scholarly journals Delayed myocardial enhancement in children with different types of cardiomyopathy: a diagnostic and prognostic tool

2019 ◽  
Vol 50 (1) ◽  
Author(s):  
Hend Gamal Mohamed Fathy Abuo Elfadl ◽  
Sabry Alam El Dean Mohamed El Mogy ◽  
Mohamed Magdy Aly Abouelkeir ◽  
Ghada Mohamad Gaballah ◽  
Nevertiti Kamal El-Din Eid
Keyword(s):  
Adverse Effect ◽  
Late Gadolinium Enhancement ◽  
Imaging Modality ◽  
Cardiac Effect ◽  
Contrast Study ◽  
Gadolinium Enhancement ◽  
Non Invasive ◽  
Major Adverse Effect ◽  
Significant Difference ◽  
Different Types

Abstract Background The pattern of late gadolinium enhancement (LGE) in cardiomyopathy is quite different in children compared to adults. In addition, the data about LGE imaging in children are still restricted, so the goal was to study the role of cardiac magnetic resonance (CMR) with different techniques, including LGE images in diagnosis and evaluation of different types of cardiomyopathy in children. Results In group A (enhancement group), LVEDV 146.2 (144) ml, indexed LVEDV 81.8 (195) ml, LVESV 50 (357) ml, indexed LVESV 47.5 (243) ml, and LVEF 36% (64%), and a major adverse effect was found in 12 out of 15 cases (80%). However, in group B (non-enhancement group), the results were LVEDV 72 (303) ml, indexed LVEDV 75 (318) ml, LVESV 30 (220) ml, indexed LVESV 37.1 (189) ml, and LVEF 45.79% (65%), and a major adverse cardiac effect was found in 2 out of 16 cases (12.5%). The LVEF was lower, and LV volume indices including LVEDV and LVESV were higher in patients with LGE compared to those without LGE with a statistically significant difference (p value = 0.001, p value = 0.003, and p value = 0.005, respectively). Furthermore, it was also found that a major adverse effect occurs with higher incidence in enhancement cases (92%) as compared to non-enhancement cases (12.5%) with a statistically significant difference (p value ≤ 0.001). LGE was found in 15 cases out of 31 cases (48.4%); however, the remaining 13 cases had no contrast study. Conclusion Cardiac MRI can be considered as an important non-invasive imaging modality, not only for assessment but also for differentiation between ischemic and non-ischemic cardiomyopathy in the pediatric age group. Using its different techniques allows a better assessment of morphologic and functional parameters in cardiomyopathy. Moreover, the late gadolinium enhancement is regarded as a promising non-invasive tool in the detection and quantification of myocardial scars. That is considered of high importance in diagnosis, categorization, and detection of etiology in most cases of different types of cardiomyopathy, in addition to risk stratification that can be an essential step in patient management.

scholarly journals Effects of candesartan on left ventricular hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
H Maqsood ◽  
H.A Shakeel ◽  
H.F Shoukat ◽  
M.D Khan ◽  
S.A.Y Shah ◽  
...  
Keyword(s):  
Late Gadolinium Enhancement ◽  
Hypertrophic Cardiomyopathy ◽  
Interstitial Fibrosis ◽  
Angiotensin Receptor Blockers ◽  
Left Ventricular ◽  
Funding Source ◽  
Gadolinium Enhancement ◽  
Percent Change ◽  
Lv Mass ◽  
Significant Difference

Abstract Introduction Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular (LV) hypertrophy in the absence of pressure overload. Manifestations of the disease include heart failure associated with diastolic dysfunction and atrial and ventricular tachyarrhythmias. Pathological features of HCM include myocyte hypertrophy, interstitial fibrosis, and myocyte disarray and are mediated by angiotensin II. Purpose This study aimed to evaluate the effects of candesartan on left ventricular (LV) hypertrophy and fibrosis in patients with hypertrophic cardiomyopathy (HCM). Methods In double-blind fashion, 30 patients (6 women, 24 men; age: 55±11 years) with HCM were randomly assigned to receive placebo (n=13) or candesartan 50 mg twice a day (n=17) for 1 year. To measure LV mass and extent of fibrosis, cardiac magnetic resonance imaging was performed at baseline and 1 year as assessed by late gadolinium enhancement. Results There was a trend toward a significant difference in the percent change in LV mass (median: +5% with placebo vs. −5% with candesartan; p=0.06). There was a significant difference in the percent change in the extent of late gadolinium enhancement, with the placebo group experiencing a larger increase (+30±27% with placebo vs. −22±44% with candesartan; p=0.03). Conclusion Our study concludes reduction of the progression of myocardial hypertrophy and fibrosis with candesartan in patients with hypertrophic cardiomyopathy. Our study population was limited so we warrant larger trials to confirm a place for angiotensin receptor blockers in the management of patients with hypertrophic cardiomyopathy. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): Self funding

scholarly journals Clinico-radiological profile of abdominal tuberculosis in HIV/AIDS patients-a study from rural central India

2017 ◽  
Vol 5 (5) ◽  
pp. 1980 ◽  
Author(s):  
Nisar A. Wafai ◽  
Sudhir K. Yadav ◽  
Prem S. Singh ◽  
Manoj Kumar ◽  
Prafulla K. Singh ◽  
...  
Keyword(s):  
Imaging Modality ◽  
Central India ◽  
Abdominal Tuberculosis ◽  
Cd4 Count ◽  
Common Finding ◽  
Non Invasive ◽  
Significant Difference ◽  
Average Size ◽  
Loss Of Appetite ◽  
Hiv Aids

Background: One of the major challenge of present era is dual epidemic of HIV/AIDS and tuberculosis. With immunosuppression, risk of opportunistic diseases increases in these patients and tuberculosis is most common opportunistic infection. The prevalence of abdominal tuberculosis seems to be rising, particularly due to increasing prevalence of HIV infection. The diagnosis of abdominal tuberculosis can often be difficult and it remains underdiagnosed, in view of its nonspecific manifestations. The investigations involved in its diagnosis are expensive and time consuming, however, ultrasonography (USG) is an affordable, non-invasive and widely available modality which can be of help in the diagnosis of abdominal tuberculosis. Therefore, this study was undertaken to evaluate clinical and USG finding among Abdominal Tuberculosis patients with HIV/AIDS.Methods: After informed consent, patients underwent thorough history taking and clinical examination followed by high quality USG abdomen and other biochemical and haematological tests including CD4 count. Follow up USG abdomen was done at time of completion of course of ATT and data was analysed.Results: 45 were found to have abdominal tuberculosis. Of these patients, 31(68.9%) were male and 14 (31.1%) were female. Mean age of HIV-abdominal TB was 34.27±9.66 years. most common symptoms were weight loss 41(91.1%), loss of appetite 38(84.4%), fever       32(71.1%), generalized weakness 30(66.7%) and abdominal pain 27(60.0%). On USG abdomen, intraabdominal lymphadenopathy was most common finding found in 44(97.8%). Average size of enlarged lymph node was 3.1+-1.0 cm. Mesenteric lymphnodes were enlarge in 40(88.89%), paraaortic 8(17.78%), retroperitoneal 4(8.89%) while peripancreatic and porta hepatic in 3(6.67%). splenomegaly was noted in 14(31.1%) cases. Hepatomegaly was found in 6 cases, who all were male. Ascites was evident in 5(11.1%) patients. Extensive involvement, defined as involvement of two or more intraabdominal sites, was found 24(53.3%) cases. There was no statistically significant difference found among these USG findings and CD4 count.Conclusions: The findings of lymphadenopathy (size>15mm) and hypoechoic/necrotic echotexture, hepatosplenomegaly with hypoechoic lesions in ultrasonography are suggestive of abdominal tuberculosis in HIV infected patients with unexplained nonspecific symptoms and low CD4 count.  However, above findings are not standardized and inability to confirm the diagnosis of tuberculosis by direct microscopy and culture is the limitation of this study. Ultrasonography is an affordable, widely available, non-invasive imaging modality which may be optimally utilized for the diagnosis of abdominal tuberculosis in HIV infected patients, especially in the rural setup where microbiological and other sophisticated radiological investigations have limited availability.

Abstract 5920: Usefulness of Late Gadolinium Enhancement as Non-invasive Arrhythmic Risk Marker in Patients with Heart Failure and Systolic Dysfunction

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Alfonso Valle ◽  
Mercedes Nadal ◽  
Jordi Estornell ◽  
Nieves Martinez ◽  
Miguel Corbi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Late Gadolinium Enhancement ◽  
Risk Stratification ◽  
Systolic Dysfunction ◽  
Total Mortality ◽  
Left Ventricular ◽  
Gadolinium Enhancement ◽  
Non Invasive ◽  
Patients With Heart Failure

The identification of prognostic markers in patients with heart failure of both ischemic and non ischemic etiology is an increasing need in the era of devices therapy. Risk stratification for sudden cardiac death (SCD) remains problematic with reliance on left ventricular function which predicts total mortality rather than arrhythmic events (AE). Recently cardiac magnetic resonance was employed to predict susceptibility for malignant arrhythmias. This study sought to determine the utility of late gadolinium enhancement (LGE) to predict AE. Three hundred consecutive patients with symptomatic heart failure and systolic dysfunction of both ischemic and non ischemic cause undergoing CMR, were classified into two groups attending to the presence (n 160) or absence of LGE (n 140), and were followed prospectively during 842 days. The primary endpoint was the combined of SCD or Ventricular tachycardia (VT). 23 patients had AE (8 SCD/15 VT) during the follow-up, 19 of them presenting LGE (83%). The presence of LGE was associated to a significantly higher AE rate (11.8.% vs 2.8% p< 0.001)(figure ). Compared to patients without LGE, midwall fibrosis and an ischemic pattern of LGE predicted AE. (3% vs 5% vs 14%, p= 0.001) LGE is a new non-invasive predictor of AE in patients with heart failure and systolic dysfunction. This suggest a potential role for risk stratification and better selection of patients who needs device therapy

scholarly journals Influence of sex and age on sonographic infant hip indices

2014 ◽  
Vol 2 (4) ◽  
Author(s):  
Kakale SB ◽  
Tabari AM ◽  
Isyaku K ◽  
Yunusa A
Keyword(s):  
Imaging Modality ◽  
Alpha Angle ◽  
Late Presentation ◽  
Radiology Department ◽  
Age Group ◽  
Hip Joints ◽  
Non Invasive ◽  
Significant Difference ◽  
Males And Females ◽  
The Mean

Ultrasound is a non-invasive, cheap and readily available imaging modality for studying the infant hip. Early detection of developmental hip subluxation, acetabular dysplasia and the prevention of late presentation of a developmentally dislocated hip with consequent secondary premature degenerative arthritis are goals that all practitioners should strive for. Provision of axial indices of alpha and beta angles of the infant hip joint in Kano, Nigeria using ultrasonography to establish a normogram as reference values for further studies is the objective of this study. This descriptive prospective study was conducted at the Radiology Department of Aminu Kano Teaching Hospital, Kano state, Nigeria. Successive four hundred appropriately consented infants were recruited for this study. The axial angle relationships of both hip joints were measured using 7.5 MHz linear transducer of Mindray DP-8800 Digital plus ultrasound machine. The mean alpha and beta angles for both hips in females were 56.590 and 49.580 respectively while those for males were 56.730 and 50.530 respectively. Minimum and maximum alpha angle for both hips ranged from 380 to 780 while the beta angles ranged 290 to 660 respectively. The age group 1-3 months has the highest frequency of respondents (251) while age group 10 - 12 months has the lowest (22). There was no statistically significant difference in the alpha and beta angles between males and females hips and age of the infants did not affect the hip indices. The study showed no statistical significant difference in the measured alpha and beta angles between males and females. Age of measurement in infants did not affect the hip indices.

scholarly journals Dark-blood late gadolinium enhancement cardiovascular magnetic resonance for improved detection of subendocardial scar: a review of current techniques

2021 ◽  
Vol 23 (1) ◽  
Author(s):  
Robert J. Holtackers ◽  
Caroline M. Van De Heyning ◽  
Amedeo Chiribiri ◽  
Joachim E. Wildberger ◽  
René M. Botnar ◽  
...  
Keyword(s):  
Cardiovascular Magnetic Resonance ◽  
Late Gadolinium Enhancement ◽  
Magnetic Resonance ◽  
Myocardial Viability ◽  
Current Evidence ◽  
Future Research ◽  
Gadolinium Enhancement ◽  
Dark Blood ◽  
Magnetization Preparation ◽  
Non Invasive

AbstractFor almost 20 years, late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has been the reference standard for the non-invasive assessment of myocardial viability. Since the blood pool often appears equally bright as the enhanced scar regions, detection of subendocardial scar patterns can be challenging. Various novel LGE methods have been proposed that null or suppress the blood signal by employing additional magnetization preparation mechanisms. This review aims to provide a comprehensive overview of these dark-blood LGE methods, discussing the magnetization preparation schemes and findings in phantom, preclinical, and clinical studies. Finally, conclusions on the current evidence and limitations are drawn and new avenues for future research are discussed. Dark-blood LGE methods are a promising new tool for non-invasive assessment of myocardial viability. For a mainstream adoption of dark-blood LGE, however, clinical availability and ease of use are crucial.

P1113Patchy localisation of late gadolinium enhancement associated with ventricular arrhythmia in dilated cardiomyopathy

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
V Pooranachandran ◽  
A Mistry ◽  
Z Vali ◽  
X Li ◽  
B Sidhu ◽  
...  
Keyword(s):  
Late Gadolinium Enhancement ◽  
High Risk ◽  
Ventricular Arrhythmia ◽  
Dilated Cardiomyopathy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Lv Function ◽  
Gadolinium Enhancement ◽  
Ventricular Ejection Fraction ◽  
Significant Difference

Abstract Funding Acknowledgements None Introduction Myocardial fibrosis detected using late gadolinium enhancement(LGE) on cardiac magnetic resonance(CMR) imaging holds prognostic value in dilated cardiomyopathy(DCM). Recent reports have demonstrated the localisation of LGE to be promising predictors of ventricular arrhythmic (VA).Aim: To determine the localisation of LGE associated with high risk of VA in DCM patients. Methods: Retrospective review of consecutive DCM patients(n = 85) implanted with an implantable cardioverter defibrillator(ICD) at a single tertiary centre between 2011-2018. All patients with insufficient follow-up data, cardiac channelopathies, primary valvular pathology and congenital heart disease were excluded from analysis(n = 11). Details of VA occurrence were obtained from medical and pacing notes. VA was defined as VA causing haemodynamic compromise or appropriate device therapy (anti-tachycardia pacing/shock). Localisation of LGE was defined as midwall, patchy, subepicardial or transmural. Left ventricular ejection fraction(LVEF) &lt;35% was defined as severely impaired function. Results:74 DCM patients implanted with an ICD were identified for analysis; LGE was observed in 18(60%) VA and 29(66%) non-VA patients(p = 0.6). There was no observed difference in mean age for patients with and without LGE (68 ± 10 vs. 65 ± 10 years,p = 0.07). A significant difference was seen between localisation and VA (p = 0.04), with patchy LGE demonstrating a higher arrhythmic risk(p = 0.005). There was no association between LVEF and LGE(p = 0.2) however, a significant difference was seen in LVEF and arrhythmic risk, with a more severely impaired LV function seen in patients without VA(p = 0.01). Conclusion:This study has demonstrated a patchy LGE localisation to be strongly associated with ventricular arrhythmia in DCM. Whilst this is a valuable tool in risk stratification, a prospective study with a larger population is required to confirm the validity of this finding. Moreover, an additional method will need to be considered to identify high risk patients without LGE. Ventricular Arrhythmia (n = 30) No Ventricular Arrhythmia (n = 44) P Value Male(%) 20(67%) 24(55%) p = 0.29 Age(Mean ± SD) 65 ± 12 65 ± 10 p = 0.36 LGE Midwall 10(56%) 24(83%) p = 0.04 Subepicardial 1(5.5%) 2(7%) p = 0.85 Transmural 1(5.5%) 2(7%) p = 0.85 Patchy 6(33%) 1(3%) p = 0.005 LVEF &lt;35% 23(77%) 42(95%) p = 0.01

scholarly journals Diagnosis of Cardiac Involvement in Amyloid A Amyloidosis by Cardiovascular Magnetic Resonance Imaging

2021 ◽  
Vol 8 ◽  
Author(s):  
Bishwas Chamling ◽  
Stefanos Drakos ◽  
Michael Bietenbeck ◽  
Karin Klingel ◽  
Claudia Meier ◽  
...  
Keyword(s):  
Cardiovascular Magnetic Resonance ◽  
Late Gadolinium Enhancement ◽  
T1 Mapping ◽  
Cardiac Involvement ◽  
Diagnostic Yield ◽  
Aa Amyloidosis ◽  
Gadolinium Enhancement ◽  
Amyloid A ◽  
Non Invasive ◽  
Work Up

Background: Diagnosis of cardiac involvement in amyloid A (AA) amyloidosis is challenging since AA amyloidosis is a rare disease and cardiac involvement even less frequent. The diagnostic yield of currently available non-invasive imaging methods is not well-studied and rather limited, and invasive endomyocardial biopsy (EMB) is rarely performed due to the potential risk of this procedure. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization by late-gadolinium-enhancement (LGE) imaging and novel-mapping approaches may increase the diagnostic yield in AA amyloidosis.Methods: Two patients with AA amyloidosis in whom cardiac involvement was suspected based on CMR findings and subsequently proven by biopsy work-up are presented. CMR studies were performed on a 1.5-T system and comprised a cine steady-state free precession pulse sequence for ventricular function and a late-gadolinium-enhancement (LGE) sequence for detection of myocardial pathology. Moreover, a modified Look-Locker inversion recovery (MOLLI) T1-mapping sequence was applied in basal, mid and apical short-axes prior to contrast agent administration and ~20 min thereafter to determine native T1 and ECV values.Results: Both patients showed slightly dilated left ventricles (LV) with mild to moderate LV hypertrophy and preserved systolic function. Only a very subtle pattern of LGE was observed in both patients with AA amyloidosis. However, markedly elevated native T1 (max. 1,108 and 1,112 ms, respectively) and extracellular volume fraction (ECV) values (max. 39 and 48%, respectively) were measured in the myocardium suggesting the presence of cardiac involvement - with subsequent EMB-based proof of AA amyloidosis.Conclusion: We recommend a multi-parametric CMR approach in patients with AA amyloidosis comprising both LGE-based contrast-imaging and T1-mapping-based ECV measurement of the myocardium for non-invasive work-up of suspected cardiac involvement. The respective CMR findings may be used as gatekeeper for additional invasive procedures (such as EMB) and as a non-invasive monitoring tool regarding assessment and modification of ongoing treatments.

scholarly journals Analysis of inferior nasal turbinate width and concha bullosa in subjects with nasal septum deviation: a cone beam tomography study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Shishir Ram Shetty ◽  
Saad Wahby Al Bayatti ◽  
Natheer Hashim Al-Rawi ◽  
Hesham Marei ◽  
Sesha Reddy ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Imaging Modality ◽  
Inferior Turbinate ◽  
Cone Beam ◽  
Concha Bullosa ◽  
Low Radiation Dose ◽  
Nasal Turbinate ◽  
Turbinate Hypertrophy ◽  
Significant Difference ◽  
Different Types

Abstract Background In individuals with nasal septal deviation (NSD), compensatory hypertrophy of the nasal turbinates occurs as a protective mechanism of the nasal passage from dry and cold air. NSD associated nasal turbinate hypertrophy is usually recurrent, requiring repetitive imaging. Therefore, a multiplanar imaging modality with a low radiation dose is best suited for long-term follow-up of this condition. This study aimed to evaluate the association of width of inferior turbinates and presence of concha bullosa with the degree of NSD using Cone beam computed tomography (CT). Methods The CBCT scans of 100 patients with NSD were selected as per convenience sampling and were evaluated by two maxillofacial radiologists. The width of the non-hypertrophied inferior turbinate (NHT) on the convex side of the NSD, and hypertrophic inferior turbinates (HT) on the concave side of the NSD were measured at three locations. The septal deviation angle (SDA) and the presence of concha bullosa (CB) were determined. Results A significant difference was observed in the anterior, middle, posterior, and mean widths between HT and NHT (p < 0.001). There was a significant difference in the widths of the HT and NHT among different types of NSD. A strong positive correlation (r = 0.71, p < 0.001) was found between SDA and the mean width of the HT. Age (P = 0.71) and gender (P = 0.65) had no significant difference among different types of NSD. Regression analysis revealed that the presence of CB (p = 0.01) and middle width of the HT (p < 0.001) are significant predictors of SDA and type of NSD. Conclusion The results of the present study reveal that the middle width of the HT and the presence of CB influence the degree of NSD. The present study results recommend the use of CBCT as a substitutive low radiation dose imaging modality for evaluation of NSD, CB, and associated inferior turbinate hypertrophy.

Abstract 13901: Spatial Distribution of the Late Gadolinium Enhancement on Cardiac MRI Strongly Affects Maximal T-wave Alternans Sites on the 12-lead Holter ECG in Hypertrophic Cardiomyopathy

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Naka Sakamoto ◽  
Nobuyuki Sato ◽  
Ahmed Talib ◽  
Keisuke Otsu ◽  
Eitaro Sugiyama ◽  
...  
Keyword(s):  
Spatial Distribution ◽  
Late Gadolinium Enhancement ◽  
Hypertrophic Cardiomyopathy ◽  
Cardiac Mri ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Gadolinium Enhancement ◽  
T Wave ◽  
Significant Difference ◽  
T Wave Alternans

[Background]: Late gadolinium enhancement (LGE) on cardiac MRI (CMR) predicts the mortality in hypertrophic cardiomyopathy (HCM) patients. T-wave alternans (TWA) is a potential cardiac mortality predictor. However, whether LGE localization affects TWA is unclear. [Purpose]: To elucidate the localization relationship between the LGE and maximal TWA lead (TWAmax-lead) and maximal TWA voltage (TWAmax) using 12-lead Holter ECGs (Holter12) in HCM. [Methods]: Holter12s and CMR were performed in 46 HCM patients. TWA was assessed using a modified moving average method and the TWAmax was determined in each lead. The average transmural LGE extent was scored using a 4 point score (Score 0:no LGE, 1:1-25%, 2:26-50%, 3:51-75%, 4:76-100%) in 12 left ventricular segments and the sum (LGEtotal) was calculated. Left ventricular LGE sites were classified into anterior, septal, inferior, and lateral. Corresponding ECG lead groups were defined as V3-4 for anterior, V1-2 for septal, II, III, aVF for inferior, and I, aVL, and V5-6 for lateral. The TWAmax was analyzed depending on the Score of the 5 stages, and the coincidence between the LGE distribution and TWAmax-lead was investigated. Furthermore, the differences in the TWAmax, LGEtotal, and left ventricular ejection fraction (LVEF) in the presence or absence of ventricular tachycardia (VT) were also studied. [Results]: The TWAmax was 50±11μV for Score=0, 54±13μV for Score=1, 61±18μV for Score=2, 67±20μV for Score=3, and 47±16μV for Score=4. The TWAmax for Scores 2 and 3 was significantly greater than for Score=0 (p<0.001, p<0.001, respectively), but there was no significant difference between Scores 1 and 4, and Score=0 (p=0.14, p=0.41). The TWAmax-lead revealed scores ranging from 1 to 3 in all segments. The LGEtotal and TWAmax were significantly greater in patients with VT (n=23) than without (17±7 vs. 10±7 [p<0.01], 83±17μV vs. 64±18μV [p<0.001], respectively). The LVEF did not statistically differ between the two groups (48±16% vs. 54±10%, p=0.21). [Conclusions]: The LGE distribution correlated with the TWA, i.e., a 50-75% transmural extent of the LGE yielded the maximal local TWA. The spatial distribution of the LGE strongly affects myocardial repolarization abnormalities indicated by TWA as VT substrates in HCM.

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