Inferolateral T-wave Inversion Research Articles

Imaging associations enhance the understanding of ECG abnormalities in male Brazilian football players: findings from the B-Pro Foot ECG study

ObjectivesTo evaluate the prevalence of abnormal ECG findings and their association with imaging results in male Brazilian football players.MethodsThe ‘B-Pro Foot ECG’ is a multicentre observational study conducted in 82...

Inferior T wave inversion in young individuals: should we be worried

Abstract Introduction Cardiac screening in young individuals may identify individuals at risk of sudden cardiac death (SCD). The ECG is crucial to identify individuals who harbour pre-clinical/clinical phenotypes. T wave inversion (TWI) are often found at screening. Outcomes and clinical implications of individuals with TWI are dependent on demographic variables and territory involved. However, the implications of inferior TWI in young individuals are poorly understood. Aim This study was carried out to ascertain prevalence and outcomes of adolescent individuals with inferior TWI. Methodology Cardiac screening (questionnaire/ECG) was carried out in 2672 students (14-17 years) attending year 11 classes during the 2017/2018 scholastic year (3991 eligible citizens) as part of a national cardiac screening program (BEAT-IT). Cases with contiguous TWI in ≥2 leads in the inferior (II/III/aVF) leads were included (isolated and those extending into the lateral leads). ECGs with inferior TWI were repeated (in shallow breathing) to ensure appropriate lead placement. An athlete was defined as an individual who participated in organized sport and/or engaged in >4 hours of physical activity weekly. Results 2672 adolescents gave consent (mean, 50.4% were female). 1042 (39.0%) were athletes. Most were of Caucasian ethnicity (95.8%). Inferior TWI were present in 15 (0.6%), all were Caucasian and 9 of these were non-athletic individuals. 4 had symptoms (26.7%) and 1 (6.7%) had a positive family history [HCM]. Inferior TWI (n=15) was more frequent in females (n=13 [1.0%] vs n=2 [0.2%] vs 0.2%, p=0.037). The prevalence was similar in athletes and non-athletes (n=6 [0.6%] vs n=9 [0.6%], p=0.858). 11 (0.4%) had isolated inferior TWI. Only 1 (9.1%) had TWI involving all three inferior leads. Another 4 (0.1%) had inferior TWI extending into the lateral leads. Borderline/other pathological ECG patterns were as likely in both groups (p=0.770). Two participants with inferior TWI (22.2%) had other abnormal ECG patterns (P mitrale [n=1] and ST segment depression [n=2]). One participant (24.0%) from the inferolateral TWI group had ST segment depression. Two patients (13.3% of all participants with inferior TWI) were given a clinical diagnosis (one HCM [inferolateral TWI] and one MVP [inferior TWI]). Both were asymptomatic. The yield was similar for inferolateral (25.0%) and isolated inferior (11.1%) TWI [2 leads] (p=0.523). Most participants with isolated inferior TWI (n=5, 55.6%) were discharged after referral vs 0% in those with inferolateral TWI. Some (n=6) are under surveillance (mean±SD 1897±9 days). Two refused further evaluation. Conclusion Inferior TWI is an infrequent finding in young individuals and may be a marker of pathology in a small group of subjects. The number of leads with TWI (inferior [2 leads], inferior [3 leads] and inferolateral TWI) did not influence the diagnostic yield. Further evaluation is warranted in such cases.

Clinical genetic testing in arrhythmogenic mitral valve prolapse syndrome highlights a potential overlap with familial dilated cardiomyopathy

Abstract Background/Introduction Arrhythmogenic mitral valve prolapse syndrome (AMVPS) is a female-predominant sudden cardiac death (SCD)-predisposing disorder characterized clinically by myxomatous mitral valve prolapse (MVP), inferolateral T-wave inversions and complex ventricular ectopy. However, insights into the pathogenesis and potential genetic basis of AMVPS are currently lacking. Purpose Considering recent case reports that suggest a potential role for genetic cardiomyopathies in the pathogenesis of AMVPS, we sought to determine the yield of pathogenic/likely pathogenic (P/LP) genetic variants in strong evidence cardiomyopathy-susceptibility genes amongst AMVPS patients who underwent clinical genetic testing. Methods In this retrospective study, the medical records of 4,907 patients referred to our cardiovascular genetics clinic was used to identify those patients with a clinical phenotype consistent with AMVPS. After exclusion of individuals with severe mitral valve regurgitation, pertinent clinical, electrocardiographic, imaging and genetic testing data was extracted from the electronic record. For those AMVPS that underwent a form of genetic testing that encompassed 23 Clinical Genome Resource-defined strong/definitive evidence cardiomyopathy-susceptibility genes, ultra-rare (minor allele frequency ≤ 0.00005 in the Genome Aggregation Database [n=141,456 individuals]) non-synonymous variants identified within these genes were adjudicated independently as P, LP or variant of uncertain significance with the assistance of Varsome. The frequency of P/LP variants was then compared to a previously published cohort of 973 ostensibly healthy control exomes. Results Overall, 56 unrelated patients with suspected AMVPS were identified (82% female; average age at presentation of 31 ± 13 years; 32% with a family history of MVP and/or SCD). Of these, 24/56 (43%) underwent a form of clinical genetic testing that encompassed the pre-defined panel of cardiomyopathy-susceptibility genes. In comparison to control exomes (n=973), P/LP variants in strong/definitive evidence cardiomyopathy-susceptibility genes were over-represented in AMVPS patients [4/24 (16.7%) vs 20/973 (2.1%); p=0.002]. Interestingly, this enrichment was driven in large part by an excess number of A-band-localizing P/LP truncating variants in TTN-encoded titin in AMVPS cases [3/24 (12.5%) versus 4/973 (0.4%); p=0.0004]. Conclusion This study provides further evidence that a subset of AMVPS may arise secondary to a "two-hit" model whereby an underlying cardiomyopathic genetic substrate is exacerbated by the mechanical force generated by genetically unrelated myxomatous MVP resulting in maladaptive and ventricular arrhythmia-predisposing fibrosis within the inferobasal left ventricle and posteromedial papillary muscles. Larger studies are needed to better understand the potential role of genetic testing in the diagnosis, risk-stratification and management of patients with suspected AMVPS.

Abstract 13631: Desmoplakin Cardiomyopathy in Pediatric Patients - A Distinct, Underrecognized Cohort of Arrhythmogenic Cardiomyopathy

Introduction: Arrhythmogenic cardiomyopathy is a spectrum of diagnoses including the historically recognized arrhythmogenic right ventricular cardiomyopathy. More recent literature describes predominately left ventricular (LV) or biventricular (BiV) involvement. Variants in the desmoplakin ( DSP) gene commonly cause LV and BiV phenotypes, though data in children are sparse. Hypothesis: Pediatric patients (pts) with DSP mutation have predominantly LV or BiV disease and may present with early onset malignant arrhythmia. Methods: We performed a multicenter, retrospective cohort study of pts <21 years with pathogenic or likely pathogenic DSP variants from 6 tertiary referral children’s hospitals. We describe clinical variation in DSP probands (PBs), the first affected family member prompting genetic testing due to clinical history, as compared to genotype-positive family members (FMs) <21 years of age diagnosed by familial cascade screening. Results: We identified 34 pts; 12 (35%) were PBs and 22 (65%) were FMs. Median age at genetic diagnosis was 13.3 and 12.3 years for PBs and FMs, respectively. Four PBs had LV-predominant disease; 6 had BiV disease (table 1). The most common initial diagnosis for PBs was myocarditis and dilated cardiomyopathy. ECG abnormalities were common in PBs (75%) and included left axis deviation, inferolateral T-wave inversion, and low QRS complex amplitude. The LV ejection fraction (EF) on echo was 48% and 65% for PBs and FMs, respectively. Eight PBs underwent MRI and 6 had late gadolinium enhancement involving the LV only, while 2 had BiV involvement. Six PBs underwent ICD implantation and 2 received appropriate ICD therapy (LVEF 25% and 41%). Two PBs had cardiac transplantation. Conclusion: Pediatric DSP -cardiomyopathy has predominantly LV or BiV involvement and may be misdiagnosed as myocarditis or dilated cardiomyopathy. Probands in particular, may present with early malignant ventricular arrhythmias and significant LV dysfunction.

The Diagnostic Value of the 12-Lead ECG in Arrhythmogenic Left Ventricular Cardiomyopathy: Novel ECG Signs

BackgroundElectrocardiographic (ECG) findings in arrhythmogenic left ventricular cardiomyopathy (ALVC) are limited to small case series. ObjectivesThis study aimed to analyze the ECG characteristics of ALVC patients and to correlate ECG with cardiac magnetic resonance and genotype data. MethodsWe reviewed data of 54 consecutive ALVC patients (32 men, age 39 ± 15 years) and compared them with 84 healthy controls with normal cardiac magnetic resonance. ResultsT-wave inversion was often noted (57.4%), particularly in the inferior and lateral leads. Low QRS voltages in limb leads were observed in 22.2% of patients. The following novel ECG findings were identified: left posterior fascicular block (LPFB) (20.4%), pathological Q waves (33.3%), and a prominent R-wave in V1 with a R/S ratio ≥0.5 (24.1%). The QRS voltages were lower in ALVC compared with controls, particularly in lead I and II. At receiver-operating characteristic analysis, the sum of the R-wave in I to II ≤8 mm (AUC: 0.909; P < 0.0001) and S-wave in V1 plus R-wave in V6 ≤12 mm (AUC: 0.784; P < 0.0001) effectively discriminated ALVC patients from controls. It is noteworthy that 4 of the 8 patients with an apparently normal ECG were recognized by these new signs. Transmural late gadolinium enhancement was associated to LPFB, a R/S ratio ≥0.5 in V1, and inferolateral T-wave inversion, and a ringlike pattern correlated to fragmented QRS, SV1+RV6 ≤12 mm, low QRS voltage, and desmoplakin alterations. ConclusionsPathological Q waves, LPFB, and a prominent R-wave in V1 were common ECG signs in ALVC. An R-wave sum in I to II ≤8 mm and SV1+RV6 ≤12 mm were specific findings for ALVC phenotypes compared with controls.

The impact of ethnicity on abnormal electrocardiographic findings in elite Brazilian football players: B-pro foot ECG pilot study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Black athletes may be more likely to have uncommon electrocardiogram findings than white athletes. The prevalence of abnormal electrocardiographic findings in elite Brazilian football players (EBFP) of different ethnicities is unknown. Purpose To compare the prevalence of these changes and their correlation with the echocardiogram and cardiac magnetic resonance (CMR) in Caucasian, Mixed-race (MR), and Afro-Brazilian (AB) EBFP. Methods A multicenter cross-sectional descriptive study was conducted with exams performed on EBFP as a pre-participation assessment from February 18, 2002, through October 20, 2022. Results 4,363 EBFP from 51 professional clubs (from all five regions of Brazil; 15 states, and 21 cities), aged 15-35 years (median: 19 years; IQR: 16-23) were evaluated. 2,027 were Caucasians, 1,324 were MRs, and 1,012 were ABs. T-wave inversion (TWI) in leads II and aVF (4.2% vs. 2.3%), V5 (4.0% vs. 1.7%), and in V5-V6 (3.0% vs. 1.4%) was more common in AB than in Caucasian players, respectively (P = 0.002 for all comparisons). In addition, AB demonstrated a significantly greater prevalence of inferolateral TWI (2.3%) than Caucasian (1.1%), and MR (1.3%) EBFP, respectively. TWI in leads V1-V3 in Caucasians or MRs &amp;gt;16 years was present in 0.9% (30/3,351). PR interval ≥400 ms was observed in one Caucasian and in one AB athlete. The Wolff-Parkinson-White pattern was identified in two Caucasians, and a suggestive case of a type 2 Brugada Pattern in one Caucasian. Overall, 208 (4.8%) EBFP had electrocardiographic changes considered to be abnormal (4.5% in Caucasians, 4.8% in MRs, and 5.2% in ABs). Of these, 150/208 (72.1%) underwent an echocardiogram. Isolated inferior TWI was not associated with echocardiographic abnormalities (n = 25), similar to persistent juvenile TWI patterns (in Caucasians or MRs). However, TWI in inferolateral leads was associated with 10.5% echocardiographic abnormalities (4/38). Of these, 75% (3/4) had abnormal CMR findings: one AB with hypertrophic cardiomyopathy (CMP), and two Caucasians with non-compaction CMP; one Caucasian with an abnormal echocardiogram demonstrated normal CMR, suggesting "athlete's heart". Finally, one AB had normal echocardiogram results, but the CRM showed a finding compatible with apical hypertrophic CMP. Conclusion In this large cohort of EBFP, approximately 5% of the electrocardiographic findings were considered abnormal. In those with inferolateral TWI, the use of CMR may indicate the presence of potentially malignant cardiac disease, even with normal echocardiographic findings. AB ethnicity was associated with a higher prevalence of TWI in the inferior and/or lateral leads in comparison to Caucasian or MR ethnicities.

Electrocardiogram-based deep learning improves outcome prediction following cardiac resynchronization therapy.

This study aims to identify and visualize electrocardiogram (ECG) features using an explainable deep learning-based algorithm to predict cardiac resynchronization therapy (CRT) outcome. Its performance is compared with current guideline ECG criteria and QRSAREA. A deep learning algorithm, trained on 1.1 million ECGs from 251 473 patients, was used to compress the median beat ECG, thereby summarizing most ECG features into only 21 explainable factors (FactorECG). Pre-implantation ECGs of 1306 CRT patients from three academic centres were converted into their respective FactorECG. FactorECG predicted the combined clinical endpoint of death, left ventricular assist device, or heart transplantation [c-statistic 0.69, 95% confidence interval (CI) 0.66-0.72], significantly outperforming QRSAREA and guideline ECG criteria [c-statistic 0.61 (95% CI 0.58-0.64) and 0.57 (95% CI 0.54-0.60), P < 0.001 for both]. The addition of 13 clinical variables was of limited added value for the FactorECG model when compared with QRSAREA (Δ c-statistic 0.03 vs. 0.10). FactorECG identified inferolateral T-wave inversion, smaller right precordial S- and T-wave amplitude, ventricular rate, and increased PR interval and P-wave duration to be important predictors for poor outcome. An online visualization tool was created to provide interactive visualizations (https://crt.ecgx.ai). Requiring only a standard 12-lead ECG, FactorECG held superior discriminative ability for the prediction of clinical outcome when compared with guideline criteria and QRSAREA, without requiring additional clinical variables. End-to-end automated visualization of ECG features allows for an explainable algorithm, which may facilitate rapid uptake of this personalized decision-making tool in CRT.

EKG Abnormalities in a Youth Athlete Following COVID-19: It's Not Always Myocarditis!

COVID-19 associated myocarditis following mild infections is rare while incidental findings may be more common. A young athlete fully recovered from a mild COVID-19 infection presented with inferolateral T-wave inversions and left ventricular hypertrophy on imaging. Exercise testing aided in correctly diagnosing the patient with masked systolic hypertension.

MEDIASTINAL MASS-INDUCED T WAVE INVERSION: FROM A ROUTINE EKG TO A MEDIASTINAL MASS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: T-wave inversion (TWI) is a negative T-wave of ≥1 mm in depth in two or more contiguous leads, with exclusion of leads aVR, III, and V1[1]. TWI has a wide differential diagnosis that can range from benign causes including normal variants to life-threatening causes including coronary artery disease and rarely can be related to non-cardiac causes [1]. CASE PRESENTATION: Our patient is an 18-years-old female with a past medical history of asthma and major depressive disorder. She presented to the psych emergency department (ED) because of suicidal attempts. Patient complaints of worsening feelings of sadness, loss of interest, and decreased energy. Also, she reported having suicidal ideations. Review of systems was unremarkable She was vitally stable. On physical examinations, lungs were clear to auscultation, cardiovascular exam of normal heart sounds, no murmurs or gallops. Labs were within normal limits, including electrolytes, TSH, D-Dimer, and cardiac enzymes. The routine evaluation protocol in the psych ED includes Electrocardiogram (EKG) mainly to look for QTC intervals, as many of the medications that are used for the psych population may alter the QTC interval. Her EKG showed sinus rhythm with T wave inversion in leads II, III, aVF, and V3-V6 with QTc of 483; there were no previous EKGs for comparison. The EKG was repeated on different days and showed the same findings. The patient reported no family history of cardiovascular diseases. Cardiology was consulted, an echocardiogram showed a large extracardiac mediastinal mass which appears to press on the right ventricle; otherwise, ejection fraction was normal, and no significant valvular disease was observed. A computerized tomography scan of the chest revealed a large, 12 x 7 x 6 cm mediastinal mass along the inferior wall of the heart, exerting mass effect and displacing the heart superiorly. The patient was discharged and referred to a cardiothoracic surgeon for further evaluation. DISCUSSION: Different clinical conditions can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia and pulmonary embolism, to entirely benign conditions[1]. The mediastinum is a potential space in the thoracic cavity that is subdivided into anterior, middle, posterior, and superior mediastinum to form a differential diagnosis for the lesion [2]. In our case, our patient was presented with Inferolateral TWI that was investigated and was found to have a lesion in the middle mediastinum that could be a pericardial cyst, bronchogenic cyst, esophageal implications cyst or lymph node enlargement that can be secondary to tuberculosis or sarcoidosis or histoplasmosis. CONCLUSIONS: This case highlights that inferolateral TWI should always be investigated thoroughly, including by imaging studies when the cause is not clear to prevent life threatening conditions. REFERENCE #1: Hayden GE, Brady WJ, Perron AD, Somers MP, Mattu A. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med. 2002 May;20(3):252-62. doi: 10.1053/ajem.2002.32629. PMID: 11992349. REFERENCE #2: Mediastinum. In: Gurney JW, Winer-Muram HT, Stern EJ, et al, editors. Diagnostic imaging: chest. Section I. Salt Lake City (Utah): Amirsys; 2006 DISCLOSURES: No relevant relationships by Hasan Abuamsha, source=Web Response No relevant relationships by Abdul Rahman Al Armashi, source=Web Response No relevant relationships by Isaac Alsallamin, source=Web Response No relevant relationships by Ameed Bawwab, source=Web Response No relevant relationships by Eleonora Demyda, source=Web Response No relevant relationships by Faris Hammad, source=Web Response

Sequential FDG-PET in the management of multiorgan sarcoidosis

A 32-year-old man presented with palpitations and central chest pain, examination was unremarkable and chest radiograph was normal. ECG demonstrated right axis deviation and inferolateral T-wave inversion; cardiac enzymes were...

Relationship between papillary muscles abnormalities and apparently unexplained infero-lateral T-wave inversion in athletes

Abstract Aims To evaluate by cardiac magnetic resonance (CMR) if left ventricle papillary muscle abnormalities, such as hypertrophy and abnormal location, may be the anatomo-functional substrates responsible for TWI inversion in lateral or infero-lateral leads in otherwise healthy athletes. Methods We included competitive athletes with TWI in lateral or infero-lateral leads in the absence of cardiac diseases detected by CMR. The control population included healthy athletes with normal ECG, matched for age and gender. We compared thickness, volume (both absolute and relative to the cardiac mass) and position of the papillary muscles between cases and controls. Results We included 53 athletes with apparently unexplained TWI in the lateral or infero-lateral leads (median age 20 years (17–42), 86.8% males) and 53 athletes with no TWI matched for age and gender. 4 patients (7.6%) had family history for cardiomyopathy or sudden cardiac death. Athletes with TWI showed more hypertrophic papillary muscles compared to controls, with statistically significant difference in diameter, area and volume (p&amp;lt;0.01). The median ratio between the papillary muscles and the left ventricular mass was 4.4% among athletes with TWI versus 3% among those without TWI (p&amp;lt;0.001). Papillary muscles showed apical displacement in 47% of cases, compared to 17% in the control group (p=0.001). Conclusions Idiopathic TWI in lateral or infero-lateral leads is associated with left ventricle papillary muscle hypertrophy and their apical displacement detected by CMR. The comprehension of clinical and prognostic significance of papillary muscle abnormalities responsible for these ventricular repolarization alterations requires further studies. Example Funding Acknowledgement Type of funding source: None

3254Manifestations of myocardial fibrosis in the standard 12-lead electrocardiogram

Abstract Background Myocardial fibrosis has substantial role in sudden cardiac deaths (SCD). Major challenge in preventing SCDs is early recognition of vulnerable patients with fibrotic cardiomyopathy. Our aim was to find manifestations of myocardial fibrosis in 12-lead electrocardiogram (ECG). Methods Study population is based on the Fingesture study, which has gathered data from 5,869 consecutive autopsied SCD victims between 1998 and 2017 in Finland. The degree of fibrosis was determined based on the histological samples taken from the heart during autopsy and was categorized into four groups; 1) no fibrosis, 2) scattered mild fibrosis, 3) moderate patchy fibrosis and 4) substantial fibrosis. We were able to collect pre-mortem 12-lead ECGs from 1,100 SCD victims. Ischemic cardiomyopathy was the cause of death in 689 cases and 411 had nonischemic cardiomyopathy at autopsy in the group where ECG was available. Results Mean age of the study subjects was 66±13 years and 75% were male. At least some amount of myocardial fibrosis was present in 92% of the victims. QRS duration in ECG correlated with the degree of fibrosis in autopsy as follows; 96±21ms in group 1 (n=93), 97±20ms in group 2 (n=357), 103±26ms in group 3 (n=506) and 108±27ms in group 4 (n=144; p&lt;0.001, β=0.153). Prevalence of fragmented QRS complex was higher among victims with severe fibrosis (40% in group 1, 43% in group 2, 60% in group 3 and 65% in group 4; p&lt;0.001). Additionally, inferolateral T-wave inversions were more common in groups with increasing amount of myocardial fibrosis (5.4% in group 1, 13.2% in group 2, 20.4% in group 3 and 31.9% in group 4; p&lt;0.001). Associations were visible in both ischemic and nonischemic SCDs but reached statistical significance only among ischemic SCD victims. Heart rate corrected JT interval and Sokolow-Lyon index had no linear correlation with the degree of fibrosis. Conclusions Myocardial fibrosis was associated with QRS prolongation, T-wave inversions and QRS fragmentation among SCD victims. Fibrosis did not manifest as clearly in ECG among patients with nonischemic cardiomyopathies as among ischemic SCD victims. The results may explain the increased risk for SCD in patients with abnormal QRS complex or inverted T waves providing means for recognizing patients with underlying fibrotic cardiomyopathy. Acknowledgement/Funding Sigrid Juselius Foundation, Foundation of Cardiac Research, Paavo Nurmi Foundation and Paulo foundation, Finland

Pre-participation cardiovascular evaluation in Pacific Island athletes

BackgroundPre-participation cardiovascular evaluation (PPE) aims to detect cardiac disease with sudden cardiac death (SCD) risk. No study has focused on Pacific Island athletes. MethodsA total of 2281 Pacific Island athletes were studied with (i) a questionnaire on family, personal history and symptoms, (ii) a physical examination and (iii) a 12-lead ECG. Results85% presented a normal history and examination. A positive family history was 1.4–1.9 fold higher in Melanesians, Polynesians and Métis than in Caucasians, while a positive personal history, abnormal symptoms and abnormal examination was 1.3 fold higher in Melanesians and Métis than in others. Neither gender nor training level had a bearing on these results. Melanesians had higher T wave inversions (TWIs) in V2–V4 leads but had no CV abnormalities. Lateral or infero-lateral TWIs were found in 6 male and in 5 highly trained athletes and cardiomyopathies were diagnosed in 3/6 athletes. Overall, 3.9% athletes were found to have a CV abnormality and 0.8% had a risk of SCD. Polynesians and males were more at risk than the others while the level of training made no difference. In athletes at risk of SCD, the main detected CV diseases were cardiomyopathies, Wolff-Parkinson-White (WPW) and severe valve lesions of rheumatoid origin. ConclusionsPPE revealed that 3.9% presented CV abnormalities. A risk of SCD was found in 0.8% with cardiomyopathies, WPW, and severe valve lesions of rheumatoid origin. Melanesians, Polynesians and male of high level of training were more at risk than others.

Prevalence and clinical phenotype of concomitant long QT syndrome and arrhythmogenic bileaflet mitral valve prolapse

BackgroundMitral valve prolapse (MVP), including the recently described arrhythmogenic bileaflet MVP syndrome (ABiMVPS), is associated with repolarization abnormalities and may represent an underestimated cause of sudden cardiac death. The impact of concomitant MVP or ABiMVPS on long QT syndrome (LQTS) clinical severity is unknown. Methods and resultsRetrospective review of 754 LQTS patients [445 females (58%) and mean QTc 471 ± 41 ms] with available echocardiographic data was performed to identify LQTS patients with not only MVP, but also a pro-arrhythmic ABiMVPS phenotype defined as bileaflet MVP, inferolateral T-wave inversions, and frequent complex ventricular ectopy/arrhythmia. As expected, 18/754 (2%) LQTS patients had concomitant MVP. Of these, 5/18 (28%) LQTS patients with MVP satisfied ABiMVPS diagnostic criteria. No difference in symptomatology, degree of QT prolongation, or clinical management was observed between LQTS patients with and without MVP. In contrast, LQTS plus ABiMVPS resulted in a severe cardiac phenotype as illustrated by symptomatic status (LQTS-ABiMVPS; 5/5; 100%; vs LQTS: 279/736; 39%; p = .008), degree of baseline QTc prolongation (LQTS-ABiMVPS: 536 ± 58 ms; vs LQTS: 470 ± 40 ms; p = .009), and number of patients experiencing ≥1 on-therapy break-through cardiac event (LQTS-ABiMVPS: 4/5; 80%; vs LQTS: 48/736; 7%; p < .001]. Lastly, individuals with LQTS plus ABiMVPS were more likely to experience appropriate ICD therapies post-cardiac denervation (LQTS-ABiMVPS: 2/3; 67% vs LQTS: 4/49; 8%; p = .03]. Conclusions and relevanceThe co-existence of LQTS and ABiMVPS may lead to a rare, but malignant, clinical entity characterized by potentially life-threatening arrhythmias despite maximal LQTS therapy.

A Case Report on Type II Myocardial Infarction Secondary to Methamphetamine-Induced Coronary Artery Spasm (CAS)

A 40-year-old male presented to the emergency department in acute psychosis following high dose intravenous crystalline methamphetamine use over two days. A drug history revealed chronic methamphetamine use over 20 years, testosterone therapy and anabolic steroid use. Initial routine ECG conducted pain-free showed inferolateral T-wave inversion with inferior ST depression, and 0.5-1.5 mm of ST elevation in V1-3. Troponin was elevated to 0.34 and creatinine kinase to 5780. Following four hours of observation the patient reported central and upper chest pressure with no radiation or associated symptoms. He was aspirin loaded and commenced on GTN and heparin infusions. With ongoing chest pain, repeat ECGs revealed evolution of ST elevation in leads V1-5 of 0.5-2 mm. Subsequent urgent coronary angiography revealed no significant coronary artery disease and preserved left ventricular systolic function with the interventional cardiologist's impression to be coronary vasospasm noting myopericarditis as a possible differential. Clinical lesson: This case serves as a reminder to clinicians that in young patients with an atypical presentation of acute coronary syndrome (ACS) and no significant cardiovascular risk factors, a thorough drug history should be elicited. Drug-induced myocardial infarction is not a common phenomenon and is often related to coronary artery spasm (CAS) secondary to both illicit drugs and prescription medications [[1]Menyar A.A. Drug-induced myocardial infarction secondary to coronary artery spasm in teenagers and young adults.J Postgrad Med. 2006; 52: 51-56PubMed Google Scholar]. Future research into management of CAS should look to target postulated hyperactivity of vascular smooth muscle cells (VSMCs) stimulated by sympathetic activation [[2]Lanza G.A. Careri G. Crea F. Mechanisms of Coronary Artery Spasm.Circulation. 2011; 124: 1774-1782Crossref PubMed Scopus (236) Google Scholar].

Left dominant arrhythmogenic cardiomyopathy: A morbid association of ventricular arrhythmias and unexplained infero-lateral T-wave inversion

Left-dominant arrhythmogenic cardiomyopathy is a subtype of arrhythmogenic right ventricular cardiomyopathy characterized by early predominant left ventricular involvement. Α 34-year-old man presented with palpitations and a history of frequent ventricular extrasystoles of both LBBB and RBBB configuration. Cardiac workup revealed repolarization abnormalities at infero-lateral leads in the absence of diagnostic structural/functional alterations or obstructive coronary artery disease. Six months later he died suddenly. Histopathology was diagnostic for arrhythmogenic right ventricular cardiomyopathy affecting predominantly the left ventricle at subepicardial/midwall myocardial layers. Thus, ventricular arrhythmias accompanied by unexplained infero-lateral T-wave inversion should warn of a possible morbid association underlying left-dominant arrhythmogenic cardiomyopathy.

Differentiating Athlete's Heart from Inherited Cardiac Pathology: The Challenge of Repolarisation Abnormalities Presenting during Anaesthesia

This case report describes an asymptomatic healthy male professional athlete who underwent general anaesthesia for a routine orthopaedic operation. Peri-procedure, pronounced ST elevation suggestive of myocardial ischaemia manifested on the electrocardiogram lasting for four hours post-procedure, upon which the athlete developed deep and diffuse inferolateral T-wave inversion. These changes resolved spontaneously and the patient remained clinically stable throughout. This case demonstrates the clinical conundrum facing anaesthetists attempting to differentiate between repolarisation anomalies that are commonly observed in high-level athletes and those of inherited cardiac pathology, namely hypertrophic cardiomyopathy, which is the leading cause of sudden cardiac death in young athletes.