Clinical aspects of Arrhythmogenic Cardiomyopathies

Transcription

1 Clinical aspects of Arrhythmogenic Cardiomyopathies INTERNATIONAL CLINICAL CARDIOVASCULAR GENETICS CONFERENCE 25 May 2018 Dr Hari Raju MBChB PhD ECES FRACP Clinical Associate Professor, Macquarie University, Sydney Cardiologist & Electrophysiologist, Macquarie University Hospital Cardiologist & Electrophysiologist, Concord Repatriation General Hospital

2 Arrhythmogenic (RV) Cardiomyopathy CLINICAL ASPECTS Recognition Arrhythmia burden Exercise Pregnancy ICD indications Difficult clinical case Patient / Relative Management 2

3 Arrhythmogenic Cardiomyopathy FORMERLY KNOWN AS ARVD/C

4 Arrhythmogenic (RV) Cardiomyopathy ACM = ARRHYTHMOGENIC CARDIOMYOPATHY Degeneration of cardiac myocytes Fibrofatty replacement RV predominance Disorder of cardiac desmosome Generally AD + monogenic Successful genotyping 60% Task Force criteria revised 2010 Concealed forms Under-recognition of non-classical disease Prevalence 1:2000-1:5000 Leading cause of SCD in young (+/- athletes) Ventricular arrhythmias 4

5 Distribution of ARVC myocardial pathology AUTOPSY DIAGNOSES OF ARVC (N=98 FROM CRY UK SCD SERIES AGE 14-35) Basso (1996) n=30 Fornes (1998) n=20 PATHOLOGICAL LV involvement: 84% Corrado (1997) n=42 STUDIES Tabib (2003) n=200 RV Tavora 16 (2012) n=50 (16%) Lindström (2005) n=15 Mast (2015) n=38 Biventricular 63 IMAGING El Ghannudi (2014) n=21 (64%) STUDIES Te Riele(2013) n=74 MHW 400g; LV 47% MHWRV 380g; Septum LV 40% MHW 416g; 33% LV 76% MHW 416g; LV 32% MHW 438g; LV 88% SPECT LV 93% ECHO STRAIN LV 68% CMR LV 52% CMR LV 52% LV Septum 38% LV Involvement 32 88% LV Post 62% LVAL 60% LV 19 (19%) Miles C et al (unpublished 2018) 5

6 Arrhythmia Modification EXERCISE & SPORTS

7 Sporting Activity and SCD SCD RISK IN COMPETITIVE ATHLETES WITH HISTOLOGIC ARVC Circumstances of death (n=92) Died during exertion, % (n) 53% (49) Died at rest, % (n) 41% (38) 18/57 = 32% Died during sport: 25/35 = 71% 31/35 = 89% Died in sleep, % (n) 5% (5) Exercise: Restriction vs Self-determination? Miles C et al (unpublished 2018) 7

8 Exercise dose in ARVC EXERCISE DOSE PREDICTS FIRST ARRHYTHMIA PRESENTATION 61 ARVC / mut +ve cases (38 athletes) diagnosis prior to VT/VF James CA. J Am Coll Cardiol. 2013;62(14):

9 Exercise dose in ARVC INTENSITY VS DURATION? ARVC (TFC) / familial mutation +ve 173 patients (53% proband) >6METS predicts arrhythmia risk Intensity >2.5h/wk predicts RV dilation Duration Advise low intensity (& short duration) Lie OH. JACC EP. 2018; in press doi /j.jacep

10 Age and Exercise Related Penetrance NATURE VS NURTURE? Probands Greater MET-hours exercise Younger age of phenotype penetrance (TFC) General Population ARVC mutations / VUS no increased risk 30k patients - whole exome analysis Sawant AC. Heart Rhythm. 2016;13(1): Haggerty CM. Genet Med. 2017;19(11):

11 Arrhythmic Risk PREGNANCY

12 Clinical Case 34 YEAR OLD FEMALE 1st trimester of pregnancy Exertional syncope Extensive exercise history amateur triathlete PMH/DH/FH nil Courtesy of Miles C et al, St George s University of London 12

13 Investigations IDIOPATHIC RVOT VT VS MALIGNANT RVOT VT / ARVC Repetitive monomorphic VT 14k monomorphic late-coupled VEs 13

14 Management & Progress SEVEN MONTHS POST-PARTUM Repetitive monomorphic RVOT VT Rendered asymptomatic with oral verapamil (during pregnancy) No FH Planned for OP ablation implantable loop recorder genetic mutation analysis Awaiting ablation (logistics) Collapsed during jogging VF cardiac arrest Pronounced dead (<2h) Genetic Testing: No pathogenic variants identified in 119 cardiomyopathy related genes. 14

15 Pregnancy with ARVC DOES NOT AFFECT DISEASE PROGRESSION & FAVOURABLE PERI-PARTUM COURSE(?) 77 pregnancies Mainly retrospective Castrini AI. Eur Heart J Cardiovasc Imaging Apr 6. doi: /ehjci/jey061. Hodes AR. Heart. 2016;102(4):

16 Arrhythmogenic Cardiomyopathy ICD IMPLANTATION

17 ICD indications AND COMPLICATIONS Corrado D. Eur Heart J. 2015;36(46): Corrado D. Circulation. 2010;122(12):

18 My thoughts ARRHYTHMOGENIC CARDIOMYOPATHY Malignant ventricular arrhythmias may occur with equivocal Task Force criteria for ARVC Syncope in RVOT VT??? ARVC malignant form of RVOT VT? EPS useful in borderline cases Risk management restriction competitive sports <6METS (<30min/5d) universal beta-blockade serial surveillance exercise ECG, echo, Holter pregnancy lower risk if normal LV/RV function risk of first VT/VF event? ICD if high risk at-risk relatives +ve: sporting restriction -ve: surveillance through adulthood Clinical Assoc Prof H Raju, Macquarie University, Sydney 18

19 Ambulatory Cardiac Monitoring 165 beats of monomorphic VT on a 24-hour ECG. 14,000 unifocal ventricular ectopics documented. 19

20 Ambulatory Cardiac Monitoring EXERTIONAL SYNCOPE WHILE WEARING CARDIAC EVENT MONITOR 20

21 Cardiac Evaluation SIGNAL AVERAGED ECG / ECHOCARDIOGRAPHY Echocardiography Mildly dilated LV Normal RV dimensions No regional wall motion abnormalities Normal biventricular function. 21

22 Cardiac MRI 22

23 Diagnosis 2010 ARVC TASK FORCE CRITERIA 4 minor criteria from 3 different categories: Borderline diagnosis ARVC 23

24 Cardiac Autopsy Clinical Pregnancy: case Afterload conditions equivalent to exercise? Serial surveillance? Genetic Testing: No pathogenic variants identified in 119 cardiomyopathy related genes. 24