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Differentiation between arrhythmogenic cardiomyopathy and early repolarization pattern: A case report with these two entities
International Journal of Cardiology 215 (2016) 132–134
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Differentiation between arrhythmogenic cardiomyopathy and early repolarization pattern: A case report with these two entities Stefan Peters ⁎ St.Elisabeth Hospital gGmbH, Salzgitter, Germany
a r t i c l e
i n f o
Article history: Received 12 February 2016 Accepted 19 March 2016 Available online 05 April 2016 Keywords: Arrhythmogenic cardiomyopathy Early repolarization pattern Epsilon wave ST-segment elevation
A 38-year old male patient was admitted to hospital due to regular sinus tachycardia without any chest complaints. In his first ECG he had early repolarization pattern with prominent ST elevation in lead III (Fig. 1). His second ECG confirmed again early repolarization in inferolateral leads and additionally signs of epsilon waves in lead V2 and the phenomenon of localized right ventricular QRS prolongation. In lead aVR typical abnormalities were visible for suspected arrhythmogenic cardiomyopathy: large Q wave, small R wave and T-wave inversion (Fig. 2). Echocardiography revealed normal contracting left ventricle, but a sacculation of the right ventricular outflow tract, dilatation of the right ventricular inferior area and two outpouchings of the apical region of the right ventricle making arrhythmogenic cardiomyopathy a possible diagnosis. Coronary angiography excluded abnormalities of the coronary arteries, left ventricular angiography was completely normal, but right ventricular angiography revealed dilated right ventricle with sacculations
⁎ St.Elisabeth Hospital gGmbH Salzgitter, Liebenhaller Str. 20, 38259, Salzgitter, Germany. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2016.03.112 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
inferior and apical and deep horizontal fissures in the right ventricular outflow tract (Fig. 3). As the patient did not suffer any syncope and long lasting regular tachycardia a beta blocking agent was given. The combination of early repolarization with severe ST-segment elevation [1] and arrhythmogenic cardiomyopathy [2] in unusual and up to now not published in the literature. Severe ST-segment elevation in early repolarization pattern (Fig. 4) alone refers to severe ventricular arrhythmias leading to sudden cardiac death caused by ventricular fibrillation. Arrhythmogenic cardiomyopathy is another cause of sudden cardiac death with unstable ventricular tachycardia or ventricular fibrillation. With the combination of both cardiac entities the principle indication of ICD implantation is given but lacking complaints makes it very difficult to draw the right conclusion. For asymptomatic provocable Brugada syndrome the complications of ICD implantation are about 31%, but an arrhythmogenic event appears in only 1.6% [3]. For this specific case the situation seems to be similar and the administration of a beta blocking agent is absolutely justified under continuous monitoring. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] M. Haissaguerre, N. Derval, F. Sacher, L. Jesel, I. Deisenhofer, L. de Roy, et al., Sudden cardiac arrest with early repolarization, N. Engl. J. Med. 358 (2008) 2016–2023. [2] F.I. Marcus, W.J. McKenna, D. Sherrill, C. Basso, B. Bauce, D.A. Bluemke, et al., Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia. Proposed modification of the task force criteria, Eur. Heart J. 31 (2010) 806–814. [3] O. Havakuk, S. Viskin, A tale of 2 diseases: the history of long-QT syndrome and Brugada syndrome, J. Am. Coll. Cardiol. 67 (2016) 100–108.
S. Peters / International Journal of Cardiology 215 (2016) 132–134
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Fig. 1. Early repolarization with ST-segment elevation in lead III.
Fig. 2. 12-lead ECG with epsilon wave in V2, localised right precordial QRS prolongation and inferolateral early repolarization phenomenon. Left side: limb leads I, II, III, aVR, aVL, aVF, right side: precordial leads V1–V6.
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S. Peters / International Journal of Cardiology 215 (2016) 132–134
Fig. 3. Right ventricular angiography in 30° RAO: sacculation inferior and apical, deep horizontal fissures of the right ventricular outflow tract.
Fig. 4. Early repolarization pattern by electrocardiographic findings and risk of arrhythmias.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Differentiation between arrhythmogenic cardiomyopathy and early repolarization pattern: A case report with these two entities Stefan Peters ⁎ St.Elisabeth Hospital gGmbH, Salzgitter, Germany
a r t i c l e
i n f o
Article history: Received 12 February 2016 Accepted 19 March 2016 Available online 05 April 2016 Keywords: Arrhythmogenic cardiomyopathy Early repolarization pattern Epsilon wave ST-segment elevation
A 38-year old male patient was admitted to hospital due to regular sinus tachycardia without any chest complaints. In his first ECG he had early repolarization pattern with prominent ST elevation in lead III (Fig. 1). His second ECG confirmed again early repolarization in inferolateral leads and additionally signs of epsilon waves in lead V2 and the phenomenon of localized right ventricular QRS prolongation. In lead aVR typical abnormalities were visible for suspected arrhythmogenic cardiomyopathy: large Q wave, small R wave and T-wave inversion (Fig. 2). Echocardiography revealed normal contracting left ventricle, but a sacculation of the right ventricular outflow tract, dilatation of the right ventricular inferior area and two outpouchings of the apical region of the right ventricle making arrhythmogenic cardiomyopathy a possible diagnosis. Coronary angiography excluded abnormalities of the coronary arteries, left ventricular angiography was completely normal, but right ventricular angiography revealed dilated right ventricle with sacculations
⁎ St.Elisabeth Hospital gGmbH Salzgitter, Liebenhaller Str. 20, 38259, Salzgitter, Germany. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2016.03.112 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
inferior and apical and deep horizontal fissures in the right ventricular outflow tract (Fig. 3). As the patient did not suffer any syncope and long lasting regular tachycardia a beta blocking agent was given. The combination of early repolarization with severe ST-segment elevation [1] and arrhythmogenic cardiomyopathy [2] in unusual and up to now not published in the literature. Severe ST-segment elevation in early repolarization pattern (Fig. 4) alone refers to severe ventricular arrhythmias leading to sudden cardiac death caused by ventricular fibrillation. Arrhythmogenic cardiomyopathy is another cause of sudden cardiac death with unstable ventricular tachycardia or ventricular fibrillation. With the combination of both cardiac entities the principle indication of ICD implantation is given but lacking complaints makes it very difficult to draw the right conclusion. For asymptomatic provocable Brugada syndrome the complications of ICD implantation are about 31%, but an arrhythmogenic event appears in only 1.6% [3]. For this specific case the situation seems to be similar and the administration of a beta blocking agent is absolutely justified under continuous monitoring. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] M. Haissaguerre, N. Derval, F. Sacher, L. Jesel, I. Deisenhofer, L. de Roy, et al., Sudden cardiac arrest with early repolarization, N. Engl. J. Med. 358 (2008) 2016–2023. [2] F.I. Marcus, W.J. McKenna, D. Sherrill, C. Basso, B. Bauce, D.A. Bluemke, et al., Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia. Proposed modification of the task force criteria, Eur. Heart J. 31 (2010) 806–814. [3] O. Havakuk, S. Viskin, A tale of 2 diseases: the history of long-QT syndrome and Brugada syndrome, J. Am. Coll. Cardiol. 67 (2016) 100–108.
S. Peters / International Journal of Cardiology 215 (2016) 132–134
133
Fig. 1. Early repolarization with ST-segment elevation in lead III.
Fig. 2. 12-lead ECG with epsilon wave in V2, localised right precordial QRS prolongation and inferolateral early repolarization phenomenon. Left side: limb leads I, II, III, aVR, aVL, aVF, right side: precordial leads V1–V6.
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S. Peters / International Journal of Cardiology 215 (2016) 132–134
Fig. 3. Right ventricular angiography in 30° RAO: sacculation inferior and apical, deep horizontal fissures of the right ventricular outflow tract.
Fig. 4. Early repolarization pattern by electrocardiographic findings and risk of arrhythmias.