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Canadian Journal of Cardiology

The Application of Ambulatory Electrocardiographically-Based T-Wave Alternans in Patients with Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy

  • Fa-Po Chung
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Yenn-Jiang Lin
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Eric Chong
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Department of Cardiology, Jurong Health Pte Ltd, Singapore, Singapore
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  • Shih-Lin Chang
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Li-Wei Lo
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Yu-Feng Hu
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Ta-Chuan Tuan
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Tze-Fan Chao
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
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  • Jo-Nan Liao
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Shih-Ann Chen
    Correspondence
    Corresponding author: Dr Shih-Ann Chen, Division of Cardiology, Taipei Veterans General Hospital, 201 Sec 2, Shih-Pai Road, Taipei, Taiwan. Tel.: 886-2-2875-7156; fax: 886-2-2873-5656.
    Affiliations
    Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University Taipei, Taipei, Taiwan
    Search for articles by this author
Published:February 05, 2016DOI:https://doi.org/10.1016/j.cjca.2016.01.035

      Abstract

      Background

      Patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) carry the risk of ventricular arrhythmias and sudden cardiac death (SCD). This study investigated the prognostic information of modified moving average T-wave alternans (MMA TWA) in patients with ARVD/C.

      Methods

      A total of 63 consecutive patients (mean age, 44.7 ± 14.8 years; 38 men) with ARVD/C were enrolled. Baseline characteristics and structural and electrocardiographic parameters were obtained. All patients underwent ambulatory electrocardiographic examination at the time of diagnosis, and MMA TWA data were exported for further analysis. Events were defined as documented SCD or ventricular tachyarrhythmias during clinical follow-up.

      Results

      During a mean follow-up of 28.1 ± 15.4 months, 19 of 63 (30.2%) patients experienced events, including SCD in 2 patients (10.5%) and ventricular tachyarrhythmias in 17 patients (89.5%). Patients with events had higher TWA within modified V5 and V1 channels than did those without events (54.7 ± 24.9 μV vs 35.0 ± 18.3 μV; P = 0.004; 58.8 ± 27.6 μV vs 38.4 ± 18.6 μV; P = 0.007, respectively). After multivariate Cox regression analysis, maximal TWA derived from either the modified CM5 or NASA channel predicted the occurrence of events (P < 0.001; hazard ratio, 1.06; 95% confidence interval, 1.03-1.10). At the cutoff value of > 66 μV, maximal TWA yielded a sensitivity and a specificity of 89.5% and 90.5%, respectively, in predicting SCD or ventricular tachyarrhythmias.

      Conclusions

      The initial analysis of MMA TWA could provide prognostic implications in the prediction of SCD or ventricular tachyarrhythmias in patients with ARVD/C.

      Résumé

      Introduction

      Les patients atteints d'une cardiomyopathie ventriculaire droite arythmogène (CVDA), également appelée dysplasie ventriculaire droite arythmogène, risquent l'arythmie ventriculaire et la mort cardiaque subite (MCS). Cette étude visait à déterminer la capacité pronostique de la moyenne mobile modifiée de la variation d'amplitude de l'onde T chez les patients présentant une CVDA.

      Méthodes

      Au total, 63 patients (âge moyen de 44,7 ± 14,8 ans; 38 hommes) atteints de CVDA ont été recrutés de manière consécutive pour cette étude. Les caractéristiques initiales de même que les paramètres structurels et électrocardiographiques des patients ont été recueillis. Tous les patients ont été soumis à une électrocardiographie ambulatoire au moment du diagnostic. Les données servant à l’établissement de la moyenne mobile modifiée de la variation d'amplitude de l'onde T ont été extraites en vue d'une analyse plus poussée. Les événements étaient définis par la survenue d'une MCS ou d'une tachyarythmie ventriculaire lors du suivi clinique.

      Résultats

      Au cours d'un délai moyen de suivi de 28,1 ± 15,4 mois, 19 des 63 patients (30,2 %) ont subi un événement : deux patients ont connu une MCS (10,5 %), tandis que 17 patients (89,5 %) ont subi une tachyarythmie ventriculaire. Les patients qui ont subi un événement présentaient une plus importante variation d'amplitude de l'onde T pour les électrodes V5 et V1 modifiées que ceux qui n'ont pas subi d’événement (54,7 ± 24,9 μV vs 35,0 ± 18,3 μV; p = 0,004; 58,8 ± 27,6 μV vs 38,4 ± 18,6 μV; p = 0,007, respectivement). L'analyse multivariée selon le modèle de régression de Cox a démontré que la variation maximale d'amplitude de l'onde T issue de l’électrode CM5 ou NASA modifiée permettait de prédire la survenue d'un événement (p < 0,001; rapport de risque: 1,06; intervalle de confiance à 95 %: de 1,03 à 1,10). La variation d'amplitude de l'onde T (valeur seuil maximale de > 66 μV) était assortie d'une sensibilité et d'une spécificité de 89,5 % et de 90,5 %, respectivement, quant à sa capacité à prédire la survenue d'une MCS ou d'une tachyarythmie ventriculaire.

      Conclusions

      L'analyse initiale de la moyenne mobile modifiée de la variation d'amplitude de l'onde T pourrait aider à prédire la survenue d'une MCS ou d'une tachyarythmie ventriculaire chez les patients atteints de CVDA.
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      References

        • Marcus F.I.
        • Fontaine G.H.
        • Guiraudon G.
        • et al.
        Right ventricular dysplasia: a report of 24 adult cases.
        Circulation. 1982; 65: 384-398
        • Thiene G.
        • Nava A.
        • Corrado D.
        • Rossi L.
        • Pennelli N.
        Right ventricular cardiomyopathy and sudden death in young people.
        N Engl J Med. 1988; 318: 129-133
        • Corrado D.
        • Basso C.
        • Thiene G.
        • et al.
        Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study.
        J Am Coll Cardiol. 1997; 30: 1512-1520
        • Marcus F.I.
        • McKenna W.J.
        • Sherrill D.
        • et al.
        Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the Task Force criteria.
        Circulation. 2010; 121: 1533-1541
        • Peters S.
        • Peters H.
        • Thierfelder L.
        Risk stratification of sudden cardiac death and malignant ventricular arrhythmias in right ventricular dysplasia-cardiomyopathy.
        Int J Cardiol. 1999; 71: 243-250
        • Walker M.L.
        • Rosenbaum D.S.
        Repolarization alternans: implications for the mechanism and prevention of sudden cardiac death.
        Cardiovasc Res. 2003; 57: 599-614
        • Armoundas A.A.
        • Tomaselli G.F.
        • Esperer H.D.
        Pathophysiological basis and clinical application of T-wave alternans.
        J Am Coll Cardiol. 2002; 40: 207-217
        • Klingenheben T.
        • Zabel M.
        • D'Agostino R.B.
        • Cohen R.J.
        • Hohnloser S.H.
        Predictive value of T-wave alternans for arrhythmic events in patients with congestive heart failure.
        Lancet. 2000; 356: 651-652
        • Hohnloser S.H.
        • Klingenheben T.
        • Bloomfield D.
        • Dabbous O.
        • Cohen R.J.
        Usefulness of microvolt T-wave alternans for prediction of ventricular tachyarrhythmic events in patients with dilated cardiomyopathy: results from a prospective observational study.
        J Am Coll Cardiol. 2003; 41: 2220-2224
        • Kitamura H.
        • Ohnishi Y.
        • Okajima K.
        • et al.
        Onset heart rate of microvolt-level T-wave alternans provides clinical and prognostic value in nonischemic dilated cardiomyopathy.
        J Am Coll Cardiol. 2002; 39: 295-300
        • Hennersdorf M.G.
        • Niebch V.
        • Perings C.
        • Strauer B.E.
        T wave alternans and ventricular arrhythmias in arterial hypertension.
        Hypertension. 2001; 37: 199-203
        • Stein P.K.
        • Sanghavi D.
        • Domitrovich P.P.
        • Mackey R.A.
        • Deedwania P.
        Ambulatory ECG-based T-wave alternans predicts sudden cardiac death in high-risk post-MI patients with left ventricular dysfunction in the EPHESUS study.
        J Cardiovasc Electrophysiol. 2008; 19: 1037-1042
        • Verrier R.L.
        • Nearing B.D.
        • La Rovere M.T.
        • et al.
        Ambulatory electrocardiogram-based tracking of T wave alternans in postmyocardial infarction patients to assess risk of cardiac arrest or arrhythmic death.
        J Cardiovasc Electrophysiol. 2003; 14: 705-711
        • Chung F.P.
        • Li H.R.
        • Chong E.
        • et al.
        Seasonal variation in the frequency of sudden cardiac death and ventricular tachyarrhythmia in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy: the effect of meteorological factors.
        Heart Rhythm. 2013; 10: 1859-1866
        • Chinushi M.
        • Restivo M.
        • Caref E.B.
        • El-Sherif N.
        Electrophysiological basis of arrhythmogenicity of QT/T alternans in the long-QT syndrome: tridimensional analysis of the kinetics of cardiac repolarization.
        Circ Res. 1998; 83: 614-628
        • Pastore J.M.
        • Girouard S.D.
        • Laurita K.R.
        • Akar F.G.
        • Rosenbaum D.S.
        Mechanism linking T-wave alternans to the genesis of cardiac fibrillation.
        Circulation. 1999; 99: 1385-1394
        • Narayan S.M.
        T-wave alternans and the susceptibility to ventricular arrhythmias.
        J Am Coll Cardiol. 2006; 47: 269-281
        • Yalin K.
        • Golcuk E.
        • Aksu T.
        • et al.
        Distinguishing right ventricular cardiomyopathy from idiopathic right ventricular outflow tract tachycardia with T-wave alternans.
        Am J Med Sci. 2015; 350: 463-466
        • Nieminen T.
        • Lehtimaki T.
        • Viik J.
        • et al.
        T-wave alternans predicts mortality in a population undergoing a clinically indicated exercise test.
        Eur Heart J. 2007; 28: 2332-2337
        • Kinoshita O.
        • Tomita T.
        • Hanaoka T.
        • et al.
        T-wave alternans in patients with right ventricular tachycardia.
        Cardiology. 2003; 100: 86-92
        • Minkkinen M.
        • Kahonen M.
        • Viik J.
        • et al.
        Enhanced predictive power of quantitative TWA during routine exercise testing in the Finnish Cardiovascular Study.
        J Cardiovasc Electrophysiol. 2009; 20: 408-415
        • Fox J.J.
        • McHarg J.L.
        • Gilmour Jr., R.F.
        Ionic mechanism of electrical alternans.
        Am J Physiol Heart Circ Physiol. 2002; 282: H516-H530
        • Diaz M.E.
        • O'Neill S.C.
        • Eisner D.A.
        Sarcoplasmic reticulum calcium content fluctuation is the key to cardiac alternans.
        Circ Res. 2004; 94: 650-656
        • Clusin W.T.
        Mechanisms of calcium transient and action potential alternans in cardiac cells and tissues.
        Am J Physiol Heart Circ Physiol. 2008; 294: H1-H10
        • Verrier R.L.
        • Kumar K.
        • Nearing B.D.
        Basis for sudden cardiac death prediction by T-wave alternans from an integrative physiology perspective.
        Heart Rhythm. 2009; 6: 416-422
        • Asimaki A.
        • Kleber A.G.
        • Saffitz J.E.
        Pathogenesis of arrhythmogenic cardiomyopathy.
        Can J Cardiol. 2015; 31: 1313-1324
        • Hoffmayer K.S.
        • Machado O.N.
        • Marcus G.M.
        • et al.
        Electrocardiographic comparison of ventricular arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy and right ventricular outflow tract tachycardia.
        J Am Coll Cardiol. 2011; 58: 831-838
        • Folino A.F.
        • Buja G.
        • Bauce B.
        • et al.
        Heart rate variability in arrhythmogenic right ventricular cardiomyopathy correlation with clinical and prognostic features.
        Pacing Clin Electrophysiol. 2002; 25: 1285-1292
        • Lemola K.
        • Brunckhorst C.
        • Helfenstein U.
        • et al.
        Predictors of adverse outcome in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy: long term experience of a tertiary care centre.
        Heart. 2005; 91: 1167-1172
        • Khan A.
        • Mittal S.
        • Sherrid M.V.
        Arrhythmogenic right ventricular dysplasia: from genetics to treatment.
        Anadolu Kardiyol Derg. 2009; : 24-31
        • Morin D.P.
        • Mauer A.C.
        • Gear K.
        • et al.
        Usefulness of precordial T-wave inversion to distinguish arrhythmogenic right ventricular cardiomyopathy from idiopathic ventricular tachycardia arising from the right ventricular outflow tract.
        Am J Cardiol. 2010; 105: 1821-1824
        • Lemery R.
        • Brugada P.
        • Janssen J.
        • et al.
        Nonischemic sustained ventricular tachycardia: clinical outcome in 12 patients with arrhythmogenic right ventricular dysplasia.
        J Am Coll Cardiol. 1989; 14: 96-105
        • Saguner A.M.
        • Medeiros-Domingo A.
        • Schwyzer M.A.
        • et al.
        Usefulness of inducible ventricular tachycardia to predict long-term adverse outcomes in arrhythmogenic right ventricular cardiomyopathy.
        Am J Cardiol. 2013; 111: 250-257
        • Bhonsale A.
        • James C.A.
        • Tichnell C.
        • et al.
        Risk stratification in arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated desmosomal mutation carriers.
        Circ Arrhythm Electrophysiol. 2013; 6: 569-578
        • te Riele A.S.
        • Bhonsale A.
        • James C.A.
        • et al.
        Incremental value of cardiac magnetic resonance imaging in arrhythmic risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated desmosomal mutation carriers.
        J Am Coll Cardiol. 2013; 62: 1761-1769