1 Correlation Between Signal-Averaged Electrocardiogram and the Histologic Evaluation of the Myocardial Substrate in Right Ventricular Outflow Tract Arrhythmias Running title: Santangeli et al.; SAECG and the diagnosis of RVOT arrhythmias substrate Pasquale Santangeli, MD 1 ; Maurizio Pieroni, MD, PhD 4,6 ; Antonio Dello Russo, MD, PhD 5 ; Michela Casella, MD, PhD 5 ; Gemma Pelargonio, MD; PhD 4 ; Luigi Di Biase, MD, PhD, FHRS 1,2,3 ; Andrea Macchione, MD 1 ; J. David Burkhardt, MD, FACC, FHRS 1 ; Fulvio Bellocci, MD 4 ;Pietro Santarelli, MD 4 ; Claudio Tondo, MD, PhD 5 ; Andrea Natale, MD, FACC, FHRS, FESC 1,2 1 Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX; 2 Dept of Biomedical Engineering, University of Texas, Austin, TX; 3 Dept of Cardiology, University of Foggia, Foggia; 4 Catholic University of the Sacred Heart, Rome; 5 Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, Milan; 6 Department of Cardiovascular Diseases, San Donato Hospital, Arezzo, Italy Corresponding author: Andrea Natale, MD, FACC, FHRS, FESC Executive Med Director, TX Cardiac Arrhythmia Inst at St. David’s Medical Ctr, Austin, TX, Consulting Prof, Division of Cardio, Stanford Univ, Palo Alto, CA, Clinical Assoc Prof of Med, Case Western Reserve Univ, Cleveland, OH, Director, Interventional Electrophysiology, Scripps Clinic, San Diego, Sr Clinical Director, EP Services, CA Pacific Med Ctr, San Francisco, CA 3000 N. I-35, Suite 720; Austin, TX 78705 Tel: +15215448186 Fax: +15125448184 E-mail: [email protected]Journal Subject Codes: [5] Arrhythmias, clinical electrophysiology, drugs; [171] Electrocardiology. M M M M M M MD D D D D D D 4 ;P ;P ;P ;P ;P ;P ;Pie ie ie ie ie ie etr tr tr tr tr tr tro o o o o o o Sa Sa Sa Sa Sa Sa Sant nt nt nt nt nt nt ACC, C, F F F F F F FHR HR HR HR HR HR HRS, S, S, S, S, S, S, F F F F F F FE E E E ES E E Arrhythmia Institute, St. David’s Medical Center, Austin, T e y a y a r Donato Hospital Arezzo Italy Arrhythmia Institute, St. David’s Medical Center, Austin, T eering, Univer sity of Texas, Austin, TX; 3 Dept of Cardiology atholic University of the Sacred Heart, Rome; 5 Cardiac Arrhy ardiologico Monzino, Milan; 6 Department of Cardiova scular Donato Hospital Arezzo Italy by guest on May 7, 2018 http://circep.ahajournals.org/ Downloaded from
26
Embed
Correlation Between Signal-Averaged Electrocardiogram …circep.ahajournals.org/content/circae/early/2012/03/15/CIRCEP.111... · Correlation Between Signal-Averaged Electrocardiogram
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Correlation Between Signal-Averaged Electrocardiogram and the
Histologic Evaluation of the Myocardial Substrate in Right
Ventricular Outflow Tract Arrhythmias
Running title: Santangeli et al.; SAECG and the diagnosis of RVOT arrhythmias substrate
Pasquale Santangeli, MD1; Maurizio Pieroni, MD, PhD4,6; Antonio Dello Russo, MD, PhD5;
Luigi Di Biase, MD, PhD, FHRS1,2,3; Andrea Macchione, MD1;
J. David Burkhardt, MD, FACC, FHRS1; Fulvio Bellocci, MD4;Pietro Santarelli, MD4;
Claudio Tondo, MD, PhD5; Andrea Natale, MD, FACC, FHRS, FESC1,2
1Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX; 2Dept of Biomedical Engineering, University of Texas, Austin, TX; 3Dept of Cardiology, University of
Foggia, Foggia; 4Catholic University of the Sacred Heart, Rome; 5Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, Milan; 6Department of Cardiovascular Diseases, San
Donato Hospital, Arezzo, Italy
Corresponding author:
Andrea Natale, MD, FACC, FHRS, FESC
Executive Med Director, TX Cardiac Arrhythmia Inst at St. David’s Medical Ctr, Austin, TX,
Consulting Prof, Division of Cardio, Stanford Univ, Palo Alto, CA, Clinical Assoc Prof of Med,
Case Western Reserve Univ, Cleveland, OH, Director, Interventional Electrophysiology, Scripps
Clinic, San Diego, Sr Clinical Director, EP Services, CA Pacific Med Ctr, San Francisco, CA
MMMMMMMDDDDDDD4;P;P;P;P;P;P;Pieieieieieieetrtrtrtrtrtrtro o o o o o o SaSaSaSaSaSaSantntntntntntnt
ACC,C,,,,,, F F F F F F FHRHRHRHRHRHRHRS,S,S,S,S,S,S, F F F F F FFEEEEESEE
Arrhythmia Institute, St. David’s Medical Center, Austin, Te ya ya r
Donato Hospital Arezzo Italy
Arrhythmia Institute, St. David’s Medical Center, Austin, Teering, University of Texas, Austin, TX; 3Dept of Cardiologyatholic University of the Sacred Heart, Rome; 5Cardiac Arrhyardiologico Monzino, Milan; 6Department of Cardiovascular
Donato Hospital Arezzo Italy by guest on May 7, 2018
cardiomyopathic involvement of the RVOT, and should prompt to perform further diagnostic
investigations, including EAM with EAM-guided biopsy, to identify the underlying myocardial
substrate. Our findings clarify the pathophysiologic basis of SAECG abnormalities in such
patients, and provide an explanation to the observed high specificity but low sensitivity of late
potentials in diagnosing cardiomyopathy-related RVOT-VAs. With the current cut-off values to
define abnormal SAECG parameters, most patients with small RVOT areas of cardiomyopathic
involvement (i.e., <8 cm2) are missed. The diagnostic sensitivity of SAECG in detecting
cardiomyopathy-related RVOT-VAs may significantly increase (16/19 [84%] patients correctly
diagnosed) considering a value of the fQRSd 100 ms as abnormal. Such findings, if confirmed
in larger series, could lead to redefine the relevance of SAECG in the differential diagnosis
between idiopathic and cardiomyopathy-related RVOT-VAs.
Funding Sources: This study was partially supported by a Telethon Foundation Grant (GGP10186 to M.P.).
Conflict of Interest Disclosures: Dr. Andrea Natale has received consultant fees or honoraria from Biosense Webster, Boston Scientific, Medtronic, Biotronic, and LifeWatch. Dr. Claudio Tondo has served as a member of the advisory board of Biosense Webster and has been a consultant for and received lecture fees from St. Jude Medical. Dr. Luigi Di Biase has received consultant fees from Biosense Webster and Hansen Medical.
References:
1. Buxton AE, Waxman HL, Marchlinski FE, Simson MB, Cassidy D, Josephson ME. Right ventricular tachycardia: clinical and electrophysiologic characteristics. Circulation. 1983;68:917-927. 2. Lerman BB, Stein K, Engelstein ED, Battleman DS, Lippman N, Bei D, Catanzaro D. Mechanism of repetitive monomorphic ventricular tachycardia. Circulation. 1995;92:421-429. 3. Marcus FI, Fontaine GH, Guiraudon G, Frank R, Laurenceau JL, Malergue C, Grosgogeat Y. Right ventricular dysplasia: a report of 24 adult cases. Circulation. 1982;65:384-398.
mal. Such findiiiiiingnnnnnn
n thhe e e e ee e dididididididiffffffffffffferererererererenenenenenenentititititititia
a
T)
and cardiomyopathy-related RVOT-VAs.
This study was partially supported by a Telethon Foundation ).
4. Pedersen DH, Zipes DP, Foster PR, Troup PJ. Ventricular tachycardia and ventricular fibrillation in a young population. Circulation. 1979;60:988-997. 5. Lesch M, Lewis E, Humphries JO, Ross RS. Paroxysmal ventricular tachycardia in the absence of organic heart disease. Report of a case and review of the literature. Ann Intern Med. 1967;66:950-960.
6. Maddox K. Intermittent ventricular tachycardia in youth: report of case with fatal termination. Am Heart J. 1947;33:739-740. 7. Santangeli P, Infusino F, Sgueglia GA, Sestito A, Lanza GA. Ventricular late potentials: a critical overview and current applications. J Electrocardiol. 2008;41:318-324. 8. Nasir K, Rutberg J, Tandri H, Berger R, Tomaselli G, Calkins H. Utility of SAECG in arrhythmogenic right ventricle dysplasia. Ann Noninvasive Electrocardiol. 2003;8:112-120. 9. Nava A, Folino AF, Bauce B, Turrini P, Buja GF, Daliento L, Thiene G. Signal-averaged electrocardiogram in patients with arrhythmogenic right ventricular cardiomyopathy and ventricular arrhythmias. Eur Heart J. 2000;21:58-65. 10. Pieroni M, Dello Russo A, Marzo F, Pelargonio G, Casella M, Bellocci F, Crea F. High prevalence of myocarditis mimicking arrhythmogenic right ventricular cardiomyopathy differential diagnosis by electroanatomic mapping-guided endomyocardial biopsy. J Am Coll Cardiol. 2009;53:681-689. 11. Jadonath RL, Schwartzman DS, Preminger MW, Gottlieb CD, Marchlinski FE. Utility of the 12-lead electrocardiogram in localizing the origin of right ventricular outflow tract tachycardia. Am Heart J. 1995;130:1107-1113. 12. Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA, Calkins H, Corrado D, Cox MG, Daubert JP, Fontaine G, Gear K, Hauer R, Nava A, Picard MH, Protonotarios N, Saffitz JE, Sanborn DM, Steinberg JS, Tandri H, Thiene G, Towbin JA, Tsatsopoulou A, Wichter T, Zareba W. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation. 2010;121:1533-1541. 13. Santarelli P, Lanza GA, Biscione F, Natale A, Corsini G, Riccio C, Occhetta E, Rossi P, Gronda M, Makmur J. Effects of thrombolysis and atenolol or metoprolol on the signal-averaged electrocardiogram after acute myocardial infarction. Late Potentials Italian Study (LAPIS). Am J Cardiol. 1993;72:525-531.
14. Breithardt G, Cain ME, el-Sherif N, Flowers NC, Hombach V, Janse M, Simson MB, Steinbeck G. Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography. A statement by a Task Force Committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. Circulation. 1991;83:1481-1488.
Thiene G. Sigiggggggnnannnnnulululllullaaaaaaarrr rrrr cacacacacacacardrdrdrdrdrdrdioioioioioioiomymymymymymymyopopopopopopopaaaaaaa
o ra ys s
hwartzman DS Preminger MW Gottlieb CD Marchlinski F
o Russo A, Marzo F, Pelargonio G, Casella M, Bellocci F, Crarditis mimicking arrhythmogenic right ventricular cardiomyrrs by electroanatomic mapping-guided endomyocardial biops1-689.
hwartzman DS Preminger MW Gottlieb CD Marchlinski F by guest on May 7, 2018
15. Kamath GS, Zareba W, Delaney J, Koneru JN, McKenna W, Gear K, Polonsky S, Sherrill D, Bluemke D, Marcus F, Steinberg JS. Value of the signal-averaged electrocardiogram in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Heart Rhythm. 2011;8:256-262. 16. Chimenti C, Calabrese F, Thiene G, Pieroni M, Maseri A, Frustaci A. Inflammatory left ventricular microaneurysms as a cause of apparently idiopathic ventricular tachyarrhythmias. Circulation. 2001;104:168-173. 17. Chimenti C, Pieroni M, Maseri A, Frustaci A. Histologic findings in patients with clinical and instrumental diagnosis of sporadic arrhythmogenic right ventricular dysplasia. J Am Coll Cardiol. 2004;43:2305-2313. 18. Frustaci A, Priori SG, Pieroni M, Chimenti C, Napolitano C, Rivolta I, Sanna T, Bellocci F, Russo MA. Cardiac histological substrate in patients with clinical phenotype of Brugada syndrome. Circulation. 2005;112:3680-3687. 19. Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation.2006;113:593-595. 20. Noutsias M, Fechner H, de Jonge H, Wang X, Dekkers D, Houtsmuller AB, Pauschinger M, Bergelson J, Warraich R, Yacoub M, Hetzer R, Lamers J, Schultheiss HP, Poller W. Human coxsackie-adenovirus receptor is colocalized with integrins alpha(v)beta(3) and alpha(v)beta(5) on the cardiomyocyte sarcolemma and upregulated in dilated cardiomyopathy: implications for cardiotropic viral infections. Circulation. 2001;104:275-280. 21. Angelini A, Basso C, Nava A, Thiene G. Endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy. Am Heart J. 1996;132:203-206.
22. Belhassen B, Caspi A, Miller H, Shapira I, Laniado S. Extensive endocardial mapping during sinus rhythm and ventricular tachycardia in a patient with arrhythmogenic right ventricular dysplasia. J Am Coll Cardiol. 1984;4:1302-1306.
23. Corrado D, Basso C, Leoni L, Tokajuk B, Bauce B, Frigo G, Tarantini G, Napodano M, Turrini P, Ramondo A, Daliento L, Nava A, Buja G, Iliceto S, Thiene G. Three-dimensional electroanatomic voltage mapping increases accuracy of diagnosing arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circulation. 2005;111:3042-3050. 24. Ladyjanskaia GA, Basso C, Hobbelink MG, Kirkels JH, Lahpor JR, Cramer MJ, Thiene G, Hauer RN, MF VO. Sarcoid myocarditis with ventricular tachycardia mimicking ARVD/C. JCardiovasc Electrophysiol. 2010;21:94-98. 25. Corrado D, Calkins H, Link MS, Leoni L, Favale S, Bevilacqua M, Basso C, Ward D, Boriani G, Ricci R, Piccini JP, Dalal D, Santini M, Buja G, Iliceto S, Estes NA, 3rd, Wichter T, McKenna WJ, Thiene G, Marcus FI. Prophylactic implantable defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and no prior ventricular fibrillation or sustained ventricular tachycardia. Circulation. 2010;122:1144-1152.
teria. Circulatttttttioioioiioii
hner H de Jonge H Wang X Dekkers D, Houtsmuller AB, c ru at mf
so C Nava A Thiene G Endomyocardial biopsy in arrhythm
hner H, de Jonge H, Wang X, Dekkers D, Houtsmuller AB, ch R, Yacoub M, Hetzer R, Lamers J, Schultheiss HP, Pollerus receptor is colocalized with integrins alpha(v)beta(3) and ate sarcolemma and upregulated in dilated cardiomyopathy: imdfections. Circulation. 2001;104:275-280.
so C Nava A Thiene G Endomyocardial biopsy in arrhythm by guest on May 7, 2018
Values expressed as median (interquartile range) or n (%). LPs = ventricular late potentials; RVOT-VA = right ventricular outflow tract ventricular arrhythmia; VT = ventricular tachycardia; PVC = premature ventricular contraction; CMR = cardiac magnetic resonance; RV = right ventricular; LV = left ventricular. *Comparison between “Positive LPs” and “Negative LPs”
Table 2. Invasive findings of the overall sample and according to results of the SAECG. Overall Sample
(n = 24) Positive LPs
(n = 11) Negative LPs
(n = 13) P*
Electroanatomic scar 19 (79) 11 (100) 8 (62) 0.041 N. of EAM scars 2 (1-2) 2 (1-2) 2 (0-2) 0.69 Localization of EAM
Values expressed as median (interquartile range), or n (%).LPs = ventricular late potentials; N. = number; EAM = electroanatomic mapping. *Comparison between “Positive LPs” and “Negative LPs”
M = major criteria; m = minor criteria; Other = finding not included among current criteria. *Cardiac magnetic resonance not performed for claustrophobia. +Per study inclusion criteria, all ventricular arrhythmias had a left bundle-branch block morphology and inferior axis (i.e., RVOT origin, minor criteria). RVOT = right ventricular outflow tract; VT = ventricular tachycardia; Sust. = sustained; NSVT = nonsustained VT; PVCs = premature ventricular contractions; LGE = late gadolinium enhancement.
NNNNNNN
lc
E
N
N
ld global RV dilatation. cant RV dilatation and dysfunction.
Tondo and Andrea NataleLuigi Di Biase, Andrea Macchione, J. David Burkhardt, Fulvio Bellocci, Pietro Santarelli, Claudio Pasquale Santangeli, Maurizio Pieroni, Antonio Dello Russo, Michela Casella, Gemma Pelargonio,
Myocardial Substrate in Right Ventricular Outflow Tract ArrhythmiasCorrelation Between Signal-Averaged Electrocardiogram and the Histologic Evaluation of the
Dallas, TX 75231is published by the American Heart Association, 7272 Greenville Avenue,Circulation: Arrhythmia and Electrophysiology
published online March 15, 2012;Circ Arrhythm Electrophysiol.
http://circep.ahajournals.org/content/early/2012/03/15/CIRCEP.111.967893World Wide Web at:
The online version of this article, along with updated information and services, is located on the
http://circep.ahajournals.org//subscriptions/
is online at: Circulation: Arrhythmia and Electrophysiology Information about subscribing to Subscriptions:
http://www.lww.com/reprints Information about reprints can be found online at: Reprints:
document. Permissions and Rights Question and Answerinformation about this process is available in the
requested is located, click Request Permissions in the middle column of the Web page under Services. FurtherCenter, not the Editorial Office. Once the online version of the published article for which permission is being
can be obtained via RightsLink, a service of the Copyright ClearanceCirculation: Arrhythmia and Electrophysiology Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions: