fragmentation of the qrs complex as a prognostic sign in brugada syndrome douglas p. zipes, md...
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Fragmentation of the QRS Complex as a Prognostic Sign in Brugada
Syndrome
DOUGLAS P. ZIPES, MDDISTINGUISHED PROFESSORKRANNERT INSTITUTE OF CARDIOLOGYINDIANA UNIVERSITY SCHOOL OF MEDICINEEDITOR-IN-CHIEF HEARTRHYTHMSEPTEMBER 5, 2013
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Figure 1. Different morphologies of an fQRS on a 12-lead ECG.
Das M K et al. Circulation 2006;113:2495-2501
Copyright © American Heart Association
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Figure 2. Twelve-lead ECG, showing an fQRS (various RSR′ patterns; QRS duration <120 ms) in inferior leads that is correlated with an inferior wall MI on a myocardial perfusion study
(QRS complexes are enlarged in the lower row).
Das M K et al. Circulation 2006;113:2495-2501Copyright © American Heart Association
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Figure 3
Source: Heart Rhythm 2009; 6:S8-S14 (DOI:10.1016/j.hrthm.2008.10.019 )
Copyright © 2009 Terms and Conditions
Kaplan-Meier analysis: all-cause mortality in patients with fragmented (fQRS group) and without fragmented QRS (non-fQRS group)
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I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
V1
V2
Male (55 y.o.), aborted sudden death
VF initiation (ICD monitoring)
Fragmented QRS (fQRS) in Brugada syndrome
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Source: Heart Rhythm 2009; 6:S34-S43 (DOI:10.1016/j.hrthm.2009.07.018 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
ELECTROPHYSIOLOGIC BASIS OF EP AND ECG CHANGES
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Source: Heart Rhythm 2009; 6:S34-S43 (DOI:10.1016/j.hrthm.2009.07.018 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
REPOLARIZATION HYPOTHESIS OF ECG CHANGES
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1
2
3
4
Epi
ECG
Endo
100 ms
1 2
1 2
1 2
Epi
Mid
Endo
ECG
100 ms
1 2
1 2
1 2Endo
Epi
EpiAPD map
270(ms)
200
PVC activation map
Epi
Endo
Epi
130
150
80
12
3
4 (ms)
70130
14010
Morita, Zipes, et al
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Morita, Zipes, et al. Heart Rhythm 2009; 6:S34-S43 (DOI:10.1016/j.hrthm.2009.07.018 )Copyright © 2009 Heart Rhythm Society Terms and Conditions
HETEROGENEITY IS CRITICAL
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c 462
RVAI
445
(ms)
LVa b
Pilsicainide
497 401
RVOT
B. QT Map
ST elevation and QT dispersion in body surface mapping
Modified from Morita, Zipes et al. Heart Rhythm 2008;5:725
61 M VFPost pilsicainide
500
450
400
(ms)
a
b
c
d
0.8
0.4
0
(mV)
- 0.2a
b
c
d
dc
A. ST Map
C. ECG
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Source: Heart Rhythm 2009; 6:S34-S43 (DOI:10.1016/j.hrthm.2009.07.018 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
DEPOLARIZATION BASIS OF ECG CHANGES
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HRA
His
CS
RVA
Conus branch (Epi)
RVOT(Endo)
ECG (V2)
Epicardial mapping in Brugada syndrome
RVOT-Epi
RVOT-Endo
Filter : 30-300 Hzdelayed potential
RVOT-Epi
RVOT-Endo
Filter : 0.05-300 Hz Local QT
433 ms
350 ms
200 ms
Nagase et al. JACC 2008; 51:1154Nagase et al. JACC 2002; 39:1992
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Depolarization hypothesis: Wilde, PostemaJMCC 2010
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Examples of f-QRS in Brugada syndrome.
Morita Zipes et al. Circulation 2008;118:1697-1704
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f-QRS and LP. Upper panel shows ECGs in lead V2
Morita Zipes et al. Circulation 2008;118:1697-1704
Copyright © American Heart Association
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Spontaneous variations of f-QRS and ST elevation
Morita Zipes et al. Circulation 2008;118:1697-1704
Copyright © American Heart Association
SUDDEN DEATH 6 MONTHS AFTER LAST ECG
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Incidence of fQRS
• Incidence of fQRS in Brugada syndorme: 50/115 pts (43%)
• fQRS can be recorded within 1.5 months of their initial visit to hospital
p<0.01
(%)Incidence of f-QRS
Morita, Zipes et al. Circulation 2009; 118:1697
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f-QRS (-)
f-QRS (+)
5 10
100
50
0(yrs.)
(%)
0
Recurrent syncope due to VF
f-QRS (-)
f-QRS (+)
Fragmented QRS
Morita, Zipes et al. Circulation 2009; 118:1697
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KH 50y.o. Male 1890840
IIHRA
RVA
RVOT
MAP
TVARV
RVOT
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Fatty infiltration at RV in Brugada syndrome
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Depolarization abnormality in Brugada syndrome
• Decrease in Na+ current
• Myocardial injury ( fatty infiltration, fibrosis, myocarditis )
• PQ 、 QRS 、 HV prolongation 、 fragmented QRS 、 delayed potential 、 late potential
• Index of poor prognosis?
• Depolarization abnormality can be associated with onset of VF.
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Figure 1 ECG Presentation in Brugada Syndrome Examples of electrocardiographic (ECG) traces (A to C) . (A) A 35-year-old male patient with presenting spontaneous type I ECG; (B) 30-year-old male patient presenting with type III ECG (left panel) con...Silvia G. Priori , Maurizio Gasparini , Carlo Napolitano , Paolo Della Bella , Andrea Ghidini Ottonelli , Biagio S...Risk Stratification in Brugada Syndrome : Results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) Registry
Journal of the American College of Cardiology Volume 59, Issue 1 2012 37 - 45
ECG Presentation in Brugada Syndrome in the PRELUDE trial: Examples of electrocardiographic (ECG) traces
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Silvia G. Priori , Maurizio Gasparini , Carlo Napolitano , Paolo Della Bella , Andrea Ghidini Ottonelli , Biagio S...Risk Stratification in Brugada Syndrome : Results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) Registry
Journal of the American College of Cardiology Volume 59, Issue 1 2012 37 - 45
Survival According to Refractory Period and QRS-f Kaplan-Meier survivorship analysis of arrhythmic event-free survival
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Morita, Zipes Heart Rhythm 2009; 6:665-671 (DOI:10.1016/j.hrthm.2009.01.007 )Copyright © 2009 Heart Rhythm Society Terms and Conditions
EPICARDIAL ABLATION IN CANINES
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Source: Heart Rhythm 2009; 6:665-671 (DOI:10.1016/j.hrthm.2009.01.007 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
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Source: Heart Rhythm 2009; 6:665-671 (DOI:10.1016/j.hrthm.2009.01.007 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
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Figure 7
Source: Heart Rhythm 2009; 6:665-671 (DOI:10.1016/j.hrthm.2009.01.007 )
Copyright © 2009 Heart Rhythm Society Terms and Conditions
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Left lateral view of the right ventricular outflow tract (RVOT) displays the difference in ventricular electrograms between the endocardial (ENDO) and epicardial (EPI) site of the
anterior RVOT of the same patient (patient 4) as Figure 2.
Nademanee K et al. Circulation 2011;123:1270-1279
Copyright © American Heart Association
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A scattered plot of all electrograms (n=827 points) recorded from the 9 patients from the 4 major areas: right ventricular (RV) epicardium, anterior right ventricular outflow tract (RVOT)
epicardium, left ventricular (LV) epicardium, and RV endocardium.
Nademanee K et al. Circulation 2011;123:1270-1279
Copyright © American Heart Association
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Figure 1
SACHER ET AL. Heart Rhythm (DOI:10.1016/j.hrthm.2013.05.023 )Copyright © Heart Rhythm Society Terms and Conditions
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Source: Heart Rhythm (DOI:10.1016/j.hrthm.2013.05.023 )
Copyright © Heart Rhythm Society Terms and Conditions
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Reduced sodium channel function unmasks residual embryonic slow conduction in the adult right
ventricular outflow tract Circ Res 113:137
• Adult mice heterozygous for a mutation associated with Brugada syndrome (Scn5a1798insD/+).
• In embryonic heart, conduction velocity was lower in the RVOT than in the right ventricular free wall.
• In hearts of Scn5a1798insD/+ mice and in normal hearts treated with ajmaline, conduction was slower in the RVOT than in the right ventricular wall.
• The slowly conducting embryonic phenotype is maintained in the fetal and adult RVOT and is unmasked when cardiac sodium channel function is reduced.
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Presidents Need to Know about Sudden Death
Israeli President Shimon PeresReads “Ripples in Opperman’s Pond”
US Past President Bill Clinton“The Black Widows.”
THANK YOU FOR YOUR ATTENTION
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