ARVC when TO IMPLANT THE ASYMPTOMATIC PERSON

Transcription

1 EUROPACE 2011 INHERITED ELECTRICAL CARDIAC DISORDERS ARVC when TO IMPLANT THE ASYMPTOMATIC PERSON June 26 th 2011 Robert Lemery MD

2 CONFLICTS of INTEREST None

3 ASYMPTOMATIC ARVC 1. ECG 2. ASYMPTOMATIC PVC S / VT 3. ABNORMAL IMAGING STUDY 4. INVASIVE EPS FINDINGS / BX 5. GENETICS / FAMILY HISTORY 6. PRIMARY PREVENTION

4 ASYMPTOMATIC ARVC 1. ECG QUESTION ECG ABNORMALITIES MAY OCCUR IN ASYMPTOMATIC PATIENTS WITH ARVC 1- YES 2- NO

5 ARVC Corrado D et al. Eur Heart J 2011;32: Watkins H et al. N Engl J Med 2011;364:

6 INCIDENTAL FINDINGS of VENTRICULAR ANEURYSMS in ARVC Ly et al. Heart Rhythm 2008;5:

7 INCIDENTAL FINDINGS of VENTRICULAR ANEURYSMS in ARVC Ly et al. Heart Rhythm 2008;5:

8 2. ASYMPTOMATIC PVC s/vt QUESTION 1. PVC s/vt usually have a RBBB 2. PVC s/vt can originate from the region of the RVOT 3. PVC s/vt only occur from the triangle of dysplasia 4. PVC s/vt do not occur in Asx ARVC

9 Archetypal clinical features of ARVC Delmar, M., McKenna W., Circ Res 2010; 107:

10 ASYMPTOMATIC ARVC QUESTION SUDDEN CARDIAC DEATH CAN BE THE INITIAL PRESENTATION OF ASYMPTOMATIC PATIENTS WITH ARVC 1- YES 2- NO

11 SPORTS RELATED SCD Holst AG et al. Heart Rhythm 2010;7:

12 ADDING ECG to HISTORY & P/E for SCREENING of ATHLETES Malhotra R et al. Heart Rhythm 2011;8:

13 ADDING ECG to HISTORY & P/E for SCREENING of ATHLETES Malhotra R et al. Heart Rhythm 2011;8:

14 ADDING ECG to HISTORY & P/E for SCREENING of ATHLETES Hx & P/E: $68,745 per finding ECG: $68,893 per finding Malhotra R et al. Heart Rhythm 2011;8:

15 Annual incidence rates of sudden cardiovascular death per 100,000 person screened competitive athletes and unscreened non-athletes years of age Veneto Region of Italy, from 1979 to Corrado D et al. Eur Heart J 2011;32:

16 Sudden Arrhythmic Death Dx in Family Members Behr E R et al. Eur Heart J 2008;29:

17 Causes of sudden cardiac death in 314 autopsied cases Marcus F I, Chugh S S Eur Heart J 2011;32: , modified from Winkel et al, Eur Heart J 2011;32:

18 PROLONGED RV ENDOCARDIAL DURATION Tandri H et al. Heart Rhythm 2009;6:

19 PROLONGED RV ENDOCARDIAL DURATION Tandri H et al. Heart Rhythm 2009;6:

20 ENDOMYOCARDIAL BIOPSY guided by Voltage Mapping in ARVC Avella A et al. J Cardiovasc Electrophysiol 2008;19:

21 ENDOMYOCARDIAL BIOPSY guided by Voltage Mapping in ARVC Avella A et al. J Cardiovasc Electrophysiol 2008;19:

22 ENDOMYOCARDIAL BIOPSY guided by Voltage Mapping in ARVC Avella A et al. J Cardiovasc Electrophysiol 2008;19:

23 Immunostaining Desmosomal Protein Plakoglobin in ARVC N-cadherin NO ARVC ARVC Plakoglobin Asimaki A et al. N Engl J Med 2009; 360:

24 ASYMPTOMATIC ARVC 5. GENETICS / FAMILY HISTORY QUESTION THE REVISED TASK FORCE CRITERIA USE GENETICS AS A MAJOR CRITERIA FOR DX. 1- YES 2- NO

25 TASK FORCE CRITERIA in ARVC PROPOSED MODIFICATION Marcus FI et al. Circulation 2010;121:

26 TASK FORCE CRITERIA in ARVC PROPOSED MODIFICATION ORIGINAL REVISED Marcus FI et al. Circulation 2010;121:

27 TASK FORCE CRITERIA in ARVC PROPOSED MODIFICATION Marcus FI et al. Circulation 2010;121:

28 TASK FORCE CRITERIA in ARVC PROPOSED MODIFICATION ORIGINAL REVISED Marcus FI et al. Circulation 2010;121:

29 TASK FORCE CRITERIA in ARVC PROPOSED MODIFICATION ORIGINAL 2 MAJOR 1 MAJOR + 2 MINOR 4 MINOR DIFF. GROUPS REVISED DEFINITE: 2 MAJOR 1 MAJOR + 2 MINOR 4 MINOR DIFF. GROUPS BORDERLINE: 1 MAJOR + 1 MINOR 3 MINOR DIFF. GROUPS POSSIBLE: 1 MAJOR 2 MINOR DIFF. GROUPS Marcus FI et al. Circulation 2010;121:

30 Clinical Categories of Inherited Cardiomyopathies and Their Genetic Basis. Watkins H et al. N Engl J Med 2011;364:

31 Proteins with inherited arrhythmogenic disorders Desmosomal structure Priori, S. G. Circ Res 2010; 107: Delmar, M., McKenna W., Circ Res 2010; 107:

32 POPULATION-PREVALENT DESMOSAL MUTATIONS PREDISPOSING to ARVC (1/200 FINNS) 929 Finish ARVC probands 31/6,334 (0.5%) individuals Founder Mutation in 0.3% Finns Lahtinen et al. Heart Rhythm 2011, in press

33 Natural History and Risk Stratification in ARVC 154 Patients: VT (81%), SCD (10%), Syncope (6%), Asx (3%) Follow-up of up to 29 years, (10+/- 7 years) Annual Mortality rate 1.5% Paul et al. Heart Rhythm 2011;Poster 1-70

34 Type of Mutation and Phenotypic Expresssion in Relation to Clinical Outcome in Genotyped Patients with ARVC 91 Patients, mean f-up of 12 +/- 7 years Mutations in PKP-2: 35/91 (39%) 12/35: Frameshift 9/35: Missesnse 14/35: Stop Extensive disease in 6, Sustained VT in 11 Risk Stratification & Silent Mutation carriers without overt heart disease Paul et al. Heart Rhythm 2011;Poster 6-97

35 GENOTYPE-PHENOTYPE RELATIONS in ARVC FAMILIAL RISK: FAMILIAL CASES in 45% of families screened ASYMPTOMATIC RELATIVES: 20% ARVC, mostly ECG abnormalities-tad prolongation (84% mutation carriers) Mutation-carrying relatives: 6x ARVC vs Relatives of index patients without mutations: ++ risks Vent. Arrh. & earlier onset of disease In young relatives <20 years of age, SD and signs of ARVC exclusively in PKP2 mutation carriers PKP2 mutations were identified in 90% familial ARVC Cox, M. G. P. J. et al. Circulation 2011;123:

36 Age at sudden cardiac death of the 45 patients with pathologically proven ARVC Quarta, G. et al. Circulation 2011;123:

37 FAMILY EVALUATION in ARVC FAMILIAL RISK: MARKED INTRAFAMILIAL PHENOTYPE DIVERSITY DIFFERENCE IN DISEASE SEVERITY BETWEEN PROBANDS AND RELATIVES. IN PROBANDS, 50% DIED SUDDENLY RELATIVES HAVE A BETTER PROGNOSIS MALES=PROBANDS, FEMALES=RELATIVES 2/8 DECEASED PROBANDS: MULTIPLE MUTATIONS MECHANISMS UNDERLYING VARIABLE PENETRANCE and EXPRESSIVITY in ARVC REMAINS COMPLEX Quarta, G. et al. Circulation 2011;123:

38 PRIMARY PROPHYLAXIS in ARVC Klein G. et al. J Cardiovasc Electrophysiol 2005;16:S28-S34

39 R Lemery, P Brugada, J Janssen, E Cheriex, T Dugernier, and HJ Wellens Nonischemic sustained ventricular tachycardia: clinical outcome in 12 patients with arrhythmogenic right ventricular dysplasia ALL PATIENTS HAD SMVT Mean F-UP of 7.9 YEARS 1 pt died 1 week following RV disconnection, ALL OTHERS ALIVE in spite of VT recurrence J. Am. Coll. Cardiol., Jul 1989; 14:

40 Number of affected patients among clinically evaluated subjects for each family in 37 affected families FOLLOW-UP 2-18 YEARS (MEAN 8+/-5): ONLY 1 PATIENT DIED SUDDENLY MORTALITY RATE OF 0.08 PATIENT/YEAR BLACK=AFFECTED Nava, A. et al. J Am Coll Cardiol 2000;36:

41 PROPHYLACTIC ICD in ARVC Corrado D et al. Circulation 2010;122:

42 PROPHYLACTIC ICD in ARVC SYNCOPE, <0.01 ASYMPTOMATIC, ns Corrado D et al. Circulation 2010;122:

43 PROPHYLACTIC ICD in ARVC ASYMPTOMATIC PATIENTS 106 patients from 6 centers in Europe and USA 27 Asx patients received an ICD because of a family history of sudden death: NONE had appropriate shocks INFECTIONS & INAPPROPRIATE SHOCKS 18 pts. (17%) had device-related complications 20 pts. (19%) received inappropriate shocks Corrado D et al. Circulation 2010;122:

44 Corrado D et al. Heart 2011;97:

45 ARVC when TO IMPLANT THE ASYMPTOMATIC PERSON 1. RELATIVE OF PROBAND WITH SCD? 2. GENE NEGATIVE INDIVIDUAL? 3. YOUNGER MALE PHENOTYPE / GENOTYPE POSITIVE? 4. ASX. PATIENT WITH 2 MUTATIONS? 5. RARE FAMILIAL SYNDROMES WITH RV DYSFUNCTION AND SCD?

46 ARVC when TO IMPLANT THE ASYMPTOMATIC PERSON 1. RELATIVE OF PROBAND WITH SCD: NO 2. GENE NEGATIVE INDIVIDUAL: NO 3. YOUNGER MALE PHENOTYPE / GENOTYPE POSITIVE: YES 4. ASX. PATIENT WITH 2 MUTATIONS: YES 5. RARE FAMILIAL SYNDROMES WITH RV DYSFUNCTION AND SCD: YES

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