[ARVD-FORUM] EXPERTS ASK. EXPERTS ANSWER

[ARVD Symposium]

English - Portuguese

Dear Dr John E. Madias: 
T wave inversion in leads V1 to V3 is characteristic however, this is a 
non-specific finding, and may be considered a normal variant in RBBB, women, 
and children under 12 years old.  In 1988 the researchers from Padua showed 
the first characteristic vectorcardiogram (VCG) of BrS in a series of 6 
patients, from which 5 were proven to be ARVC/D, and the sixth patient shown 
in the mentioned paper, was attributed to IVF (Nava A, Canciani B, Buja G, et 
al. Electrovectorcardiographic Study of Negative T Waves on Percordial Leads 
in Arrhtyhmogenic Right Ventricular Dysplasia: Relationship With Right 
Ventricular Volumes  J  of Electrocardiol 1998: 21: 239-245.). In other 
non-indexed paper - (Nava A, Canciani B, Schiavinato ML, et al. la 
Repolarisation precoce dans les precordiales droites: trouble de la 
conduction intraventriculaire droite? Correlations de 
l'electrocardiographie-vectocardio-graphie avec l'electrophysiologie. Mises
a Jour Cardiologiques 1988; 17:157-159.)..  the authors had interpreted the
tracing as benig early repolarization. In ARVD eventually T loop in
Horizontal Plane is located on left posterior quadrant: Negative T wave on
right precordial leads V1 and V2, Negative T waves of V1 to V2 or V3 are
very characteristic when present in children over 12 years old in the
absence of RBBB. (Metzger JT, deChillou C, Cheriax E, et al.: Value of the
12-lead electrocardiogram in arrhytmogenic right ventricular dysplasia, and
absence of correlation with echocardiographic finding. Am J Cardiol 1993;
72: 964.).
T-wave inversions in V1 through V3 were observed in 85% of ARVC/D patients
in the absence of RBBB compared with none in RVOT and normal controls,
respectively. (Nasir K, Bomma C, Tandri H,  et al. Electrocardiographic
features of arrhythmogenic right ventricular dysplasia/cardiomyopathy
according to disease severity: a need to broaden diagnostic
criteria.Circulation. 2004; 110:1527-1534.).Often presents as T-wave
inversion in the anterior leads of the electrocardiogram. (Toh KW, Nadesan
K, Sie MY, et al. Postoperative death in a patient with unrecognized
arrhythmogenic right ventricular dysplasia syndrome. Anesth Analg.
2004;99:350-352.)

Best Regard

Andrés Ricardo Pérez Riera.

------------------------------------------

Português

Prezado Dr John Madias: 
Onda T invertida de V1 a V3 é característico porém, este não é un fato 
específico e pode ser considerado uma variante normal em mulheres com BCRD e 
crianças menores de 12 anos. Em 1998 pesquzadores de Padua mostraram o primer 
VCG na síndrome de Brugada numa serie de 6 pacientes, dos quais 5 eram 
provados DAVD e o sexto paciente mostrado no trabalho foi a atribuído a 
fibrilação ventricular idiopatica  (Nava A, Canciani B, Buja G, et al.  
Electrovectorcardiographic Study of Negative T Waves on Percordial Leads in 
Arrhtyhmogenic Right Ventricular Dysplasia: Relationship With Right 
Ventricular Volumes  J  of Electrocardiol 1998: 21: 239-245.). Em outro 
trabalho não indexado  (Nava A, Canciani B, Schiavinato
ML, et al. la Repolarisation precoce dans les precordiales droites: trouble
de la conduction intraventriculaire droite? Correlations de l'
electrocardiographie-vectocardio-graphie avec l'electrophysiologie. Mises a
Jour Cardiologiques 1988; 17:157-159.) os autores interpretaron o traçado
como sendo repolarização precoce.

Na DAVD eventualmente a alça T no plano horizontal está localizada no
quadrante posterior esquerdo: Onda T negativa nas precordiais direitas  V1 e
V2, Onda T negativa de V1 a V2 ou V3 são muito características se presentes
em crianças acima de 12 anos na ausência de BRD. (Metzger JT, deChillou C,
Cheriax E, et al.: Value of the 12-lead electrocardiogram in arrhytmogenic
right ventricular dysplasia, and absence of correlation with
echocardiographic finding. Am J Cardiol 1993; 72: 964.).

Ondas T invertidas de V1 até V3 for a observada em 85% dos pacientes com
DAVD na ausencia de BCRD comparados com controles normais (Nasir K, Bomma C,
Tandri H,  et al. Electrocardiographic features of arrhythmogenic right
ventricular dysplasia/cardiomyopathy according to disease severity: a need
to broaden diagnostic criteria.Circulation. 2004; 110:1527-1534.).

Frequentemente se observa ondas T invertidas nas precordiais anteriores do
ECG (Toh KW, Nadesan K, Sie MY, et al. Postoperative death in a patient with
unrecognized arrhythmogenic right ventricular dysplasia syndrome. Anesth
Analg. 2004;99:350-352.).

Saludações

Andrés Ricardo Pérez Riera
 _____________________________________
>
> English - Spanish
>
> LECTURES
> http://www.arvd-symposium.org/lectures.shtml
>
> Regarding the answer of Dr. Marcus to Dr. Caorsi:
>
> I wonder whether the presence of T-wave inversions beyond lead V1 is a safe
> (specific) indicator of possible ARVD/C; patients with frequent PVCs show
> T-wave changes, via the mechanissm of cardiac memory. Indeed, since the
> T-wave vector is expected with such a mechanism to assume the vector of the
> predominant forces of the LBBB right frontal axis PVCs, T-wave inversions
> would be expected in the precordial leads. In the presence of ventricular
> bigeminy /trigeminy, or frequent PVCs, certainly I would not rely on the
> T-wave vector of intrinsic (non PVC) beats; only if one is assured that the
> patient did not have PVCs prior to the recording of the ECG, one could rely
> on the precordial T-wave inversion as an diagnostic indicator of ARVD/C.It
> goes without saying that after a bout od documented VT, the T-wve, of
> cardiac memory pathophysiology may persiss for sometime, before
> dissipating.
>
> Thanks to the organizers of one more marvelous opportunity for all of us to
> learn!!!!! Greetings to all our colleagues throughout the world.
>
> Sincerely,
>
> John E. Madias, MD
> Mount Sinai School of Medicine
>
> ----------------------
>
> CONFERENCIAS
> http://www.arvd-symposium.org/lectures.shtml
>
> Con respecto a la respuesta del Dr. Marcus al Dr. Caorsi:
>
> Me pregunto si la presencia de las inversiones de la onda T mas alla de la
> derivacion V1 es un indicador (especifico) seguro de una posible M/DAVD;
> los pacientes con EV frecuentes muestran cambios en la onda T, a traves del
> mecanismo de la memoria cardiaca. Ciertamente, puesto que se espera que el
> vector de la onda T tenga tal mecanismo para asumir el vector de las
> fuerzas predominantes de las EV del eje frontal derecho del BRI, se
> esperaria que hubiera inversiones de la onda T en las derivaciones
> precordiales. En presencia de bigeminia/trigeminia ventricular o de EV
> frecuentes, por cierto yo no confiaria en el vector de la onda T de latidos
> intrinsecos (sin EV); solo si se esta seguro de que el paciente no tuvo EVs
> previas al registro del ECG, se puede confiar en la inversion de la onda T
> precordial como un indicador diagnostico de C/DAVD. No hace falta decir que
> despues de una rafaga de TV documentada, la onda T de fisiopatologia de
> memoria cardiaca, puede persistir por algun tiempo, antes de disiparse.
> Gracias a los organizadores de otra oportunidad maravillosa para que todos
> nosotros aprendamos!!!!! Saludos a todos nuestros colegas de todo el mundo.
>
> Atentamente,
>
> John E. Madias, MD
> Mount Sinai School of Medicine
>
> > English - Spanish
> >
> > LECTURES
> > http://www.arvd-symposium.org/lectures.shtml
> >
> > Dr. Walter Reyes Caorsi from Uruguay asks. Dr. Frank Marcus from USA
> > responds
> >
> > QUESTION
> > - Patients with ventricular extrasystoles (VE) that originate in the RV
> > are frequent. Some of them, a minority, could have ARVD. What studies
> > should be performed in these patients to rule out ARVD, with a good
> > cost/effectiveness ratio?
> >
> > ANSWER
> > - Dr Caorsi asks how to best differentiate ARVD from RVOT tachycardia in
> > individuals who have PCVs from the RV.
> > Answer: First examine the morphology of the PVCs  If they orininate from
> > the RVOT, they should have a LBBB morphology.  The QRS axis should be
> > positive in leads 2, 3, and AVF and it should be negative in lead AVL. 
> > If the Pvcs have a different morphology, they may be benign, but it
> > raises your suspicion for the presence of ARVD.Other clues that raise
> > your suspicion for ARVD are the presence of T wave inversion beyond lead
> > V1 in otherwise healthy mindividuals between the ages of 19 to 45 years
> > of age, since this finding is uncommon in normals at this age, especially
> > in men.Signal averaged ECG and a carefully performed 2 D ech, done
> > according to protocol is useful.  See the article re echo in ARVD that
> > was published this week in the JACC by Yoerger et al. I do not recommend
> > that you do an MRI because the there are too many false positives and
> > some false negatives.  Frank Marcus
> >
> > ------------------------------
> >
> > CONFERENCIAS
> > http://www.arvd-symposium.org/lectures.shtml
> >
> > Pregunta el Dr. Walter Reyes Caorsi de Uruguay. Responde el Dr. Frank
> > Marcus de EEUU.
> >
> > PREGUNTA
> > - Los pacientes con EV de origen en VD son frecuentes. Algunos de ellos,
> > una minoría, podrán tener una ARVD. ¿Qué estudios deben realizarse en
> > estos pacientes para descartar ARVD, con una buena relación costo
> > efectividad?
> >
> > RESPUESTA
> > - El Dr. Caorsi pregunta cómo diferenciar mejor la DAVD de la taquicardia
> > del TSVD en individuos que padecen CVP (Contracciones ventriculares
> > prematuras) del VD.
> > Respuesta: Primero examinamos la morfología de las CVP. Si se originan en
> > el TSVD, deberían tener una morfología de BRI. El eje QRS debería ser
> > positivo en las derivaciones 2, 3 y AVF y debería ser negativo en la
> > derivación AVL. Si las CVP tienen una morfología diferente, quizás sean
> > benignas, pero surge la sospecha de la presencia de DAVD. Otros indicios
> > que despiertan sospechas de que exista DAVD son la presencia de inversión
> > de las ondas T más allá de la derivación V1 en individuos por otro lado
> > saludables, entre 19 y 45 años, puesto que este hallazgo no es común en
> > personas normales a esta edad, especialmente en hombres. Un ECG de
> > señales promediadas y un cuidadoso Eco 2D, hechos de acuerdo al
> > protocolo, resultan útiles. Ver el artículo de referencia, eco en DAVD
> > que se publicó esta semana en el JACC por Yoerger y cols. No recomiendo
> > que se haga una IRM porque hay demasiados falsos positivos y algunos
> > falsos negativos.