Aνταλένα Τσατσοπούλου ΝΙΚΟΣ ΠΡΩΤΟΝΟΤΑΡΙΟΣ ΙΑΤΡΙΚΟ ΚΕΝΤΡΟ - ΝΑΞΟΣ. Arrhythmogenic Cardiomyopathy

Transcription

1 Aνταλένα Τσατσοπούλου ΝΙΚΟΣ ΠΡΩΤΟΝΟΤΑΡΙΟΣ ΙΑΤΡΙΚΟ ΚΕΝΤΡΟ - ΝΑΞΟΣ Arrhythmogenic Cardiomyopathy

2 Aνταλένα Τσατσοπούλου ΝΙΚΟΣ ΠΡΩΤΟΝΟΤΑΡΙΟΣ ΙΑΤΡΙΚΟ ΚΕΝΤΡΟ - ΝΑΞΟΣ There is no conflict of interest

3 Arrhythmogenic Cardiomyopathy Phenotype

4 Arrhythmogenic Cardiomyopathy Phenotype Recognise the Spectrum

5 Arrhythmogenic Cardiomyopathy Phenotype VT

6 Arrhythmogenic Cardiomyopathy Phenotype Re-entry VT

7 ECG Repolarization Depolarization Abnormalities V1 V2 V3 Re-entry VT

8 ECG Repolarization Depolarization Abnormalities V1 V2 V3 IMAGING RV Functional / Structural Alterations

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10 PHENOTYPES Juvenile sudden deaths HCM Uhl s Normal coronaries

11 TFC 1994 ARVD / C

12 I ARVC - TFC Diagnostic Criteria ARRHYTHMIAS II III IV V VI REPOLARIZATION ABNORMALITIES DEPOLARIZATION ABNORMALITIES STRUCTURAL / WALL MOTION STRUCTURAL (TISSUE CHARACTER) FAMILY HISTORY / GENETICS Major or Minor Definite ARVC: 2 Major or 1 Major + 2 minor or 4 minor Borderline ARVC: 1 Major + 1 minor or 3 minor Suspected ARVC: 1 Major or 2 minor Unlike ARVC: 0 or 1 minor -

13 Dominant Recessive

14 Dominant Recessive

15 PHENOTYPE ~ CLINICAL PICTURE ECG, Str/Funct Birth Adolescence Age

16 SKIN MYOCARDIUM

17 SKIN Affected cell-cell contacts (desmosomes) MYOCARDIUM Plakoglobin McKoy G, Protonotarios N, Crosby A, Tsatsopoulou A, Anastasakis A, Coonar A, Norman M, Baboonian C, Jeffery S, McKenna WJ. Lancet 2000

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19 RV + LV Family studies

20 RV + LV JACC 2001 Pinamonti B, Sinagra G, Salvi A, et al. Left ventricular involvement in right ventricular dysplasia. Am Heart J 1992;123: Norman M, Simpson M, Mogensen J, et al. Novel mutation in desmoplakin causes arrhythmogenic left ventricular cardiomyopathy. Circulation 2005;112:636. Bauce B, Basso C, Rampazzo A, et al. Clinical profile of four families with arrhythmogenic right ventricular cardiomyopathy caused by dominant desmoplakin mutations. Eur Heart J 2005;26(16): Sen-Chowdhry S, Syrris P, Prasad SK, et al. Left-dominant arrhythmo-genic cardiomyopathy: an under-recognized clinical entity. J Am Coll Cardiol 2008;52:2175. Available online at Journal of Electrocardiology xx (2013) xxx xxx Quarta G, et al. ARVC and Lamin A/C gene mutations; Eur Heart J 2012 Kato K, Takahashi N, Fujii Y, et al. LMNA cardiomyopathy detected in Japanese arrhythmogenic right ventricular cardiomyopathy cohort. J Cardiol 2016;68(4): Left dominant arrhythmogenic cardiomyopathy: A morbid association of ventricular arrhythmias and unexplained infero-lateral T-wave inversion Alexandros Protonotarios, a, Alexandros Patrianakos, a Elpida Spanoudaki, b Georgios Kochiadakis, a Emmanouel Michalodimitrakis, b Panagiotis Vardas a a Department of Cardiology, University Hospital of Heraklion, Heraklion, Greece b Department of Forensic Sciences, University Hospital of Heraklion, Heraklion, Greece Ortiz-Genga MF, Cuenca S, Dal Ferro M, et al. Truncating FLNC Mutations Are Associated With High-Risk Dilated and Arrhythmogenic Cardiomyopathies. J Am Coll Cardiol 2016;68 Abstract Left-dominant arrhythmogenic cardiomyopathy is a subtype of arrhythmogenic right ventricular cardiomyopathy characterized by early predominant left ventricular involvement. Α 34-year-old man presentedwithpalpitationsandahistory of frequent ventricular extrasystolesof bothlbbb andrbbb configuration. Cardiac workup revealed repolarization abnormalities at infero-lateral leads in the absence of diagnostic structural/functional alterations or obstructive coronary artery disease. Six months later he died suddenly. Histopathology was diagnostic for arrhythmogenic right ventricular cardiomyopathy affecting predominantly theleft ventricleat subepicardial/midwall myocardial layers. Thus, ventricular arrhythmias accompanied by unexplained infero-lateral T-wave inversion should warn of apossible morbid association underlying left-dominant arrhythmogenic cardiomyopathy. Begay RL, et al. Filamin C Truncation Mutations Are Associated With Arrhythmogenic Dilated Cardiomyopathy and Changes in the Cell Cell Adhesion Structures. J Am Col Cardiol EP; 2018

21 Three main patterns of cardiac involvement are observed: 1. Predominant right ventricular disease, with minor or absent left ventricular involvement. 2. Biventricular disease, when both ventricles are affected. 3. Left dominant disease that is characterized by mild or absent right ventricular involvement. Terminology poorly defined Overlaps with dilated cardiomyopathy

22 Arrhythmogenic Dilated Cardiomyopathy (ADC) Recent registry study: Arrhythmogenic dilated cardiomyopathy (DCM) = DCM phenotype with 1 or more of the following: 1. Unexplained syncope (likely due to ventricular tachyarrhythmia). 2. Rapid non-sustained ventricular tachycardia defined as 5 consecutive ventricular beats lasting <30 seconds, with a rate 150/min on 24 hour Holter monitoring. 3. or 1000 premature ventricular contractions in, or 50 couplets, in 24 hours. 4. By these criteria, one third of DCM patients had an arrhythmogenic phenotype that was associated with an increased risk of arrhythmia during follow up. 5. A family history of ventricular arrhythmias predicted a poor prognosis and an increased risk of sudden cardiac death (SCD).

23 TFC Borderline phenotype minor disease TFC Borderline = borderline fitting to ARVC

24 Man, 43 year-old Asymptomatic

25 Man, 43 year-old Asymptomatic SD, 14 yrs Myocarditis

26 PRE-PARTICIPATION ECG?

27 Man, 43 year-old QRSf=126 ms LAS=78 ms RMS=11 μv 24-hour Holter: 324 monomorphic isolated VES TFC: 1 minor TFC: 1 minor

28 Man, 43 year-old, asymptomatic No diagnostic TFC structural / functional changes on ECHO - CMR CMR-Late Enhancement Imaging Extensive LV-LGE Scar in LV!

29 SD, previous day of admission for ICD implantation LV

30 Man, 43 year-old, asymptomatic SD 55y 60y DSP:Trp180Stop SD, 14 yrs DSP mutations mostly associated with Left- Dominant ARVC Diagnostic challenge Increased Risk for SD

31 Flow chart for ICD implantation Typical ARVC? Corrado D et al. Circulation 2015

32 Flow chart for ICD implantation Typical ARVC LV Scar Corrado D et al. Circulation 2015

33 Flow chart for ICD implantation Typical ARVC LV Scar Corrado D et al. Circulation 2015 DSP LMNA/C FLNC...

34 Man, 34 year-old

35 Man, 34 year-old Palpitations since 27-year-old No reports of syncope or pre-syncope No family history of cardiomyopathy or sudden death

36 Man, 34 year-old

37 Man, 34 year-old Low QRS voltage T-wave inversion in infero-lateral leads

38 RVOT=30 mm (<32 mm) LVEDD=59 mm (<58 mm) LVEF=60% Borderline cavity size Good function

39 LVEDD=59 mm LVEF=60% Regional hypokinesia of LV apex Mild regional wall motion abnormalities

40 Modified Apical View Mild hypokinesia of RV apex Mild regional wall motion abnormalities

41 Holter: VES >1000/24 h No VT 12-lead ECG: (Infero)lateral repolarization abnormalities ΕCHO: Mild/regional hypokinesia of LV/RV apex Exercise Test: Negative for myocardial ischemia No VT Coronary arteriography: No stenoses CMR-LE Metoprolol (50mgx2) and aspirin (100mgx1)

42 SD at rest Autopsy / Histopathology Eosin - Hematoxylin Masson Heart weight: 550 gr Fibrotic sub-epicardial / mid-wall bands in antero-lateral and postero-apical LV wall

43 K-Cr2707 Control N-Cadherin Plakoglobin Plakophilin2 Desmoplakin Connexin43 No desmosomal mutation

44 Ortiz-Genga, M.F. et al. J Am Coll Cardiol. 2016

45 FLNC Ortiz-Genga, M.F. et al. J Am Coll Cardiol. 2016

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48 LV RV

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50 DCM SD, 58 yrs Paroxysmal AF RV, LV progressive SD, 67 yrs Paroxysmal AF Bradycardia episodes No str/funct RV/LV Quarta G, et al. ARVC and Lamin A/C gene mutations; Eur Heart J 2012

51 50% loss of myocytes Control PG Immunostaining Quarta G, et al. ARVC and Lamin A/C gene mutations; Eur Heart J 2012

52 DCM SD, 58 yrs LMNA Paroxysmal AF RV, LV progressive SD, 67 yrs Paroxysmal AF Bradycardia episodes No str/funct RV/LV Quarta G, et al. ARVC and Lamin A/C gene mutations; Eur Heart J 2012

53 FLNC LMNA/C

54 Key points for Arrhythmogenic Cardiomyopathy A group of myocardial disorders with a high burden of ventricular arrhythmias AC is familial in about 60% of cases AC can affect one or both ventricles Three major sub-phenotypes: classical ARVC, left dominant ARVC, Arrhythmogenic DCM ECG abnormalities can precede overt structural manifestations. Exercise may promote disease progression and ventricular arrhythmia. Phenotype progresses during time: FU is important

55 Key points for Arrhythmogenic Cardiomyopathy Diagnostic criteria and management guidance exist for classical ARVC but further studies are required for other forms of AC

56 Key points for Arrhythmogenic Cardiomyopathy Symptomatic presentation of ventricular arrhythmias or a history of arrhythmic cardiac arrest in an otherwise normal myocardium should raise suspicion of an early AC phenotype.

57 TFC classical ARVC THE PHENOTYPES Early forms Left dominant ARVC Arrhythmogenic DCM Myocarditis Sarcoid The hidden phenotypes

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60 Conditions affecting the Right Ventricle and Red Flags differentiating from ARVC Conditions affecting the RV and red flags differentiating from ARVC Cardiac displacement Pectus excavatum/ carinatum Kyphoscoliosis and/or another chest deformity Partial absence of pericardium RV pressure or volume overload Congenital heart defects - Ostium secundum - Sinus venosus - Ebstein s anomaly and/or tricuspid regurgitation Careful chest inspection for deformities and correlation of anatomy with CMR imaging To be excluded by TTE and/or CMR Absence of regional wall motion abnormalities Pulmonary Hypertension To be excluded by TTE and/or CMR. Absence of regional wall motion abnormalities Athlete s heart T-wave inversion extremely rare beyond V3 in whites. Myocardial Scarring Infectious myocarditis Absence of regional wall motion abnormalities. Symmetrical increase of wall thickness. Absence of LGE on CMR. Reversal upon deconditioning. Absence of familial disease Prodrome of an upper respiratory or GI tract infection Rapidly progressing ventricular dysfunction Sarcoidosis Inferior myocardial infarction Absence of familial disease 2 nd or 3 rd Degree atrioventricular block Extra-cardiac manifestations (pulmonary, mediastinum): chest x-ray, CT, PET, CMR-LGE. Evaluation of coronary artery anatomy A. Tsatsopoulou, E. Bossone, Common presentation of rare diseases: Arrhythmogenic right ventricular cardiomyopathy and its mimics, Int J Cardiol (2018), (In Press)

61 Not always as it seems to be