[ARVD-FORUM] ECG with modified protocol. Dr. Perez Riera
ARVD Symposium
info at arvd-symposium.org
Tue Apr 5 22:01:24 ART 2005
English - Portuguese
Dear Dr. Manlio F. Márquez from beatifull Mexico!!!!!!!
You say: "High precordial leads can also be useful to be able to see an
epsilon wave". This concept is very, very logical because are near of RVOT
similar with Brugada Syndrome. Several works carried out conclude that
12-lead ECG sensitivity increases by applying accessory leads located in the
high right precordial area (V1H - V2H), over the 3rd or 2nd intercostal
space, just to the right (V1H) or left (V2H) of the sternum. In certain
cases, Brugada sign that was not observed using only the 12 conventional
leads, is now visualized. The procedure is founded on the fact that modified
precordial leads on right precordial leads (V1H - V2H) or on anteroseptal
wall (V1H to V3H) at higher intercostal space positions are located exactly
opposite to the RVOT
RIGHT VENTRICLE REGIONS AND THEIR CORRESPONDING LEADS
The right ventricle has five regions that are better detected by the
following leads:
1) V2 and V3.: trabecular area;
2) V3 - V4: Low right paraseptal area;
3) V1 to V4.: Free wall. Inside of dysplasia triangle;
4) aVF, V4R and V5R: Right Ventricle Inflow Tract (RVIT);
5) aVR, V1H, V2H, V3H : RVOT: the area affected in the Brugada syndrome and
DAVD 1; 2; 3; 4; 5; 6; 7..
References
1) Farre J. The Brugada syndrome: Do we need more than the 12-lead
ECG? Eur Heart J 2000;21:264-265.
2) Sangwatanaroj S, Prechawat S, Sunsaneewitayakul B, Sitthisook S,
Tosukhowong P, Tungsanga K. Right ventricular electrocardiographic leads for
detection of Brugada syndrome in sudden unexplained death syndrome survivors
and their relatives. Clin Cardiol 2001;24:776-781.
3) Sangwatanaroj S, Prechawat S, Sunsaneewitayakul B, est al. New
electrocardiographic leads and the procainamide test for the detection of
the Brugada sign in sudden unexplained death syndrome survivors and their
relatives. Eur Heart J 2001;22:2290-2296.
4) Nagatomo T, Abe H, Oginosawa Y, et al. Reproduction of typical
electrocardiographic findings of the Brugada syndrome using modified
precordial leads. J UOEH 2002;24:383-389.
5) Nagase S, Kusano KF, Morita H, Fujimoto Y, Kakishita M, Nakamura K,
Emori T, Matsubara H, Ohe T. Epicardial electrogram of the right ventricular
outflow tract in patients with the brugada syndrome. Using the epicardial
lead. J Am Coll Cardiol 2002;39:1992-1995.
6) Takagi M, Toda I, Takeuchi K, et al.Utility of right precordial
leads at higher intercostal space positions to diagnose Brugada
syndrome.Pacing Clin Electrophysiol. 2002;25::241-242.
7) Cabezon Ruiz S, Errazquin Saenz De Tejada F, Pedrote Martinez A, et
al. Normal Conventional Electrocardiogram with Negative Pharmalogical Stress
Test does Not Rule Out Brugada Syndrome. Rev Esp Cardiol 2003;56:107-110.
---------------------------------------
Português
Prezado Dr Manilo F Marques da bela México.
O senhor diz: precordiais altas podem tamber ser boas para observar a onda
epsilon
Este conceito é muito, muito, lógico porque estas derivações estão perto da
via de saída do VD similar com a síndrome de Brugada, Nesta entidade vários
trabalhos mostram que a sensibilidade do ECG de 12 derivacos melhora quando
se coloca o eletrdo explorador mais alto (V1H - V2H), sobre o terceiro oou
segundo espaço interecostal a direita (V1H) ou a esquerda (V2H) do esterno.
Em certos casos o sinal de Brugada pode ser observado usando apenas as 12
derivacoes convencionais mais quando se agregam as altas modificadas
(V1H - V2H) ou na parede Antero-septal (V1H a V3H) encontra-se exatamente
enfrentando a via de saída do ventrículo direito;1; 2; 3; 4; 5; 6; 7.
Best Regard
Andrés Ricardo Pérez Riera
REGIOES DO VD E SUAS CORRESPONDENTES DERIVAÇÕES
O VD possui 5 regiões que são detectadas pelas seguintes derivações
1) V2 e V3.: área trabecular. Dentro do triângulo da displasia;
2) V3 - V4: Area baixa para-septal;
3) V1 aV4.: parede livre do VD;
4) aVF, V4R eV5R: Via de entrada do VD
5) aVR, V1H, V2H, V3H : RVOT: esta area e afetada na Síndrome de Brugada e
na DAVD
Saudações
Andrés Ricardo Pérez Riera.
>
> English - Spanish
>
> Dear Dr. Perez Riera and colleagues,
> Let me make some notes regarding modified ECGs.
>
> 1. I agree with Dr. Marcus in that the leads we should amplify (double
> velocity, double voltage) to see the epsilon wave are V1 to V3.
> 2. On occasions, double velocity makes it difficult to interpret ECG and it
> also would be convenient to have an ECG with standard velocity and double
> voltage.
> 3. High precordial leads can also be useful to be able to see an epsilon
> wave.
> 4. The lead originally described by Lian is: right arm below sternal
> wishbone and left arm in the 5th right intercostal space and parasternal
> line. With this electrode position leads I, II, and III must be recorded.
> Someone has said that these are Fontaine leads, but they actually were
> described by Lian in the 50's. To avoid confusions, maybe we should call
> them LI, LII, and LIII.
> 5. The lead that is original from Fontaine is the use of the left leg
> electrode on the precordial region at V4 level. Anyway, leads I, II, and
> III are recorded; which may as well be called FI, FII, and FIII.
>
> Best regards,
>
> Dr. Manlio F. Márquez
> Departamento de Electrocardiología
> Instituto Nacional de Cardiología "Ignacio Chávez"
> México, D.F.
>
> ---------------------------------------
>
> Estimado Dr. Perez Riera y colegas, me permito hacer
> algunas anotaciones pertinentes a los ECG modificados.
>
> 1. Concuerdo con el Dr. Marcus en que las derivaciones que debemos
> amplificar (doble velocidad, doble voltaje) para ver la onda epsilón son V1
> a V3. 2. En ocasiones la doble velocidad hace difícil interpretar el ECG y
> también sería conveniente contar con un ECG a velocidad estándar y doble
> voltaje. 3. Las derivaciones precordiales altas también pueden ser de
> utilidad para poder apreciar una onda epsilón
> 4. La derivación descrita originalmente por Lian es: brazo derecho por
> debajo de horquilla esternal y brazo izquierdo en 5° espacio intercostal
> derecho y línea paraesternal. Con esta posición de electrodos se deben
> registrar las derivaciones I, II y III. Alguien ha dicho que estas son las
> derivaciones de Fontaine pero en realidad fueron descritas por Lian en los
> años 50's. Para evitar confusiones tal vez deberiamos llamarlas LI, LII y
> LIII.
> 5. La derivación que sí es original de Fontaine es el empleo del electrodo
> de la pierna izquierda sobre la región precordial a nivel de V4. Igualmente
> se registran las derivaciones I, II y III que bien pudieran llamarse FI,
> FII y FIII.
>
> Cordialmente
>
> Dr. Manlio F. Márquez
> Departamento de Electrocardiología
> Instituto Nacional de Cardiología "Ignacio Chávez"
> México, D.F.
>
> > English - Portuguese
> >
> > ECG with modified protocol
> >
> > 1) Rhythm strips should be obtained of the precordial leads V1-V6
> > at double speed (50mm/s) and double amplitude (20mm/mv) in order to
> > compare the duration of the QRS complex (QRSD) in different leads as well
> > as to record the epsilon wave;
> >
> > 2) Rhythm strips should be obtained of leads DI-aVF at double speed
> > (50mm/s) and double amplitude (20mm/mv). Place the left arm lead over the
> > xyphoid process, the right arm lead on the manubrium sternum and the left
> > leg lead over a rib at the V4 or V5 position in order to elicit the
> > epsilon wave.
> >
> > Localized prolongation of QRSD interval in V1-V3 / QRSD interval in V4-V6
> > > than 1.2 has been found in 97% of cases of ARVC/D. The QRSD is
> > correlated with the amount of fibrous tissue in patients with VT of RV
> > origin The sensitivity of this QRS diagnostic criterion has not been
> > established in patients who do not have overt manifestation of this
> > disease. The specificity of this criterion has not been completely
> > established yet in patients without this entity. In Brurga Syndrome QRS
> > > 110 ms in V1, V2 or V3. It is possible. There is a paper showing that
> > BrS may also present prolongation in QT interval duration from V1 to V3
> > and consequently prolongation of the QTc interval in the right precordial
> > leads. (Pitzalis MV, Anaclerio M, Lacoviello M, et al. QT-interval
> > prolongation in right precordial leads: an additional
> > electrocardiographic hallmark of Brugada syndrome. J Am Coll Cardiol.
> > 2003; 42:1632-1637 ). If the QT interval is prolonged only from V1 to
> > V3, being normal from V4 to V6, it is clear that this increase may be due
> > to prolongation of ventricular depolarization (QRS complex) and/or by
> > ST/T prolongation (repolarization). If we admit that in Brurgada Syndrome
> > there is some degree of branch block, clearly the QT interval
> > prolongation is due partly to this. The QTc interval constitutes the
> > classical measurement for ventricular repolarization; however, this
> > parameter includes ventricular depolarization (QRS), and therefore
> > represents the so-called electric systole, which includes depolarization
> > (QRS) and ventricular repolarization (ST/T = JT interval). Thus, when
> > there is branch block (as in the some cases of Brugada syndrome), the
> > measurement of ventricular repolarization through QTc may be incorrect.
> > In these cases, the measurement of the JT interval (JT = QT - QRSD) is
> > more accurate than the QT interval, because it excludes the
> > depolarization that is found prolonged, because the biventricular chamber
> > activates sequentially and not concomitantly as normally. This is the
> > reason why it is essential to know accurately the exact point where
> > depolarization ends and repolarization begins.
> >
> > Best regard
> >
> > Andrés Ricardo Pérez Riera
> >
> > --------------------------------------------------------
> >
> > Português
> >
> > ECG com protocolo modificado
> >
> > 1) A tira das precordiais de V1-V6 realizadas a dupla velocidade de
> > 50mm/s e dupla voltagem (20mm/mV) para comparar a duração do QRS nas
> > diversas derivacoes e para tentar observar a onda epsilon. Colocar o
> > eletrodo do braço esquerdo sobre a apéndice xifoides o do braço direito
> > no manubrio do esterno e o eletrodo da perna esquerda sobre a costela na
> > posição de V4 or V5 para tentar observar a onda epsilon.
> >
> > 2) A tira deveria se obter en DI e aVL (50mm/s) a dupla velocidade
> > e a dupla voltagem (20mm/mv).
> >
> > Prolongamento localizado de V1 a V3 com relação V1-V2-V3/ V4-V5-V6 > 1.2
> > ha sido encontrado em 97% dos casos de DAVD. A duração do complexo QRS
> > estaria relacionada com a quantidade de tecido fibroso. A especificidade
> > de este critério não ha sido determinada, todavia em pacientes sem esta
> > entidade.
> >
> > Na síndrome de Brugada QRS > 110 ms em V1, V2 ou V3 é posível. Há uma
> > publicação mostrando prolongamento do QT de V1 aV3 e consequente aumento
> > do intervalo QTc nas precordiais direitas no Brugada (Pitzalis MV,
> > Anaclerio M, Lacoviello M, et al. QT-interval prolongation in right
> > precordial leads: an additional electrocardiographic hallmark of Brugada
> > syndrome. J Am Coll Cardiol. 2003; 42:1632-1637). Se o intervalo QT está
> > prolongado de V1 a V3 e normal de V4 a V6 é claro que este aumento
> > poderia ser dado por prolongamento da despolarização ventricular (QRS) e
> > ou por prolongamento do ST/T (repolarização) Se nos admitimos que na
> > sindrome de Brugada há algum grau de bloqueio de ramo claramente o
> > prolongamento do intervalo QT é dado parcialmente por este.
> >
> > O intervalo QT constitui uma medida clássica da repolarizacao, porém,
> > incli a despolarização ventricular (QRS) e represente a chamada sístole
> > elétrica a qual inclui despoarização (QRS) e repolarização (ST/T =
> > intervalo JT). Assim sendo, quando existe bloqueio de ramo (como acontece
> > em alguns casos de sindrome de Brugada) a medida da repolarizaçao usando
> > o intervalo QT pode ser incorreta. Nestes casos a medida do intervalo JT
> > (JT = QT - QRSD) é mais precisa que a medida do intervalo QT porque excui
> > a despolarizacao que esta prolongada porque a câmara biventricular
> > ativa-se em forma sequencial e não concomitantemente. Esta é a razão
> > porque é fundamental conehcer em forma exata em que ponto termina a
> > despolarizacao e quando inicia a repolarizacao
> >
> > Saludações
> >
> > Andrés Ricardo Pérez Riera
> >
> > > English - Spanish
> > >
> > > Dear colleagues,
> > > The questions and answers by the experts that are being distributed in
> > > the Forum, deal with the management to follow with the relatives of the
> > > patients.
> > > Regarding this, I have noticed a subtle difference between the reply by
> > > Dr. Frank Marcus to Dr. Laura Sanzani, and the reply by Dr. Perez Riera
> > > to Dr. Martinez Rubio.
> > > Dr. Andres includes in the algorithm of studies to be performed on
> > > these relatives, the "ECG with modified protocol", which is not
> > > included between the studies suggested by Dr. Marcus.
> > > I ask the first one if he could explain what is this modified protocol
> > > and what is its value in ARVD, and to Dr. Marcus, if he suggests
> > > including it in the routine for the family members of the patients with
> > > ARVD.
> > >
> > > Thanking you in advance,
> > >
> > > Jose Siringa
> > >
> > > -----------------------------------------
> > >
> > > Estimados colegas:
> > > l;as preguntas y respuestas de los expertos que se estan distribuyendo
> > > en el Foro, estan haciendo referencia a la conducta a seguirse con los
> > > familiares de los pacientes.
> > > En ese sentido he notado una sutil diferencia entre la respuesta que el
> > > Dr. Frank Marcus le da a la Dra. Laura Sanziani, en relacion a la que
> > > el Dr. Perez Riera utiliza para responderle al Dr. Martinez Rubio. El
> > > Dr. Andres incluye en el algoritmo de estudios de estos familiares el
> > > "ECG con protocolo modificado", que no figura entre los estudios
> > > sugeridos por el Dr. Marcus.
> > > Le pregunto al primero si puede explicar en qué consiste tal protocolo
> > > modificado y que valor tiene en la ARVD y al Dr. Marcus, si sugiere
> > > incluirlo en la rutina para los familiares de pacientes con ARVD.
> > >
> > > Gracias anticipadas
> > >
> > > Jose Siringa
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