Europace Advance Access published online on October 22, 2008
Europace, doi:10.1093/europace/eun279
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SHORT COMMUNICATION
Early repolarization phenomenon in arrhythmogenic right ventricular dysplasia–cardiomyopathy and sudden cardiac arrest due to ventricular fibrillation
1 Asklepios Harzkliniken GmbH Goslar, Cardiology and Intensive Care, Kösliner Street 12, 38642 Goslar, Germany; 2 Klinikum Quedlinburg, Cardiology, Quedlinburg, Germany
Manuscript submitted 18 July 2008. Accepted after revision 15 September 2008.
* Corresponding author. Tel: +49 5321 44 1400. E-mail address: ste.peters{at}asklepios.com
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Abstract |
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 Top Abstract IntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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The case of a 26-year-old male with sudden cardiac arrest due to ventricular fibrillation and the final diagnosis of arrhythmogenic right ventricular dysplasia–cardiomyopathy (ARVD/C) and initial early repolarization phenomenon is presented in detail. An additional analysis of early repolarization in additional 359 patients with ISFC/ESC diagnostic criteria of ARVD/C revealed a frequency within the threshold in healthy volunteers with 3% in isolated lateral leads and 7% in inferolateral leads. The high frequency of electrocardiographic early repolarization limited to inferior leads (22%) is probably due to late depolarization and represents an already reported typical feature of ARVD/C.
Key Words: Arrhythmogenic right ventricular dysplasia-cardiomyopathy, Early repolarization, Late depolarization
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Introduction |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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Recently, early repolarization phenomenon was identified as an ECG feature associated with idiopathic ventricular fibrillation.1
Arrhythmogenic right ventricular dysplasia–cardiomyopathy (ARVD/C) was excluded in these cases by right ventricular angiography or cardiac magnetic resonance imaging. Late potential analysis was not different in patients with and without early repolarization phenomenon. According to the literature, early repolarization phenomenon does not belong to the classical electrocardiographic criteria of ARVD/C.
We describe a case of sudden cardiac arrest due to ventricular fibrillation in a patient with ARVD/C and early repolarization phenomenon. Furthermore, early repolarization is analysed retrospectively in additional 359 patients with the diagnosis of ARVD/C according to IFSC/ESC diagnostic criteria.
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Case report |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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A 26-year-old male suffered from sudden cardiac arrest due to ventricular fibrillation and was successfully resuscitated. Early repolarization phenomenon in inferolateral leads (Figure 1, left panel) was documented. Coronary artery disease was excluded. On day 2 after successful resuscitation, standard ECG still reveals early repolarization in inferior leads and right pre-cordial T wave inversions (Figure 1, right panel).
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Right ventricular angiography revealed a grossly enlarged right ventricle with reduction of global function (ejection fraction 45%) and segmental sacculations in the inferior and apical segments. The electrophysiological study could provoke non-sustained ventricular flutter. Implantable cardioverter defibrillator implantation was performed.
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Analysis of early repolarization phenomenon in ARVD/C |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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We reviewed the ECG of 359 patients (174 males, mean age 47.3 ± 13.7 years) with ARVD/C according to the ISFC/ESC diagnostic criteria. ECGs were recorded at 50 mm/s paper speed, 10 mm/mV amplitude, and 40 and 50 Hz filtering technique. Early repolarization was defined as an elevation of the QRS–ST junction (J point) of at least 1 mm (0.1 mV) in at least two leads,2
,3 either as QRS slurring (a smooth transition from the QRS segment to the ST-segment) or notching (a positive J deflection inscribed on the S wave) in inferior (leads II, III, and aVF) or lateral leads (I, aVL, and V4–V6). In a total of 112 out of the 359 patients (31%), early repolarization phenomenon could be found in inferior, lateral, or inferolateral leads. In 79 cases (22%), early repolarization was limited to inferior leads. In isolated lateral leads with 10 patients (3%) or both inferolateral leads with 23 patients (7%), early repolarization was a rare phenomenon. There was no correlation between the electrocardiographic phenomenon of early repolarization and clinical findings with regard to sudden cardiac arrest, syncope, sustained ventricular tachycardia, or no arrhythmic events.
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Discussion |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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The phenomenon of early repolarization has long been recognized as a benign ECG variant. Only systematic analysis of early repolarization in idiopathic ventricular fibrillation recently published1
shed a new light on the meaning of this electrocardiographic feature. In ARVD/C, early repolarization has not been described earlier. In the recently published report of early repolarization in idiopathic ventricular fibrillation, ARVD/C was excluded in all patients by right ventricular angiography or magnetic resonance imaging. To our best knowledge, the reported case in this paper represents the first description of early repolarization with consecutive ventricular fibrillation in a typical case of ARVD/C.
In the collective of additional 359 patients with ISFC/ESC diagnosis of ARVD/C, the frequency of early repolarization is as high as in the recently published cohort of ventricular fibrillation. The main difference, however, is that in the majority of cases with ARVD/C, early repolarization is limited to inferior leads. Prolongation of the QRS interval duration in inferior leads due to slurring or notching of the transition of the QRS complex and the ST-segment was already reported as a typical finding of ARVD/C in more than 20% of cases and associated with left ventricular abnormalities in the inferior and posterolateral segments.4 Without exclusion of late potentials in inferior leads the main question remains whether early repolarization according to electrocardiographic criteria is indeed late depolarization. In isolated lateral and both inferolateral leads, early repolarization in ARVD/C is within the threshold of early repolarization in apparently healthy adults with a frequency of 7%.5 This interpretation of the reported data is in very good accordance to the fact that arrhythmic events in ARVD/C patients with and without early repolarization show no significant differences.
In conclusion, the case reported in this paper represents the first description of early repolarization with ventricular fibrillation in ARVD/C. Early repolarization is a rare finding in lateral and inferolateral leads of ARVD/C patients not different from healthy adults.
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Limitations |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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In all cases of electrocardiographic early repolarization phenomenon in patients with typical ARVD/C delayed depolarization cannot be excluded without performance of signal-averaged ECG. Even in the case reported with extensive segmental sacculation in the inferior wall of the right ventricle inferolateral ECG changes might be due to late depolarization.
Furthermore, it is difficult to decide whether ventricular fibrillation is due to early repolarization in the case reported. Early repolarization might be a coincidental finding in the patient with ARVD/C with probable ventricular tachycardia degenerating into ventricular fibrillation.
Conflict of intereset: none declared.
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References |
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TopAbstractIntroductionCase reportAnalysis of early repolarization...DiscussionLimitationsReferences |
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[1] Haissaguerre M, Derval N, Sacher F, Jesel L, Deisenhofer I, de Roy L, et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med (2008) 358:2016–23.
[2] Klatsky AL, Oehm R, Cooper RA, Udalstova N, Armstrong MA. The early repolarization normal variant ECG: correlates and consequences. Am J Med (2003) 115:171–7.[CrossRef][Web of Science][Medline]
[3] Mehta M, Jain AC, Mehta A. Early repolarization. Clin Cardiol (1999) 22:59–65.[Web of Science][Medline]
[4] Peters S, Trümmel M. Diagnosis of arrhythmogenic right ventricular dysplasia–cardiomyopathy: value of standard ECG revisited. Ann Noninvasive Electrocardiol (2003) 8:238–45.[CrossRef][Web of Science][Medline]
[5] Kui C, Congxin H, Xi W, Yan-hong T, Okella E, Salim M, et al. Characteristic of the prevalence of J wave in apparently healthy Chinese adults. Arch Med Res (2008) 39:232–5.[CrossRef][Web of Science][Medline]
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