LVH GREY ZONE OF HYPERTROPHIED VENTRICLES

Transcription

1 LVH GREY ZONE OF HYPERTROPHIED VENTRICLES Unit of Inherited and Rare Cardiac Diseases Heart Center for the Young and Athletes Onassis Cardiac Surgery Centre

2 Common phenotype different causes By Jacopo Olivotto Diagnosis of LVH a starting point

3 Causes of Left Ventricular Hypertrophy Diagnosis of LVH is a starting point ACE Racial Gender Friedreich s Ataxia Noonan Syndrome LEOPARD syndrome Genetic Mitochondrial disease Fatty Acid Metabolism Fabry s disease Glycogen storage Hypertension Athletes Physiological Metabolic Amyloid Infants diabetic mothers Phaeochromocytoma

4 HCM FAMILY HCM PATIENT Clinical Cardiology MOLECULAR CARDIOLOGY Genetics FAMILY SCREENING TYPICAL DISEASE SUBCLINICAL DISEASE GENE CARRIER

5 SUBCLINICAL FORM OF HCM DUE TO EVOLUTION

6 Mutation: Arg286Cys CONCEALED FORM OF HCM DUE TO SUBCLINICAL EXPRESSION Q waves

7 Anastasakis,Papatheodorou, Ritsatos et al Europace 2017 UNKNOWN CAUSE SD FAMILIES Apart from channelopathies, subclinical forms of inherited structural heart diseases would appear to be implicated in SADS. LQTS 20% PVT 20% HCM 20% ARVC 40%

8 % % Black White % Maximal LVWT

9 Athletes heart vs HCM Am J Cardiol 2014

10 AJC 2014

11 Strenth athlete ECHO LVWmax :12-13 LVEDD: 48 mm

12 Differential Diagnosis HCM v s Athletic Heart Syndrome* * Athletes with LVH in Grey zone A. Stage A Clinical examination History Family history Physical examination ECG ECHO Doppler TDI Blood and urine tests B. Stage B Holter rhythm Cardiopulmonary exercise testing Exercise ECHO Clinical evaluation of the family (Stage A or B?) Cardiac MRI LGE C. Stage C Detraining? Genetics

13

14 FAMILY TREE >80 y >70 y 45y OE M = Υπερτροφική μυοκαρδιοπάθεια = Φυσιολογικό άτομο

15 24 h HOLTER

16 MRI

17 WEIGHT OF EVIDENCE? LVH : 12mm LVEDD: 47 mm ECG: mild repolarization changes MRI: significant LGE HOLTER : NSVT CAUSETIVE MUTATION on MHY7

18 AJC 2014

19 MULTI FACTORIAL APPROACH FACTORS DEMOGRAPHICS ECG STRUCTURAL CHARACTERISTICS FUNCTIONAL CHARACTERISTICS LAB TEST OTHERS Family history of HCM Female gender

20

21 HPT athlete LA ml/m NO C/P EXERCISE peakvo2>120%pred YES YES YES ECG INVERTED T waves IMPAIRED HR reserve FEMALEs NO NO

22 ESC HCM GUIDELINES 2014

23

24 Pedigree Symptoms Physical exam ECG Laboratory Echo/MRI Other Autsomal dominant Autosomal recessive X-linked-Dystrophin, Danon,FABRY. Maternal Deafness (AFD, Epicardin) Muscle pains/weakness (Dystrophin) Paraesthesia Muscle weakness Postural hypotension Rash (lentigenes, angiokeratomata) Ocular Premature conduction disease Pseudo-infarct pattern Creatinine kinase (dystrophic, Danon, Desmin) Serum creatinine Proteinuria Ferritin Lactate Pattern of hypertrophy Valve disease Pericardial effusion Pattern of gadolinium hyperenhancement Exercise test: premature acidosis Endomyocardial biopsy genetics ESC HCM GUIDELINES 2014

25 DIAGNOSTIC WORK UP IN CARDIOMYOPATHIES HCM DANON or MITOCHONDRIAL FABRY or MITOCHONDRIAL FABRY or MITOCHONDRIAL AMYLOIDOSIS DANON or MITOCHONDRIAL

26 MEDICAL HISTORY: PAF - AMIO (IV) - SR DEEP VENOUS THROMBOSIS 3 y ago (sintrom), PALPITATION (often). HEAT INTOLERANCE FAMILY HISTORY (-) MALE 33 y old Persistent AF MILD LEFT VENTRICULAR HYPERTROPHY

27 CLINICAL CARDIAC EXAMINATION S1-S2 NORMAL HEART SOUNDS NYHA II SYSTOLIC MURMUR 2/6 BP:100/80mmHg LEG LYMPHOEDEMA..

28

29

30 HOLTER 24 HOUR

31

32 MRI LV normal dimension and function LVWmax 12mm RV with in normal limits MR mild to moderate. MILD LGE (+).

33 MILD HCM?

34 HCM? angiokeratoma LYMPHOEDEMA

35 So far. MILD LEFT VENTRICULAR CONCENTRIC HYPERTROPHY EF:60% ABNORMAL ECG AV conduction defect ΝΥΗΑ ΙΙ-ΙΙΙ(VO2max 49%) History of PAF LGE mild ANGIOKERATOMA What is next LEG LYMPHOEDEMA.. NO FAMILY HISTORY

36 Pedigree Symptoms Physical exam ECG Laboratory Echo/MRI Autsomal dominant Autosomal recessive X-linked-Dystrophin, Danon. Maternal Deafness (AFD, Epicardin) Muscle pains/weakness (Dystrophin) Paraesthesia Muscle weakness Postural hypotension Rash (lentigenes, angiokeratomata) Ocular Reconsider the patient Premature conduction disease Pseudo-infarct pattern Creatinine kinase (dystrophic, Danon, Desmin) Serum creatinine Proteinuria Ferritin Lactate Pattern of hypertrophy Valve disease Pericardial effusion Pattern of gadolinium hyperenhancement Other Exercise test: premature acidosis Endomyocardial biopsy genetics

37 HCM- FABRY DISEASE angiokeratoma PREECXITATION LAB TEST PROTEINOURIA A GALACTOSIDASE 3 8 y 8 3 Α y ρρ 3 υθ 7 μί y ες 67 y AF- ΑΕΕ- 60 Θάνα y τος PA 83y F- M R- AY AY Σ Ν AY 8 3 y INHERITANCE GENETICS CONCENTRIC MILD LVH LYMPHOEDEMA

38 GENETIC ANALYSIS GENE VARIANT RESULT PATHOGENICI TY No of Refs GLA NP_ :p.Pro259Leu NM_ :c.776C>T NC_ :g G>A Heterozygosis Pathogenic or disease-causing mutation 8 83y AF-ΑΕΕ-Θάνατος 83y ΣΝ 83y Αρρυθμίες 67y 60y PAF-MR-AY AY AY 38y 37y

39 TREATMENT Sotalol 80 1x2 Triatec 2.5 1x1 Sintrom 4 mg ANGORON CONTRA INDICATION ERT

40 RCM

41

42

43 FINDINGS RCM

44 Recommended laboratory tests in adult patients with hypertrophic cardiomyopathy ESC HCM GUIDELINES 2014 AMYLOIDOSIS DANON

45 Recommended laboratory tests in adult patients with hypertrophic cardiomyopathy ESC HCM GUIDELINES 2014 AMYLOIDOSIS

46 Plasma cell dyscrasia Biopsies AL amyloid, is derived from monoclonal immunoglobulin light chains associated with plasma cell dyscrasias Biochemical tests to detect the abnormal clonal immunoglobulin production

47 Neuromuscular disorders with cardiac involvement mitochondrial disorders electrical structural Electrical and structural

48 DESMINOPATHIES Creatine phosphokinase Desmin-related cardiomyopathies RCM associated with elevated CK levels.

49

50

51 LVH gray zone HCM HPT ATHLETIC HEART Combination? SPECIAL TYPES OF HCM SARCOMERIC STORAGE - FABRY, POMPE INFILTRATION - AMYLOIDOSIS INFLAMMATORY CONNECTIVE TISSUE TUMORS

52 TAKE HOME MESSAGE LVH GRAY ZONE SEARCHING BEYOND THE MORPHOLOGY MORPHOLOGY imaging technics plus ECG Are ESSENTIAL LVH RED FLAGS ATHLETES VALVE DISEASE HPT HCM SUBTYPES CLINICALL ECG ECHO HOLTER c/p EX TEST MRI LGE LAB TESTS INTERNIST PEDIATRICIAN NEUROLOGIST GENETISIST EARLY MULTIDISCIPLINARY NETWORK