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MIGLIORE, FEDERICO (2013) Arrhythmogenic Right Ventricular Cardiomyopathy:
Prognostic Value of Electroanatomic Voltage Mapping. [Ph.D. thesis]

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Abstract (english)

Background: Endocardial voltage mapping (EVM) identifies low-voltage right ventricular (RV) areas, which may represent the electroanatomic scar substrate of life-threatening tachyarrhythmias. We prospectively assessed the prognostic value of EVM in a consecutive series of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC).

Methods: We studied 69 consecutive ARVC patients [47 males; median age 35 years(28-45)] who underwent electrophysiological study and both bipolar and unipolar EVM. The extent of confluent bipolar (<1.5mV) and unipolar (<6.0mV) low-voltage electrograms was estimated using the CARTO-incorporated area calculation software.

Results: Fifty-three patients (77%) showed ≥1 RV electroanatomic scars with an estimated burden of bipolar vs unipolar low-voltage areas of 24.8% (7.2-31.5) and 64.8% (39.8-95.3), respectively (P=0.009). In the remaining patients with normal bipolar-EVM (n=16;23%), the use of unipolar EVM unmasked ≥1 region of low-voltage electrogram affecting 26.2% (11.6-38.2) of RV wall. During a median follow-up of 41 (28-56) months, 19(27.5%) patients experienced arrhythmic events, such as sudden death (n=1), appropriate ICD interventions (n=7), or sustained ventricular tachycardia (n=11). Univariate predictors of arrhythmic outcome included previous cardiac arrest or syncope (HR=3.4; 95%CI:1.4-8.8; P=0.03) and extent of bipolar low-voltage areas (HR=1.7 per 5%; 95%CI=1.5-2; P<0.001), while the only independent predictor was the bipolar low-voltage electrogram burden (HR=1.6 per 5%; 95% CI:1.2-1.9; P<0.001). Patients with normal bipolar-EVM had an uneventful clinical course.

Conclusions: The extent of bipolar RV endocardial low-voltage area was a powerful predictor of arrhythmic outcome in ARVC, independently of history and RV dilatation/dysfunction. A normal bipolar-EVM characterized a low-risk subgroup of ARVC patients.

Abstract (italian)

Introduzione: Il mappaggio elettroanatomico mediante sistema CARTO permette di identificare e quantificare aree di basso voltaggio del ventricolo destro che corrispondono a cicatrici elettroanatomiche, substrato di aritmie ventricolari pericolose per la vita.
Lo scopo dello studio era di valutare, in modo prospettico, il valore prognostico del mappaggio elettroanatomico in una coorte di pazienti affetti da Cardiomiopatia Aritmogena del Ventricolo Destro.

Materiali e Metodi: La popolazione di studio includeva 69 pazienti (47maschi; età mediana 35 anni; 28-35) affetti da Cardiomiopatia Aritmogena del Ventricolo Destro. Tutti i pazienti sono stati sottoposti ad un completo work up clinico che includeva: elettrocardiogramma, ecocardiografia, cateterismo cardiaco, studio elettrofisiologico e mappaggio elettroanatomico del ventricolo destro, utilizzando sia mappe bipolari sia unipolari. L’estensione degli elettrogrammi confluenti di basso voltaggio bipolari (<1.5 mV) e unipolari (<6.0 mV) è stata stimata usando un software incorporato nel sistema CARTO.

Risultati: In cinquantatre pazienti (77%) è stata riscontrata ≥1 regione cicatriziale a carico del ventricolo destro con una percentuale stimata di aree di basso voltaggio bipolari e unipolari rispettivamente di 24.8% (7.2-31.5) e 64.8 (39.8-95.3), rispettivamente (P=0.009). In tutti pazienti con una normale mappa bipolare (n= 16; 23%) l’utilizzo del mappaggio unipolare ha identificato ≥1 regione con elettrogrammi di basso voltaggio che interessava il 26.2% (11.6-38.2) del ventricolo destro. Durante un follow-up di 41 (28-56) mesi 19 (27.5%) pazienti subirono eventi aritmici maggiori, quali morte improvvisa (n=1), intervento appropriato dell’ICD (n=7), o tachicardia ventricolare sostenuta (n=11). All’analisi univariata i predittori dell’outcome aritmico includevano: sincope (HR=3.4; 95%CI: 1.4-8.8; P=0.03), e l’estensione delle aree di basso voltaggio bipolare (HR=1.7 per 5%; 95%CI: 1.5-2; P<0.001). All’analisi multivariata, l’unico predittore indipendente risultava l’estensione delle aree di basso voltaggio al mappaggio bipolare (HR=1.6 per 5%;95% CI:1.2-1.9; P<0.001). Tutti i pazienti con un mappaggio bipolare normale presentavano un decorso clinico privo di eventi aritmici.

Conclusioni: l’estensione delle aree endocardiche di basso voltaggio nel ventricolo destro risulta essere un potente predittore di eventi aritmici maligni nella Cardiomiopatia Aritmogena del Ventricolo Destro indipendentemente dalla storia clinica e dalla dilatazione/disfunzione del ventricolo destro. La presenza di un normale mappaggio elettroanatomico bipolare rapprestanta un sottogruppo di pazienti affetti da Cardiomiopatia Aritmogena del Ventricolo Destro a basso rischio aritmico.




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EPrint type:Ph.D. thesis
Tutor:CORRADO, DOMENICO
Ph.D. course:Ciclo 25 > Scuole 25 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > SCIENZE CARDIOVASCOLARI
Data di deposito della tesi:21 January 2013
Anno di Pubblicazione:January 2013
Key Words:Cardiomiopatia Aritmogena del Ventricolo Destro; Mappaggio Elettroanatomico di Voltaggio; Valore prognostico; Morte Improvvisa; Arrhtrhmogenic Right Ventricular Cardiomyopathy; Electroanatomic Voltage Mapping; Prognostic Value; Sudden Death;
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari
Codice ID:5381
Depositato il:16 Oct 2013 08:00
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