar versus unipolar low-voltage areas of 24.8% (7.2-31.5) and 64.8% (39.8-95.3), respectively (P=0.009). In the remaining patients with normal bipolar EVM (n=16; 23%), the use of unipolar EVM unmasked ≥1 region of low-voltage electrogram affecting 26.2% (11.6-38.2) of RV wall. During a median follow-up of 41 (28-56) months, 19 (27.5%) patients experienced arrhythmic events, such as sudden death (n=1), appropriate implantable cardioverter defibrillator interventions (n=7), or sustained ventricular tachycardia (n=11). Univariate predictors of arrhythmic outcome included previous cardiac arrest or syncope (hazard ratio=3.4; 95% confidence interval, 1.4-8.8; P=0.03) and extent of bipolar low-voltage areas (hazard ratio=1.7 per 5%; 95% confidence interval, 1.5-2; P<0.001), whereas the only independent predictor was the bipolar low-voltage electrogram burden (hazard ratio=1.6 per 5%; 95% confidence interval, 1.2-1.9; P<0.001). Patients with normal bipolar EVM had an uneventful clinical course. CONCLUSIONS The extent of bipolar RV endocardial low-voltage area was a powerful predictor of arrhythmic outcome in ARVC/D, independently of history and RV dilatation/dysfunction. A normal bipolar EVM characterized a low-risk subgroup of ARVC/D patients.
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Affiliation(s)
- Federico Migliore
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Medical School, Padova, Italy
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Berruezo A, Fernández-Armenta J, Mont L, Zeljko H, Andreu D, Herczku C, Boussy T, Tolosana JM, Arbelo E, Brugada J. Combined endocardial and epicardial catheter ablation in arrhythmogenic right ventricular dysplasia incorporating scar dechanneling technique. Circ Arrhythm Electrophysiol 2011; 5:111-21. [PMID: 22205683 DOI: 10.1161/circep.110.960740] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Ventricular tachycardia (VT) ablation in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) has a low success rate. A more extensive epicardial (Epi) arrhythmogenic substrate could explain the low efficacy. We report the results of combined endocardial (Endo) and Epi VT ablation and conducting channel (CC) elimination. METHODS AND RESULTS Eleven consecutive patients with ARVD/C were included in the study. A high-density 3D Endo (321±93 sites mapped) and Epi (302±158 sites mapped) electroanatomical voltage map was obtained during sinus rhythm to define scar areas (<1.5 mV) and CCs inside the scars, between scars, or between the tricuspid annulus and a scar. The end point of the ablation procedure was the elimination of all identified CCs (scar dechanneling) and the abolition of all inducible VTs. The mean procedure and fluoroscopy time were 177±63 minutes and 20±8 minutes, respectively. Epi scar area was larger in all cases (26±18 versus 94±45 cm(2), P<0.01). The combined Endo and Epi VT ablation eliminated all clinical and induced VTs, and the addition of scar dechanneling resulted in noninducibility in all cases. Seven patients continued on sotalol. During a median follow-up of 11 months (6-24 months), only 1 (9%) patient had a VT recurrence. There was a single major bleeding event that did not preclude a successful procedure. CONCLUSIONS Combined Endo and Epi mapping reveals a wider Epi VT substrate in patients with ARVD/C with clinical VTs. As a first-line therapy, combined Endo and Epi VT ablation incorporating scar dechanneling achieves a very good short- and midterm success rate.
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Affiliation(s)
- Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS, Barcelona, Catalonia, Spain.
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Marra MP, Leoni L, Bauce B, Corbetti F, Zorzi A, Migliore F, Silvano M, Rigato I, Tona F, Tarantini G, Cacciavillani L, Basso C, Buja G, Thiene G, Iliceto S, Corrado D. Imaging study of ventricular scar in arrhythmogenic right ventricular cardiomyopathy: comparison of 3D standard electroanatomical voltage mapping and contrast-enhanced cardiac magnetic resonance. Circ Arrhythm Electrophysiol 2011; 5:91-100. [PMID: 22139887 DOI: 10.1161/circep.111.964635] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The hallmark lesion of arrhythmogenic right ventricular cardiomyopathy (ARVC) is fibrofatty scar replacement. We compared endocardial voltage mapping (EVM) and contrast-enhanced cardiac magnetic resonance (CE-CMR) for imaging scar lesions in ARVC patients. METHODS AND RESULTS We studied 23 consecutive ARVC patients (16 males; mean age, 38±12 years) who underwent RV EVM and CE-CMR and 37 control subjects. In 21 (91%) of 23 ARVC patients, RV EVM was abnormal, with a total of 45 electroanatomical scars (EAS): 17 (38%) in the inferobasal region, 12 (26.6%) in the anterolateral region, 8 (17.7%) in the RV outflow tract (RVOT), and 8 (17.7%) in the apex. RV delayed contrast enhancement (DCE) was found in 9 (39%) of 23 patients, with a total of 23 RV DCE scars: 4 (17.4%) in the inferobasal region, 9 (39.1%) in the anterolateral region, 4 (17.4%) in the RVOT, and 6 (26.1%) in the apex. There was a mismatch in 24 RV scars, with 22 EAS not confirmed by DCE and 2 DCE scars (both in the RVOT) undetected by EVM. In 9 (75%) of 12 patients with abnormal RV EVM/normal RV DCE, ≥1 DCEs were identified in the left ventricle (LV). Overall, ventricular DCE was detected in 78% of patients. No control subjects showed either EAS or DCE. CONCLUSIONS EVM and CE-CMR allow identification of RV scar lesions in most ARVC patients. CE-CMR is less sensitive than EVM in identifying RV scar lesions. The high prevalence of LV DCE confirms the frequent biventricular involvement and indicates the diagnostic relevance of LV scar detection by CE-CMR.
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Affiliation(s)
- Martina Perazzolo Marra
- Departments of Cardiac, Thoracic, and Vascular Sciences, Radiology, and Medical-Diagnostic Sciences and Special Therapies, University of Padua Medical School, Padua, Italy
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Furushima H, Chinushi M, Iijima K, Izumi D, Hosaka Y, Aizawa Y. Relationship between electroanatomical voltage mapping characteristics and breakout site of ventricular activation in idiopathic ventricular tachyarrhythmia originating from the right ventricular outflow tract septum. J Interv Card Electrophysiol 2012; 33:135-41. [DOI: 10.1007/s10840-011-9623-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 09/04/2011] [Indexed: 11/25/2022]
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Affiliation(s)
- Simon Modi
- Arrhythmia Service, London Health Sciences Centre, 339 Windermere Road, London, Ontario, Canada
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Abstract
There are various underlying causes of tachycardia-induced cardiomyopathy (TIC), and it is critical that it be considered in any patient who presents with a newly diagnosed dilated cardiomyopathy. Unlike most other forms of cardiomyopathy, TIC should be considered a treatable form of cardiomyopathy and it is imperative that the diagnosis be fully considered. A 12-lead ECG should be obtained in all patients with a dilated cardiomyopathy. Prompt diagnosis and therapy of this relatively uncommon cause of heart failure is critical and has the potential to completely reverse the ventricular dysfunction that may be present in this abnormality.
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Affiliation(s)
- Stuart Berger
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53217, USA.
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Polin GM, Haqqani H, Tzou W, Hutchinson MD, Garcia FC, Callans DJ, Zado ES, Marchlinski FE. Endocardial unipolar voltage mapping to identify epicardial substrate in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Heart Rhythm 2010; 8:76-83. [PMID: 20933099 DOI: 10.1016/j.hrthm.2010.09.088] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 09/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND The risk and success of epicardial substrate ablation for ventricular tachycardia (VT) support the value of techniques identifying the epicardial substrate with endocardial mapping. OBJECTIVE The purpose of this study was to test the hypothesis that endocardial unipolar voltage mapping in patients with right ventricular (RV) VT and preserved endocardial bipolar voltage abnormalities might identify the extent of epicardial bipolar voltage abnormality. METHODS Using a cutoff of < 5.5 mV for normal endocardial unipolar voltage derived from 8 control patients without structural heart disease, 10 patients with known ARVC/D (group 1, retrospective) and 13 patients with RV VT (group 2, prospective) with modest or no endocardial bipolar voltage abnormalities underwent detailed endocardial and epicardial mapping. RESULTS The area of epicardial unipolar voltage abnormality in all 10 group 1 patients with ARVC/D (62 ± 21 cm²) and in 9 of the 13 group 2 patients (8 with criteria for ARVC/D) (53 ± 21 cm²) was on average three times more extensive than the endocardial bipolar abnormality and correlated (r = 0.63, P <.05 and r = 0.81, P <.008, respectively) with the larger area epicardial bipolar abnormality with respect to size (group 1: 82 ± 22 cm²; group 2: 68 ± 41 cm²) and location. In the remaining 4 group 2 patients and 3 additional reference patients without structural heart disease, endocardial bipolar, endocardial unipolar, and, as predicted, epicardial bipolar voltage all were normal. CONCLUSION Endocardial unipolar mapping with cutoff of 5.5 mV identifies more extensive areas of epicardial bipolar signal abnormalities in patients with ARVC/D and limited endocardial VT substrate.
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Affiliation(s)
- Glenn M Polin
- Section of Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Aquaro GD, Pingitore A, Strata E, Di Bella G, Molinaro S, Lombardi M. Cardiac magnetic resonance predicts outcome in patients with premature ventricular complexes of left bundle branch block morphology. J Am Coll Cardiol 2010; 56:1235-43. [PMID: 20883930 DOI: 10.1016/j.jacc.2010.03.087] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 02/19/2010] [Accepted: 03/10/2010] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We investigated whether the presence of right ventricular (RV) abnormalities detected by cardiovascular magnetic resonance (CMR) predict adverse outcome in patients presenting with frequent premature ventricular complexes (PVCs) of left bundle branch block (LBBB) morphology. BACKGROUND CMR is a component of the diagnostic workup for the differential diagnosis between arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) and idiopathic RV tachycardia. RV abnormalities evaluated by CMR could have prognostic importance. METHODS Four hundred forty consecutive patients with >1,000 PVCs of LBBB morphology (minor diagnostic criterion of ARVC/D) and no other pre-existing criteria were prospectively enrolled. RV wall motion (WM), signal abnormalities, dilation, and reduced ejection fraction evaluated by CMR were considered imaging criteria of ARVC/D. Follow-up was performed evaluating an index composite end point of 3 cardiac events: cardiac death, resuscitated cardiac arrest, and appropriate implantable cardiac-defibrillator shock. RESULTS Subjects with multiple RV abnormalities (RVA-2 group) had worse outcome than the no-RVA group (hazard ratio [HR]: 48.6; 95% confidence interval [CI]: 6.1 to 384.8; p < 0.001). Of the 61 patients in the RVA-2 group, only 6 had a definite diagnosis of ARVC/D applying the Task Force Criteria. Also, subjects with a single imaging criterion (RVA-1 group) had worse outcome than the no-RVA group (HR: 18.2; 95% CI: 2.0 to 162.6; p = 0.01). Patients with only WM abnormalities had higher prevalence of cardiac events than no-RVA (HR: 27.2; 95% CI: 3.0 to 244.0; p = 0.03). CONCLUSIONS In subjects with frequent PVC of LBBB morphology, CMR allows risk stratification. RV abnormalities were associated with worse outcome.
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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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Avella A, d'Amati G, Zachara E, Musumeci F, Tondo C. 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] [What about the content of this article? (0)] [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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YAMASHINA YOSHIHIRO, YAGI TETSUO, NAMEKAWA AKIO, ISHIDA AKIHIKO, SATO HIROKAZU, NAKAGAWA TAKASHI, SAKURAMOTO MANJIROU, SATO EIJI, YAMBE TOMOYUKI. Clinical and Electrophysiological Difference Between Idiopathic Right Ventricular Outflow Tract Arrhythmias and Pulmonary Artery Arrhythmias. J Cardiovasc Electrophysiol 2010; 21:163-9. [DOI: 10.1111/j.1540-8167.2009.01601.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is a genetically determined myocardial disease characterized by fibrofatty replacement of the right ventricular wall. Ventricular tachyarrhythmias can be seen in the early stages of the disease, which is one of the most important causes of sudden death in young healthy individuals. Radiofrequency (RF) catheter ablation is an option for the treatment of medically refractory ventricular arrhythmias and it has shown to successfully abolish recurrent ventricular tachycardias (VT) as well as reduce the frequency in defibrillator therapies. However, variable acute and long-term success rates have been reported. The current mapping and ablation techniques include activation and entrainment mapping during tolerated VT and substrate ablation using 3-dimensional electroanatomic mapping systems. This article aims at providing a comprehensive review of RF catheter ablation of ventricular arrhythmias in the context of ARVD.
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Affiliation(s)
- Elena Arbelo
- Cardiology Service, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain.
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Casella M, Perna F, Dello Russo A, Pelargonio G, Bartoletti S, Ricco A, Sanna T, Pieroni M, Forleo G, Pappalardo A, Di Biase L, Natale L, Bellocci F, Zecchi P, Natale A, Tondo C. Right ventricular substrate mapping using the Ensite Navx system: Accuracy of high-density voltage map obtained by automatic point acquisition during geometry reconstruction. Heart Rhythm 2009; 6:1598-605. [PMID: 19786371 DOI: 10.1016/j.hrthm.2009.07.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 07/19/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Contact point-to-point electroanatomic mapping (Pt-Map) is a validated tool to evaluate right ventricular (RV) substrate. When using the EnSite NavX system (St. Jude Medical, St Paul, Minnesota), geometry reconstruction by dragging the mapping catheter (Geo-Map) allows for quicker acquisition of a large number of points and better definition of anatomy, but it is not validated for substrate mapping. OBJECTIVE This study evaluates the feasibility and accuracy of Geo-Map. METHODS Thirteen patients (mean age 38 +/- 12 years) with RV arrhythmias and an apparently normal heart underwent cardiac magnetic resonance imaging (MRI), Pt-Map, and Geo-Map. The 2 maps were compared in terms of mapping procedural time, radiation time, and total number of points acquired. We finally compared the number and characteristics of low-potential areas on each patient's Pt-Map, Geo-Map, and cardiac MRI. RESULTS Geo-Map required significantly shorter mapping and radiation times in comparison to Pt-Map (12.4 +/- 4.6 vs. 31.9 +/- 10.1 and 5.8 +/- 2.1 vs. 12.1 +/- 3.9, P <.001). Furthermore, Geo-Map was based on a significantly higher density of points in comparison to Pt-Map (802 +/- 205 vs. 194 +/- 38, P <.001). Taking into consideration the total number of RV regions analyzed, the Pt-Map and Geo-Map disagreed in 2 of 65 (3%) regions (P = NS), which only Geo-Map identified as low-potential areas and indeed corresponded to wall motion abnormalities on MRI. CONCLUSION Voltage maps obtained through RV geometry acquisition have accuracy comparable to that of conventional point-by-point mapping in detecting low-voltage areas, have a good correlation with MRI wall motion abnormalities, and allow a significant reduction in procedural time and x-ray exposure.
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Affiliation(s)
- Michela Casella
- Cardiac Arrhythmia and Heart Failure Research Center, Catholic University of the Sacred Heart, San Camillo-Forlanini Hospital, Rome, Italy.
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Haapalahti P, Viitasalo M, Kaartinen M, Väänänen H, Oikarinen L, Heliö T, Toivonen L. Electrocardiographic ventricular repolarization during cardiovascular autonomic function testing in patients with arrhythmogenic right ventricular cardiomyopathy. SCAND CARDIOVASC J 2009; 42:375-82. [DOI: 10.1080/14017430802192337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yamashina Y, Yagi T, Namekawa A, Ishida A, Sato H, Nakagawa T, Sakuramoto M, Sato E, Yambe T. Distribution of Successful Ablation Sites of Idiopathic Right Ventricular Outflow Tract Tachycardia. Pacing and Clinical Electrophysiology 2009; 32:727-33. [PMID: 19545334 DOI: 10.1111/j.1540-8159.2009.02358.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Marras E, Basso C, Sciarra L, Delise P. Unexplained syncope, Brugada-like ECG and minimal structural right ventricular abnormalities: which is the right diagnosis? J Cardiovasc Med (Hagerstown) 2009; 10:273-5. [DOI: 10.2459/jcm.0b013e328322fc09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a genetic cardiomyopathy characterized by ventricular arrhythmias and structural abnormalities of the right ventricle (RV). The diagnosis is based on the International Task Force criteria. Cardiologists may not be aware of these diagnostic criteria for ARVC/D and may place too much importance on the results of MRI imaging of the right ventricle. Patients with ARVC/D usually have an abnormal 12-lead electrocardiogram, abnormal echocardiogram, and ventricular arrhythmias with a left bundle branch block morphology. If noninvasive testing suggests ARVC/D, invasive testing with an RV angiogram, RV biopsy, and electrophysiologic study is recommended. Once a diagnosis of ARVC/D is established, the main treatment decision involves whether to implant an implantable cardioverter-defibrillator. We also recommend treatment with beta blockers. Patients with ARVC/D are encouraged to avoid competitive athletics. Recent advances in the understanding of the genetic basis of ARVC/D have revealed that ARVC/D is a disease of desmosomal dysfunction.
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REITHMANN CHRISTOPHER, ULBRICH MICHAEL, HAHNEFELD ANTON, HUBER ARMIN, MATIS TOMAS, STEINBECK GERHARD. Analysis during Sinus Rhythm and Ventricular Pacing of Reentry Circuit Isthmus Sites in Right Ventricular Cardiomyopathy. Pacing Clin Electrophysiol 2008; 31:1535-45. [DOI: 10.1111/j.1540-8159.2008.01224.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arruda M, Armaganijan L, Fahmy T, Di Biase L, Patel D, Natale A. Catheter ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia. J Interv Card Electrophysiol 2009; 25:129-33. [DOI: 10.1007/s10840-008-9317-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 09/09/2008] [Indexed: 10/21/2022]
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Rizzi N, Liu N, Napolitano C, Nori A, Turcato F, Colombi B, Bicciato S, Arcelli D, Spedito A, Scelsi M, Villani L, Esposito G, Boncompagni S, Protasi F, Volpe P, Priori SG. Unexpected structural and functional consequences of the R33Q homozygous mutation in cardiac calsequestrin: a complex arrhythmogenic cascade in a knock in mouse model. Circ Res 2008; 103:298-306. [PMID: 18583715 DOI: 10.1161/circresaha.108.171660] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmogenic disorder characterized by life threatening arrhythmias elicited by physical and emotional stress in young individuals. The recessive form of CPVT is associated with mutation in the cardiac calsequestrin gene (CASQ2). We engineered and characterized a homozygous CASQ2(R33Q/R33Q) mouse model that closely mimics the clinical phenotype of CPVT patients. CASQ2(R33Q/R33Q) mice develop bidirectional VT on exposure to environmental stress whereas CASQ2(R33Q/R33Q) myocytes show reduction of the sarcoplasmic reticulum (SR) calcium content, adrenergically mediated delayed (DADs) and early (EADs) afterdepolarizations leading to triggered activity. Furthermore triadin, junctin, and CASQ2-R33Q proteins are significantly decreased in knock-in mice despite normal levels of mRNA, whereas the ryanodine receptor (RyR2), calreticulin, phospholamban, and SERCA2a-ATPase are not changed. Trypsin digestion studies show increased susceptibility to proteolysis of mutant CASQ2. Despite normal histology, CASQ2(R33Q/R33Q) hearts display ultrastructural changes such as disarray of junctional electron-dense material, referable to CASQ2 polymers, dilatation of junctional SR, yet normal total SR volume. Based on the foregoings, we propose that the phenotype of the CASQ2(R33Q/R33Q) CPVT mouse model is portrayed by an unexpected set of abnormalities including (1) reduced CASQ2 content, possibly attributable to increased degradation of CASQ2-R33Q, (2) reduction of SR calcium content, (3) dilatation of junctional SR, and (4) impaired clustering of mutant CASQ2.
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Affiliation(s)
- Nicoletta Rizzi
- Molecular Cardiology, IRCCS Maugeri Foundation, Pavia, Italy
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Avella A, d'Amati G, Pappalardo A, Re F, Silenzi PF, Laurenzi F, DE Girolamo P, Pelargonio G, Dello Russo A, Baratta P, Messina G, Zecchi P, Zachara E, Tondo C. Diagnostic value of endomyocardial biopsy guided by electroanatomic voltage mapping in arrhythmogenic right ventricular cardiomyopathy/dysplasia. J Cardiovasc Electrophysiol 2008; 19:1127-34. [PMID: 18554207 DOI: 10.1111/j.1540-8167.2008.01228.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UNLABELLED Voltage Mapping-Guided Biopsy in ARVC/D. INTRODUCTION To improve the endomyocardial biopsy (EMB) diagnostic sensitivity for arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D), we hypothesized a biopsy sampling focused on selected right ventricle (RV) low-voltage areas identified by electroanatomic voltage mapping. METHODS AND RESULTS The study population (22 patients, 10 men; mean age 34 +/- 10 years) included 11 patients with overt ARVC/D (group A) and 11 patients with suspected ARVC/D (group B), according to both arrhythmic profile and standardized noninvasive diagnostic criteria. In all 22 patients, an RV bipolar voltage mapping was performed with CARTO system sampling multiple endocardial sites (262 +/- 61), during sinus rhythm, with a 0.5-1.5 mV color range setting of voltage display. All 11 (100%) group A patients and 8 of the 11 (73%) group B patients (P = nonsignificant [NS]) presented RV low-voltage areas (<0.5 mV). In 8 group A patients and in all 8 group B patients with a pathological RV voltage map, an EMB focused on the low-voltage areas was performed. In 6 (75%) group A patients and in 7 (87%) group B patients (P = NS), voltage mapping-guided EMB was diagnostic for ARVC/D. In the remaining 3 patients, only nonspecific histological findings were observed. CONCLUSIONS The results of our study (1) confirm the high diagnostic sensitivity of RV voltage mapping in patients with overt ARVC/D, (2) document a high prevalence of RV low-voltage areas even in patients with suspected ARVC/D, and (3) demonstrate that in patients with clinical evidence or suspicion for ARVC/D, presenting RV low-voltage areas, EMB guided by voltage mapping may provide ARVC/D diagnosis confirmation.
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Affiliation(s)
- Andrea Avella
- Cardiology Division, Cardiac Arrhythmia and Heart Failure Research Institute, St Camillo-Forlanini Hospital/Catholic University of Sacred Heart, Rome, Italy.
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Takemura N, Kono K, Tadokoro K, Shinbo G, Ito I, Abe C, Matsuhashi N, Iemura T, Nishikimi T, Horinaka S, Matsuoka H. Right atrial abnormalities in a patient with arrhythmogenic right ventricular cardiomyopathy without ventricular tachycardia. J Cardiol 2008; 51:205-9. [DOI: 10.1016/j.jjcc.2008.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 03/03/2008] [Accepted: 03/03/2008] [Indexed: 10/22/2022]
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Corrado D, Basso C, Leoni L, Tokajuk B, Turrini P, Bauce B, Migliore F, Pavei A, Tarantini G, Napodano M, Ramondo A, Buja G, Iliceto S, Thiene G. Three-dimensional electroanatomical voltage mapping and histologic evaluation of myocardial substrate in right ventricular outflow tract tachycardia. J Am Coll Cardiol 2008; 51:731-9. [PMID: 18279737 DOI: 10.1016/j.jacc.2007.11.027] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 10/24/2007] [Accepted: 11/08/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We tested whether 3-dimensional electroanatomical voltage mapping (EVM) may help in the differential diagnosis between idiopathic right ventricular outflow tract (RVOT) tachycardia and arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). BACKGROUND Right ventricular EVM has been demonstrated to reliably identify low-voltage regions ("electroanatomical scar"), which in patients with ARVC/D correspond to areas of fibrofatty myocardial replacement. METHODS The study population comprised 27 patients (15 men and 12 women, age 33.9 +/- 8 years) with RVOT tachycardia and no echocardiographic/angiographic evidence of right ventricular (RV) dilation/dysfunction, who underwent EVM and endomyocardial biopsy (EMB) for characterization of ventricular tachycardia (VT) substrate before catheter ablation. RESULTS Electroanatomical voltage mapping was normal in 20 of 27 patients (74%, group A), with electrogram voltage >1.5 mV throughout the RV. The other 7 patients (26%, group B) showed >/=1 (1.4 +/- 07) RV electroanatomical scar area(s) (bipolar voltage <0.5 mV) that correlated with fibrofatty myocardial replacement at EMB (p < 0.001). Clinical predictors of RV scar were right precordial QRS prolongation (p < 0.001) and VT inducibility (p = 0.001). Catheter ablation successfully eliminated VT in 18 of 20 patients (90%). During a follow-up of 41 +/- 8 months, 3 of 7 patients (43%) from group B received an implantable defibrillator because of life-threatening ventricular arrhythmias, compared with no patients from group A (p = 0.016). CONCLUSIONS An early/minor form of ARVC/D may mimic idiopathic RVOT tachycardia. Electroanatomical voltage mapping is able to identify RVOT tachycardia due to concealed ARVC/D by detecting RVOT electroanatomical scars that correlate with fibrofatty myocardial replacement at EMB and predispose to sudden arrhythmic death.
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Affiliation(s)
- Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Padua, Italy.
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