[ARVD-FORUM] Ablations in ARVD pts. Dr Perez Riera

Wed Apr 13 22:05:19 ART 2005

English - Portuguese

Empirical Drug Therapy

Sotalol, beta-blockers, carvedilol (alpha and beta blocker) and amiodarone
are used.

Beta-blockers are the drugs of choice in the cases where the arrhythmias are
clearly induced for the efforts. In patients with ARVC/D, regional 
abnormalities of sympathetic innervation are frequent and can be
demonstrated by 123I-MIBG scintigraphy. Sympathetic denervation appears to
be the underlying mechanism of reduced 123I-MIBG uptake and may be related
to frequent provocation of ventricular arrhythmias by exercise or
catecholamine exposure in ARVC/D. Therefore, in patients with ARVC/D, the
noninvasive detection of localized sympathetic denervation by 123I-MIBG
imaging may have implications for the early diagnosis and for the choice of
antiarrhythmic drugs in the treatment of arrhythmias. (Wichter T, Hindricks
G, Lerch H,  et al. Regional myocardial sympathetic dysinnervation in
arrhythmogenic right ventricular cardiomyopathy. An analysis using
123I-meta-iodobenzylguanidine scintigraphy. Circulation. 1994; 89:667-683.).

Sotalol, a beta-blockers and a class III antiarrhythmic agent, is the most
effective antiarrhythmic agent in ARVC/D. (Wichter T, Borgreffe M, Haverkamp
W, et al. Efficacy of antiarrhythmic drugs in patients with arrhythmogenic
right ventricular disease. Circulation 1992; 86:29-37).

Treatment with sotalol cause eventually severe, symptomatic sinus
bradycardia in ARVC/D patients requiring permanent pacing.(Kazmierczak J,
Kornacewicz-Jach Z, Wojtarowicz A. Atrial epicardial pacing with long
stimulus to P wave interval in a patient with arrhythmogenic right
ventricular dysplasia complicated by right atrial thrombosis.Pacing Clin
Electrophysiol. 1999;22:1111-1113.). Additonally, coronary vasospasm may be
induced by the non-selective beta-blocking properties of sotalol.( Muto S,
Ashizawa N, Arakawa S, et al. Sotalol-induced coronary spasm in a patient
with dilated cardiomyopathy associated with sustained ventricular
tachycardia. Intern Med. 2004;43:1051-1055.).

Carvedilol is not only useful for controlling arrhythmia but also for
improving LV function in some patients with ARVC/D. Sympathetic overactivity
is reported to cause SCD, so carvedilol may be a first-line drug for some
patients with ARVC/D. (Hiroi Y, Fujiu K, Komatsu S, et al. Carvedilol
therapy improved left ventricular function in a patient with arrhythmogenic
right ventricular cardiomyopathy. Jpn Heart J. 2004; 45:169-177.).

Other antiarrhythmic agents used include amiodarone and conventional beta
blockers (ie: metoprolol). If antiarrhythmic agents are used, their efficacy
should be guided by series ambulatory Holter Monitoring, to show a reduction
in arrhythmic events. Amiodarone and beta-blockers can both be effective, in
addition there appears to be a synergistic affect when they are used
together.

Best regard

Andrés

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Português

Sotalol, um beta-bloqueador da class III dos aniarrítmicos é o agente mais
eficaz na DAVD. (Wichter T, Borgreffe M, Haverkamp W, et al. Efficacy of
antiarrhythmic drugs in patients with arrhythmogenic right ventricular
disease. Circulation 1992; 86:29-37).  O tratamento com sotalol causa
eventualmente severa bradicardia sinusal na DAVD e alguns necesitam de
Marcapasso permanente (Kazmierczak J, Kornacewicz-Jach Z, Wojtarowicz A.
Atrial epicardial pacing with long stimulus to P wave interval in a patient
with arrhythmogenic right ventricular dysplasia complicated by right atrial
thrombosis.Pacing Clin Electrophysiol. 1999;22:1111-1113.). Adicionalmente
espasmo coronário pode ser induzido por um beta-bloqueador no seletivo  como
o sotalol. (Muto S, Ashizawa N, Arakawa S, et al. Sotalol-induced coronary
spasm in a patient with dilated cardiomyopathy associated with sustained
ventricular tachycardia. Intern Med. 2004;43:1051-1055.).

Carvedilol não apenas resultou eficaz no controle da arritmia como também
melhorou a função do VE em alguns pacientes com DAVD. Hipertatividade
simpática pode ser encontrada na entidade  assim o carvedilol em alguns
paciente pode ser de primeira linha (Hiroi Y, Fujiu K, Komatsu S, et al.
Carvedilol therapy improved left ventricular function in a patient with
arrhythmogenic right ventricular cardiomyopathy. Jpn Heart J. 2004;
45:169-177.).

Outro antiarrítmicos empregados incluem amiodarona e beta-bloqueadoes
convencionais como o metoprolol. Se um antiarrítmico é usado sua eficácia
deveria ser acompanhada com Holter seriados para observar se de fato ocorre
redução dos eventos.

Amiodarona e beta-bloqueadores podem ser eficazes e adicionalmente parecem
possuir um efeito sinérgico quando empregados juntos.  Beta-bloquedores são
as drogas de escolha em caso onde a arritmias são claramente induzidas pelo
esforço. Em pacientes portadores de DAVD se ha verificado anormaidade
regional na inervação simpática que pode ser demonstrada pela redução na
captação de 123I-MIBG na cinilografia. A denervação simpatia parece ser o
meanismo sujacente da captação reduzida do  123I-MIBG  e pode ocasionar
freqüente provocação de arritmias ventriculares perante exercício o
exposição a catecolaminas na entidade. A deteção não invasivade denervação
simpática localizada de 123I-MIBG  tem implicancias no diagnóstico precocoe
e para a escolha do antiarrítmico no tratamento  (Wichter T, Hindricks G,
Lerch H,  et al. Regional myocardial sympathetic dysinnervation in
arrhythmogenic right ventricular cardiomyopathy. An analysis using
123I-meta-iodobenzylguanidine scintigraphy. Circulation. 1994; 89:667-683.).

Outro agents antiarrítmicos empregados incluem  amiodarona e os
beta-bloquedores convencionais como o metoprolol, Se um antiarrítmico é
empregado a sua eficácia deve ser controlado com Holter seriados para
certificarnos da redução dos eventos.

Amiodarona e beta-boqueadores untos podem apresentar um efeito sinérgico

Saludações

Andrés

_______________________________________

>
> English - Spanish
> A big "Thank You" goes out to all of you who are involved in putting
> this symposium together, it is a wealth of information.  My first
> question is,  How successful is ablation with patients with ARVD?
> Secondly,  I reviewed Dr. Wichter's lecture and found Sotolol to be the
> most effective drug, however, the dosage seemed very high, did all of
> these patients actually tolerate the side effects of high dose  Sotolol?
>
> Warmest Regards,
>
> Terri Bentley, R.N.
>
> ------------------
>
> Les mando un enorme "gracias" a todos los que estuvieron involucrados en la
> organización de este simposio, que es abundantisimo en informacion. Mi
> primera pregunta es: cuan exitosa es la ablacion con pacientes con DAVD?
> En segundo lugar, revise la conferencia del Dr. Wichter y halle que el
> Sotalol es la droga mas efectiva, sin embargo, la dosis parece ser muy
> alta: todos estos pacientes realmente toleraron los efectos secundarios de
> la alta dosis de Sotalol?
>
> Un abrazo,
>
> Terri Bentley, R.N.
>
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-- 
Dr. Sergio Dubner
Director

Dr. Edgardo Schapachnik
Director