6123A novel ECG parameter predicts lack of eligibility for Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) in patients with Brugada Syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Mazzanti ◽  
S Marelli ◽  
T Chargeishvili ◽  
A Trancuccio ◽  
M Marino ◽  
...  

Abstract Background A conclusive estimate of the eligibility rate for the use of subcutaneous implantable cardioverter defibrillators (S-ICD) in patients with Brugada Syndrome (BrS) is lacking. Objective We aimed to: 1) evaluate the eligibility for S-ICD in patients with BrS using a novel automated tool; 2) investigate predictors of ineligibility for S-ICD, based on baseline 12-lead electrocardiogram. Methods Automated screening for S-ICD was performed in 118 consecutive BrS patients using the programmer provided by the S-ICD producer. The system automatically assessed the acceptability of each of the three sense vectors used by the S-ICD for the detection of cardiac rhythm. Eligibility was defined when at least one vector was acceptable both in supine and standing position. Results The clinical characteristics of 118 BrS patients were as follow: age 43±11 years; 89% males; 2% with aborted cardiac arrest; 14% with a history of syncope; 81% with spontaneous type 1 ECG pattern; 21% with a familial history of sudden cardiac death; 24% with an SCN5A mutation. No patients had an indication for pacing. Only 8/118 (7%) patients were ineligible for S-ICD. Of note, 5/8 (63%) patients who failed the screening exhibited a slurred S wave of ≥80 ms duration in the peripheral lead aVF on the 12-lead baseline electrocardiogram, vs. 4/110 (4%) of those who passed the screening (sensitivity of S wave in aVF for screening failure 63%, specificity 97%; p<0.001). Remarkably, the presence of a slurred S wave of ≥80 ms duration in lead aVF remained significantly associated to the failure of eligibility for S-ICD (odds ratio 50, p<0.001) in a multivariable analysis that included the previous history of symptoms, the presence of a spontaneous type 1 ECG pattern, the gender and the presence of SCN5A mutations. ECG predictor of S-ICD screening Conclusion Up to 93% of BrS patients are eligible for S-ICD when the automated screening tool is used. The presence of a slurred S wave in lead aVF on the 12-lead electrocardiogram is a powerful predictor of screening failure.

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
P M Berne ◽  
T Fancello ◽  
G Viola ◽  
V Carboni ◽  
G Mula ◽  
...  

Abstract Funding Acknowledgements Project Code CRP- 6175. Regione Autonoma della Sardegna Background The subcutaneous defibrillator (S-ICD) is an attractive option for patients with Brugada syndrome (BrS) at high risk, as it is highly effective to prevent arrhythmic sudden cardiac death (SCD) while avoiding some of the complications associated to transvenous devices. However, S-ICD are not free from complications, one of the most common being inappropriate shocks. Objective To assess the causes and predictors of inappropriate shocks by subcutaneous defibrillators (S-ICD) in a cohort of sardinian BrS patients Methods From February 2013 to September 2019, 373 patients were diagnosed as BrS patients. Sixty-five patients were considered to be at high risk of SCD, and implanted with an ICD. Of them, 36 were implanted with an S-ICD. Patients went through regular follow-up visits (physical examination, 12-lead ECG, device interrogation, occurrence of symptoms). Appropriate and inappropriate shocks were analyzed to establish their cause. Results Thirty-six BrS patients were implanted with an S-ICD (9.7% of the total BrS group, 55% of ICD implants). Twenty-four patients (67%) were male, mean age at diagnosis was 45± 14 y.o., and 31 (86%) were probands.  Seventeen patients (47%) had a family history of SCD. Ten patients (28%) had a spontaneous type 1 ECG at diagnosis and 14 (19%) had an spontaneous type 1 ECG at least once since the diagnosis , 2 patients (5.7%) had a type 1 ECG during fever, and 11 (31%) presented an S wave ≥40 msec in lead DI. Twelve patients (33%) underwent EP study, and 8 (67%) were inducible for ventricular fibrillation. During a mean follow-up of 46 ± 67 months, 2 patients (6%) had appropriate shocks, while 5 (14%) had inappropriate shocks. The rate between inappropriate and appropriate shock was 2.5.  The causes of inappropriate shock were T-wave oversensing (4 patients, 80%) and air entrapment (1 patient, 20%). Gender, proband status, sport practice, family history of SCD, type 1 ECG during fever, S wave ≥40 msec in lead DI, VF inducibility EP study, or the presence of symptoms during the follow-up (vaso-vagal syncope, arrhythmic syncope, nocturnal enuresis, ventricular fibrillation, atrial fibrillation) did not associated with inappropriate shock; neither did the technique of screening for S-ICD (manual or automated tool) nor the selected vector of sensing of the S-ICD. A spontaneous type 1 ECG at diagnosis (4 (80%) versus 6 (21%), p = 0.009), or at any time from diagnosis during follow-up (4 (80%) versus 10 (33%), p = 0.0049) and having a high-pass filter programmed OFF/not available [3 (75% versus 7 (25%), p = 0.044], were significantly associated with inappropriate shock of S-ICD in these population. Conclusions Brugada syndrome patients implanted with S-ICD present a higher rate of inappropriate shock compared to appropriate shock (2.5 times). Patients with spontaneous type 1 ECG are at  higher risk to receive inappropriate shock from S-ICDs, while programming a high-pass filter ON may prevent some of these episodes.


2019 ◽  
Vol 40 (2) ◽  
Author(s):  
Ardian Rizal ◽  
Sunu Budhi Raharjo ◽  
Dicky Armein Hanafy ◽  
Yoga Yuniadi

Background : Brugada syndrome is an inherited disease characterized by an increased risk of sudden cardiac death owing to ventricular arrhythmias in the absence of structural heart disease. It has been reported that this syndrome is more prevalent in South-East Asia than in Western countries. Furthermore, genetic studies showed important contributions of several gene mutations to the phenotype of BrS. These suggest that ethnic difference play significant roles in the pathogenesis of BrS. In addition, ICD implantation remains the cornerstone management with a low rate of appropriate shocked. Therefore, it is important to investigate patients’ characteristics for risk stratification. Our objective to investigate the clinical, electrocardiography (ECG) and electrophysiological characteristics that can be used as predictor of appropriate shock due to ventricular arrhythmia (VA) in Indonesian patients with BrS. Methods : We analyse data from Brugada syndrome registry at National Cardiovascular Centre Harapan Kita since January 2013. Total 22 patients were included. Characteristics of BrS that we analysed were baseline characteristics (age and sex), Clinical finding (syncope, cardiac arrest), ECG finding (spontaneous type 1 or drug induced) and Electrophysiology study result (inducible VA and RV ERP). We also added some new ECG characteristic (S wave in lead 1, S wave duration in V1, Fragmented QRS, Junction ST elevation and early repolarization pattern in infero-lateral) to  be analysed. Our end point are appropriate shock during ICD interrogation for those who have been implanted an ICD, and documented VA for those who didn’t receive ICD. Result : We found high incidence of  appropriate ICD’s shock in our population (50% in our study vs 5-11.5% in real world). Predictors of appropriate shock and documented VA are history of syncope (p = 0.045; OR 2.57 [1.44-4.59]), spontaneous type-1 ECG (p = 0.005) and right ventricular effective refractory period (RV ERP) of <200 ms (p=0.018). Other parameters that have been reported to correlate with the occurrence of VA (S Wave in lead 1 (p = 0.530), early repolarization pattern (p = 0.578), fragmented QRS (p = 0.601), S Wave duration (p = 0.365) and J Point STE (p = 0.800) were found to be not correlated to appropriate shock in our populations. Conclusion : History of syncope, spontaneous type-1 Brugada ECG and RV ERP of <200 ms have predictive values for risk stratification of Indonesian patients with Brugada syndrome.    Keywords : Brugada Syndrome, Ventricular arrhythmia, ICD shock       


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Mazzanti ◽  
D Guz ◽  
A Trancuccio ◽  
E Pagan ◽  
T Chargeishvili ◽  
...  

Abstract Background Andersen-Tawil Syndrome type 1 (ATS1) in a rare arrhythmogenic disease caused by loss-of-function mutations in the KCNJ2 gene and characterized by ventricular arrhythmias, dysmorphic features and episodes of periodic paralysis. Although the prognosis of ATS1 patients is typically considered benign, definitive outcome data are lacking. Purpose We aimed to: 1) define the risk of life-threatening arrhythmic events (LAEs); 2) identify risk factors for such events; 3) assess the efficacy of anti-arrhythmic drugs in preventing LAEs. Methods We included 118 ATS1 patients from 57 families with confirmed pathogenic or likely pathogenic KCNJ2 mutations. Clinical and genetical data were acquired by investigators from 23 centers in 9 countries. Results Baseline characteristics of the population are presented in the Table. Over a follow-up of 6.2 years, 17/118 (14%) patients experienced a first LAE, with a 5-year cumulative probability of 7.9% (Figure). Cox multivariable analysis demonstrated that a previous history of syncope (HR 4.5, p=0.02), the documentation of sustained VT (HR 9.3, p=0.001) and the administration of amiodarone (HR 268, p&lt;0.001) were associated with an increased risk of LAE. The baseline rate of LAE was not reduced by beta-blockers alone (1.37 per 100 py; p=1), or in combination with class Ic antiarrhythmic drugs (1.46 per 100 py, p=1). Conclusions Our data demonstrate that the clinical course of patients with ATS1 is characterized by a high rate of LAE. A history of unexplained syncope, and documentation of sustained ventricular tachycardia are independently associated with a higher risk of LAE. Amiodarone is proarrhythmic and should be avoided in ATS1 patients. ATS1: Diagnosis, Outcome, Risk Factors Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): ERN Guard-Heart European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart


Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Yu Kang ◽  
Srinivas Denduluri ◽  
Bruna M Assuncao ◽  
Marielle Scherrer-Crosbie

Introduction: The incidence of acute leukemia has been increasing by about 1.6% per year in the last decade. Anthracyclines remain a standard of care for patients with acute leukemia; survival is increasing at about 1.0% per year. However, little is known about the incidence and risk of major adverse cardiovascular events (MACE) in patients with acute leukemia. Hypothesis: To investigate the incidence of MACE and the risk factors for MACE in patients with acute leukemia treated with anthracyclines. Methods: All adult patients with acute leukemia treated with anthracyclines between January 2005 and April 2018 at the hospital of University of Pennsylvania were studied. MACE were defined as cardiovascular death, symptomatic heart failure, non-fatal acute coronary syndrome, non-fatal ventricular arrhythmia and non-fatal ischemic stroke. Differences between patients with or without MACE were compared by Student’s t test or the Wilcoxon rank comparison. Cox proportional hazard analysis was used to determine significant clinical and echocardiographic parameters associated with MACE. Results: Six hundred and seventy-four patients (234 acute lymphoblastic leukemia (ALL), 440 acute myeloid leukemia (AML), age range: 22 to 93 years) were studied. Seventy-one patients (10.5%) experienced MACEs during a median follow-up period of 16 months (4 to 146 months) after the initiation of chemotherapy. The median time to MACE was 13 months (5 to 107 months). In the patients with MACE,59 (8.8%) developed symptomatic heart failure, 7 (1.0%) died of cardiovascular causes, 3 (0.4%) experienced non-fatal acute myocardial syndrome and 2 (0.3%) had an ischemic stroke. The Table summarizes the characteristics of patients with and without MACE. In a multivariable analysis, a previous history of heart failure (HR: 4.632, P=0.000, 95% CI: 2.572-8.341), leukemia type (HR: 3.155, P=0.002, 95% CI: 1.544-6.446) and baseline LVEF (HR: 0.973, P=0.000, 95% CI: 0.955-0.991) remained associated with MACE. Conclusion: Patients with acute leukemia treated with anthracyclines have a high rate of MACE after chemotherapy. A previous history of heart failure, baseline LVEF and type of leukemia may help to stratify acute leukemia patients at highest risk for MACEs after anthracycline therapy.


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Marelli ◽  
D Kukavica ◽  
A Mazzanti ◽  
T Chargeishvili ◽  
A Trancuccio ◽  
...  

Abstract Background Manual electrocardiographic (ECG) screening tools for the use of subcutaneous cardiac defibrillator (S-ICD) have been associated with high ineligibility rates in Brugada syndrome patients (BrS). Although recent works identified ECG parameters for S-ICD eligibility in general population, automated screening tool (AST) for S-ICD eligibility have not even been assessed in large series of patients with BrS. Purpose This study evaluates the AST-derived eligibility rates for an S-ICD in patients with BrS, and ECG parameters associated with S-ICD eligibility. Methods Screening for S-ICD eligibility was performed using AST in 194 consecutive patients with BrS. Eligibility was defined when at least one of the three vectors was acceptable both in supine and standing position. Twelve-lead ECGs were registered during the screening. ECG parameters associated with AST eligibility were identified using multivariable logistical regression. Results Our study population consisted of 194 patients, with male preponderance (n=165/194; 85%); and were 43±12 years old at the time of screening. Majority of patients presented a spontaneous type 1 pattern during screening (n=128/194; 66%), with an average pattern height of 3±3 mm. Remarkably, 93% of patients passed the screening with AST. No differences in eligibility rates in terms of gender (93% males vs. 93% females eligible; p=1) and age (48±9 years non-eligible vs. 42±12 eligible; p=0.07) existed. Notably, our eligibility rate was 2.5 times higher than rates reported in literature when using manual screening tools (p=0.023). Independent 12-lead ECG parameters (Table) associated with AST eligibility were duration of S wave &lt;80 ms in aVF and R/T ratio ≥3 in lead II (Figure), which have a high positive predictive value (97% and 99%, respectively) for screening eligibility. Conclusions Most BrS patients (93%) are eligible for S-ICD when AST is used. S wave &lt;80 ms in aVF, and R/T ratio ≥3 in lead II have a high positive predictive value for S-ICD eligibility. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Italian Ministry of Research and University Dipartimenti di Eccellenza 2018–2022 grant to the Molecular Medicine Department (University of Pavia)


2020 ◽  
Vol 13 (3) ◽  
pp. 1185-1190
Author(s):  
Shoko Marshall ◽  
Aki Kizuki ◽  
Tadashi Kitaoji ◽  
Hiroshi Imada ◽  
Hayato Kato ◽  
...  

Nivolumab, a fully human IgG4 immune checkpoint inhibitor (ICI) antibody, has been approved for a variety of cancers. Several endocrine-associated immune-related adverse events have been reported, but the incidence rate is relatively low. This is a case of a patient with gastric cancer who underwent nivolumab therapy, leading to type 1 diabetes as well as adrenocorticotropic hormone (ACTH) deficiency and hypothyroidism almost simultaneously. A 70-year-old man with no previous history of diabetes was treated with nivolumab monotherapy for gastric cancer in November 2018. After 8 courses of nivolumab, he was diagnosed with type 1 diabetes associated with ICI; consequently, insulin therapy was initiated in March 2019. In April 2019, he was transported to hospital due to suffering from prolonged hypoglycemia, disturbed consciousness, and fever. He frequently experienced episodes of hypoglycemia, with poor controlled glycemia. His disturbed consciousness and fever also sustained. Further investigation of his hormones revealed low cortisol and ACTH levels, as well as hypothyroidism. His blood glucose control was improved after the introduction of hydrocortisone and thyroid hormone; he became alert and afebrile. In January 2020, he received a followed-up in an outpatient setting under insulin, hydrocortisone, and thyroid replacement therapy. Endocrine defect associated with ICIs, especially type 1 diabetes or ACTH deficiency, is a rare condition. To the best of our knowledge, this is the 1st case of multiple endocrinopathies simultaneously induced by nivolumab. Various endocrine concomitant defects should be taken into consideration when treating with nivolumab.


2021 ◽  
Vol 10 (20) ◽  
pp. 4774
Author(s):  
Byung-Hyun Lee ◽  
Hyemi Moon ◽  
Jae-Eun Chae ◽  
Ka-Won Kang ◽  
Byung-Soo Kim ◽  
...  

Previous studies have reported the survival benefit after ruxolitinib treatment in patients with myelofibrosis (MF). However, population-based data of its efficacy are limited. We analyzed the effects of ruxolitinib in MF patients with data from the Korean National Health Insurance Database. In total, 1199 patients diagnosed with MF from January 2011 to December 2017 were identified, of which 731 were included in this study. Patients who received ruxolitinib (n = 224) were matched with those who did not receive the drug (n = 507) using the 1:1 greedy algorithm. Propensity scores were formulated using five variables: age, sex, previous history of arterial/venous thrombosis, and red blood cell (RBC) or platelet (PLT) transfusion dependence at the time of diagnosis. Cox regression analysis for overall survival (OS) revealed that ruxolitinib treatment (hazard ratio (HR), 0.67; p = 0.017) was significantly related to superior survival. In the multivariable analysis for OS, older age (HR, 1.07; p < 0.001), male sex (HR, 1.94; p = 0.021), and RBC (HR, 3.72; p < 0.001) or PLT (HR, 9.58; p = 0.001) transfusion dependence were significantly associated with poor survival, although type of MF did not significantly affect survival. Considering evidence supporting these results remains weak, further studies on the efficacy of ruxolitinib in other populations are needed.


2012 ◽  
Vol 140 (1-2) ◽  
pp. 84-90
Author(s):  
Vesna Bisenic ◽  
Sasa Hinic ◽  
Mirjana Krotin ◽  
Branislav Milovanovic ◽  
Jelena Saric ◽  
...  

Introduction. Brugada syndrome is an arrhythmogenic disease characterized by coved ST segment elevation and J point elevation of at least 2 mm in at least two of the right precordial ECG leads (V1-3) and ventricular arrhythmias, syncope, and sudden death. Risk stratifications of patients with Brugada electrocardiogram are being strongly debated. Case Outline. A 23-year-old man was admitted to the Coronary Care Unit of the Clinical Centre ?Bezanijska kosa? due to weakness, fatigue and chest discomfort. The patient suffered from fainting and palpitations. There was a family history of paternal sudden death at 36 years. Electrocardiogram showed a coved ST segment elevation of 4 mm in leads V1 and V2, recognised as spontaneous type 1 Brugada pattern. Laboratory investigations revealed normal serum cardiac troponin T and serum potassium, and absence of inflammation signs. Echocardiographic finding was normal, except for a mild enlargement of the right atrium and ventricle. The diagnosis of Brugada syndrome was made by Brugada-type 1 electrocardiogram and the family history of sudden death <45 years. The patient was considered as a high risk, because of pre-syncope and palpitations. He underwent ICD implantation (Medtronic MaximoVR7232Cx) using the standard procedure. After implantation, noninvasive electrophysiology study was done and demonstrated inducible VF that was interrupted with the second 35 J DC shock. The patient was discharged in stable condition with beta-blocker therapy. After a year of pacemaker check-ups, there were no either VT/ VF events or ICD therapy. Conclusion. Clinical presentation is the most important parameter in risk stratification of patients with Brugada electrocardiogram and Brugada syndrome.


Author(s):  
Anil Sarica ◽  
Serhat Bor ◽  
Mehmet Orman ◽  
Hector Barajas-Martinez ◽  
Jimmy Juang ◽  
...  

Introduction: Irritable bowel syndrome (IBS) is one of the most widely recognized functional bowel disorders (FBDs) with a genetic component. SCN5A gene and SCN1B loci have been identified in population-based IBS cohorts and proposed to have a mechanistic role in the pathophysiology of IBS. These same genes have been associated with Brugada syndrome (BrS). The present study examines the hypothesis that these two inherited syndromes are linked. Methods and Results: Prevalence of FBDs over a 12 months period were compared between probands with BrS/drug-induced type 1 Brugada pattern (DI-Type1 BrP) (n=148) and a control group (n=124) matched for age, female sex, presence of arrhythmia and co-morbid conditions. SCN5A/SCN1B genes were screened in 88 patients. Prevalence of IBS was 25% in patients with BrS/DI-Type1 BrP and 8.1% in the control group (p=2.34×10−4). On stepwise logistic regression analysis, presence of current and/or history of migraine (OR of 2.75; 95% CI: 1.08 to 6.98; p=0.033) was a predictor of underlying BrS/DI-Type1 BrP among patients with FBDs. We identified 8 putative SCN5A/SCN1B variants in 7 (12.3%) patients with BrS/DI-Type1 BrP and 1 (3.2%) patient in control group. Five out of 8 (62.5%) patients with SCN5A/SCN1B variants had FBDs. Conclusion: IBS is a common co-morbidity in patients with BrS/DI-Type1 BrP. Presence of current and/or history of migraine is a predictor of underlying BrS/DI-Type1 BrP among patients with FBDs. Frequent co-existence of IBS and BrS/DI-Type1 BrP necessitates cautious use of certain drugs among the therapeutic options for IBS that are known to exacerbate the Brugada phenotype.


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