<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><P class="MsoNormal" style="text-indent: 14px;"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Dear Dr. Haghjoo:</FONT><O:P></O:P></SPAN></P><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial"><BR> It’s a true challenge for treating such young LQTS patient (5-y-o), especially, it is difficuilt to increase the dosage of Betablocker while patient has low heart rate.</FONT><SPAN style="mso-spacerun: yes"><FONT class="Apple-style-span" face="Arial"> </FONT></SPAN><FONT class="Apple-style-span" face="Arial">Based our experience ,my suggestion is:</FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal" style="text-indent: 14px;"></DIV><P class="MsoNormal" style="text-indent: -24px;margin-left: 18pt; "><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">1.</FONT><SPAN style="font:7.0pt "Times New Roman""> </SPAN></SPAN><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">To change betablocker from propranolol to </FONT></SPAN><SPAN lang="EN-US">Metoprolol extended action tablet</SPAN><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial"> or nadolol (depending on what you can get in your country);</FONT><O:P></O:P></SPAN></P><P class="MsoNormal" style="text-indent: -24px;margin-left: 18pt; "><SPAN lang="EN-US">2.<SPAN style="font:7.0pt "Times New Roman""> </SPAN></SPAN><SPAN lang="EN-US">If the patient continues to have syncope episode during betablocker administration, recommend her to receive the left sympathetic denervation surgery.<SPAN style="mso-spacerun: yes"> </SPAN>We had undergo such surgery for a 6 y-o boy 5 years ago and for a 7-y-o girl last Sept. in Peking University People’s Hospital, China.<SPAN style="mso-spacerun: yes"> </SPAN>It’s not unconquerable for surgery though it’s more difficult than that for adult patients. Dr. Schwartz’s group has more experiences to deal with patients who need surgery.<SPAN style="mso-spacerun: yes"> </SPAN><SPAN style="mso-spacerun: yes"> </SPAN></SPAN></P><P class="MsoNormal" style="text-indent: -24px;margin-left: 18pt; "><SPAN lang="EN-US">3.<SPAN style="font:7.0pt "Times New Roman""> </SPAN></SPAN><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">When her body size is large enough, ICD may be considered depending on her symptom at that time.</FONT><SPAN style="mso-spacerun: yes"><FONT class="Apple-style-span" face="Arial"> </FONT></SPAN></SPAN></P><DIV class="MsoNormal" style="text-indent: 0px;"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">It’s a wonderful experience to exchange opinions with experts from world wide, and thanks to the organizers, thanks to the participants from so many countries!</FONT><SPAN style="mso-spacerun: yes"><FONT class="Apple-style-span" face="Arial"> </FONT></SPAN><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial"> </FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Cuilan Li, Ph. D</FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Department of Cardiology,</FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Peking University People’s Hosp., </FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Beijing 100044, China</FONT><O:P></O:P></SPAN></DIV><DIV class="MsoNormal"><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial">Tel: 86-10-68314422 Ext. 5940</FONT><O:P></O:P></SPAN></DIV><SPAN lang="EN-US" style=""><FONT class="Apple-style-span" face="Arial" size="4"><SPAN class="Apple-style-span" style="font-size: 14px;"><A href="mailto:licuilan@gmail.com">licuilan@gmail.com</A></SPAN></FONT></SPAN> <DIV><BR><DIV> <SPAN class="Apple-style-span" style="border-collapse: separate; border-spacing: 0px 0px; color: rgb(0, 0, 0); font-family: Helvetica; font-size: 12px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; text-align: auto; -khtml-text-decorations-in-effect: none; text-indent: 0px; -apple-text-size-adjust: auto; text-transform: none; orphans: 2; white-space: normal; widows: 2; word-spacing: 0px; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">--</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Sergio<SPAN class="Apple-converted-space"> </SPAN>Dubner</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Scientific<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; ; font-family: Lucida Grande; font-size: 13px; "><BR style="font-family: Lucida Grande; font-size: 13px; "></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Edgardo<SPAN class="Apple-converted-space"> </SPAN>Schapachnik</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Steering<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV></SPAN></DIV><DIV><BLOCKQUOTE type="cite"><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dear Dr. Dubner,</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Thank you and your colleagues for this nice online symposium. <SPAN class="Apple-converted-space"> </SPAN></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Recently, a</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">5-year-old children with no evidence of structural heart disease <SPAN class="Apple-converted-space"> </SPAN></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">referred to</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">our center for evaluation of syncope. He also had history of congenital</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">deafness. One of the episodes of syncope occurred 48-hrs after <SPAN class="Apple-converted-space"> </SPAN></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">betablocker</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">withdrawal and second episodes on 10 mg propranolol tid. Surface ECG</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">revealed a QTc=600 ms and heart rate of 55 bpm. We think that onset in</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">childhood, congenital deafness and QTc=600 would place this patient at</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">higher risk for cardiac events and therefore a candidate for ICD</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">implantation. However, small body size and future risk of inappropriate</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">therapy with its devastating consequences are unfavorable aspects of ICD</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">implantation. Our limitimg factors for increase in dose of <SPAN class="Apple-converted-space"> </SPAN></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">betablocker is</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">low baseline hear rate. What is recommendation of scientific <SPAN class="Apple-converted-space"> </SPAN></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">committee of</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">SCD symposium regarding our patient?</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Thank you in advance for your recommendation.</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Regards,</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><BR></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Majid Haghjoo,MD</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Department of Pacemaker and Electrophysiology</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Rajaie Cardiovascular Medical and Research Center</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Tel: +98 21 2392 2931</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Fax:+98 21 2204 8174</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Tehran, Iran</DIV></BLOCKQUOTE></DIV><BR></DIV></BODY></HTML>